STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II STAFF APPRAISAL REPORT
Item
- Title
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STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
STAFF APPRAISAL REPORT - extracted text
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Document of
The World Bank
Report No.
15106-IN
I
STAFF APPRAISAL REPORT
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
FEBRUARY 20, 1996
South Asia Country Department II
(Bhutan, India,Nepal)
Population and Human Resoureces Operations Division
J
i
ABBREVIATIONS AND ACRONYMS
AIDS
AP
ASCI
BOD
CHC
CSSM
DALY
EMTC
FW
GDP
GOI
GOK
GOP
GOWB
HIV
HMIS
ICB
1CDS 1
IDA
IEC
IPP 7
1PP 8
IPP 9
ISHA
NCB
MCH
MIS
MOHFW
NGO
NHP
NSS ;
PAR '
PCR
PGB
PHC
PHN
PHR
PHSC
PWD
SA
SC
SOE
ST
STD
SUBC
TB
HIP
WDR
WHO
Acquired Immunodeficiency Syndrome
Andhra Pradesh
Administrative Staff College of India
Board of Directors (PHSC)
Community Health Center
Child Survival & Safe Motherhood Project
Disability Adjusted Life Years
Equipment Maintenance and Training Center
Family Welfare
Gross Domestic Product
Government of India
Government of Karnataka
Government of Punjab
Government of West Bengal
Human Immunodeficiency Virus
Health Management Information System
International Competitive Bidding
First Integrated Child Development Services Project
International Development Association
Information, Education and Communication
Seventh India Population Project
Eighth India Population Project
Ninth India Population Project
Indian Society of iicalth Administrators
National Competitive Bidding
Maternal and Child Health
Management Information Systems
Ministry of Health and Family Welfare
Non-Governmental Organization
National Health Policy
National Sample Survey
Performance Audit Report
Project Completion Report
Project Governing Board
Primary Health Center
Population, Health and Nutrition
Population & Human Resources
Punjab Health Systems Corporation
Public Works Department
Social Assessment
Scheduled Castes
Statement of Expenditures
Scheduled Tribes
Sexually Transmitted Disease
Subcenter
Tuberculosis
Umvcisal hiuiiumzalioii Program
World Development Report
World Health Organization
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iii
Page Nq.
IV.
PROJECT BENEFITS
A.
B.
C.
V.
..41
..42
..43
Benefits
*.....................
Program Objective Categories
Risks....................................
AGREEMENTS REACHED AND RECOMMENDATION
7
f
... )
/
44
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Pa&g Nq.
TABLES
1.1
1.2
3.1
3.2
3.3
3.4
Lessons Applied From IDA Experience in PHN Lending
to the Proposed Project
Linkages with Other PHN Projects in Karnataka, West Bengal and Punjab
Cost By Component
Cost By Categories of Expenditures
Procurement Arrangements
Estimated Expenditures and Disbursements
10
12
26
27
30
32
ANNEXES
Annex 1
Annex 2
Annex 3
Annex 4
Annex 5
Annex 6
Annex 7
Annex 8
Annex 9
Annex 10
Annex 11
Annex 12
Annex 13
Annex 14
Annex 15
Annex 16
Annex 17
Annex 18
Annex 19
Annex 20
Annex 21
Annex 22
Health Status and Epidemiology
Health Sector Development Program
Public Expenditures on the Health Sector
Costs and Efficiency Comparisons of First Referral
vs. Tertiary Level Hospital Care
User Charges and Cost Recovery
Project Management
Training
Referral System
Quality Assurance Program in Hospitals
Medical Waste Management
......................
Epidemiological Surveillance of Communicable Diseases
and Health Management Information System
........
Information, Education and Commumcation Strategy
Tribal and Underdeveloped Areas Strategy......................
Social Assessment
Project Costs
Summary of Construction Program
Procurement Arrangements..............................................
Implementation Plan
Performance Indicators
...........................
Supervision Plan..............................................................
Forecast of Expenditures and Disbursements
Documents Available in Project File.................. ’•
46
51
68
.80
.85
.91
111
125
130
133
•
139
147
150
155
169
193
223
224
237
247
251
252
Vi
Ikudila,
In luldilion Io Nyslcinic bcncliLs which would indirectly bciicfil (he popuhilion of Lire
stales of Karnataka, Punjab and West Bengal, the project would directly benefit
approximately 10 million out-patients and 0.7 million in-patients currently utilizing
existing hospital services in the three states through the provision of better quality of
health services. The project is expected to directly benefit an estimated 5.2 milhon
incremental out-patients and an estimated 0.8 million incremental in-patients in the three
states. A major benefit of the proposed project would be to assist the states of
Karnataka, West Bengal and Punjab to_put in place a coherent approach to establishing
a cost-effective and sustainable health system. This would indirectly benefit the states’
population as a whole. First, the broader sectoral policy reform envisaged under the
project would increase the efficiency of the health sector by improving the environment^ /
in which the health sector operates. Second, there would be substantial cost savings in
each state through the implementation of streamlined service norms and rationalization
of service provision at different levels of the system. The technical and quality
improvements, i n: uding operations and maintenance functions, at the institutional and
health facility levels would enhance the effectiveness and efficiency of health care
services by encouraging patients to seek timely care, resulting in higher cure rates at
lower costs. Third, patients currently utilizing existing services would benefit from
better quality services. Other qualitative benefits would be: the enhanced credibility and
vital support to the primary health care system through the strengthening of first referral
facilities; and externalities associated with improvements in waste disposal methods and
surveillance systems for major communicable diseases. Finally, the proposed project
would have a direct long-term impact on improving the health status of the people of Z* - aH
each state and would thus contribute to increasing the earning potential of the poor.
‘
Risks.
The proposed project carries several risks that have affected, to varying degrees, PHN
projects in India. These include poor procurement, late disbursement, untimely and
inadequate flow of funds, poor maintenance of buildings and equipment, and inadequate
attention to software and qualitative aspects. Most of these risks have been substantially
reduced through careful project design. There arc two additional risks associated with
this project. Institutional. The capacity of existing institutions to undertake systemic
improvements and to establish a more rational health delivery system has not been tested
in India. Institutional strengthening, including strengthening of the management
structure in all three states would be emphasized in the proposed project to
address this risk. In Punjab, the newly established PHSC might initially have some
start-up problems. The Government of Punjab, at the highest level, has made a
commitment to enable the PHSC to effectively implement the Project. Financial. As
with other projects in India, the overall financial status of the states is a risk. The
position of public finances in Karnataka and recent trends in expenditure on health both
suggest that the projects’ incremental recurrent costs are sustainable. In Punjab, the
necessary resources needed to sustain this commitment can be mobilized with a small
increase in revenue. In West Bengal, some reorientation of its fiscal policies may be
required to ensure sustainability. To help reduce the risk to financial sustainability, an
on-going mechanism for monitoring overall state finances as well as the financial
situation of the health sector would be undertaken through a comprehensive mid-term
review. If necessary, additional measures to achieve financial sustainability of project
benefits would be agreed upon based on that review.
V
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT H
CREDIT AND PROJECT SUMMARY
r
Borrower
India, acting by its President
Beneficiaries:
States of Karnataka, Punjab, West Bengal and Punjab Health Systems Corporation
(PHSC)
Amount:
IDA Credit SDR 235.5 million (US$350.0 million equivalent)
Poverty:
Program of Targeted Interventions (PTI). This project is classified as a PTI because a
large proportion of project beneficiaries will be from the poor and vulnerable segments
of the states’ population. In Karnataka and West Bengal, about two-thirds of expected
project beneficiaries would belong to the lowest 40% of the population in terms of
income distribution. In Punjab, a relatively large share of the investment under the
project would be targeted in the Upper Bari Doab and rural Southern Malwa regions
where 30% and 25% respectively of the overall population live below the poverty line.
- IDA Standard, with 35 years maturity
Terms:
On-Lending T<fejjjgL The Government of India would make the proceeds of the Credit available to the States of
Karnataka^ Punjab and West Bengal under standard arrangements for development
assistance to the States of India; Punjab would further transfer the funds to PHSC as a
grant. GOI would assume foreign exchange risk.
Dcscnpticxi:
\V
The project would be implemented in Karnataka, Punjab and West Bengal. It would
be an investment loan with policy reform in areas of resource allocation for the health
sector, capacity development for sector analysis and management strengthening,
enhance participation of the private and voluntary sectors in the delivery of health
services, and implementation of user charges for those who can afford to pay. The
project would finance investment related to three main activities:
(i) Management Development and Institutional Strengthening: (a) improving the
institutional framework for policy developmci.t; (b) strengthening the management and
implementation capacity of institutions; and (c) developing a surveillance capacity
for major communicable diseases and response capabilities; (ii) ImprQving Sgrvigg
Quality, Access and Effectiveness at the First Referral Level, through: (a) upgrading
community, subdivisional and district hospitals; (b) upgrading the effectiveness
of clinical and support services through streamlining of norms and provision of
training, management information system, waste management and support services;
and (c) improving the referral mechanism and strengthening linkages with the primary
and tertiary health care levels; and (iii) Improving Access to Primary Health Care in
Remote and Underdeveloped areas: (a) upgrading primary health centers in the
Sunderban area of West Bengal; and (b) increasing access to primary care services
among the SC/ST population in Karnataka.
vii
Estimated Project Cost: 1
Fgrgign
Local
Component
I2U1
•USS MillionManagement Development & Institutional
Strengthening
22.7
3.9
26.6
Improve Service Quality, Access and
Effectiveness
237.7
70.5
308.2
Improve Access to Basic Health Services
1L6
^7
24.3
TOTAL BASELINE COSTS
277.9
81.1
359.1
Physical Contingencies
25.6
8.0
33.6
Price Contingencies
18.5
5.4
24.0
TOTAL PROJECT COSTS
322.1
94,6
1 Including taxes and duties estimated at USS22.3 million equivalent
Foreign
Local
Financing Plan:
Total
•USS MillionGOK
25.0
0.0
25.0
GOP
16.4
0.0
16.4
GOWB
25.3
0.0
25.3
IDA
255.4
94.6
350.0
Total
322.1
94.6
416.7
Estimated Disbursements;
Annual
Cumulative
FY97
24.5
24.5
Economic Rate of Return:
FY98
57.9
82.4
IDA Fiscal Year
------- US $ Million-----------FY01
FY2000
FY99
67.2
87.6
85.9
323.1
255,9
168.3
Not Applicable.
FY02
26,9
350.0
i
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT H
L STATE/SECTOR BACKGROUND
A. Health Sector in India
11
Introduction During the past two decades, India has developed a health care system in which
the Government sector finances and manages a basic health care infrastructure, while the pnvate sector
predominantly provides ambulatory care services. Substantial gaps, however, remain m tiie effective
delivery of health care, especially for the poorest sections of the population. Key health indicators
show that the health status of India's population remains low. Communicable diseases continue to be
major health problems; maternal mortality is high; acute respiratory and diarrheal diseases account for
a large proportion of childhood mortality; and preventable mortality and morbidity, especially among
the Door exact a high toll. Moreover, with tho increasing ago profile °f it» population .India is moving
mto an epidemiological transition with the double burden of significant communicable diseases and
increasing non-commuaicable diseases such as cardio-vascular diseases, cancers, diabetes and cataract
blindness.
12
Health Policy The Eighth Plan (1992-1997) identified health as one of the six priority areas,
and determined that public investments in health are critical for human resource development and
poverty alleviation in India. India’s long term strategy for health sector development is enunciated m
the National Health Policy (NHP) of 1983. Public policy for health has been based on an implicit
assumption that primary health care is a basic right to which people should not be demed access due to
inability to pay or for other socio-economic reasons. The NHP emphasizes the role of the state m
providing basic health care, through the development of publicly run health facilities and draws
attention to the strengthening of cooperation between the public and private sectors. The NHP gives
high priority to the control of fertility, infectious diseases of public health importance and preventable
causes of mammal and childhood mortality and morbidity. This is an appropriate health policy given
India's burden of disease (see Annex 1). However, investment allocations do not folly reflect foe
priorities highlighted in the government's health policy and implementation of health programs
continues to be weak.
1.3
Health Care Financing. In 1991, total health spending in India accounted for about 6 percent
1.3
of GDP, or about US$13 per capita per year. Of this, Government contributions including center,
states and municipalities account for about 20% of total health-spending or 1.3% of GDP. Private
health spending accounts for foe remaining 80%. As a percentage of GDP, total health spending is
higher than in other Asian countries which are at about India’s level of per capita income. However,
the percentage of Government to total health spending in India is lower than in comparable Asian
countries. There is also a difference in the type of health services provided in foe public and pnvate
sectors Public provided services arc the dominant source of preventive health care, such as
immunization, ante-natal care, and infectious disease control services, in both rural and urban areas.
2
Private providers are dominant in the provision of ambulatory care for acute illnesses, or illnesses not
requiring hospitalization. Moreover, private health spending is almost entirely from out-of-pocket
sources, and health insurance is insignificant and limited in scope. This places a disproportionate
burden on the poor.
1.4
The structure of Government’s financing of the health sector is quite complex. Under the
federal structure of the Indian Union, public provision of health services is primarily the responsibility
of the state governments. The center, however, exercises its discretion to initiate and fully or partially
finance centrally-financed schemes through a mechanism of specific grants to the states. The state
governments retain responsibility for implementing such schemes. Public financing of health at the
central and state levels is influenced by the planning process which takes place within the framework of
central and state five-year plans. Within this structure of Government spending, states spend about
87%, the center about 10%, and municipalities account for the remaining 3%. A large component of
public spending on health is directed towards tertiary care and medical education, and on public health
interventions that are not the highest priority. The share of salaries in the health budget has continued
to increase, and recent sector work indicates that it accounts for 70-80% of funds targeted to the health
sector. As a result, the share of non-salary recurrent costs has fallen and operation and maintenance of
health programs continue to suffer. As a result, the total amount of resources available for high
priority, cost-effective health services is small.
1.5
The capacity of the health care system in India to effectively address the short- and long-term
health care needs of the country remains limited. The country needs to be prepared to deal with the
evolving burden of disease in the next decade and to put in place a sustainable health system which
would combine elements of public health and clinical services in providing an adequate and necessary
package of basic health services. This package of basic health care services would integrate primary
health care with secondary level or first referral hospitals.1 The emphasis on the first referral frcilities
at the state level in the proposed project is to complement the existing investments in primary care
infrastructure and provide vital support to primary health care services and the rest of the health sector.
In addition, a program of health sector policy reform needs to be initiated to provide the general
framework for health sector development. These changes need to take place within the context of state
health systems and will provide technical effectiveness and improved quality of health care.
B. The States of Karnataka, Punjab and West Bengal
1.6
The Governments of Karnataka, Punjab and West Bengal have expressed early commitment to
undertake health reform. Based on several workshops, presentations and project proposals from about
10 states, these three states have been included in the proposed project since they are ahead of the
others in developing a package of policy reform. In addition. West Bengal has been chosen
of
the hi^i level of poverty in large areas of the state and Punjab because it can set an example for other
states in areas of policy reform. These states also provide an interesting geographical, cultural and
The terms first referral and secondary level hospitals are used synonymously in this report. They denote
community/rural hospitals that have a bed strength of about 30-50 beds; area/taluka hospitals that have
about 75-100 beds; sub-divisional/State General hospitals that have about 100-350 beds; and district
hospitals that have about 300-550 beds. The level of services offered increase from community to area to
sub-divisional to districts hospitals.
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ethnic diversity. Furthermore, the administrative capacity to undertake a project of this type is
relatively strong in these states. The reason for combining the three states under one project is that they
will share common elements that are key to the functioning of health systems, such as service norms,
training, referral systems, surveillance systems for major communicable diseases, equipment
management systems, quality assurance and information, education and communication (IEC)
networks. The implementation of the project in each state would be mutually beneficial for lesson
learning and sharing of experience with respect to these key elements. A brief description of the health
status and burden of disease in Karnataka, West Bengal and Punjab, which have a combined
population of about 140 million people (1995), follows.
Health Status and Epidemiology in the Three States: Karnataka. The state of Karnataka,
1.7
covering an area of 191,791 square kilometers, is located in the southwest part of India. The
population in 1995 was about 48 million, with urban areas accounting for about 31 percent of the
population. Both in terms of area and population, Karnataka ranks eighth among the states of India.
The state is divided into twenty districts which are grouped into four Revenue Divisions with
headquarters at Bangalore, Belgaum, Gulbarga and Mysore. Scheduled Castes (SC) and Scheduled
Tribes (ST) formed 16.4 and 4.0 percent respectively of the population. According to the 1991 census,
the literacy rate was 67 percent among males and 44 percent among females, which is marginally
higher than the country average. In 1991, the last year for which consistent estimates across states are
available, the per capita income was USS329 equivalent, compared to the per capita average for India
of US$330. 32% of the population is below the poverty line compared to about 33% for India as a
whole.
1.8
Karnataka is performing slightly better than the national average in terms of health status and
epidemiological profile. In Karnataka, the birth rate of 26.3, death rate of 8 and infant mortality rate of
67 per thousand live births compares to the national averages of 29.3, 9.8 and 80 per thousand live
births respectively. In the last decade, the number of patients admitted to government hospitals has
increased by 60 percent, putting a great deal of pressure on hospital facilities. State level
epidemiological data indicate that injury and poisoning (19.9%) are among the leading causes of
morbidity, followed by infectious and parasitic diseases (16.3%); diseases of the respiratory system
(14.5%); and complications of pregnancy and childbirth (11.1%). During the period 1982-92, the
increase’in in-patients has been greatest for the treatment of infectious diseases, neoplasm, endoenne,
nutritional and metabolic diseases; immunity disorders; complications due to pregnancy and
puerperium; and injuries and poisoning. The burden of disease in Karnataka reflects the initial phase
of the health transition taking place during the late 80’s and early 90’s. On the one hand, selected
health indicators, such as infant mortality, neonatal and post natal mortality and stillbirth rates, have
deteriorated; on the other hand, injuries and trauma are increasing.
1.9
West Bengal. West Bengal, situated in eastern India, is bound by Bangladesh, Nepal and
Bhutan, and covers an area of about 88,700 square kilometers. With a total population of 72 million in
1995, it is the most densely populated state in India (810 per square kilometer). 39% of the population
is below 15 years of age, and about 28% is urban. The large rural population is mainly agricultural,
with a predominance of small and marginal farmers. It is estimated that more than 30% of the rural
population fives below the poverty line. ST and SC constitute 5.6/o and 23.6/o of the population,
respectively. The literacy rate is about 58%, with a large urban-rural differential. The state is divided
I
4
344 community blocks- In
with 28 /q of the population below the poverty line.
the per capita income was US$294 equivalent
.
In terms of selected health indicators, West Bengal is better off than the average Indian state
with a birth rate of 25.6, death rate of 7.3 and infant mortahty rate of 58 per thousand live births. A
recent study indicated the following burden of disease: obstetric and gynecological (23%); gastromtcstinal dkcascs (12%); cardiovascular diseases (9%); pulmonary diseases (10%); muskul’oskeletal
diseases (9/o); accidents and injury (9%); urinary diseases (8%); skin diseases (7%) and neonatal
diseases (6%). More than 50% of the burden of disease is attributable to maternal and child health and
communicable diseases, indicating that the health transition has not yet begun in West Bengal.
hVm <PUDjab'
StHte of PunJab 13 Sltuated in the north-westem part of India and covers an area of
131,015 square kilometers, with a population of 21.9 million (1995), 29% of the population lives in
urban areas. The state is divided into 14 districts, grouped into three regional divisions, with
headquarters at Firozpur, Patiala and Jalandhar. According to the 1991 census, the average literacy
rate for the state is about 59%, and the sex ratio is 882 females per thousand males compared to the
national average of 927 females per thousand males In 1991, the per capita income was US$554
equivalent, and only 12% of the state’s population was below the poverty line. However, as in other
states, there is substantial regional variation in per capita income. The Upper Bari Doab area, in the
northwest corner of the state, has 30% of its population below the poverty line; rural poverty is most
pervasive m the Upper Ban Doab area, and Southern Malwa, where 40% and 25%, respectively are
below the poverty line.
1.12
Punjab has a birth rate of 27.7, a death rate of 7.8 and an infant mortahty rate of 53 per
thousand live births. The 1992 Survey of Cause of Death (rural) shows that fevers resulting from
infective conditions (24%) were the leading cause of death followed by circulatory system disorders
(17%), degenerative conditions (17%), trauma (11%) and respiratory disorders (11%). In terms of
outpatients seen at medical institutions, the Annual Dispensary Report also shows that 76 percent of
the disease burden is due to non-communicable diseases; acute respiratory infection is the other major
disease burden at 17 percent. These figures, when compared to other Indian states, reflect the health
transition underway in Punjab.
1.13
Organization of the Public Health Care System. The public health system in Karnataka,
Punjab and West Bengal consists of three tiers. At the bottom are primary health care facilities where
basic health services arc provided, with cmpliasis on preventive and piomotivc aspects such as family
planning, maternal and child health (MCH), treatment of minor ailments, malarial treatment and
spraying, sanitation, and public healdi education. This level includes, in Karnataka, 1,875 Primary
Health Centers (PHCs) and Primary Health Units (PHUs); in Punjab, 1,462 subcenters, 484 PHCs and
104 Community Health Centers (CHCs); in West Bengal, 914 PHCs and 249 Block PHCs. The
management of this level of health care in West Bengal and Punjab is under the Directorate of Health
Services. In Karnataka, however, family planning and MCH services are-under the Directorate of
Family Welfare.
L14
In the middle are the first referral hospitals or secondary level hospitals, consisting of hospitals
of vanous bed strengths, ranging generally between 30 and 550 beds, at community area,
subdivisional and distnct levels. These first referral hospitals provide in-patient and out-patiait care
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with diagnostic and treatment facilities not available at the primary level. This level includes, in
Karnataka, 239 community, sub-divisional and district hospitals (a total of 14,858 beds); in Punjab,
217 community, sub-divisional and district hospitals (a total of 6,745 beds); and in West Bengal, 175
community, sub-divisional, state general and district hospitals (a total of 19,964 beds). This level of
health care is managed by the Directorate of Health Services. The provision of services at the first
referral level is inadequate in all three states and this tier does not provide the critical support needed at
the primary level.
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1.15
At the top of the health structure are the tertiary hospitals, including teaching hospitals, which
are staffed and equipped to provide more specialized treatments and generally have a capacity
exceeding 750 beds, with some variations across states. This level includes, in Karnataka, 17 teaching
hospitals; in Punjab, 3 tertiary hospitals; and in West Bengal, 13 teaching hospitals. In addition, each
state has other specialized hospitals such as TB hospitals, mental hospitals, infectious disease hospitals
and leprosy hospitals. They arc managed by the Directorate of Medical Education. In addition to the
three major Directorates mentioned above, there arc other smaller Directorates within the Department
ol 1 leal di and Family Welfare and these vary across slates. In Karnataka, for example, there ia also a
Directorate of Indian Systems of Medicine and Homeopathy, and the Drug Controller.
1.16
Utilization of Health Services. The national sample survey (NSS) utilization data from the
42nd round show that an overwhelming majority of households utilized the allopathic system of
medicine both for hospitalization (98%) and ambulatory care (96%). The preference for the allopathic
system was universal and not influenced by household characteristics such as income, social class or
Uteracy. Public hospitals appear to be more often utilized both in rural and urban areas. For example,
in West Bengal, 77% and 73% of hospitalized cases utilized public hospitals in rural and urban areas,
respectively. About 8% utilized private hospitals and nursing homes in rural areas, and 24% in urban
areas. Despite some regional and rural/urban variations, occupancy rates at first referral hospitals are
close to 100% in West Bengal and between 60-70% in Karnataka and Punjab. Among ST households,
utilization of public hospitals was much lower; and ST households choose private hospitals much less
compared to other household groups. About 95% of government services were free (although there
were indirect costs to the individual) compared to only 7% of services in the private sector. Of the
kinds of ailments treated by the private sector, preliminary analysis suggest that 35% of cases treated
were related to child birth, 30-40% were fevers and injuries and 20-30% were for surgery.
1.17
Beneficiary assessment studies show that Government hospitals, especially first referral
hospitals, are utilized predominantly by lower income groups. For example, in Karnataka, over 45% of
the patients have an annual income below Rs. 15,000 (close to me official poverty line) and over 90%
of the patients have an annual income below the taxable level of Rs. 50,000. Moreover, Government
facilities are used mainly for treatment of communicable diseases which affect the poor more
intensively. Those who can afford to pay usually prefer to use private hospitals since the quality of
services available at Government hospitals is poor, as is the availability of staff, drugs and essential
supplies (see Annex 14).
1.18
Public Health Expenditure. The public health care budget was about Rs. 4,872 million in
Karnataka (FY95), Rs. 5,570 million in West Bengal (FY96) and Rs. 2,202 million in Punjab (FY94).
In FY94, the share of health and family welfare in the total revenue budget in each state was about
6.4%, 5.3% and 7.2% respectively. Since FY90, the share of health in the revenue budget has declined
6
in Punjab (from 6.6 /o to 5.3%) and West Bengal (from 8.4% to 7.2%) and has increased marginally in
Karnataka (from 6.1% to 6.4%). Annual public health expenditure as a percentage of the state’i Net
Domestic Product is only 1.3% in Karnataka, 0.9% in Punjab and 1.2% in West Bengal (see Annex. 3).
1.1^9
In FY94, about 40% of public health expenditures in Karnataka and West Bengal and about
60% in Punjab was allocated to the provision of primary health care services, the largest component of
which included expenditures on family welfare and programs for the prevention and eradication of
communicable diseases. Analysis of the composition of public expenditures on health during the last
five years shows that the budgetary emphasis on primary health care has been maintained.
1.20
Allocation to public hospitals (secondary and tertiary) in Karnataka in FY95 was about 33%
of the health budget; in West Bengal, it was 37%; and in Punjab it was about 41%. This analysis of
subsectoral allocations highlights some important issues. First, the allocation of expenditures for
hospital services is relatively low in the states, compared to other low income countries. Only 4
countries in the 29 countries reviewed by Barnum and Kutzrn (1993) spent less than 40% of their
health budget on hospital services. Second, allocations to hospital services in the states, especially at
the first referral level, have been adversely affected even in years when the overall health budget has
grown. Third, resource allocations within the hospital sector have been unfavorable to sub-divisional
and rural/community hospitals.
1.21
The non-salary recurrent cost budget has been shrinking and the share of salaries of staff have
increased in recent years (see Annex 3). For example, in West Bengal, salaries and wages accounted
for about 75 /o of total expenditures at urban hospitals, and materials and supplies accounted, for less
than 10%. With a rising share of salaries and total allocations remaining constant, the norms for
expenditure on drugs, supplies and other consumables have been held constant in nominal terms. Since
price inflation for these commodities have been greater than average, real expenditures on critical
inputs other than personnel has declined substantially in recent years.
C. Health Sector Issues in Karnataka, Punjab and West Bengal
1.22
Recent sector work on “Policy and Finance Strategies for Strengthening Primary Health Care
Services” (Report No. 13042-IN, May 1995) recommended that the financing of health care in India
needs to be increasingly viewed within the context of structural adjustment and stabilization policies
since the latter are likely to affect government health spending at the central and state levels. Since
more than 80% of public spending on health is accounted for by the state budgets, and since the states
are primarily responsible for implementing various health programs, financing and policy reform to
increase efficiency and unprove effectiveness needs to be targeted at the state level. However, the need
and the challenge for each state can be quite different given the burden of disease, existing public health
programs, past pattern of public investment in the health sector, the importance and the level of
involvement of the private sector, the level of poverty etc. In spite of these differences, there are some
common themes at the state level which emerge as being of equal concern for all states, and which need
to be addressed.
1.23
Budgetary/Resource Allocation Issues. Public resources allocated to the health sector in
Karnataka, Punjab and West Bengal from the national, state and municipality budgets are inadequate
to meet basic health care needs and compare unfavorably to several Asian countries with similar levels
7
of per capita income. The main problems at the state level, where more than 80% of public funds come
from the state budgets, are: (i) the relatively small allocation within the state budget to the health
sector; (ii) the disproportionately high contribution to the tertiary level of health care at the expense of
first referral fiicilities and preventive and promotive care services; (iii) the lack of adequate allocations
for operations and maintenance of investments in the health sector, in particular the size of allocations
for non-salary recurrent expenditures; and (iv) low level of revenue collection from user charges.
1.24 Institutional Issues. Institutional weaknesses m the health system result in a low level of
efficiency. The referral system is largely ineffective; clinical skills at first referral hospitals are below
standard; and technical support for the primary level of care is weak. Structure of Service Delivery:
The mechanism for delivering public health services at the state level faces serious problems related to
the overlapping functions among the various tiers of health care provision. Services provided at
different tiers of the system are often duplicated, and there is no clear delineation of services at each
type of facility. Since the first referral hospitals are performing inadequately, tertiary level facilities are
over-burdened. Moreover, the lower tier institutions such as PHCs are underutilized due to lack of
technical support (such as treatment and diagnosis) from first referral level institutions. Referral
System: Institutional and technical linkages for referral between different tiers are weak. It is estimated
that, with the streamlining of service norms and adequate provision of inputs, a third of all cases which
are currently treated at tertiary facilities could be adequately treated, and at lower costs, at first referral
facilities, Surveillance Development and Response Capability: The ability of the public health system
to cope with unforeseen health emergencies is limited due to weak surveillance and rapid response
capability. For instance, the plague scare in September-October 1994 exposed the inability of the
public health system to respond to such events.
I
I
I
!
1.25
Management and Planning Issues. Management of facilities at the primary and first referral
levels is inefficient, especially with regard to the integration of administrative and financial
responsibilities. There are few incentives for hospitals to improve their management system. The
capacity to undertake health planning, including the ability to undertake the monitoring of the evolving
epidemiological profile and the burden of disease, analysis of cost-effective means of achieving the best
use of limited resources, analysis of the medical manpower situation and monitoring of private health
sector development at the state level, is madequate.
1.26 Technical and Quality Issues. Health facilities at the primary and first referral hospitals in
the states contmue to face operational deficiencies due to general and technical inefficiencies.
Streamlined clinical and support service norms are not applied at first referral hospitals, as a result of
which lower tiers of the health system remam underutilized. Support services and infrastructure at
secondary hospitals are madequate to deliver quality care. Shortages of diagnostic facilities, including
equipment for performing laboratory procedures, are common and adversely affect day-to-day
functioning Commumcations networks and transport facilities are inadequate to meet health care
demand. Shortages of tramed personnel in key areas affect quality of services, and inadequate repair
and mnintenanre services for machinery and equipment leads to malfunction and frequent breakdowns.
Furthermore, the quality of services is also affected by the absenteeism of doctors and other medical
staff in less developed areas of the state.
8
1.27
Access to Health Services. According to hospital data, the proportion of hospital users
belonging to SC/ST groups is commensurate with their proportion in the general population. However,
considering the p<x>r socio-economic condition of these groups, and their low nutritional level, the
morbidity and mortality in this population is greater and warrants a higher utilization of secondary
hospital services. An additional issue is the low utilization of health services by women. In Karnataka,
for example, the NSS survey indicates that the sex ratio among hospitalized cases is 786 females for
1,000 males, whereas the sex ratio in the population is 960 females per 1,000 males. There is a need to
enhance the utilization of hospital services by women and SC/ST groups by strengthening links
between primary and secondary levels of care through an effective referral mechanism and reducing the
physical and psychological distances traveled. Dispanties also exist between the urban and rural parts
of the states with respect to access to health facilities and service quality. The urban based secondary
hospitals tend to be overcrowded, especially the outpatient facilities, and operate at near full capacity,
whereas some of the remote rural facilities remain underutilized because they are unable to provide
even basic services.
1.28
Role of the Private Sector and NGOs. Detailed information on the scope, quality and size of
the private sector is not easily available. Recent sector work found that the private sector plays a major
role in the provision and financing of health care in India. There has been a significant growth of
private sector facilities in recent years, especially in Punjab and Karnataka. In Punjab, 40% of all
hospital beds are in the private sector; in Karnataka, about 33% of all hospital beds are in the private
sector; and in West Bengal, private hospitals and nursing homes account for about 23% of hospital
beds in the state. In all three states, about 80% of all private hospital beds are located in urban areas.
The private sector comprises a wide range of health providers, ranging from the household doctors in
the villages to the corporate sector in the cities and charitable hospitals and dispensaries. However,
many of these providers arc unqualified, licensing is weak or non-existent, and quality is varied. Lack
of regulations and effective legal remedies contributes to inappropriate practices. Government's ability
to monitor, regulate, register and certify private care providers could be strengthened and there still
remains scope for expanding the role of the privak: sector
u*
p(
ar
mt
i
1
i
1.x
(JaCF'
I
fuiic
anaj
l.^
iden
1.29
The role and scope of NGOs in delivering health care services have so far been limited. NGOs
have a comparative advantage in improving access to health services for some disadvantaged groups in
remote and rural areas. Opportunities remain for effective NGO participation in service delivery as
well as behavior changing information, education and communication (IEC) activities.
D. Lessons from Experience
1.30
This is the second project in India that involves the health system at the state level. It is more
broadly based than the on-going or completed population, health and nutrition (PHN) projects in India
Even so, the experience of social sector projects in India is varied and extensive enough to provide
some important lessons for the preparation and implementation of this project.
In
19
Tn
9
s
i
1.31
There are five completed PHN projects in India for which Project Completion Reports (PCRs)
or Performance Audit Reports (PARs) are available.2 These are the First, Second, Third and Fourth
Population projects and the First Tamil Nadu Integrated Nutrition project. The Operations Evaluation
Department has also undertaken an Impact Evaluation Report of the Tamil Nadu Integrated Nutrition
project. Overall, the projects have met an important part of their development objectives. Population I
and II met most of their aims, but did not have any systemic impact on the Family Welfere program.
Population III had significant outcomes in Kerala but not in Karnataka. Population IV appears to have
contributed to very significant improvements in contraceptive prevalence and reduction in infant
mortality. The Tamil Nadu Nutrition project is well-documented as having a major impact on
improving the nutritional status of young children.
3
1.32
There are currently fourteen on-going PHN projects iu
i Jndia. The list below shows eight that
arc now on-going in Karnataka, Punjab and West Bengal:
Health sector: National AIDS_ Control, National Leprosy Elimination and Cataract
Blindness projects;
Family Welfare (FW) sector: Population VII, Population VIII, Population IX and
Child Survival and the Safe Motherhood (CSSM) projects; and
(
•
Nutrition sector: First Integrated Child Development Scheme (ICDS I) project.
1.33
Despite many positive outcomes, the completed and ongoing projects have suffered to varying
degrees from a variety of implementation problems. These have included: late start-up, poor
procurement, slow disbursement, frequent management turnover, untimely and inadequate flow of
funds, poor maintenance of buildings and equipment, and inadequate attention to software and
qualitative aspects.
1.34
The design of the proposed project would take account of the concerns and problem areas
identified above as shown in Table 1.1.
1
2 India. PCR - First Population Project (Cr. 312-IN), Muy 19, 1981; PPAR No. 3748,
December 31, 1981.
India: PCR - Second Population Project (Cr. 981-IN), June 20, 1989; PPAR No 8896 June 29
1990.
India: PCR - Tamil Nadu Integrated Nutrition Project (Cr. 1003-IN), November 26, 1989; Impact
Evaluation Report No. 13783, December 12, 1994.
India: PCR - Third Population Project (Cr. 1426-IN), Report No. 12278, August 1, 1993.
India: PCR - Fourth Population Project (Cr.1623), Report No. 13785, December 12, 1994.
10
Table 1.1: Lessons Applied From IDA Eipeii
rience in PHN Lending to the Proposed Project
Leiioru
Corresponding Action to be Taken
Reference
1.
At the early state of implementation the following
actions would be taken: enhancement of
management and supervision authority for
construction and maintenance of operational
activities by the implementing agencies; adequate
staffing of key project management personnel;
adequate staffing arrangements at district, subdivisional and community hospitals; strengthening
of management procedures. In addition, a mid-term
icvicw of the management systems would l>c
undertaken.
paras. 2.21,2.22,2.23,
2.28, 2.29, 2.30,3.24,3.25,
3.26,3.27
2.
Inadequate Attention to
Management Aspects
Annex 6
Slowness in Implementation
and Weak Supervision
Strengthen implementation capacity; enhancement
of implementation capacity of the engmeering wing
of the implementing agencies; detailed
implementation plan in place; regular field
supervision by local consultants included in
Supervision Plan.
para. 2.30
3.
Poor Maintenance of
Buildings and Equipment
The state Governments will provide adequate
resources during project period for operations and
mamtenance services; capacity for equipment
maintenance and training to be enhanced.
para. 2.10, 2.30
4.
Untimely and Inadequate
Flow of Funds to Project
Assurance provided by the state Governments that
annual review of project expenditures and resource
requirements will be earned out with IDA m order
to ensure timely flow of funds; assurance provided
by GOI that it would release about three months of
project expenditure in advance to the state
Governments.
paras. 3.21, 3.42
5.
Poor Procurement
Procurement arrangements for works and services in
advanced state of preparation; lists of hospitals
prepared, use of standard bidding documents; first
phase of construction plan completed; equipment
lists prepared and specification lists discussed with
IDA.
paras. 3.31,3.32,3.34
Annexes 16, 18
6
huidcquiiU: AltcnlHHj to
Qualitative Asjxxls
.Stalling and technical nouns al dislncl, subdivisional and community hospitals agreed upon;
referral system and linkages with primary care
services to be established according to agreed
norms; clinical training needs developed;
management training needs developed; quality
assurance program developed collaboratively with
clinicians and practitioners from around the state;
performance indicators developed and agreed with
borrower.
puma. 2.27, 2.31. 2.32.
3.35,3.36
Annexes 6, 18, 20
Annexes 7, 8, 9, 19
11
, 2.z3,
: >4, 3.25,
c
1.35
In addition, international experience has also been considered in the design and scope of the
project. The World Development Report (1993) on Investing in Health suggested that a broad sectoral
approach within a supportive policy environment produces significant positive results and benefits. It
also suggested that a limited package of public health measures and essential clinical interventions is a
top priority for government finance. On the components of the public health package, the list includes:
(i) the expanded program on immunization, including micronutrient supplementation; (ii) school health
programs to treat worm infection, micronutrient deficiencies and health education; (iii) programs to
increase public knowledge about family planning, health and nutrition; (iv) programs to reduce
consumption of tobacco, alcohol and other drugs; and (v) AIDS prevention program with a strong STD
component. On the components of the essential clinical services the list includes: (i) prenatal and
delivery care; (ii) family planning services (these two components together constitute a Safe
Motherhood Program); (iii) management of the sick child; (iv) treatment of TB; (v) case management
of SI Ds; and (vi) treatment of minor infection and trauma, otherwise known as limited care. This
project, in recognizing the specific administrative, burden of disease and socio-technical issues in India,
would provide a number of the services listed above. It would also establish the institutional structure
that can lead to the provision of some of the other services in the future.
E. Linkages With Other PHN Projects
1.36
The proposed project would complement and consolidate investments made by on-going
projects by providing policy and implementation coordination with other health and FW projects in the
state. The need for this has also emerged as an important lesson of experience. For example, the
strengthening of the first level referral for obstetrics and child care in this project through the provision
of essential clinical and diagnostic services would complement the primary level of services being
provided under Population VII, Population VIII, Population IX and CSSM projects. In addition, the
actions of these on-going projects with regard to initiating a referral system from the community to the
community hospital level, providing equipment at the first level referral for obstetrics units and defining
the facilities needed for emergency obstetrics care will be further strengthened under this project by
putting in place a referral system that will be able to link up preventive and curative aspects of health
services. These complementary curative actions, which are somewhat higher level interventions than
the preventive and promotive primary care services provided by on-going projects, will improve the
healtli status of women and children and reduce fertility. Similarly, this project will complement the
AIDS Control and Leprosy Elimination projects by enhancing the physical facilities located in the
states that arc providing services under the national programs. The same is true of the complementarity
with the Cataract Blindness project. Where the blindness wards are located in the distnet hospitals in
the states, the project will upgrade the clinical and diagnostic activities of those facilities.
I
12
Table 1.2: Linkages with Other Projects in Karnataka, West Bengal and Punjab3
Name of Project
Primary Health Care
Objectives
Linkages with State Health Systems Development Project II
Kama taka: Population V
Population IX, CSSM
Enhance service delivery
for FW, and strengthen
management at the
district and block level,
and slum areas; support
Child Survival program;
enhance Sale
Motherhood Program.
——Health. Children identified by primary care services as
suffering from severe stages of diarrheal disease, acute respiratory
infection and nutritional disorders will be referred to first referral
hospitals for appropriate treatment.
MlilVintll llcilllli: Thu CSSM program has identified by name the
hirst Referral Units (LRUs) for the states, most of which are under
first releiral management. Mothers identified as having life
threatening complications of pregnancy and child birth will be
referred to these FRUs for appropriate treatment.
.l uchnical supervision and training: First referral will improve the
quality of care at the primary level through: (a) visits to PHCs by
Specialists from the hospitals to conduct clinics for patients who need
more skilled care; and (b) training at first referral hospitals for
upgrading clinical and technical skills for PHC and SUBC staff;
provide on-going training for medical and paramedical staff from
PHCs and SUBCs.
AIDS Cell and Empowered Committee promote coordination between
AIDS Program and first referral hospitals. The MIS capability and
patient statistics gathered by first referral hospitals are of vital use to
the AIDS project.
Wcat Den util: Population
VUI, CSSM
Punjab: Population VII,
CSSM
Karnataka, West Bengal.
Punjab: National AIDS
Control
Involve states in program
development.
Monitor epidemic;
Screen blood; logistical
support.
Surveillance sites or HIV testing faciliues located in first referral
hospitals to facilitate monitoring of the AIDS epidemic. HTV
screening to be done within blood banks of first referral hospitals: the
AIDS project provides the kits, training and procedure; first referral
hospitals provide infrastructure, staffing and support services. First
referral facilities provide essential logistical support for storage of
equipment, medicines, medical supplies and waste management.
Raise public awareness;
develop clinical
management skills m
AIDS and STD control.
The EC component of the AIDS project targets staff of first referral
hospitals for disseminating information. Selected staff of first referral
to be trained by the AIDS project to provide counseling and medical
needs of AIDS patients.
Karnataka, West Bengal: Multi drug therapy;
National Leprosy
disability care and
Eradication
prevention.
The health infrastructure of first referral is a channel of treatment and
drug delivery. The staff and hardware provided by the Leprosy project
will function within first referral infrastructure, providing
physiotherapy facilities, operation theaters (OT) and lab facilities.
logistics and MIS.
first referral facilities provide storage and support services for the
Leprosy project. MIS and statistical support are also provided.
Expand sendee delivery
and institutional
development.
The Blindness Control Programme, through the District Blindness
Control Societies, is financing'support services for cataract blindness
in district hospitals. The Project will provide: support .staff who will
receive specialized training under the Blindness programme
logistical support and other facilities. The referral system will
Karnataka, West
Bengal:
Blindness Control
Program with Danida
Assistance
3
This project will provide additional primary care services not included i:in the on-going Population & Human
Resources Division portfolio.
J
13
Table 1.2 (continued)
Name of Project
■°rj
tral
Karnataka: KIW German
assisted Secondary Level
Services Project
I
der
l-re
the
West Bengal: National
Tuberculosis Control
Program
4
Bi
een
and
Primary Health Care
Objectives
Expand and upgrade of
existing secondary level
health care facilities in
the four backward
districts of Gulbarga
division.____________
Detect TB amongst
chest symptomatics;
vaccinate new bom and
infants with B.C.G.;
sputum diagnosis and
intensive supci vised
treatment of sputum
positive cases
Linkages with State Health Systems Development Project II
complement and facilitate the referral of blind patients to district
hospitals for specialist care.______________
The component will be complementary to the KfW Project and will
contribute to reducing regional imbalances, which is the main
objective of the project This project will also supplement KfW
investment by providing training of staff, waste management system,
referral system, quality assurance, MIS and EC activities and access
to basic health facilities._____________________________________
Pathological laboratory services will be strengthened under the
project with both manpower and logistical support These
laboratories will play a vital role in detection of TB by sputum
microscopy and help in establishing a treatment schedule.
F. IDA Strategy and Rationale for Involvement
The World Bank Group’s Country Assistance Strategy for India (May 19, 1995; Report No.
14509-IN) supports GOI's efforts to provide an enabling environment for broad-based, efficient private
sector-led growth while accelerating the development of human resources. In the human resource sectors,
the strategy is to enhance access to basic services for the poor and to support well-targeted safety net
programs that protect the most vulnerable groups in Indian society. As part of this approach, the Bank’s
strategy in the health sector is to assist India to reduce the level of mortality, morbidity and disability
through a two-pronged approach. The first is to reduce the burden of the most significant diseases
through the support of priority programs; the second is to strengthen the performance of state health
systems to deal with the evolving burden of disease by providing more efficient and effective health care.
The basis of this strategy for the health sector in India is rooted in an on-going dialogue between GOI and
EDA, and is reflected in recent sector work, “India: Policy and Finance Strategies for Strengthening
Primary Health Care Services”, May 1995.
1.37
rral
heal
«__ u
ness
ne
IDA investment in the proposed project is justified for the following reasons. First, the project
1.38
is consistent with IDA's strategy of strengthening state health systems by optimizing resource use and
avoiding duplication and wastage. Second, the project would strengthen the states’ capacity to implement
priority health programs and provide basic health care in rural areas. Third, the project would
consolidate the investments made by a number of other IDA supported projects in the PHN sector, and
add incremental value to the health care system at the state level. Fourth, the project is in line with the
overall IDA strategy of poverty reduction in India through its focus on underprivileged people, especially
women. Scheduled Castes and Scheduled Tribes. Finally, the proposed project would assist Karnataka,
•
Punjab and West Bengal to establish the foundation for a sustainable and coherent approach to health
care.
)ject
th-
c.
will
14
II. THE PROJECT
A. Project Approach
pr0pOSed pr°^ would be 311 Diment operation with substantial policy content It will
coherent, efficient and susUinlblXth Zm.
wZdXXX
picture of preventive and curative aspects of health care by integrating primary health care services
• i 6
?fefnd ^ospitalsadequate and necessary package of health services would be
implemented in each state, based on service norms developed, and consistent with the burden of
belK scSiZ? “et«
PrePa" '*■'
" b""r ad‘teSS '>"0"W
“ ■'»
B. Project Objectives
p 2 K Tbex °bJ'xotlvc:i of tbc proposed project would be to assist the Governments of Karnataka
Punjab and West Bengal to: (.) nnprove efficiency in the allocation and use of health resources through
policy and institutional development, and (li) improve the performance of the health care system
through improvements in die quality, effectiveness and coverage of health services at the first referral
level and selective coverage at Ute primary level to better serve die neediest sections of society The
ulumatc goal of the project would be to improve the health status of the people, especially the poor bv
reducing mortality, morbidity and disability. The achievement of the objectives will be evaluatal on’the
basis of timely implementation of the policy reform spelled out in the Letters of Health Sector Development
Program of the three state Governments in Annex 2.
2.3
The set of development indicators mclude the foUowing m each state: (a) an increase in each year
m the share of resources for the primary and secondary levels of health care in the total resources (plan
and non-plan) allocated to the health sector, until the year 2002; (b) adequate and timely budget
allocations for recunent expenditures at the first referral level, in order to meet the resource
requirements under the project’s annual operating plan; (c) adequate budget allocations for provision of
chugs and essential supplies; and (d) implementation of a user charge policy. The implementation of
these policy reforms will be monitored during supervision through the review of relevant financial and
budgetary documents of the Government, and field visits. These would provide monitorable evidence
of policy actions in each state and their sustamed adherence to key elements of the policy letter.
2.4
In addition, the achievement of the development objectives would be evaluated on the basis of
n^vity
efficiency indicators as well as quality, access and effectiveness indicators as shown in Annex 19
on Performance Indicators. These include a number of indicators to monitor Interim progress towards the
achievement of development objectives, summarized below.
i5including turnover rate, bed occupancy and average length of stay which are
nved from bed occupancy, cumulative inpatient days and admissions during a given period of time, would
be measured against the baseline. Efficiency indicators including the following would be measured against a
i
3
r
r
r
(
se
0
Se
i
15
baseline: clinical services, such as number of major surgeries and deliveries and their percentages to
admissions during a given time period; diagnostic services, such as number of imaging and electro-medical
tests and their percentages to admissions during a given time period; non-clinical services such as post
mortems, percentage of post-operative case fetalities and percentage of infection acquired at the hospital; and
emergency service index measures such as emergency outpatient and entry ratios. These efficiency measure
would be evaluated against the baseline, and compared with the best performing facilities and against
comparable inlcmalional standards.
ii
h
2.6
Quality, access and effectiveness indicators including the following would be measured staffing,
equipment and drug norms met at each fecility; inpatient and outpatient waiting time; patient satisfaction;
upgradation of clinical, management and equipment maintenance skills; awareness among target group of
services offered; awareness among doctors of how the referral system is expected to function; and hinds
recovered from user charges. Some of these would be measured against the baseline, while others will be
measured against the norms that were developed during project preparation.
il
.f
C. Project Content
I. The Reform Program
2.7
The Governments of Karnataka, Punjab and West Bengal have made a commitment to
improving their health system and establishing the necessary framework to achieve project objectives.
All three states have taken action to strengthen the implementation and supervision capacity of the
implementing agency. Punjab has established the Punjab Health Systems Corporation (PHSC) which
was passed as an Ordinance on October 20, 1995. The three states have developed streamlined service
norms at district, sub-divisional and community hospitals that would result m substantial increases in
efficiency and effectiveness. The proposed project would build upon the institutional and policy
changes initiated by the states of Karnataka, Punjab and West Bengal. All three state Governments
have emphasized their commitment to a policy package of health sector reform reflecting key sectoral
development issues for the primary and first referral levels of health care. Letters of Health Sector
Development Program provided by the three states are attached in Annex 2. Details of the Reform
Program arc provided below.
d
e
T*
J
(1) Increase Financing and Improve Resource Allocation for the Health Sector by (a) ensuring adequate
budgetary allocations to the health sector; (b) increasing the share of health sector resources to the
primary and secondary levels of health care; and (c) safeguarding the operations and maintenance
component of the health budget to ensure adequate supplies of drugs and essential medical materials
and mamtenance of equipment and infrastructure;
i
)f
(2) Strengthen the Capacity of the Implementing Agency in Sector Analysis and Management by
(a) setting up a Strategic Planning Cell under the Health Secretary to undertake analyses of health
sector issues; and (b) strengthening the implementing agency’s role and provide it with authority to
manage essential operational activities including civil works construction and maintenance activities;
y
ie
(3) Enhance the Role of the Private and Voluntary Sectors in the Delivery and Management of Health
Services by (a) contracting-out selected services; and (b) promoting linkages in health care deliveiy
with the private and voluntary sectors; and
e
a
j.
16
(4) Implement 4 User Charge Policy by (a) implementing existing user charges more rigorously;
(b) retaining and using revenue collected; and (c) exempting the poor from user charges.
(1) Increase Financing and Improve Resource Allocation for the Health Sector
2.8
Ensuring Adequate Budgetary Allocations to the Health Sector. In FY93, public
expenditure on health and family welfare, as a percentage of State Domestic Product, in Karnataka,
Punjab and West Bengal was about 1.3%, 0.9% and 1.1% respectively; as a percentage of the total
state revenue budget, the contribution of the health budget was 6.4%, 5.3% and 7.2% in Karnataka,
Punjab and West Bengal respectively (see Annex 3). These contributions are low when compared to
several Asian countries with similar or even higher levels of income. In Punjab and West Bengal,
where the rate of growth of health expenditure has been below the overall rate of Government
expenditure in some years, continuation of recent trends in health expenditure would not be sufficient to
absorb the incremental costs to meet the basic health care service needs of the population. At
Negotiations, the Governments of Karnataka, Punjab and West Bengal confirmed that they would at
least maintain the share of health sector allocations within the overall budget at the FY94 level.
2.9
Increasing the Share of Health Sector Resources to the Primary and First Referral
Levels. Within the health sector resource allocation is skewed in favor of tertiary care services,
compared to secondary and primary care services. In particular, resource allocations within the hospital
sector have been unfavorable to sub-divisional and rural/community hospitals. Moreover, tertiary
hospitals have received a large share of total Plan resources allocated for the hospital sector. First
referral care has, therefore, traditionally suffered from a low level of public funding. Investments at the
first referral level would redress some of this imbalance during the implementation years (see Annex 3).
At Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that the
share of both the primary and secondary levels in the total resources (Plan and Non-plan) allocated for
the health sector would be increased each year until the year 2002.
2.10
Safeguarding the Operations and Maintenance Component of the Budgetary Allocations
for the Secondary Health Sector. The non-salary recurrent cost budget of the health sector overall
has been shrinking. With total grants remaining more or less constant, a rising share of salaries has
meant that expenditures on critical inputs other than personnel, such as drugs and essential supplies
have dec I med in recent years. Since price inflation for these commodities has been greater than
average, there has in fact been a decline in real expenditures on non-salary recurrent costs. Moreover,
during the last two years, even nominal expenditures per bed for drugs and consumables have declined.
At Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that
they would allocate adec;_ate resources for drugs, essential supplies and maintenance of equipment and
buildings at first referral hospitals in accordance with norms agreed with IDA.
(2) Strengthen the Capac.::y of the Implementation Agency in Sector Analysis and Management
2.11
Enhancing Capacity for Strategic Planning. A strategic planning cell has been set up in
each state to address ste^gic planning issues m the health sector and provide management with policy
options. It would under^ke operational and policy related research projects, either independently or
through local consultants, and it would organize workshops and seminars. In addition, the strategic
17
planning cell would undertake analyses of a number of other equally important health issues includingmonitoring the role of the private sector and reviewing the suitability of present regulations ml a ting to
the quality of private care provision; analyzing the evolving epidemiological profile in the gtates; and
undertaking of periodic review of the health manpower supply situation and training needs in
state. At Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances
that they would mamtain the Strategic Planning Cell with adequate staff, resources, and terms of
reference acceptable to IDA.
c
2.12
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(3) Enhance the Role of the Private and Voluntary Sectors in the Delivery and Management of Health.
Services
2.13
Contracting-out Selected Services. Private contractual services are often more efficient and
effective than direct labor. In view of the difficulties of employing government staff, such as slow
recruitment and poor attendance, contracting-out certain services, especially support services, becomes
even more attractive. It has been confirmed that there are no legal barriers inhibiting the use of
contractual services for support functions and that the Contract Labor Regulation and Abolition Act
(1970), which prohibits certain institutions from contracting-out perennial services, exempt hospitals
and health care facilities. At Negotiations, an understanding was reached that in order to cut costs and
increase efficiency, the Governments of Karnataka, Punjab and West Bengal would review and
implement, as appropriate, private contractual services, especially supporting services.
i
1
Strengthening the implementing Agency’s Role in Managing Essential Operational
Activities. A new system of managing essential operational activities, particularly with regard to civil
works construction and maintenance, has been proposed to successfully implement the large scope and
volume of activities under die project. This would be achieved by making the DOHFW in Karnataka
and West Bengal, and die PHSC in Punjab more directly responsible both financially and
administratively to undertake civil works construction and maintenance activities under the project. At
. Negotiations, the three state Governments provided assurances that they would take all necessary
actions to ensure that the DOHFW in Karnataka and West Bengal and PHSC in Punjab would provide,
and thereafter maintain authority to manage essential operational activities such as civil works
construction and maintenance activities.
2.14
Linkages with the Private and NGO Sectors. As noted earlier, the private sector has a
predominant presence in the health sector in the three states, especially in the provision of ambulatory
care services. Ihc role of the private sector in health care delivery can be further enhanced in the
future, provided that the regulatory framework for ensuring the quality of health care provision can be
appropriately strengthened. I hc state Governments propose to enhance the participation of the private
and NGO sectors, especially for improving access to primary health care and first referral services in
remote and underdeveloped areas of the Sunderbans in West Bengal and for disadvantaged groups,
particularly SC/STs m Karnataka (see Annex 13). The state Governments are also exploring
opportunities for contracting out the delivery of health care in remote areas to the NGO sector which
has a comparative advantage in improving access to such health services for some disadvantaged
groups. On matters of ensuring the quality of health care provision, state Governments would also play
a more pro-active role, through legislation such as the Nursing Home Registration Act.
18
(4) Implementing a User Charge Policy
2.15
Implementing Existing User Charges More Rigorously. The health financing sector work
iixficaies that the revenue colkcxed m the three states from user charges vanes between 3% and 7% of
the heaim oudget of the states. Lmemauonal experience m developing countries with somewhat higher
per capita income than India, and where the performance of the public health sector has been relatively
better, shows that revenue collected from user charges accounts for about 15-20% of the health budget.
The Governments of the three states recognize the importance of increasing revenue collection through
user charges for the sustainability of the sector. A major problem in increasing revenue is a lack of
enforcement in the collection of existing user charges.
2.16
The system of user charges proposed by each state would be a combination of voluntary
payments and targeting the poor for exemptions. In order to generate revenue and provide services for
those willing to pay, district and sub-divisional hospitals will provide private paying bed facilities and
begin to charge for services m a phased manner after improvements in the quality of basic services and
infrastructure development have been completed. All three states would ensure that at least 20% of all
beds at first referral hospitals would be designated as paying beds. It was agreed that user fees would
be used specifically for non-salary recurrent cost purposes. Enhanced charges would be made effective
after improved services are provided at each facility. The Governments would institute adequate
admuustrative mechanisms for collecting user fees through Distnct Health Committees and through the
appomtment of key staff at the district level who would be responsible for implementing and collecting
user charges more rigorously (see Annex 5). At Negotiations, the Governments of Karnataka, Punjab
and West Bengal provided assurances that the arrangements for mamtenance and collection of user
charges would be maintained and user charges would be implemented in a phased manner after
improvements in the quality of basic services and infrastructure development have been completed.
2.17
Retention and Use of Revenue Collected. The Governments of Karnataka, Punjab and West
Bengal would implement a system that would ensure that funds collected through user charges would
not revert to the state treasury, where they become part of general revenue. To provide incentives for
hospitals to collect user charges, all three states would implement a system that would retain the funds
collected at the institutional level. Funds collected through user charges would be utilized for non
salary recurrent cost purposes in all three states. At Negotiations, the Governments of Karnataka and
West Bengal provided assurances that in Karnataka and West Bengal, the system established as a
condition of Negotiations for the retention and reallocation of funds collected at the hospital level, that
would reallocate funds, on the ba^is of both need and level of revenue collection by the District Health
Committees, would be maintained. In Punjab, regulations on user charges would stipulate that funds
collected would be retamed at the point of collection.
2.18
Exempting the Poor from User Charges. Given the differences in management and
administration, income levels and underlying structure of the economy in the three states, the states
propose to use different criteria for exempting the poor from user charges (see Annex 5). In Karnataka,
the Government proposes to use the existing green/tiicolor card system within the Public Distribution
System (PDS) in the state, which is used to provide nutritional support through issue of subsidized
grain, as a basis for exemption from user fees. Green card holders arc also entitled to subsidized cloth
and kerosene. All poor families with an annual income level of Rs. 11,850 orJycLow (i.c., the nationally
accepted norm under the J RY program) are entitled to such green cards. The number of green card
19
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holders m the state are about 5.3 million compared to the 9 million ration card holders of the PDS
system. Understainding was reached with the Government that it would carefully monitor the green
card system as a basis for exempting the poor from user fees and ensure that leakages are minimized
In Punjab, exemptions to the “charges would include state government employees and members of
families holding yellow cards which signify a family income of below Rs. 11,850 based on the JRY
norms. New lists of families eligible for these cards are being put together. Total revenue raised by
DOHFW in 1993/94 was Rs. 25 million or just over 1 percent of expenditure. According to the
National Sample Survey 1987/88, almost 50 percent of hospitalized cases are in non public hospitals
The average payment per case in these institutions was Rs. 1,200, indicating a willingness to pay
among the general population. Because of the higher income level in Punjab, the ability and
willingness to pay for services is greater than in the other two states. As a result, there exists
considerable opportunity to increase revenue collection through increased charges and better collection
methods. In V/gst Bengal, the existing system for exempting the poor is based on an * Indigent
Certificate’ from the local elected representative, given to families with an income level below Rs.
I, 500 per month. The West Bengal Government proposes to use this criterion rather than the JRY
criterion because the latter docs not apply to large portions of the urban population of West Bengal. At
Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that the
agreed mechanism for exempting the poor from user fees would remain in place.
II. Project Investments
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2.19
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The project in Karnataka, Punjab and West Bengal would finance the activities noted below:
(0 Management Development and Institutional Strengthening by: (a) improving the institutional
framework for policy development; (b) strengthening the management and implementation capacity of
institutions, and (c) developing a surveillance capacity for major communicable diseases and response
capabilities;
(2) Imgroving Service Quality, Access and Effectiveness at the First Referral Level, through:
(a) upgrading community, subdivisional and district hospitals; (b) upgrading effectiveness of clinical
and support services; and (c) improving the referral mechanism and strengthening linkages with the
primary and tertiary health care levels; and
(2) Improving access to Primary Health Care in Remote and Underdeveloped areas by:
(a) upgrading primary health centers and improving access to primary health care services in the
Sunderban area of southern West Bengal; and (b) increasing access to primary health care services
among the SC/ST population in Karnataka.
Component 1. Management Development and Institutional Strengthening (US$26,6 million. 7% of
base costs)
2.20
Improving the Institutional Framework for Policy Development. Sectoral capacity for
development of policy would be strengthened in each state through the creation of a strategic planning
cell headed by a person ol the rank of a Joint Secretary who would report directly to the Secretaryt
DOHFW in each state. The planning cell would monitor die critical issues m the health sector in the
state by commissioning studies, workshops and seminars and by directly hiring consultants to facilitate
20
these activities. As noted earlier, some of the issues would include monitoring the development of the
private health sector including private and social insurance, reviewing the suitability of present
regulations relating to the quality of private care provision, evaluating the burden of disease and cost
effectiveness of public health interventions and reviewing medical manpower. In addition, the strategic
planning cell in each state would review implementation of cost recovery mechanisms and sectoral
resource allocation patterns. Under this sub-component the project would finance furniture, vehicles,
equipment including computers, local training, studies, fellowships, workshops, consultants,
operational expenses and salaries of incremental staff on a decreasing basis.
2.21
Strengthening Management and Implementation Capacity.
Project management
arrangements in tlie three states have several common elements and some differences. Project
management arrangements have taken into account the existing organizational set-up and
implementation capacity of DOHFW, the health programs currently being implemented by the
Department and the overall set-up of public administration in the state, especially with regard to the
nature of decentralized administration in each state. In Karnataka and West Bengal, the project will be
managed and implemented by DOHFW, which will be strengthened under the project to address
increased investment at the primary and secondary levels of health care under the project. In Punjab,
the project will be managed and implemented by the PHSC, which was passed as an Ordinance on
October 20, 1995. The PHSC is an autonomous agency under the aegis of DOHFW. The aim of the
PHSC is to establish, expand, improve and administer medical care at the secondary or first referral
level in Punjab (see Annex 6 on Project Management). The project would also provide support to the
PHSC for the promotion of health care activities in Punjab, through private and voluntary
organizations, the details of which would be worked out during implementation. In addition, the
project would provide physical facilities in Karnataka and West Bengal to consolidate, in one location,
project related activities that are currently dispersed across Bangalore and Calcutta; and upgrade the
office facilities of the PHSC and DOHFW in Punjab. At Negotiations, the Government of Punjab and
the PHSC provided assurances that they would take all measures necessary to: (i) enable PHSC to
carry out its part of the project; and (ii) the PHSC would undertake health care activities under the
project at the secondary level in accordance with service delivery norms acceptable to the Association,
and in carrying out other health care activities would ensure that the ability of PHSC to perform its
obligations under the Agreement would not be materially and adversely affected.
2.22
Management arrangements in each state would be evaluated from time to time to see whether
the management system is producing the best results. In addition, a review of overall state finances as
well as the financial situation of the health sector would be undertaken, and, if necessary, would form
the basis of additional measures to achieve financial sustainability of the project. At Negotiations, the
Governments of Karnataka, Punjab and West Bengal provided assurances that not later than June 30,
1999, they would carry out, jointly with GOI and IDA, a detailed mid-term review of project progress
including management and financial reviews, in accordance with terms of reference agreed with IDA,
and thereafter implement their recommendations.
2.23
Staff strength at the Head Office to undertake increased responsibilities and perform some new
functions would be enhanced. Headquarters staff would be increased to meet the increased workload
and reonent the structure of DOHFW in Karnataka and West Bengal and the PHSC in Punjab to meet
their new challenges. Specific areas targeted for strengthening include the training and referral unit, the
finance and audit unit, the Office of the Director (General) and the Office of the Director, (Service
21
Delivery). Parallel improvements and strengthening of the management and implementation capacity at
the hospital level would be undertaken. These actions would facilitate systems improvement, wider
access and improved data collection and utilization for planning and policy making, problem solving
and momtoring at all levels of management, including the facility level. In all the states, at the hospital
level, both information collection and management are fairly rudimentary. The project would:
(i) enhance and extend the computerized system through the provision of hardware and software, and
consultancy support; (li) establish trained and equipped information cells at HQ and district levels;
(iii) train all management staff in appropriate record keeping; and (iv) introduce a completely revised
medical record system for in-patients and diagnostic services. Under tins sub-component the project
would finance minor civil works, professional services, furniture, other equipment including computers,
vehicles, other supplies, MIS/1EC materials, studies, workshops, local training, fellowships and
operational expenses and salaries of incremental staff on a decreasing basis. At Negotiations, the
Governments of Karnataka, Punjab and West Bengal provided assurances that DOHFW in Karnataka
and West Bengal and PHSC in Punjab would appoint or engage additional headquarters personnel and
all other personnel to be hired under the project in accordance with a schedule agreed with IDA.
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2.24
Developing Surveillance Capacity for Major Communicable Diseases. The surveillance
system for major communicable diseases proposed under the project would cover the identification of
cases through education of health workers and community involvement; indexing of cases or isolation
of cases and treatment; and tracing of contacts for monitoring and evaluation. In the long-term,
however, the surveillance system would need to be expanded to mclude preventive examination among
those most likely to be infected and carrying out immunization; and an enhanced response capability in
case of outbreak or epidemic. This project would fill some of the gaps in the national disease programs
by linking the three elements noted above and providing treatment at the primary and secondary levels.
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2.25
Each state has identified a list of communicable diseases for routine surveillance. Explicit
entena for monitoring these communicable diseases would be set to avoid any ambiguity in reporting
by different agencies. Emphasis has been put on a community-based system for early detection and
reporting and the full participation of local level institutions working at the village or community will
be necessary to make the system more effective. For example in West Bengal, stamp printed red cards
would be introduced for quick transmission of information on communicable diseases, and would
contain information such as name, age, sex, address, date of onset, immunization status, date of death
(if any) of every patiunl with or died Irom a .specif ic coiniiiiinicablc disease 1 he red card would bo
used in out-palieiil dcpaitments and enliy points of in-patient cases in all health and medical units of
the state. As soon as a case is detected the card will be filled out and posted to the distnet
epidemiological cell which would be provided with the facility under the project to sort, analyze and
report such incidences to the appropriate authority for quick follow up action. It will also be important
to include the support of private medical practitioners and private mstitutions through workshops as
well as training programs. The implementation of the health management information system (HM1S)
will improve tracing of contacts as well as provide information on other diseases that are slated to be
included under HMIS activities. To improve the system, quick containment measures have been
developed even in the case of a single incidence to prevent possible outbreak of a specific disease
identified in the pnority list. In the case of outbreak/epidentic daily monitoring would be required.
Under this subcomponent, the project would finance minor civil works, professional services, furniture,
other equipment and supplies, MIS/IEC materials, local training, operational expenses and salaries of
incremental staff on a declining basis.
22
Component 2. Improving Service Quality and Effectiveness at District, Subdivisional and
Community/Rural Hospitals (US$308.2 million, 86% of Base Costs)
2.26
Renovating/Extending District, Subdivisional and Community/Rural Hospitals. Tn
Karnataka, 21 district, 107 subdivisional and 74 community hospitals would be renovated/extended; in
Punjab, 13 district, 46 subdivisional, 91 community, one children’s and one maternity hospitals would
be renovated/extended; in West Bengal, 15 district, 60 subdivisional and 95 rural hospitals would be
rcnovatud/cxtcndcd. 'lEcrc would not be any new hospitals built under the project. The state
Governments have confirmed that no new sites will be acquired for upgrading facilities and that all
premises slated for repovation/extension have existing land. In Karnataka, 3,832 new beds will be
added to the existing bed strength of 14,858 at first referral facilities; in Punjab, about 2,140 new beds
will be added to the existing bed strength of 5,822 at first referral facilities; and in West Bengal, no
additional beds are proposed to the existing 21,723 operational beds in these facilities which a current
capacity for only 19,964 beds. In West Bengal, the project would create supporting infrastructure for
the overcrowded facilities to adequately accommodate the 21,723 beds that are already operating but at
a low level. The proposed increase in bed strength at the secondary level in Karnataka and Punjab are
justified on the basis of: (i) Indian Planning Commission norms of 1 bed per 1,000 population overall,
of which 70% are recommendeffat the secondary level, and (ii) the epidemiological approach, which is
based on the total number of beds required to address the burden of disease at the state level. Both
approaches suggest a greater mcrease in bed strength in each state than is proposed under the project.
Staff quarters would also be built in all three states in areas where housing is a problem for .staff
Under this sub-component, the project would finance civil works, professional services, equipment,
building maintenance and operational expenses.
2.27
Upgrading the Effectiveness of Clinical and Support Services and Quality of Services at
District, Subdivisional and Community/Rural Hospitals. Streamlined norms and standards for
clinical and support services would be applied at the first referral hospitals. Staffing norms conforming
to services provided at each type of facility would be adopted, a system for monitoring improvements
in the quality of clinical care would be established through the adoption of a quality assurance program
and the capacity of support services would be expanded. Staff skills in clinical and technical areas
would be enhanced through the provision of training to improve the quality and range of services.
Management training for professional cadres and on-going in-service training for clinical and technical
cadres would also be strengthened. This would facilitate the implementation of the quality improvement
strategy of the project, through which new responsibilities would be provided. It is expected that
decision-making would be decentralized down to the appropriate management level. Under this sub
component the project would finance minor civil works, professional services, furniture, medical and
other equipment, medical laboratory' and other supplies, medicines, vehicles, MIS/IEC materials, local
training, studies, workshops, fellowships, consultants, equipment and building maintenance,
operational expenses and salaries of additional staff on a decreasing basis. At Negotiations, the
Governments of Karnataka, Punjab and West Bengal provided assurances that they would adopt,
within six months of upgrading each facility, staffing and technical norms at district, subdivisional and
community/rural hospitals, as agreed with IDA, to ensure the quality of services.
2.28
At the first referral level, the focus of improving management effectiveness would be on
strengthening service delivery'. Die first referral level would be able to better manage its resources,
23
deliver clinical services effectively, and hospitals will be able to play a more important role within the
district health systems. DOHFW in West Bengal and Karnataka and the PHSC in Punjab would have
greater freedom of action with regard to recruitment of staff and revenue raising; establish clarity of
goals, objectives and procedures; create opportunities for contracting out services, especially support
services; improve medical record-keeping, health management information systems (HMIS) and related
evaluation and monitoring capacities; provide management training; improve capacity for equipment
management, especially state-wide maintenance services by enhancing the capacity for equipment
maintenance and training. To facilitate an early start to this process, the states have taken the
following action: m Karnataka, the Project Governing Board, Steering Committee and Engineering
Wmg have been established, and key staff have been approved or hired; in Punjab, key staff, including
the Managing Director of the PHSC, have been appointed; and in West Bengal, key staff, including
Project Director, have been hired. They have also provided a schedule for the hiring of key staff
(Annex 6)
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llieie is (.nncnily no aculc shoilagc ol piolcssional slalf overall, but there is a shortage of
.oniu medical spcci.iliic.s and nuises I lie In.st .step would be to improve leciuilment and prompt filling
ol job vacancies by improving recruitment procedures An understanding was reached with the states
llial llic implementing agencies would have the aullioiily to (i) advertise, appoint, promote and transfer
stall mteiiially, (li) post stall as needed, especially in tribal areas; (iii) introduce appropriate incentives
to retain staff in remote areas including: provision of staff quarters, bonus at the end of a specified
period of posting, educational allowance for children of staff posted in remote and tribal areas,
additional leave eligibility and extra credit for doctors and other staff for post-graduate qualification
admission and for fellowships; and (iv) relax service rules as necessary to maintain service when
appropriately qualified staff are unavailable.
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2.30
Due to the scope of the civil works component and the need to ensure adequate maintenance of
assets as a result, DOHFW in Karnataka and West Bengal and the PHSC in Punjab would be
strengthened by providing them with enhanced management and supervision responsibilities of essential
operational activities, including construction and maintenance activities, in collaboration with local
Government. An Engineering Wing in the implementing agency in each state would be set up at the
state and district levels, adequate funds would be provided and the flow of these funds would be
channeled through the implementing agency In addition, a Maintenance Cell will be established in
each large hospital, to manage day-to-day emergent mamtenance works. At Negotiations, the
Governments of Karnataka, Punjab and West Bengal provided assurances that they would provide
funds, satisfactory' to the Association, annually for the maintenance of previously existing equipment in
health facilities supported under die project.
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Improving Referral System. The referral system in Karnataka, Punjab and West Bengal, as
in the rest of India, docs not function well (see Annex 8). Patients perceive the lower level facilities as
providing lower quality of services. As a result, the lower tiers are underutilized since patients directly
proceed to higher level hospitals for minor illnesses, thereby overloading the higher level institutions.
The. beneficial v n'i.scssmcnl sliidy in Wc.hI Bengal found (li.it about 2“o ol (he patients al first referral
I.a limes wcic lufciicd liom PI K's II is estimated that a (hud ol idl cases which arc currently treated
.it luiliary facilities could be treated, and al lower costs, al fust referral facilities if those facilities
received adequate inputs.
24
2.32
The project would seek to ensure that a much higher proportion of patients coming to first
referral hospitals had been seen at PHCs and referred upwards. Likewise, for those patients going to
tertiary hospitals, the project would implement several measures to strengthen the referral system and
improve the quality of care at the first referral level. Special attention would also be given to
establishing mechanisms to improve access for remote and disadvantaged groups and tribal
communities. The referral system would also be strengthened by establishing an incentive system with
differentiated user fees for. users and non-users and allowing patients to by-pass waiting lines when
they carry a referral slip. Under this sub-component the project would finance vehicles (purchase, hire
and maintenance), other supplies, MIS and IEC materials, local training, consultants, fellowships,
workshops and operational expenses. At Negotiations, the Governments of Karnataka, Punjab and
West Bengal provided assurances that they would strengthen the referral system between the primary,
secondary and tertiary levels by December 31, 1996, by: (i) issuing appropriate directives to hospitals
to strengthen the management of the referral system; (ii) establish and thereafter maintain and
implement appropriate referral protocols and clinical management protocols; and (iii) establish and
thereafter maintain and implement an appropriate incentive system for patients who use the system.
Component 3. Improving Access to Primary Health Care in Remote and Underdeveloped Areas
(US$ 24,3 million, 7% of base costs)
2.33
Upgrading of Primary Health Centers in the Sunderban Area of West Bengal. The
Sundarban area in southern West Bengal, with a population of about 3.1 million people is among the
poorest regions in the stale with a predominance of small and marginal fanners -- 40% of the
population belong to SC/STs. Ihc 54 islands, interspersed with bodies of water, arc covered with
forests and swamps. 'I’hey are intersected from north to south by wide tidal rivers and estuaries and
from east to west by narrow tidal creeks. Transport and communication networks are inadequate in
this hostile geographical and topographical location. Metalled roads comprise about 10% of the total
road surface area. Where available, transport is painfully slow and people have to travel in an
assortment of country boats, cycle-rickshaws and buses to reach their destinations. There are no major
hospitals in the region and travel time is at least eight hours from the closest point by public transport
to Calcutta and its overcrowded health facilities. The remoteness of the region, the lack of transport,
the poverty' of the people and lack of access to health facilities have contributed to the health problems
of the people m the Sundarban Areas. It is, therefore, proposed that the project would upgrade ail the
28 PHCs and 8 block PHCs m the Sunderban area. In addition, three floating medical units will be set
up to deliver effective health care in the riverine areas and would be supported by wireless connection.
A wireless communication system will also link up the 36 PHCs and block PHCs with the gram
panchayat office. Under this subcomponent, the project will finance civil works, professional services,
furniture, riverine vehicles, medical and other equipment, medical and laboratory supplies, medicines,
other supphes, MIS/1EC materials, local training, studies, workshops and operational expenses.
2.34
Increasing Access to Primary Care Services Among SC/ST Population in Karnataka. A
system of annual health check-ups is proposed under the project for the SC/ST population of
Karnataka, which account for nearly 20% of the population. The medical check-ups will be made
available in health check-up camps to be organized at the headquarters of every auxiliary nurse
midwife (ANM). At the beginning of each year, the district health and family welfare worker would
draw up a calendar for every PHC indicating the date, time and place at which health check-up teams
would visit the subcenter. Prior to the date for which health check-up is fixed in a particular village, the
25
!
ANM and the male health worker would make house-to-house contact with each SC/ST household to
ensure maximum attendance. This would also be a good venue for IEC activities relating to the
dissemination of general public health related issues. The health-check up team would consist of a
medical officer of the PHC, lady medical officer drafted for the purpose from a government hospital,
laboratory technician, lady health visitor, ANM and a paramedical staff. Much of the work will be
done at the level of the ANM, who will do the early screening. The PHC medical officer will review a
smaller number of more complex cases. Referral to first referral hospitals will follow the system set up
under the referral system for the general population. A record of health check-ups will be maintained in
a master register and each individual would be issued a health check-up card free of cost. These camps
will also provide family planning services. The novelty of this program is that it will mobilize the PHC
staff in a manner consistent with the delivery of primary care services originally envisaged under the
NHP. The subcomponent will finance furniture medical and laboratory supplies, medicines, other
supplies, MIS/IEC materials, local training operational expenses and salaries of additional staff on a
decreasing basis.
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III. PROJECT COST, FINANCING, IMPLEMENTATION
AND DISBURSEMENT
A. Project Costs
™eSpSrX7c^
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. 3
' 1716
and mdlreCt f°regn exchange cost >s estimated at US$94.6 nullion The
project would finance civil works, equipment aid fiimiturc, vehicles, medical and laboratory supplies
medicines, other supplies, MIS/1EC supphes. mofessional services, training, studies and e^aluXT
workshops, and operational expenses and sala-es of incremental staff on a declining basis. Details of
cost estimates, fituncmg plan, procurement a-angements and disbursements plans are shown in the
• various annexes of the S AR.
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Tne breakdown of project costs by canconent and categories of expenditure for the project is
summarized in Tables 3.1 and 3.2.
Table 3.1: .jst By Component
(MUBoe)
(USS MHBoc)
Cmpaartut
Foraicn
Total
TirfaJ
Ik - Irnpcov. iMUCutload Fr*/mwort for Polkcy DavaJprrwnt
58.:
16.4
74.7
1.7
.5
2.1
lb - Surnfttwa Mxaa<am«r* it impkawnauon Capwy
22%
667J
1%
105.4
772.9
19.2
3.0
22.2
14%
6%
LU
22J.
U
a
U
12i
1%
789.t
137.1
926.7
22.7
3.9
26.6
15%
7%
Ic - Doatop SurwilUnca C^pcity
SubtoUl
2. Imprvr* S«rT-kc« Qualky, Accmi a*d EffKdr*M«
21 - Rxqovm A ExMod CoouDunMy, Atm & Duma Hcaptul*
4.085.9
740.8
4,826.7
117.4
39%
0%
3.982.7
1,431.8
5.414.5
114.4
21J
41.1
138.7
2b - Upgrade Qiniral EfTecxivanMa
155.6
2c - Improve RcfemJ Meduuuua
43%
0%
202-'
280.0
482-8
U
LQ
LL2
Qi
8^71 A
2,452.6
li
10.724.0
237.7
70.5
308^
86%
0%
6U.C
233.8
844.9
17.6
6.7
24.3
7%
0«
9.672.1
2.323.5
12.495.6
277.9
81.1
359.1
100%
0%
PhywaJ CoaanfBacMi
8902
279.6
1.170.1
25.6
8.0
PTkw Coadn^caQaa
33.6
9%
2.340.9
584.9
3,023.7
18.5
5.4
24.0
7%
0%
0%
12,903.5 3.788.0
16,691.4
322.1
94.6
416.7
116%
0%
SubtoUi
J - L»f>r*Tw Xcoaa m
H—B— ik—
ToUi BASELINE COSTS
Toed PROJECT COSTS
1
27
Table 3.2: Cost by Categories of Expenditures
(Rupe* MiMoal
%TooU
(LSS MiJlion)
Foeskfa
LooJ
Fortipi
Tool
Load
Foreign
Toad
F irhinp
Costs
Inrestmeat Cost!
i
Civil Works (Renovation)
1,131.1
199.6
1,330.7
32.5
5.7
38.2
15%
11%
Civil Works (New Const! or Extension)
2.737.3
483.0
3,220.3
78.7
13.9
92.5
15%
26%
4%
Professional Services
356.1
89.0
445.1
10.2
2.6
12.8
20%
Furniture
304.7
33.9
338.5
8.8
1.0
9.7
10%
3%
Major Medical Equipment
562.7
844.1
1,406.8
16.2
24.3
40.4
60%
11%
Minor Medical Equipment
4) 1
10 8
54 2
1.1
.1
Medical |-.t|ulpmcm
Ml 0
20 J
101 J
2.J
O
I 6
2 9
20%
1%
Equipment (Oilici)
761 1
190 8
953 8
21.9
5 5
27.4
20%
8%
3.2
9.5
12.6
75%
4%
.9
4.6
20%
1%
11.5
23.1
50%
6%
Singh al I'ucki
Vehicles
109 9
329.8
439.7
Medical Lab Supplies
127 9
32.0
159.9
Medicines
401 5
401.6
803.0
11.5
Other Supplies
550.3
550.3
15.8
MIS/IEC Materials
156.2
208.3
4.5
Local Training
220.5
220.5
6.3
Saidies
66.7
Fellowships
6.2
Workshops
Consultants
NGO’s
52.1
15.8
1.5
6.0
66.7
1.9
.2
51.5
51.5
1.5
1.5
12.4
12.4
.4
.4
18.7
18.7
.5
.5
10,443.4
221.3
Total InTestrnent Casts
7,701.0
Recurrent Costs
Salaries of Additional Staff
1,225.2
2,742.4
4%
25%
6.3
61.8
55.6
20%
1.9
1.6
78.8
1.8
300.1
2%
2%
1%
90%
26%
84%
1,225.2
35.2
Operational Expenses
473.5
52.6
526.1
13.6
1.5
15.1
10%
4%
Building Maintenance
69.4
7.7
77.1
2.0
.2
2.2
10%
1%
Surgical Pack Maintenance
2.9
3.1
.1
.0
.1
5%
35.2
10%
Vehicle Maintenance
15.6
1.7
17.4
.4
.0
.5
10%
Equipment Maintenance
170.2
18.9
189.1
4.9
.5
5.4
10%
2%
Furniture Maintenance
14.3
14.3
.4
4
Total Recurrent Costs
1.971.1
81.1
2.052.2
56.6
2.3
59.0
4%
16%
Total BASELINE COSTS
9,672.1
2,823-5
12.495.6
277.9
81.1
359.1
23%
100%
Physical Contingencies
890.5
279.6
1,170.1
25.6
8.0
33.6
24%
9%
Price Contingencies
2.340.9
684.9
3.025.7
18.5
5.4
24.0
23%
7%
Total jniOJECT COSTS
12.903 5
3.78H.O
16,691.4
322.1
94 6
416.7
23%
116%
L
28
J t ^aS‘S °J 5°St Es‘‘raates' Estmated costs for civil works are based on current unit costs for
nstruction which vary from US$135 per square meter in Karnataka and Punjab to US$165 per
square meter m West Bengal of gross floor area of construction. The higher unit costs in West Bengal
are duetothe rela-ve seyoty of ta,M„g matena! m .he
These Tsh. are
t ’bfZ Z7trUCtl0)n m Indla- Costs of Professional services for design reflect the scale of fees
established for similar services provided by local architectural consulting firms. Costs for supervision
meZca|tTLCt,On
°ngOm8 char8es m 1116 Pnvate sector. Cost estimates for fumrture
edical equipment, vehicles and medical supplies are product of lists developed by DOHFW and
current X
Ff Z
°f
SUpplleS
baSed on tfle state
and reflect
current prices. Estimated costs for the salanes of additional staff are based on basic pay scales
including standard allowances for social and other benefits applicable in each project State.
3.4
Customs Duties and Taxes. All imported goods are
subject to customs duties and taxes. The
estimated cost of the project includes import duties and
taxes estimated at about US$22.2 million
equivalent.
.n.llu.n
i“C,yin'/0W(annCS. hst,maU;d >’r°Jcct CO!its incl^ Physical contingencies (US$33.6
}
nUltC<J al 1.°/u of a" l,hys,cal components and at 5% for technical assistance training and
a ancs. he estimated costs of die project also include price contingencies (US$24.0 million) to ^over
expected price escalation at the following rates. For civil works, goods, salaries, technical assistance
XogPnTo/0n 7^““ ’ f°reign C°StS: 4 4% in FY96> L8% in ^97 and FY98, 2.2% in
-7 co/9’ 2r3/° 1,1 Y ° and Y0 ' and 2-4% ln EY02; local costs: s 7% in FY96, 8 2% in FY97 and
7-5/o in FY98, 6.5% in FY99, 6.0% in FY00 through FY02.
M^Zdic^rFStr^
B. Financing Plan
Credit oH ^$350 0^ nPrOjeCt,COSt °f.USS_41-6-2 million equivalent would be financed by an IDA
Credit of US$350.0 million equivalent, which would cover about 8JL7.percent of the project costs net
nfUsSa?12 u
Of Kamatoka’ PunJab “d West Bengal would finance the remaining costs
of US$44.o million plus all taxes (US$22,2 million).
3.8
The credit would be made available to GOI on standard terms and conditions and on-lent to the
ovemments of Karnataka, Punjab and West Bengal under standard arrangements for development
assistance to the states; and Punjab would further transfer the funds to PHSC as a grant. Under current
?rm1/P7°(W 7
rS/11005’ On_iend,nB t0 Kamataka, Punjab and West Bengal takes the form of 30%
8^11/70/„ loan at I2/O interest per annum over 20 years. GOI would assume foreign exchange nsk
At Negotiations, an understanding was reached with GOI that it would release about three month’s
Pr°JkCt Aexpendltures- ln
to the project states (in accordance with the’amounts
established in the Annual Plans), and that upon receipt of fimds from GOI, the Governments of
1
29
Karnataka, Punjab and West Bengal would transfer all such funds, together with its quarterly
counterpart contributions, immediately to the project accounts of DOHFW in Karnataka and West
Bengal and the DOHFW/PHSC in Punjab.
C. Procurement Arrangements
Table 3.3 summarizes the project items, their related cost estimates and proposed methods of
3.9
procurement. Project-related procurement for goods, works and services would follow procedures
acceptable to IDA using ICB and NCB documents acceptable to the Association. Project-financed
consultants would be recruited according to Guidelines on the Use of Consultants by World Bank
Borrowers. Procurement of equipment, vehicles, and medical laboratory supplies would be bulked to
the extent possible and any individual contract exceeding US$200,000 equivalent would be procured
under ICB procedures. This is also true for vehicles including riverine vehicles, except for those
needed for immediate use costing up to an aggregate of US$300,000 only, which may be procured
through national shoppmg or Directorate General of Supplies and Disposals (DGS&D), New Delhi
rate contract. Shopping under the project would include international shopping procedures, based on
comparing price quotations obtained from at least three suppliers from two eligible countries, or
national shopping procedures with solicitation of price quotations from at least three suppliers, all in
accordance with Bank Guidelines.
3.10
Civil Works (US$152.2 million). The civil works component entails no new hospital
construction but does involve large and small scale renovations and extensions to 557 hospitals over
the five year life of the project. An estimated 475 contracts (costing US$134.2 million) will be earned
out through national competitive bidding. These works average between US$300,000 and US$500,000
and would not be of any interest to foreign bidders and would be procured under NCB procedures.
Contracts for the remaining works estimated to cost about US$ 45,000 equivalent or less per contract
at about 400 sites up to an aggregate not exceeding US$18.0 million scattered and in remote areas
shall be procured, in accordance with procedures acceptable to the Association: (i) through Force
Account limited to US$10,000,000; (ii) by direct contracting; or (iii) under quotations solicited from at
least three qualified contractors.
3.11
Equipment (US$84.5 million). Procurement of most of the equipment would be phased on an
annual basis in accordance with the requirements of the project activities. Contracts valued at over
US$200,000 would be procured through ICB for an amount equal to US$54.9 million. Contracts
valued at US$200,000 or less would be procured through NCB procedures acceptable to IDA for an
amount not exceeding US$12.7 million. Purchases totaling US$50,000 or less, and not exceeding in
aggregate US$12.7 million and US$4.2 million equivalent, may respectively be awarded on the basis of
national and international shopping based on comparing price quotations obtained from at least
(a) three suppliers from two eligible countries for international shopping and (b) three national
suppliers for national shopping. An estimated 200 contracts will be carried out through ICB and NCB,
ranging from over US$200,000 to US$750,000 per contract. Phasing of the procurement of equipment
will be closely sequenced with the civil works program. Details on the type of equipment and
packaging are available as working papers.
3.12
Vehicles (US$14.6 Million) would be procured during the first two years of the project
through ICB for an amount not exceeding US$14.3 million. To facilitate project start-up activities
30
procurement of vehicles up to an <
ol US$300,000 will be undertaken by the three states under
national shopping procedures or DGS<£D rate contracts. An estimated 24 contracts would be carried
out through ICB, ranging from US$200,000 to US$800,000 per contract.
Table 3.3: Procurement Arrangements
(Total Costs in USS Millions)
Itaferxxiri
Coopcturre
Btddlnf
PrcKumutta Virlbod
Nan—al
Coal pea or«
lataraarirMiel
Bkidust
SUpfXM
tool
Sbo^HM
Other
Methods/a
CIVIL WORKS
Civil Works
134.2
(U4.1)
/b
8.5
(7.7)
/c
18.0
(15.3)
152.2
(129.4)
GOODS
Fumjcurc
Equjpruau
Vehicles
54.9
(49.4)
12.7
4.2
(11.4)
(3.8)
14.3
(12.9)
Medical Lab Supplies
Medicines
Other Supplies
M1S/1EC Maienals
2.8
(2.6)
11.4
(10.2)
12.7
(11.4)
84.5
(76.0)
0.3
(0.3)
14.6
(13.1)
2.7
(2.4)
0.4
(0.3)
2.3
(2.1)
5.4
(4.9)
22.0
(19.8)
1.5
(1.3)
3.7
(3.3)
27.2
(24.5)
11.1
18.5
(16.7)
7.4
(6.7)
(10.0)
5.2
(4.7)
(1.6)
1.7
6.9
(6.2)
CONSULTANCIES
Prujoct Preparation & Iniplciriciuaiioii (inul
Tiarnuig, Worksbupa, Fcllowiliipu
10.7
(10.7)
10.7
(10.7)
18.1
(16.3)
18.1
(163)
39.3
(25.5)
39.3
(25 J)
Inwimuonai Development (includes Local
Coasulianii. Studies. Professional Services
Fees. NGO Fees)
MISCELLANEOUS
Salanes of Additional Surf
Operanonal Expenditures
17.8
17.8
(11.1)
(11.1)
Buiidinj Muntenance
3.1
(1.7)
Equipment Maintenance
Total
3.1
(1.7)
7.0
7.0
(3.8)
(3.8)
692
192.7
6.1
52J
96.2
416.7
(62.3)
(166.8)
(33)
(42.3)
(73.3)
(350.0)
Notes:
/a Other methods include Force Account, Direct Contracting and Consulting Services
/b Figures in parenthesis are the repective amounts financed by IDA
/c Figures may not appear to add exactly due to rounding
i
31
3.13
Furniture (US$11.4 million), Laboratory Supplies (US$5.4 million) MIS/IEC Materials
(US$6.9 million) and Other Supplies (US$18.5 million) would be purchased as follows. Contracts
estimated to cost less than US$50,000 equivalent up to an aggregate of US$17.6 million (furniture US$2.8 million, medical laboratory supplies - US$2.3 million, MIS/IEC materials US$1.7 million and
other supplies US$11.1 million) may be awarded on the basis of national shopping with solicitation of
price quotations from at least three suppliers. This is again based on the fact that this amount covers
purchases by 557 hospitals over a period of five years. Contracts valued at US$50,000 equivalent or
more would be awarded on the basis of NCB procedures acceptable to IDA for an amount not
exceeding US$23.8 million (furniture - US$8.5 million, medical laboratory supplies - US$2.7 million,
MIS/IEC materials - US$5.2 million and other supplies - US$7.4 million). Contract for medical
laboratory supply uslinialud to cost less than US$200,()()() per contract, not to exceed an aggregate
amount of US$0 4 million equivalent will be awarded under international shopping procedures, based
on comparing price quotations obtained from at least three suppliers from two different eligible
countries in accordance with Bank Guidelines.
3.14
Medicines (US$27.2 million) would be purchased by each of the 557 hospitals as well as by
DOHFW in Karnataka and West Bengal and the Health Systems Corporation in Punjab several times
per year over the five year life of the project. Bulking requirements would not always be feasible due
to shelf life of the medicines. As a result, the individual purchases would be small and not likely to
attract foreign bidders. Accordingly, contracts valued at US$50,000 equivalent or more would be
awarded on the basis of NCB procedures acceptable to IDA for an amount not exceeding US$22.0
million. Contracts estimated to cost less than US$50,000 equivalent up to an aggregate of US$5.2
million may be awarded on the basis of National and International Shoppmg procedures based on
comparing price quotations obtained from at least: (a) three suppliers for national shopping, (b) three
suppliers from two different eligible countnes, in accordance with Bank Guidelines.
3.15
Studies and Consultancy Contracts (US$2.9 million) and Professional Services (U$$15.2
million). Professional services will be used mainly for architectural and engineering services which will
be provided from within the country'. Consultants required under the project will be hired following
procedures prescribed in "Guidelines: Use of Consultants by World Bank Borrowers and by the World
Bank as Executmg Agency"; August, 1981. Documents used for inviting proposals, terms of reference
for all consultancies and single-source contracts will be subject to prior review for all contracts valued
at US$100,000 or more awarded to firms and US$50,000 or more to be awarded to individuals. The
professional services entail approximately 500 contracts valued from about US$15,000 to US$60,000;
this many contracts would not be suitable for international consulting firms. These contracts will
include topographical surveys, soil tests, architectural and engineering fees, mid supervision of
construction.
Fellowship, fraining, and Workshops (US$10.7 million). This category' includes expenses
3.16
related to training of about 22,663 medical professionals over the life of the project in respect of
seminars, workshops, travel and subsistence allowances.
3.17
Equipment Maintenance (US$7.0 million) and Building Maintenance (US$3.1 million).
Maintenance costs for vehicles, medical and other equipment items estimated to cost less than
US$5,000 per contract up to an aggregate of US$7.0 million would be procured from local commercial
suppliers of such services: (i) through direct contractmg; or (ii) under quotations solicited from at least
k
..
32
i"
three suppliers in accordance with procedures acceptable to IDA. Maintenance of buildings and
building equipment (funded by the project), estimated to cost US$5,000 equivalent or less per contract
upto an aggregate of US$3.1 million, shall be earned out by other procedures where such arrangements
already exist or by obtaining three quotations from local contractors in accordance with procedures
acceptable to IDA.
3.18
IDA Review. Prior to the issuance of any invitations to bid for contracts, the proposed
procurement plan for the project shall be furnished to the Bank for its review and approval, in
accordance with the provisions of paragraph 1 of Appendix 1 to the Guidelines. Procurement of all
goods and works shall be undertaken in accordance with such procurement plan as shall have been
approved by the Bank, and with the provisions of said paragraph 1. All procurement under contracts
costing US$300,000 equivalent or more for civil works and US$200,000 equivalent or more for goods
would be subject to prior review; the rest would be subject to post review. All other contracts would be
subject to random post review in the field by visiting missions. Other contracts for civil works and
goods would be subject to IDA review after contract award. Contracts for the hiring of consulting firm
costing US$100,000 equivalent or more and contracts for hiring individual consultant costing
US$50,000 equivalent or more, would be subject to prior review and approval by IDA. Approximately
60% of the value of the IDA Credit would require prior review.
D. Disbursement Profile
3.19
The proposed IDA credit would be disbursed over five and a half years. This is shorter by 18
months than the standard profile for PHR projects in India. The project is expected to be completed on
September 30, 2001 and the credit closed on March 31, 2002. Table 3.4 below shows forecasts of
expenditures and disbursements.
Table 3.4: Estimated Expenditures and Disbursements
(USS Million)
IDA FY
Annual
Expenditures
Annual
Disbursement
Cumulative
Expenditures
Cumulative
Disbursement
FY97
45.6
FY98
88.1
FY99
111.2
FY2000
98.2
FY01
66.2
FY02
7.4
24.5
57.9
85.9
87.6
67.2
26.9
45.6
133.7
244.9
343.1
409.3
416.7
24.5
82.4
168.3
255.9
323.1
350.0
3.20
Disbursement Percentages and Required Documentation. The IDA Credit would be
disbursed against 85% of expenditures on civil works: 100% on professional services, consultants and
fellowships; 10(5 percent of CIF and ex-factory costs or 80% of other local expenditure on furniture,
equipment, vehicles, medicines and materials, MIS and IEC materials; and 65% of salaries of
incremental staff and other recurrent costs on a declining basis during the project period starting with
1
33
90% until December 31, 1998, 75% until December 31, 2000 .ird 40% thereafter. Disbursements for
civil works over US$300,000 equivalent per contract, goods over US$200,000 equivalent per contract,
consulting firm contracts over US$100,000 and individual consultants over US$50,000 equivalent
would be fully documented and all other expenditures would be disbursed on the basis of statement of
expenditures. Each state Government would maintain complete records of funds disbursed, including
certificates of completion signed by the District Executive Engineer, the Managing Director of Punjab
Health Systems Corporation and the Project Coordinators in Karnataka and West Bengal.
3.21
Special Account and Central Government Advance to the State. In order to accelerate
disbursements in respect of IDA'S share of expenditures prefinanced by GOI and the state
Governments, and to allow for direct payment of other eligible local and foreign expenditures, a Special
Account would be maintained in the Reserve Bank of India in the amount of US$17.0 million
equivalent to cover four months of estimated disbursements through the Special Account.
3.-22
Retroactive Financing. Retroactive financing for project preparation in the amount of US$10
million, about 2.8 percent of the proposed credit, is provided to cover eligible expenditures incurred in
implementing appraised project activities after May 1, 1995. Retroactive financing in support of
project preparation would support initial staff appointments, technical survey of the existing hospitals
under the project mcluding topographical site surveys and soil tests, preparation of preliminary designs,
and initial construction activities. Procurement arrangements were reviewed and found appropnate.
E. Project Implementation
3.23
In Karnataka and West Bengal, the project will be managed and implemented by DOHFW. In
Punjab, the project will be managed and implemented by the Punjab Health Systems Corporation
(PHSC). Lists of staff or Committee Members, organograms for each state, and the functional levels of
project management in each state are shown in Annex 6.
3.24
In all three states, a Project Governing Board (PGB)/ Board of Directors (BOD) will be at the
top of the project management structure. It will include high level representation from all relevant
parts of the state Government that are associated with the project. The PBG/BOD will be fully
empowered to make major policy decisions and develop the broad policy outline for the project;
approve the annual budget; authorize major project revisions as necessary; ratify decisions made by the
Steering Committee (in Karnataka); formulate rules and regulations; and undertake an annual review of
project implementation and monitor overall project progress. The PGB/BOD in each state would have
the responsibility for supervising the activities of project management. A provision has been met under
the project for the use of consultancy/professional services under techmeal assistance to support this
function, especially with regard to the new approach to the management of civil works. The PGB in
Karnataka and West Bengal would meet twice a year, while the BOD in Punjab would meet more
often. The Strategic Planning Cell would report to the PGB/BOD.
In Karnataka, but not in West Bengal or Punjab, there would be a Steering Committee under
3.25
the PGB. The Steering Committee would delegate adequate powers to the PGB to carry out its
functions as the nodal body for project implementation. The Secretary, DOHFW, would be the
Chairman of the Steering Committee and the Project Coordinator. The Steering Committee will
34
supervise and monitor project implementation, undertake planning activities and facilitate project
management activities.
3.26
Reporting to die PGB/BOD directly, in Punjab and West Bengal, and through the Steering
Committee in Karnataka, would be the Project Management Cell (PMC). The PMC would be headed
by an Additional Secretary as the Project Administrator in Karnataka, a Special Secretary as the
Managing Director of die PHSC in Punjab, and a Special Secretary as the Project Director in West
Bengal. This official would be assisted by medical, technical, engineering services, financial
management and administration and personnel divisions. The functions of the PMC would include all
aspects of routine project management, monitoring progress, maintaining flow-of-funds and project
account, providing technical guidance and general administration, and preparing progress reports.
3.27
At the district level, a District Health Comnuiuc/Project Implementation Cell would facilitate
functioning of the various activities to be carried out under the project. In Karnataka and West Bengal,
Distnct Health Committees have been approved/established in all districts. At Negotiations, the
Governments of Karnataka and West Bengal provided assurances that they would maintain District
Health Commitees in all districts of the states to facilitate the collection and distribution of user
charges, maintenance of equipment, waste management, training of technical staff, quality assurance
surveillance of major communicable diseases and monitoring and supervision of project related
activities.
3.28
The initial phase of project implementation will focus on developmental activities including
project launch; monitoring mechanisms and performance indicators; strengthening health MIS system
and surveillance, network for major communicable disease; initiating in-service training of staff in
clinical, management and equipment matter; strengthening the functions and appomting key staff and
supplying equipment to existmg hospitals to improve the quality of service program. The disbursement
profile relating to the balance of hardware and software aspects of the project would,be monitored
during supervision to ensure that an optimal balance between the two is maintained. The first phase of
the hospital upgradation program would consist of 42 hospitals in West Bengal, 45 hospitals in
Karnataka and 40 hospitals in Punjab. During the initial phase, the implementation plan would be to:
complete topographical site surveys and soil tests; finalize and complete all drawings including site
development plans, mvite bids and commence construction for all hospitals under the four planned
phases (see Annex 18); and complete over 50 percent of phase 1 and phase II and about 25% of phase
III and phase IV; and prepare and complete all drawings including site development plans, launch bids
and sign contracts of all 557 hospitals, 28 PHCs and 8 Block PHCs requiring upgradation. About 35
percent of total construction is expected to be completed by the end of the second year. At
Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that they
would review with IDA annually by April 30 of each year the progress of project implementation over
the preceding twelve months and prepare an annual work plan for the following twelve months
acceptable to IDA.
35
F. Status of Project Development
3.29
The Governments of Karnataka, Punjab and West Bengal have finalized their project proposals
(September, 1995) in consultation with IDA missions and on the basis of workshops on service norms,
project management and policy issues organized by each state. Based on these norms and taking into
account cost-effectiveness criteria, the proposals have defined appropriate staffing patterns, physical
upgradation of facilities, equipment requirements and the need for support services. Letters of Health
Sector Development Program furnished by each state were finalized during Negotiations (see Annex 2).
Project management arrangements, additional staffing requirements and functional responsibilities have
been finalized and found satisfactory by IDA (see Annex 6).
3.30
Beneficiary assessment and private sector studies have been completed in Karnataka, Punjab
and West Bengal. The findings and recommendations of these studies liavc been used to fine-tune
project design in each state. The tribal and backward areas strategy proposed for the project in
Karnataka and West Bengal was found satisfactory by the IDA team; Punjab will have no tribal
strategy since there is no tribal population in the state (see Annex 13).
3.31
An extensive survey of ail health facilities to be included under the project lias been completed
in Karnataka, Punjab and West Bengal. Samples of the surveys in all three states have been reviewed
and found satisfactory. Each state has recruited consultants to ensure timely preparation of designs,
architectural and engineering drawings, and written bid documents. Preliminary designs of about 35
hospitals have been initially reviewed. The state Governments have been informed that these should be
in accordance with World Bank guidelines for the use of consultants to ensure that retroactive
financing would be applicable. The Governments of Karnataka, Punjab and West Bengal have
prepared procurement plans and discussed and agreed on the bidding documents for procurement
activities in the first two years of implementation.
3.32
All clinical, equipment and staffing norms have been reviewed and agreed with the states. An
essential drug list has been prepared by each state and found satisfactory by IDA. An inventory of the
nature and state of the current equipment at each facility that will receive inputs under the proposed
project, including the primary care facilities in the Sunderbans area of West Bengal, has been
completed in Karnataka and West Bengal. Following this exercise, an analysis has been completed of
the equipment requirements at each facility. Punjab is ncanng completion of this exercise.
3.33
A plan for a surveillance system for major communicable diseases has been discussed with
each state. Community participation in the surveillance network has been incorporated and links with
HMIS have been elaborated in the proposals. All three states have developed a comprehensive plan for
the implementation of medical waste management which includes tertiary hospitals not covered by the
project (see Annex 11).
3.34
'Hie overall implementation schedule for the different project components has been carefully
synchronized. With regard to implementation schedules: civil works program has been prepared in
each state and procurement packages for civil works have been finalized; lists of the equipment to be
purchased under the project has also been finalized; training for staff, IEC, HMIS, referral system,
waste management, surveillance system, and other software aspects of the project have also been
finalized and found satisfactory by IDA (see Annex 18).
36
3.35
A list of performance indicators has been discussed and agreed upon
Annex 19)
Baseline data on the performance indicators have been mostly put together by the
The concept
of medical audit, which will extend the scope of monitoring activities under the project at the hospital
level, would be finalized at a joint workshop to be held in March, 1996. The woiL?hop will also
finalize clinical training modules and the scope of the quality assurance program at the Uspital level.
3.36
Workshop on trainhiL nodules for each category of staff was held in Calcutta, and attended
by Karnataka and Punjab as well. Based on this, each state has developed a list of nuru-^er staff to be
trained, and the focus, location and duration of training (see Annex 7). The three states confirmed that
the management training component would be contracted out to management institutes.
3.37
Prior to Negotiations, the three state Governments took the following actions. ';) a Letter of
Health Sector Development Policy was furnished by each state, which was fmdized during
Negotiations; (ii) relevant state Government clearances, as well as clearai.ee from ;he Planning
Commission, GOI, were obtained; (iii) Strategic Planning Cells w'ere set up within
DOHFW in
Karnataka and West Bengal and PHSC in Punjab; (iv) a mechanism for ensuring that ez.gting level of
user charges are implemented more rigorously was approved, an agreed mechanism for exempting the
poor from user fees is m place, and District Health Committees in Karnataka and Wes Bengal have
been approved/established; (v) an Ordinance was passed by the Government of Punjab, eriablishing the
PHSC; (vi) regulations relating to Board procedures, personnel policies, audits and accumts, and user
charges have been issued; (vu) in Karnataka, the Project Governing Board, Steering C-.mmittee and
Engineering Wing were established, and key staff were approved or hired; (viii) in Puuab, key staff,
including the Managing Director of the PHSC, were appointed; (ix) in West Ben#^ key .staff
including Project Director, were hired; and (x) m Karnataka and West Bengal, Gove:intent Orders
were issued, providing authority to DOHFW to manage essential operational activities ncluding civil
works construction and maintenance activities.
G. Social Assessment
3.38
A Social Assessment (SA) was undertaken for this project and was utilized exteimvely to finetune project design (see Annex 14). Some issues addressed by the SA included: the soc:u risks which
might affect the success of the project, including the institutional and management anaicements and
capacity building at appropriate levels of administration; the social and cultural factors hat affect the
ability of stakeholders to participate or benefit from the proposed project; and the impacr if the project
on women and vulnerable groups. A multi-pronged strategy was adopted to gather the tata required
for the SA. This included: basic demographic, epidemiological and socio-econonic data from
secondary' sources; and primary data on demand and supply factors affecting health -.are delivery
generated through participatory observations, interviews, case studies, focus groups, survs/s and rapid
rural appraisal.
3.39
An important aspect of the SA was the involvement of key stakeholders. Prepiranon of the
project devoted special attention to facilitating a sense of ownership and commitment of tuose involved
in the process. They included: (i) the Government of India (GOI), the state Governments if Karnataka,
Punjab and West Bengal, and agencies responsible for project implementation; (ii) the bcudciaries i.e.
the individuals, groups and communities who would benefit from the proposec ntcrvcntion;
!•
37
(iii) women, scheduled castes (SC) and scheduled tribes (ST); and (iv) othc.^ .viia a vested interest in
development initiatives, including other donor agencies, NGOs, religious and community organizations,
local authorities and the private sector. The SA contributed to developing the following key aspects of
project design:
increased access to improved health services for women, by strengthening the link between
community hospitals with primary health centers, especially for emergency obstetric care, through
improvements in the referral mechanism for these services. In addition, the life-cycle approach to
women’s health, including screemng for reproductive tract infections (RTIs) and sexually
transmitted diseases (STDs), IEC, and increasing women’s awareness of their options in terms of
health care, has been incorporated in the service norms.
.
increased access to unproved health services for SC/ST groups, by strengthening the link between
primary and first referral health system; providing an incentive package to medical staff to accept
assignments m tribal areas; reducing costs to tribals of utilizing the system; and increasing hospital
beds in tribal areas to reflect a share of beds which is much more commensurate with their
proportion in the overall population.
•
exempting the poor from user charges, by instituting adequate mechanisms in each state. In
addition, with regard to user charges, appropriate collection mid management arrangements would
be strengthened, and die revenue collected would be reallocated to hospitals within the districts.
•
enhanced contribution of the private sector in health care delivery, through contracting-out selected
services as appropriate. In addition, NGO participation in remote and underdeveloped areas would
be promoted.
.
increased efficiency and effectiveness of the first referral network, through the development of
technical norms on the basis of the existing burden of disease in each state.
improved effectiveness of die primary health care system, by developing links with the secondary
level through the referral mechanism, and by strengthening its management, implementing referral
and clinical protocols, and establishing an incentive system for utilizing the referral mechanism.
II. Fiscal Analysis
3.40
The fiscal analysis undertaken for this project covers a number of issues that assisted in fine
tuning project design and policy reform in each state. These include: (i) an analysis of public
expenditure in the health sector and recurrent cost implications of the project (see Annex 3),
(ii) sustainability analysis of the project, including impact on health and state finances (see Annex 3),
and (iii) alternative scenarios estimating the generation of additional resources through user charges
i
(see .-Annex 5).
3.41
Public Expenditure on Health and Recurrent Cost. An analysis of public expenditure on
health is presented in paras. 1.17-1.20, and in Annex 3. The burden of recunent costs of the project in
relation to overall health expendiluies is analyzed, on the basis of the following questions: (i) what will
be size ol the incremental recurrent costs as a peicenlage ol die stales health and bW current budget,
-
38
i..
(ii) what will be tlic size of the incremental recurrent costs as a jpercentage of Jthe state's plan and nonplan current budget; (iii) what will be the likely share of the first referral. .level
—I as a percentage of the
health and FW budget at project completion; and (iv) how much funds can user charges reasonably
generate at project completion.
3.42
Incremental annual recurrent costs including contingencies at project completion are expected
to be about Rs. 360 million m Karnataka, about Rs. 250 million in West Bengal, and about Rs. 150
million in Punjab. This compares to current allocations for Health and Family Welfare of
about Rs. 4,872 million in Karnataka, Rs. 5,570 million in West Bengal and Rs 2,202 million in
Punjab. Assuming continuation of past trends in overall expenditures in the year following the end of
the project, allocations would amount to Rs. 6,950 million in Karnataka, Rs. 6,803 million m West
Bengal and Rs. 2,956 million in Punjab. Incremental recurrent costs of the project would amount to
5.2%, 3.7% and 5.1% of total revenue expenditures for the Health and Family Welfare Departments in
Karnataka, West Bengal, and Punjab respectively. The incremental recurrent costs of the project imply
an increase share for health of total Government expenditures of around 0.3 percentage points in
Karnataka, 0.3 percentage points m West Bengal and 0.2 percentage pomts in Punjab.
3.43
These increments should not be a problem for the state to provide. The state Governments
would meet the incremental recurrent cost needs by increasing the size of the health budget and by
reallocating incremental resources from the tertiary to the secondary level of health care. A
commitment to this effect has been provided in the Letter of Health Sector Development Program. At
Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that:
(i) their respective incremental budgetary allocations under the project for the primary and first referral
levels for each fiscal year during the implementation of the project would be fully additional to the
allocations made in FY95; (ii) and budgetary allocations for recurrent expenditures at the first referral
level would be provided on a timely basis adequate to meet resource requirement under the project’s
annual operating plan for each year.
3.44 Sustainability Hie deterioration in the overall financial position of (he states suggests that a
sustainability analysis beyond (he liaditional iceurient cost implications of piojcct investment be
undertaken. As such, a limited analysis oi financial sustainability is presented. In Karnataka., the
revenue account in 1993/94 was in surplus. The gross fiscal deficit is equivalent to 17 percent of
revenues -- one of the smallest among the major states. Interest payments on debt accounted for 11.6
percent of total revenue expenditures in 1992/93 rising to 12.7 percent in 1994/95. Public debt was
equal to 26.3 percent of state domestic product in 1990/91 and to 27.0 percent in 1994/95. The
indicators of public finances in Karnataka show some slight detenoration over the past few years as a
result of increased borrowing for capital expenditures but overall demonstrate a picture of reasonable
strength. The financial implications of the project for the state government include the necessity to
service the loan, as well as the incremental recurring expenditure. Including contingencies the
projected loan represents 4.7/o of the current outstanding debt of the state government. Given the
current relatively low share of interest payments in total revenue expenditures (second to lowest among
the eleven major states) the additional burden arising from this project should be manageable.
3.45
In Punjab, the deficit on the revenue account was estimated at 13.5% of revenue receipts in
1994/95 and to 23 and 24% in the two previous years. The gross fiscal deficit has been equal to 40-45
percent of revenue receipts over the past three years -- the highest for any state. Interest payments on
i
39
the state government's debt as a share of total state revenue rose from 12.5 percent in 1985/86 to 37.2
percent in 1994/95 - the second highest among the eleven most highly populated states. Revenue
growth from state taxes has been buoyant in recent years and well above that for all states combined.
However, additional efforts will be required both to increase revenue receipts further and to restructure
expenditures if growth in social sector real expenditures is to revive. The relative wealth of the state
suggests that it will not be a problem to generate the increased revenues.
3.46
In West Bengal, the deficit on tlie revenue account was equal to 19 percent of revenue receipts
in 1994/95 (the highest ratio across the 15 major states). This has increased from 14 percent in
1991/92. The gross fiscal deficit is currently (1994/95) equal to 30 percent of revenue receipts.
Interest payments on the state government's debts were equal to 19.1 of revenue expenditures in March
1995. This is slightly above the average across the major states (18.0 percent). Outstanding debt is
equivalent to 22.6% of state domestic product which is slightly below the average. Efforts are
underway to improve slate public finances. The fiscal deficit in 1995/96 is anticipated to be below the
previous years' and as a share of revenue receipts is planned to fall to 27%. The project will add 4.5%
to the current debt of the state Government. Further efforts to increase revenues and to alter the
structure of expenditure obviously will be necessary to reverse the relatively weak position of public
finances in general and the deteriorating situation of finances for the health sector in particular.
3.47
Revenue from User Charges, an analysis of potential revenue generated by implementing
user charges, based on information from llamataka, was undertaken. The analysis shows that Rs. 136
million could be generated from paying beds and wards, charges for diagno.>u.: tests and surgery, out
patient charges and charges for health certificates. This is equal to about 9% of the total or about 29%
of all non-salaiy7 recurrent expenditures. This amount of additional revenue could have a significant
effect on the levels of service quality provided by first referral level hospitals. These calculations are
based on expected revenue from more rigorous implementation of the current level of charges
prevailing at first referral level hospitals. There is, however, considerable scope for enhancing the user
charges. For example, Government hospitals charge Rs. 45 and Rs. 100 for minor and major surgery
respectively compared to the average private expenditure on. an episode, of hospitalization in a rural
private hospital in 1986-87 of Rs. 733 (NSSO). The estimates of revenue generated are, therefore, on
the lower end of the projected range.
I. Indigenous Population
3.48
In both Karnataka, with a 4% Scheduled Tribe population, mid West Bengal, with a 5.6%
Scheduled Tribe population, tribal peoples are likely to be substantial beneficianes of the proposed
project. During project preparation, a number of workshops were held to facilitate the consultative
participation of tribal populations (see section G on Social Assessment, Annexes 13 and 14).
3.49
The project's tribal and backward areas strategy is aimed at increasing the demand for hospital
services in tribal areas by improving the quality of services and providing effective 1EC to better
inform tribal populations of the benefits of usmg health services at secondary hospitals. The project
would: (a) strengthen linkages between primary' and secondary' health care services; (b) provide an
incentive package to doctors and other medical staff in tribal areas to encourage them to accept
assignment in these areas; (c) increase the appropriate utilization of non-tnbal medical system by tribal
population and reduce the cost to tribals of utilizing the system. In addition, the number of beds at sub-
I
40
F
divisional and community hospitals located in tribal areas will be increased to reflect a share of beds at
secondary hospitals that is much more commensurate with their proportion in the overall population of
the states. At Negotiations, the Governments of Karnataka and West Bengal provided assurances that
they would carry out the project in tribal areas in their respective states, and in the. Sunderban areas of
West Bengal and amongst disadvantaged groups in Karnataka in accordance with the strategy agreed
J. Environmental Aspects
3.50
The proposed project would not raise any environmental concerns. The project would enhance
medical waste disposal al health facilities where necessary. A plan for improving disposal of medical
wastes lias been provided by each state.
K. Land Acquisition
3.51
The process of acquisition of additional land, where required, for the extension of existing
hospitals has been initiated and most sites have been made available. IDA has been assured that none
of the sites for hospital upgradation would entail involuntary resettlement of any persons.
L. Accounting and Auditing
3.52
The project would be subject to normal Government accounting and auditing procedures which
are considered acceptable to IDA. At Negotiations, the Governments of Karnataka, Punjab and West
Bengal provided assurances that: (i) project accounts would be maintained and audited annually in
accordance with sound auditing standards consistently applied by independent and qualified auditors
acceptable to IDA; and (ii) certified copies of the annual financial statements and SOEs together with
the auditor's report, which would comment separately on the SOEs, would be submitted to IDA no later
than nine months after the close of each fiscal year.
k
I
41
IV. PROJECT BENEFITS
A. Benefits
4.1
A major benefit of the proposed project is that it will assist the states of Karnataka, Punjab and
West Bengal to put in place a coherent approach to establishing a cost-effective and sustainable health
system. This would indirectly benefit the states’ population as a whole. First, the broader sectoral
policy reforms envisaged under the proposed project such as improvements in health planning capacity,
management effectiveness, allocation of public resources for health, and enhanced role of the private
sector would increase the efficiency of the health sector by improving the environment in which the
health sector operates and by optimizing resource use. Second, there would be substantial cost savings
in each state through the implementation of streamlined service norms and rationalization of service
provision at different levels of health care delivery. Morever, the techmeal and quality improvements,
including operations and maintenance functions, at the institutional and health facility levels will
enhance the effectiveness and efficiency of health care services by encouraging patients to seek timely
care resulting in higher cure rates at lower costs. I bird, tliose currently utilizing existing services
would benefit from better quality of care. In addition, there would be other qualitative benefits which
would have a significant impact on the health system. For example, the strengthening and upgrading of
first referral facilities would lend vital support and credibility to the primary health care system for
implementing the various priority health programs and provide basic health care in rural areas. An
adequately functioning referral mechanism would also improve the effectiveness of the primary health
care level and encourage a greater participation of the private sector in health care. Moreover, there
are considerable externalities associated with reducing public health hazards through improvements in
waste disposal methods and through improvements in the surveillance system for major communicable
diseases. Finally, the proposed project will have a direct impact on improving the health status of the
people of each state by reducing mortality, morbidity and disability and thus increase the earning
potential of the poor.
4.2
Project Beneficiaries. In addition to systemic benefits which would indirectly benefit the
populations of the states of Karnataka, Punjab and West Bengal, noted in para. 4.1, the project would
directly benefit approximately 10 million out-patients and 0.7 million in-patients currently utilizing
existing hospital services in the three states through the provision of better quality of care. In addition,
the project is expected to directly benefit an estimated 3.3 million incremental out-patients in West
Bengal, 1.2 million in Karnataka, and 0.7 million in Punjab; and an estimated 0.4 million incremental
in-patients in West Bengal, 0.3 million in Karnataka and 0.12 milhon in Punjab. This analysis on
incremental in-patients is based on the following assumptions: (i) incremental patients at secondary
hospitals do not include those expected to be diverted ffpm tertiary hospitals; (ii) occupancy rate of
80% in West Bengal, 64% in Karnataka, and 60% in Punjab at pre-project and is assumed to increase
to 100%, 82% and 78% in West Bengal, Karnataka, and Punjab, respectively at project completion;
(iii) the average length of stay is 12 days in West Bengal, 15 in Karnataka and 12 in Punjab pre-project
and is assumed to decline to 8, 10 and 8 in West Bengal, Karnataka and Punjab, respectively at project
completion; and (iv) a corrective factor is used that assumes that a third of all in-patients are
hospitalized about 2.5 times annually based on hospital data.
42
4.3
Cost Effectiveness Analysis. The project is not suitable for a cost-benefit type analysis
because of the difficulty in quantifying benefits and data limitations. However, a micro-level analysis
based on detailed hospital level cost data, was undertaken to show the possible cost savings of treating
patients at secondary level facilities rather than at tertiary hospitals (see Annex 4). Analysis comparing
cost-effectiveness between different types of hospitals is limited in India, because of the unavailability
of data. Previous analysis has shdwn that at least a third of all costs could be saved by treating patients
at first referral facilities rather than at tertiary level facilities. However, due to variations in the case
mix, such analysis did not compare cost-effectiveness at first referral and tertiary hospitals. The
following is an illustrative example of the type of cost savings that would result from the project
investment. To estimate cost savings of treating patients at secondary level hospitals, a preliminary
analysis of the overall profile of unit costs related to specific inputs for in-patients and out-patients was
undertaken. A comparison was made between a tertiary level hospital and a first referral level hospital
m Hyderabad where comparable data based on a similar case-mix was available. Both hospitals had a
similar case-mix of ante-natal, intra-natal, family planning and gynaecological services. Since both
hospitals provided in-patient and out-patient services, a comprehensive index which captures both types
of services was used to estimate at unit costs (the day equivalent method). It was found that the day
equivalent at first referral hospitals was about two-thirds that of a tertiary hospitals — Rs 115
compared to Rs. 160. The difference was largely because of greater unit cost of infrastructure and
overheads at tertiary hospitals. This analysis provides an indicative example of cost savings that can
result from the strengthening and rationalization of health services across different tiers of the health
system.
<
B. Program Objective Categories
4'4
Poverty Aspects. A large proportion of project beneficiaries will be from the poor and
underprivileged segments of the states’ population. In West Bengal, the beneficiary assessment study
found that nearly 70% of expected project beneficiary would belong to lhe lower 40% of income
distribution. In Karnataka, the analysis found that over 45%pf the patients Lave an annual income
below Rs. 15,000 (close to the official poverty Ime) and over 90% of the patients have an annual
mcome below the taxable level of Rs. 50,000. In Punjab, a relatively large share of the investment
under the project is targeted m the Upper Bari Doab region where 30% of the overall population and
40/o of the rural population live below the poverty line; and the Southern Malwa region where rural
poverty is about 25%. Based on this data, the proposed project is classified as a Program of Targeted
Interventions (PTT).
4Gender Issues. In general, the project would provide much greater access to women,
particularly rural women, and improve the quality of services they receive. More specifically, by
strengthening the referral mechanism and linking the community hospitals with primary health centers,
the project would assist in providing timely access to emergency obstetric care. The project would also
promote a life-cycle approach to women’s health, taking into account some of the main
recommendations of the Cairo Conference on women’s reproductive health, such as screening RTIs and
STDs, providing appropriate IEC to promote the value of the girl-child, and increasing women’s
awareness of their options' in terms of health care.
e<Iuivalent method equates one in-patient day with four out-patient visits (Barnum and Kntzin
rpylip Hospitals in Developing Countries; Johns Hopkins University Press, 1993).
j
43
C. Risks
4.6
The proposed project carries several risks that are associated with PHN projects in general in
India such as poor procurement, late disbursement, untimely and inadequate flow of funds, poor
maintenance of building and equipment and inadequate attention to software and qualitative aspects.
Most of these risks have been substantially reduced through careful project design. There are two
additional risks associated with this project. Institutional. The capacity of existing institutions to
undertake systemic improvements and to establish a more rational health delivery system has not been
tested in India. Institutional strengthening would be emphasized in the proposed project to address this
risk. In Punjab, the newly formed PHSC might experience some start-up problems. The Government of
Punjab, at the highest level, has made a commitment to enable the PHSC to effectively implement the
project. Financial. As with other projects in India, the overall financial status of the states is a risk.
The position of public finances in Karnataka and recent trends m expenditure on health both suggest
that the project’s incremental recurrent costs are sustainable. In Punjab and West Bengal, however,
•continuation of recent trends in health expenditures would not be sufficient to absorb the incremental
costs. In both cases the rate of growth of health expenditures in recent years has been below the growth
rate of overall expenditure. There are, however, various measures which will help reduce the risk to
financial sustainability significantly. The state Governments are committed to ensure that health
expenditures will be maintained at least as a constant share of overall expenditures throughout the life
of the project. In the case of Punjab, the necessary resources needed to sustain this commitment can be
mobilized with small increase in revenue. In the case of West Bengal, some reorientation of its fiscal
policies may be required to ensure sustainability. An on-going mechanism for monitoring the financial
sustainability of the states was discussed at negotiations. Understanding was reached that as part of
the project’s comprehensive mid-term review, there would be a review of overall state finances, as well
as the financial situation of the health sector. If necessary, additional measures to achieve financial
sustainablity of project benefits would be agreed based on results of that review.
44
V. AGREEMENTS REACHED AND RECOMMENDATION
5.1
At Negotiations, the Governments of Karnataka, West Bengal, Punjab and the Punjab Health
ration provided assurances
siz-vt. —M _ ___ xlthat
___ .. 1 they would:
t i
Systems» (Corporation
(a)
ensure that: (>) the shaie of resources Io Hie primary and secondary levels of health
care in the total resomces (Plan and Non plan) ullocaled to the heultlr sector would be
mcreased each year until the year 2002; and allocate adequate resources for drugs essential
supplies and maintenance of equipment and buildings at first referral hospitals tn accordance
with norms agreed with IDA (paras. 2.9-2.10);
(b)
maintain a Strategic Planning Cell with adequate staff,
resources and terms of
reference acceptable to IDA (para. 2.11);
(CL
a]1nneceussa^ acdons t0 ensure
the DOHFW in Karnataka and West Bengal
and PHSC m Punjab would maintain authority in managing essential operational activities
mcluciing civil works construction and maintenance activities (para. 2.12)-
(d)
ensure that: (i) the arrangements for the management and collection of user charges
approved prior to negotaitions would be maintained; (li) user charges would be implemented in
a phased manner after improvements m the quality of basic services and infrastructure
development have been completed; (ui) the agreed mechanism for exempting the poor from
user fees would remain in place; and (iv) in Karnataka and West Bengal, the system for
reallocation of funds collected at the hospital level, to be retamed and reallocated based on
need and level of revenue collection by the Distnct Health Committees, would be maintained
In Punjab, regulations on user charges would stipulate that funds collected would be retained
at the point of collection (paras. 2.16-2.18);
(e)
not later than June 30, 1999 carry' out, jointly with GOI and IDA, a detailed mid-term
review of project progress including management and financial reviews and thereafter
implement their recommendations (para 2 22),
(0
maintain key headquarters personnel for purposes of implementing the project and
would engage and thercafler maintain key additional personnel with adequate qualifications
and experience to be hired under the project in accordance with a schedule agreed with IDA
(para. 2.23);
(g)
adopt, within six months after iupgradation
’ ' of each facility, staffing and technical
norms at all hospitals under the project, as agreed with IDA, to ensure the quality of serw^
(para. 2.27);
(h)
provide funds, satisfactory to the Association, annually for the mamtenance of
previously existing equipment in health facilities supported under the project (para. 2.30);
45
(i)
strengthen the referral system between the primary, secondary and tertiary levels by
December 31, 1996, by: (i) issuing appropriate directives to hospitals to strengthen the
management of the referral system; (ii) establish and thereafter maintain and implement
appropriate referral protocols and clinical management protocols; and (iii) establish and
thereafter maintain and implement an appropriate incentive system for patients who use the
system (para 2.32).
(j)
review with IDA by April 30 of each year the progress of project implementation over
the preceding twelve months and prepare an annual work plan for the following twelve months
acceptable to IDA (para. 3.28);
(k)
ensure that (i) the respective incremental budgetary allocations under the project for
the primary and first referral levels for each fiscal year during the implementation of the
project would be fully additional to the allocation made in FY95; and (ii) budgetary allocations
for recurrent expenditures at the first referral level would be provided on a timely basis
adequate to meet resource requirement under the project’s annual operating plan for each year
(para. 3.43); and
(1)
a project account would be maintained and audited annually in accordance with sound
auditing standards consistently applied by independent and qualified auditors acceptable to
IDA; and certified copies of the annual financial statements and SOEs together with the
auditors’ report, which would comment separately on the SOEs, would be submitted to EDA no
later than nine months after the close of each fiscal year (para. 3.52).
At Negotiations, the Governments of Karnataka and West Bengal provided assurances that
5.2
they would:
(a)
maintain District Health Commitees in all districts of the states to facilitate the
collection and distribution of user charges, maintenance of equipment, waste management,
training of technical staff, quality assurance surveillance of major communicable diseases and
monitoring and supervision of project related activities (para 3.27); and
(b)
carry out the project in tribal areas, in the Sunderban area of West Bengal, and
amongst disadvantaged groups in Karnataka, in accordance with the strategy agreed with IDA
(para. 3.49).
5.3
At Negotiations, the Government of Punjab and the PHSC provided assurances that they
would (i) take all necessary actions to enable PHSC to carry out its part of the project; and
(ii) undertake health care activity under the project in accordance with service delivery norms
acceptable to the Association, and ensure, in carrying out other health care activities, that the ability of
PHSC to perform its obligations under the Agreement would not bo-materially and adversely affected
(para. 2.21).
5.4
With the above assurances and agreements, the project would be suitable for an IDA Credit of
SDR 235.5 million (US$350.0 million equivalent) on standard IDA terms with 35 years maturity.
46
Annex 1
Page 1 of 5
health status and epidemiology
Table 1: Health Indicators
• Current Status and Targets to the Year 2000
Targets
India
Karnataka
1. Population (million)
Punjab
West Bengal
47.9
20.3
72.4
2. Crude Birth Rate
21.0
28.5
25.5
26.3
25.6
3. Crude Death Rate
9.0
9.2
8.5
7.0
7.3
74.0
6.7
55.0
58.0
4. Infant Mortality Rate
Below 60
5. Expectation of Life at Birth
- (a) Male
64.0
60.6
62.1
66.6
62.0
(b) Female
64.0
61.7
63.3
66.6
61.9
60.0
45.5
49.0
.63.7
37.2
1.2
2.1
31.9
2.1
2.2
8. Pregnant Mothers Receiving Ante-natal Care
100.0
78.1
84.0
5.1
80.0
9. Deliveries by Trained Binh Attendants
100.0
69.8
(a) T.T. (for pregnant mother)
100.0
78.1
70.0
91.3
80.0
(b) D.P.T. (infants)
100.0
88.8
69.3
90.9
84.9
(c) Polio (infants)
100.0
89.2
69.5
90.4
85.5
(d) B.C.G. (infants)
100.0
92.6
73.1
88.2
96.2
6. Percentage of Eligible Couples
Effectively Protected
7. Annual Growth Rate of Population
70.0
10. Immunisation Status % Coverage
Source: Sample Registration Survey
47
Annex 1
Page 2 of 5
HEALTH STATUS AND EPIDEMIOLOGY
Table 2: Morbidity Profile of Karnataka, Punjab and West Bengal
Cause Groups
1.
Infective & Parasitic Diseases
2.
Neoplasm
____________________
Endocrine, Nutritional & Metabolic Diseases &
Immunity Disorders
Diseases of the Blood & Blood Forming Organs
3.
4.
5. ’ Mental Disorders
6. Diseases of the Nervous Systems and Sense Organs
7. Diseases of the Circulatory System__________ ______
8. Diseases of the Respiratory System________________
9. Diseases of the Digestive System__________________
10. Diseases of the Genito Urinary System
11. Complications of Prcgnancy/Child Birth___________
12. Diseases of the Skin & Sub-cutaneous Tissue
I
Diseases of die Musculo Skclclal System Connective
Tissue
14. Congenital Anomalies
1 5. Ccitam Conditions Originating in the Pen natal Period
16. Symplons, Signs and Ill Defined Conditions
17. Injury & Poisoning
Source: Sample Registration Survey
*
Karnataka
West Bengal
Punjab
16.3
17.0
17.6
To
T?
T
0.7
2.4
______________________
0.7
0.3
1.7
TT
T?
9.9
3.0
3.12
1.1
0.9
2.9
4.1
7.8
10.1
4.8
22.7
To
TT
1.3
3.5
1.1
o.i
0.1
TT
To
7T
T
Ts
Ts
0.3
0.3
TT
5.1
T?
T?
T?
TI
3.1
T?
TT
137
8.7
Table 3: Disability-Adjusted Life Years (DALYs, In Thousands): India
Bout
Osease oi injury (iCO J code)
Al Ciuiei
I CorTvnun*Laoi4 mjte.njt j
1001-139.320 322.46Om65.466 480 487 £i< tit
63G 6 76.760-779)
A Inlecbout 1 paraviic d-s (001-139 320 322 61
< 4 1£|
Al TubeicuJdi.j
TubeiCuioi.i (010018.137)
(0 IGO 18.137)
A2
STDs eadua.ng HIV (090 099 614 616)
d PeUic utAanuiuiury disease (6i4 6it)
A3 H»V inleciion
D<J<itioeai diseases (001.002.004 006 009,
a Acute Maiery
0 Peisisieru
C Dysemery
Crwanood Uustei (03? 33 o32.0 4 5
a Penuisa (133)
ox) Uz-. U i idj
60 «
15.919
31.563
16.102
14.969
MB 211
48 927
7.3LO
10.094
2.864
1.526
82 028
2? 655
6 071
8 8/7
2.524
695
10 800
244
114
582
3.256
1.694
3
386
I 14
2
l.teAng.ks
Menm^us (O'Jti
(O'Jtj 320 322)
Hepauus |0/0)
MaUna (08l)
Tiop<ai Ouslei (085 086.120.125)
a Alncxan lrypanowm.a VI (066 3.066 4 064 5,
b Chagas d.lease (086 0.066 1.066 2)
c SchiStoxanvaMS (120)
a Lersnmarvasis (085)
• lymphabc Manaps (125 0. 125
•J
I GrK/>oceiaasas (125 3)
0 4
5 14
15 44
<5 59
145.454
69.699
16.564
35.580
11.939
70.77 I
49.010
8 294
17.257
1.837
40.822
6.282
24.165
6 65?
8 625
I 398
506
399
969
2.270
729
25
2
530
121
6
327
3 046
28
23
I
468
121
2
198
55
19
2
3
253
>0
SB
5
2 SBl
4 066
12
9
2.5b 1
28 03/
II 586
I 129
604
15 390
5 913
856
638
8 2/J
3 96/
4H
4 3/4
I./U6
225
16.'
i9 453
2 7J8
1.189
I 751
56
1 835
o Measles (055)
• Tetanus (037)
AM
16
2 950
6 Pobornyehi.s (04 5.138)
C Dipninena (032)
AB
A9
45 59
66.901
3?6
c Goxxdioej (098)
A6
A7
IS 44
292 646
808
D CHamycka
AS
U -l
3 734
a Sjpt-hs (090 037)
A4
4i agei
108
9 336
5 224
2 006
362
20
3 873
2 293
589
311
35
951
59
2 425
90
251
1.732
112
102
76
7
21
16
26
26
6
8.059
1.425
I 255
1.087
48
4 49 1
2.528
1.191
246
17
4.102
2.440
5)6
28
gib
145
3/0
56
176
63
151
44/
44?
442
13 <S
147. Hl
77.506
3ed
1X2
2
41 ?j:
4.SII
3 263
342
2t4
11
I?
2 584
2 514
15
1.314
14
13 643
14
12.268
1.305
688
113
I
20
7.498
6 260
988
545
84
15
4 015
4 201
2.130
9 579
1.006
57
260
1.726
270
502
143
29
5
52
29
I 351
14 394
7 15?
4
i t?4
I 525
741
38
744
172
47
168
I >6
5
60
4 Bit
26
9
40
12
13
31
3
143
37
74
40
219
725
39
8
30
4/6
1.459
62
67
175
355
187
|66
280
9
166
451
17
I.OIQ
67
355
2 79
118
149
4
17
19
131
31
216
13
I
156
90
9
236
725
2.707
Al *0*1
29
12
IIS
14
43
234
I
30
475
»i4
3
723
27
154
84
284
oo
2
S
3
IU
15
AID Lep/osy (030)
All Tiacooma (076)
AI2 Intcsiiaal'hclnMnihs (126 129)
a Ascans (127 0)
6 Tnchuns (12/ 3)
Acute MVet respttalory rW
(466.460 417)
B3 Ogus ntecfca (381-332)
C. Maiemal corxluons (630 676)
Cl. Haemonhaga (666.667)
C2
Sepia (670)
C3 EdampUi (642 4 642 6)
Ct
Hypartemon (642 nwnus 642 4 642 6)
C5 Otuirucied Ubouf (660)
Ct Aborvon (830 639)
0. Penna lai cauiei (760779)
r
33
?09
14
3
30
I 12
5
866
49
161
33
2.056
19
15
15
iJ
IS?
9
1.056
5
5
826
589
I4S
15
I
I 000
597
249
5
562
2
235
29
2
14?
14
1
741
1.166
c itookwonn (126)
B Respuaiory udeibons (381 382.460 466 4t>o 417)
Bl Aiule lower re spue lory ml (460 465)
B2
521
309
486
404
259
246
2
2.
31
157
14
9
211
?62
565
237
111
3l 754
11 89l
I 2B-J
I 218
340
30 133
12.556
1.485
1.04 1
1217
363
1.042
308
831
116
15.568
11.351
14.734
598
12.020
26
72
338
32
15
320
27
514
1.420
66
896
176
I 023
145
26
514
509
156
7.592
76
7.824
47
1.305
31
2.693
13
27
2.752
16
374
112
4
»4
8
HI
It
1.906
31
906
2
it
I
7824
I 365
2.752
394
191
I 941
916
2«S7|
14.361
14.341
12.290
16 IM
15 »5
15
271
50i
I.MS
l>4l
844
12^91
IS
QQ
ct>
>
3
3
O
o
M
CA hUJ
Tabic 3: Disability-Adj listed Life Years (DALYs, In Thousands): India
(Continued)
D.$*4se ex
(iCO 9 coat)
U
(HO 628.680 759|
f tuna Its
MAUS
tkuii
45-S9
60 ,
Al ages
13.567
9,Sfi9
12.051
57.734
69
1.468
2.103
1.286
5.409
2
131
202
280
627
504
58
152
142
353
IBI
111
4/1
52
48
103
BI
242
47
SS
192
52
156
14
23
22
64
32
35
78
8
18
46
207
200
474
13
32
19
39
3
10
2
4
2
8
217
260
131
M/9
292
477
189
958
5
19
22
46
93
62
47
206
6
12
53
24
IB
442
274
25
3
ages
04
5 14
IS 44
45 59
60 .
Al ages
0 4
5 14
II? 642
IS 202
4.700
14.701
12.226
13.080
59.908
17 525
5.002
12 04 1
I 908
857
713
445
220
124
$61
IB
609
9b8
46
206
194
107
44/
557
801
141
472
I 340
2.S47
2.126
6 633
4C3
3
9
226
385
658
1.280
13
57
218
230
86
202
65
76
im^vA 320 322.460 465.466.480 481. 814 616)
A I.UUgnAr* nAapUs/ni (140 208)
Al
ju-id cmopuryn» (140 149)
A2
Otsopeugos (ISO)
a3
Skjirucn (ISI)
A4
CofcxKUi ( 152.153.15;)
AS
Uvei (155)
A6 PAncicAS I > 57)
A7
Luitg (i62)
AB
kklArtCani Ana omei skin (172-173
A9
Buasi (1/4)
AIO CtlM. (ItSO)
Corpus Men (119 18 1102)
All
AI2 O.ary (183)
I
71
22
11
65
2
I
253
153
2
2
194
D l4uu>ucndVencocrv*« (240-285, nwun 250)
IB 265
5 699
5 79
2.3/6
39
25
. 42
22
46
312
346
Dl
Piou<n eneigy mAUKiiuuan (260 2tj>
5 $52
2 5JI
32
45
£
02
l-xiuu tUUurtCj (243)
1 j‘Jd
64!
25
JI
8
03
VtUirun A
4.10’J
2 Odi
4 4G9
252
506
895
216
102
1.971
2 024
214
II 831
a.'3
1.730
4.511
1.331
1.032
9.426
I 085
916
118
33
I 066
107
A13 PiosUic (185)
AH
BU.KSet (168)
AlS
Lympc'*>r<j (200 202)
A 16
I tukema (204 206)
B OiAti ruopQwn (210 239)
Duoeiet m<ikiu$ (250)
C
(264)
An.ecTtAi (280 285)
D4
Heu«o piycrvainc (290 359. nwius 320 322)
E
E I
I.UfO* aUt-cu.e us«>ae<
E2
B-pour AHcChke cisotoet (296)
E3
Psrcno*es (295. 291-294.297 299;
E4 EpJepif (345)
,
E5 Alcorns a<rp«!ftJence (303)
AJincrfT*/ A otfui detiWAbJi (330 331.333 336 290)
Pa/Sjasoa as^Aie (332)
E6
tl
E8 l.kMbpte uteiOMt (340)
Dtug cupenoence (304)
E9
E 10 Post UAM/nAuc Siiess Oisotaet
F
Sense otgan (360-385)
Fl
GMuconu-irUied ousontsf (365)
F2 Caiacaci teUiea Ut^cntss (366)
G CanuAvascuai asaasts (390 4$9)
Gl
A/uimium*: he an oszaia (390 398)
G2 luhAecrac ruan <feseas« (*)
G3 Ceieo<o«as^«4A/ cfesease (430 4 38;
Gl Inh^rrwruiory caiOuK O>tease (•)
H Crwonx: lesp^aiony as (460 519.
2
9
23
75
08
4I
133
87
21
3a
73
218
I 868
3 089
1.102
lots
11
ISO
61
85
70
308
4 I
325
2
25
121
21
198
58
308
840
183
9.183
‘ B67
7ll
II
2 629
2 803
bl
713
613
31
2 OoS
712
1.4 50
93 7
II
36
3
21
628
394
90
29
932
514
31
94
62
2
34
55
86
18B
1.776
29
34
50
2
208
2 132
2.280
1.904
1.951
Hd
266
647
838
2 38 4
398
I 8 13
21 592
I M/4
I 142
6.248
6.791
7 906
86
5
IB
413
3
995
155
218
1.331
1.664
257
569
981
109
31
SO
82
4>4
46
1.182
4.350
1.733
87
1.108
303
133
27
23
14
2?
397
455
5
4
252
726
228
799
10
3
138
62
8
18
40
75
230
17
558
27
38
16
9
32
24
394
49
12
479
8
102
140
16
3
12
88
207
17
3
327
19
141
321
26
4
62
10
120
624
422
1.238
82
18
97
570
378
t IB
49
9
90
452
330
1/6
714
1.957
3.194
7.120
24
I 10
285
395
459
I
100
25
9
136
682
335
2.S4O
4.351
6.825
232
932
14.732
14
66
190
152
IGO
602
>0
19
165
48
91
458
374
2
22
140
233
602
1.028
9.082
2.923
685
2.024
2.491
8.41 I
2.023
101
1.137
949
240
970
66
129
168
511
1.146
166
880
13 860
1.272
3.189
3.496
3.168
4.006
0
03
o
5
u
M
3
<
4
2
M
u
3
2
S43
1.725
2.680
4.953
3
2
162
729
2.293
51
47
352
663
1.632
2.752
69
93
462
784
2.088
3/4
142
98S
1.025
1.099
3.625
500
359
61/
656
914
1.36$
636
668
479
753
3.900
1.115
4G2
779
486
464
38
50
237
54 1
974
1)5
237
29G
728
a
316
*4
36
ISO
II
32
266
48
33/
366
112
44
869
a
Ec
a
nuu>s 460 466 410 487)
HI
Cmgtmc ooswa^t kesg as (490 *92 495 496)
H2 Asrwna (493)
i.no
P
CTO
>
•U
3
O
LA
M
»—
I
O
L
r
Table 3: Disability-Adjusted Life Years (DALYs, In Thousands): India
2
a
(Continued)
Bo<h
Oseist or
PCD 9 codt)
I Oteases o( ne r;--O^suve srsl«m (520 579)
it Pepuc ulcer dsea$e (531 533)
i? Cuinosrs of rw fever (S?ij
J Genrio unrtarj (580 629)
Jl
J2
NrpAnuvhkepruosis (580 589)
Benign posuuc hypertrophy (600)
A. Sun dteaw |68O 709)
I Musculo- sMvtal SySlent (710 739)
LI RheuntaiCMj arvuiM (? 14)
L2 Osietsarwtks (? 15)
U Congen.iat acna<inal.l*es (740 759)
H Oral heair (520 529)
Hl Dtnrar ca.es (521 0)
112 Per rockyastase (523)
l<3 EcUntukwr. (520)
“i l^iunet (6 800 999)
A Urunieni>ori4 (6800 9-4 9)
*i Roao uafK acaoents (Eeio 119.826 829)
<2 Po-sorung (£ ISO- B69)
*3 fans (66LG869)
*4
f «es (6690 899)
*5 0<0Arw^ 16 9 10)
*6 Occupauonai («)
B
Bl
Inienbonal (E95O 969.990 999)
Sell rtAcieo |E950-959)
B2 Honwode ar<J violence (E960 969)
83 War (E990-999)
seies
all ages
11 240
992
2 690
3 'J32
2 101
3/1
247
I 253
210
4 32
9 434
111)
324
Males
5 14
15 44
45 59
60 ♦
Al *9«s
0 4
5 14
15 44
45 59
I 619
281
1.657
751
5.607
2 t?:
49c
5
1.096
12
329
12
32
180
25
601
1.298
207
765
GOG
222
296
4
89
10
52
3
187
25
75
87
4t
135
43
s:
315
J53
568
Xi
307
742
107
297
484
177
4 78
$0 *
132
464
172
5 634
355
842
2 048
1.060
28
a
2
197
26
116
19
185
36
129
6
28
2
155
18
32
105
170
849
113
310
4.590
879
157
530
192
251
228
22
I I 952
10.494
945
77
2.109
847
832
387
1.457
1.078
285
95
195
375
30?
61
337
226
3/
9
7
23.134
3 252
288
4 996
1.557
1.729
87
5?
4 524
20
20
159
34
34
2.71)
2 696
205
50
914
3 859
3 679
355
34
83)
153
535
69
4 66
6.768
5.03^
I 492
104
81 I
1.013
892
193
85
637
335
I 848
401
I 884
196
1.041
74
371
14
77
80
405
102
6
14
157
19
33
106
363
122
4 843
934
167
574
336
62
14 775
12.640
2.308
ifi
242
65
211
2 887
125
47
18
13
710
182
380
292
31
II
697
418
84
4
506
180
116
1.730
27
2.136
16
1.1 11
10
821
29 B
n
I 105
52
47
661
209
26
17
153
121
63
51
7
64‘J 5
59 8
101 8
200 5
47 6
2.189
915
«
4.1 US
19
IS
It?
32
32
74
429
•I
166
209
489
63
426
192
508
89)
3 593
14
188
I 104
384
26.72?
£
FamaWs
0 4
24
73
87
3.164
3 138
20
2?
3
3 I 13
347
I Mt
292
2l7
SX
2E
l‘S
31
3cS
X3
144
204
11
4 756
3 560
332
17
173
178
273
340
1.196
900
243
53
513
456
183 2
46 0
40
109
6
31
45
57
28
25
60 «
89
7
10
2
23
6
16
Al ages
Ch
O
PopuaiKjii (,n rru^jnjj
439 4
U 7
28 9
410 I
?4O<«S
A da Hi ( )) srnxxa ewWaiet less ran 1.000 Oalyi
•CO 9 ccatt tot
i
-4 luruerruc
heart aseasa are as lolows 4 10 4 14. 440 9 plus ai ages 45 59 SO% o4 427 l. 427 4. 427 5. and 33% (X 428
421
•i ages 6C. 80% ol 427 I. 427 4. 427 5 and SO*., ol
•
»C0 9 code) kw mtiartvnakwy carrkac oseases an
'
Thei* <«■ fw fp‘',, *'
0"
0142‘- *'45 55
tsiabCshed ICO 9 codes tpeciGc lor
LiUrrunj ?u»« been
.
based on teponed occupational
—I m(LM>es and deaths labuiaiod by the tnlemationaJ labour Organisation
“•
“• "•
t
W
CTQ
n>
th
O
>
B
□
X
tn h-
Annex 2
Page 1 of 17
51
HEALTH SECTOR DEVELOPMENT PROGRAM
^jorcav
PAX t
GAUTAM 3ASU
32O4I/U
JJXSXJT
iAdznrl :
TUI. ; omCE I :nax.’*
USI
IUJ4. Lit*
duxdBrf; a;xa. cni wod:d4s* ZUS
doritfACb-ju.3 c:n
MULTirrOMC^ ED BUTVDINO
in arxae, rjjtrr floor
DR. o. M. AMHFOKAK YRRlJia
•ANCaLORE.400 001
xwarod tyxijrdir
fjLUcij goi^fJ ncrcxi
3U.K&XAAT 1U UUVUlhMENr
HKaLTM ANO family WHLFAKM
DCTAMTMUNT
61 118 96
CC2og DATLD
13—2—1996
Hr. Heinz Vcx^ln^
Dir oct or India Department ♦
The World Dank/
waahixxjton D.C.
air
4ub «
Ibflltn ^ogcot ^-vuAwpi^w
in the Koriwtakx* Health
System
Project•
Gov eminent at Karnataka txive proposed to
IDA a project for the developraont o£ Health
Systems in Karnataka ultli special focus on the
eccoDdazy and referral hospital upto the district
levol. In this connection, I have plaaauro in
conveying the approval of the Ccvexanent for a
prog raims-matrix for Health doctor Development
the state/ a copy of which la enclosed for
your perusal and reference.
Yourc
C^Airr/dl
EASU)
s above .
' ^°Py to shrl B.
K. Bhattacharya#
Adai. Cs and Ttixiclpal
Secretary to Government
Finance Department /
Vldhana Soodha# Bang al oca.
(GAUTAM
BASU)
GPHE
pH
'00
,3 ^6
J
Annex 2
Page 2 of 17
52
r
j
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka
Issue
Effect
Proposed Change or Action
1.
Adequacy of the overall size
of the health budget to meet
public health goals.
The share of the health and family
welfare sector is about 6.43% of
the state revenue budget and
1.29% of GDP in 1993/94. These
health expenditures are inadequate
to provide essential primary health
care together with a basic package
of clinicaL/curativc services.
2.
Imbalances in public
expenditure between different
levels of the health sector
With increasing expenditure on
tertiary level health care, there has
been a relative decline in the
investment in primary and
secondary level facilities This
imbalance needs correction
3.
Redressing regional
imbalances.
The six districts of Gulbarga,
Bidar, Bijapur, Raichur, Dhanvad
and Bellary show poor health
indicators due to uneven
development in the health
infrastructure and delivery of
services.
Recognizing the link between
basic public health provision and
poverty alleviation, the
Government will ensure that, in
each fiscal year, during
implementation of the project, the
share of overall budget (plan and
non-plan), excluding all projects
specifically financed cither
through external assistance or by
way of loan from national
financial institutions or by way of
grant/loan from Government of
India as per award of Tenth
Finance Commission, allocated to
the health sector shall be
maintained at least at the level
allocated in FY94/95.___________
The stale Government recognizes
the need for focusing attention on
the primary and secondary levels
of health care and also to stop up
allocations for these levels. A
major portion of the increased
allocation will go to the primary
and secondary levels.____________
Through both project as well as
non-projcct interventions, a policy
of positive discrimination in favor
of the underdeveloped districts
and tribal areas within advanced
districts will be followed to reduce
the existing imbalance. This
differential policy is already under
implementation. Additional
resources arc being provided out
of the state’s own funds for filling
critical gaps in primary health
care.
4.
Quality of and access to
hospital services.
Quality of medical services arc
inadequate. In addition, access to
health care services is limited^
Quality and access will be
improved by: (i) upgrading and
expanding physical capacity; (ii)
1
I
53
Annex 2
Page 3 of 17
I
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
Effect
especially for populations in the
least developed areas of the state,
particularly women, scheduled
castes and scheduled tribes.
5.
Strategic planning.
Proposed Change or Action
upgrading clinical effectiveness
and quality of services at
community, talauka and district
hospitals; (iii) improving the
referral system; and (iv) adopting
staffing and technical norms in
line with the recommendations of
the high level committee. In
respect of scheduled caste and
scheduled tribes, access will be
improved through a system of
health cards and annual health
check-ups. Patients below the
poverty line who cannot afford
high cost treatment for serious
ailments such as oncologic and
cardiac disorders, will be assisted
through a specially constituted
society, to be financed by the state
Government.___________________
The capacity' for strategic planning
Inadequate strategic planning
will be enhanced through
capacity' in the health sector has
establishment of a Planning Cell
resulted in sub-optimal use of
directly reporting to the Secretary
resources. Decisions on public
health spending priorities
Health and Family Welfare. This
will, cither independently or
presently do not take into full
consideration llie size and scope ot through sponsored specific
research projects: (i) study the
services provided by private,
commercial and voluntary sectors, role of the private sector; (ii)
review the suitability of present
the health iiiatqxnvcr supply
regulations; (iii)study the evolving
situation and the predicted future
epidemiological profile in
epidemiological profile in
Karnataka; (iv) monitor the
Karnataka.
burden of disease and recommend
b cost-effective means for achieving
the best use of limited resources;
and (v) undertake periodic review
of the health manpower supply
situation and training needs in the
stale. A study of the scope and
prospects of enlisting private
sector support for promotion of
health care at primary and
secondary levels wall be
54
Annex 2
Page 4 of 17
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
6.
Workforce.
i
Effect
Improvement of services at
hospitals is significantly restricted
by workforce problems, both in
terms of quality and quantity. The
number of staff sanctioned at
hospitals docs not fit current
needs. There arc many vacancies
due to poor and cumbersome
recruitment pioccduics, and
unimaginative personnel policies.
The distribution of medical
specialists is not commensurate
with the need (c.g., a general
surgeon in place of an
Obstetrician and Gynecologist).
7.
8.
The role of the private sector
and voluntary organizations.
Role of the NGO sector.
The health services development
strategy of the Government has
not taken sufficient account of the
scope and coverage of nonGovemmental providers and the
role of this sector in delivering
quality' health care.
NGO participation in health care
at all levels, especially at the
levels of public health and first
referral, needs to be supported and
encouraged, with a special focus
on the backward and remote
regions of the state.
Proposed Change or Action
undertaken.__________
No ban on recruitment will be
imposed with regard to recruiting
medical, paramedical and
technical staff. In a short period
the problem of mismatching in
medical staff will be solved. The
practice of deputing stall to non
essential assignments will be put
to an end Doctors will be
recruited on contract where direct
recruitment is slow. Doctors will
also be asked to serve a
mandatory period of six years in
rural areas before being
considered for postings at more
preferred places. Since there is a
large number of lady doctors’
vacancies, participation by private
lady doctors in government
facilities will be encouraged.
Legislation will be introduced to
regulate all medical institutions.
Services ofiered in the private
sector would be continuously
monitored, with a view to
improving the quality of such
services.
Referrals between private primary
care and public secondary care,
diagnosis and treatment would be
encouraged through district health
committees,________
The Government will take
initiative in enlisting the effective
panicipation of NGOs in the area
of primary and first referral health
care. In remote tnbal and
backward districts, NGOs will be
encouraged to operate some
government facilities so as to
ensure the outreach of health
Annex 2
Page 5 of 17
55
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
9.
Cost sharing and service
improvements.
Effect
Cost sharing has not been properly
implemented, resulting in low
levels of funding for supplies,
operations and maintenance.
I
i
I
10. Prevention and control of
major communicable diseases.
The existing surveillance system
is very weak, especially at the
secondary level and in urban
areas.
II. Contracting sendees.
Contracting services are under
utilized.
12. Safeguarding the operations
and maintenance component
of the health budget.
The existing secondary hospitals
face operational deficiencies and
function poorly due to a lack of
non-salary recurrent funds.
Proposed Change or Action
services to the disadvantaged
sections of the people. NGO
participation will also be
encouraged in special programs
for the socially underprivileged, as
also in IEC activities.___________
The Government will set up a
working group to examine the
issue of cost sharing (last revised
in 1988) while protecting the
poorest sections of society. The
guiding principle for cost sharing
would be to partly cover non
salary recurrent costs.
In addition, adequate
administrative and organizational
mechanisms for implementing
schemes for cost sharing would be
put in place. A mechanism to give
back a majoi |xuliou of icvcnucs
raised by die institution will be
introduced,____________________
The project will establish an
effective surveillance system
which will contribute to reducing
morbidity and mortality rates due
to major communicable diseases.
DOHFW will monitor the costeffectiveness and quality of
existing contracted services.
Furthermore, the Government will
consider new proposals for
contracting-out health services,
especially support services such as
laundry, cleaning, manufacturing
I.V. fluids, etc._________________
The state Government will make
adequate provision in the health
budget for drugs and other
medical supplies, and for
maintenance of equipment and
buildings.
56
Annex 2
Page 6 of 17
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
13. Consolidation versus
expansion of institutions.
14. Poverty alleviation.
Effect
Proposed Change or Action
The state Government has been
rapidly expanding the number of
subcenters, PHCs, CHCs, taluka
level hospitals, and sub-district
hospitals without focusing on
improving the physical facilities in
existing institutions.
About 40% of households are
below the poverty line in
Karnataka. In this group, health
indicators such as mortality and
morbidity rates, are especially
adverse.
Further expansion of beds and
hospitals will be strictly need- ■
based, and will be undertaken only
after ensuring that existing
facilities are properly maintained
and utilized.
The investment made in this
project, especially through special
programs for the disadvantaged
section (e.g., SC/ST and women)
will aim at augmenting the
product!vity/carning potential
through better health status.
Annex 2
Page 7 of 17
57
HEALTH SECTOR DEVELOPMENT PROGRAM
PSCM/96/402
C.i • i'-rsar
Sa!.i
. r
b
A-
r:i
15-2-1996
r
Subject:
Punjab Health Sector Development Program
Dear Mr.Heinz Vergin,
The Government of Punjab and the Punjab
Health Systems Corporation have proposed to the IDA to
assist the State Health Systems Development Project II.
I am pleased to send you in this connection the
attached Policy Matrix reflecting Government decisions
in respect of health policy reform.
With regards,
Yours sincerely,
-
(G.P.S.Sahi)
I
I
Mr.Heinz Vergin
Director, South Aaia Country Department II,
l
The World Bank,
Washington D.C.
t
V-
Annex 2
Page 8 of 17
58
J
HEALTH SECTOR DEVELOPMENT PROGRAM
Punjab
Issue
Effect
Proposed Change or Action
1.
Increase the overall size of
the health budget
Expenditure on health and family
wolfuio in Puivnb is 5.31% of the
slate revenue budget and 0.88% of
NDP in 1993/94. These health
expenditures arc iiuidcqunlo (o
provide essential primary hcaltli
care together with a package of
curative services.
2.
Allocate most of the
incremental funds for the
health sector to primary and
secondary' levels of care.
Primary and secondary levels of
health care have not been
receiving the requisite allocation
of funds. This has resulted in a
shortage of drugs, machinery
equipment, other materials and
supplies, lack of proper buildings
and poor maintenance of facilities.
Imbalance in the allocation of
funds has led to duplication of
services and inefficient utilization
of meager resources.
Recognizing the link between the
piovision of basic health services
and poverty alleviation, the state
Government will ensure that in
each fiscal year during
implementation of the project, the
share of overall budget (plan and
non-plan), excluding all projects
specifically financed either
through external assistance or by
way of loan from national
financial institutions, or by way of
grant/loan from the Government
of India as per award of Tenth
Finance Commission, allocated to
the health sector, shall be
maintained at least at the level
allocated in FY94/95.___________
Punjab state, pursuant to the
health sector reforms, will ensure
that within the allocations for the
health sector, the share of
resources for primary and
secondary levels of health care
shall be increased in each fiscal
year until FY02.
I
Salcguaid the o|KHahon» and
I ho oxiblmg iCLOiidrtiy level
maintenance component of the
health budget.
hospitals function poorly because
of inadequate allocation of funds
for operational and maintenance
purposes (30%-35%). 65-70% of
the current budget goes to the
salary component.
1
j mlo account the budgctaiy
provision, the state Government
and Punjab Health Systems
Corporation will maintain
sufficient funds in the non-plan
health budget for making available
adequate supplies of drugs and
other material supplies at
secondary level hospitals, and for
maintenance of equipment and
buildings.
Annex!
Page 9 of 17
59
HEALTH SECTOR DEVELOPMENT PROGRAM
Punjab (continued)
Issue
Effect
Proposed Change or Action
4.
Service improvements and
user charges.
Most of the services in public
health institutions are provided
free of cost. Nominal charges are
levied on only a few services, and
revenue collected is deposited in
the government treasury. The low
level of funds normally available
is inadequate for supplies,
operations and maintenance.
5.
Private provision of health
care services and the role of
the private sector.
The health services development
strategy of the Government has
not taken into account the scope
and coverage of health services
provided by the private sector.
Therefore, the Government is
inhibited in prioritizing and
rationalizing its investment in the
public health sector.
The Government would issue
regulations to facilitate Punjab
Health Systems Corporation to
levy charges for certain services.
These include paying beds,
diagnostics and drugs and a
registration fee for inpatients.
Existing systems for identifying
the poor (i.e., yellow card holders)
will be applied to exempt them
from paying charges and an out
patient department purchcc fee.
The user fees would be used
specifically for non-salary cost
purposes, as high proportions of
funds collected through user
charges would be retained at the
point of collection. Adequate
administrative and organizational
mechanisms for collecting user
charges would be put in place.
The role of the private sector
would be continuously monitored;
the quality of services provided by
private practitioners would be
assessed and regulations relating
to improvements in service quality
would be formulated. In addition,
referrals between private primary
care and public diagnosis and
treatment would be encouraged
I
The Nursing Home Registration
‘ Act would be implemented after
its approval by the Legal
Department.
I
In order to enable the private and
voluntary sector to contribute
effectively in providing health
facilities, the state Government
will encourage investment for the
establishment of health care
JL
Annex 2
60
Page 10 of 17
HEALTH SECTOR DEVELOPMENT PROGRAM
Punjab (continued)
Issue
6.
Contract out selected services,
especially supporting
services.
7.
Establishment of a Strategic
Planning Cell.
Effect
At present, hospital support
services must be maintained by
regular staff recruited for this
purpose. These employees have
not provided an efficient provision
of support services, resulting in
unclean hospitals, poor
maintenance and upkeep of
hospital bedding, clothing, linen,
furniture, etc.__________________
Inadequate strategic planning in
the health sector has resulted in an
ineffective utilization of resources.
Earmarking of funds for various
health schemes and programs at
various levels of health care
presently docs not take into full
consideration the size and scope of
services provided by the voluntary
and private commercial sectors;
the availability of existing
manpower and its development;
and the emerging epidemiological
profile in the state of Punjab.
Proposed Change or Action
institutions in the private and
voluntary sectors. Private sector
investment would be expanded.
Dialogue has already been
initiated with the Housing
Department and local Government
in this regard.__________________
Cost-effectiveness and quality of
existing services in hospitals will
be monitored. After review as
appropriate, proposals for
contracting out selected services,
especially support services, will
be considered. These include
laundi). canteen, landscaping,
dicuuy services, sanitation and
security.______________________
The state Government will
establish modem management
information systems to upgrade
performance in health institutions
with regard to (a) medical and
health care; (b) inventory control;
(c) performance appraisal; and
(d) financial management.
Appropriate technology will be
suitably introduced in the
DOHFW and in the Corporation.
Strategic planning in the health
sector will be strengthened by
establishment of a Strategic
Planning Cell in the Department
This cell will be provided with a
Management Specialist,
Economist (with experience in
health sector economics), Public
Health Specialist, Computer
Specialist and minimum
administrative staff.
(Requirement 25 lakhs for 3
years.) This cell will, in addition
to working for intra- sectoral and
inter-sectoral coordination, cither
Annex 2
Page 11 of 17
61
HEALTH SECTOR DEVELOPMENT PROGRAM
Punjab (continued)
Issue
8.
Surveillance system for the
major communicable diseases.
Proposed Change or Action
Effect
In the absence of a properly
developed surveillance system, it
is not possible to achieve, control,
eliminate or eradicate some of the
diseases which arc possible only
within a well developed
surveillance system
£
independently or through specific
research activities, monitor the
role of the private sector;
formulate the regulations relating
to quality of care to be provided
by the private sector; analyze the
evolving epidemiological profile
in the state; monitor the disease
pattern and suggest the costeffective means for achieving the
desired objective within the
limited resources. The Planning
Cell will also undertake periodic
review of manpower availability
and training needs for its
development.________________
The existing system for
surveillance of some diseases will
be developed to ensure proper and
systematic flow of information
about major communicable
diseases according to priorities of
the state from most peripheral
level to (he stale headquarters and
also to the Government of India.
The surveillance system proposed
to be developed will ensure flow
of information from the village
level through functionaries of the
Health Department to the PHC;
from PHC/CHC to the district
level and then to the state
headquarters. Action as
considered appropriate will be
taken at the PHC/CHC level,
district level and at state level.
Prompt investigation and
containment of outbreaks will
form a part of such a system. It
will help in the control,
elimination and eradication of
some of the diseases as per
commitment of the sstatc with
Government of India.
Annex 2
Page 12 of 17
62
HEALTH SECTOR DEVELOPMENT PROGRAM
Punjab (continued)
Issue
9.
Gender issues.
Effect
Proposed Change or Action
The sex ratio in Punjab is 882
females per 1000 males as against
the national average of 927
females per 1000 males. The stale
Government is determined to
reverse this trend. For this
purpose, apart from strictly
regulating the practice of pre-natal
diagnostic techniques for medical
termination of pregnancy, an
incentive scheme for those
adopting terminal method of
sterilization after one or two
female children will be
implemented.
For the last three years, activities
promoting the value of the girl
child have been organized at the
village level. Slogans have been
coined in the regional language
(punjabi) upholding the status of
the girl child.
Annex!
Page 13 of 17
63
5,15a L.
*
____
I X3-6O41
2s<eoes
Calcurta. the
a-***.
■mi
wtfrvm
'
a th Fatoy-
Mfta
■THQ ■ nTW’TTa aann
Department 61
Health 8 Family Welfare
Government of Weet Bengal
1996<
Me- H/P—3O/9^-
To
Mr. Halxxa Varqln,
Dlrwctnr India Departmt,
Ttxa World BadoJc.
(Fajc No, 20204776391)
Waahlnyton D.C.
SajldJ «Ct
I
weat Bacgtl HaAltn Systaf Dev«l»p»ent Pro^tet-H.
sir.
Sie Gowramt o£ W««e
havm pxopoamd to Tn*
a Pxnojacti fox th« developean t of Sacondmry Level Hospital
ServlCBi la th®
I «m ■andlng h«mwlth « Matrix
nflectin^ Gerwnunt dad al on a In napoct of dlftanot laauea
on health ictor ra£oD».
Yotrip faithfully.
faU L. Ch
Mo. H/P*30/96/1.
abartl.
Dated,Calcutta,the 8th Fabruaxy«1996•
Copy forwarded to Mr. Tawhld Hawax, Senior Bocncnlit,
fopulatlon &■ Human Raaourcea Dlvn., Xndla Country Departmat.
lhe World Bank. Wohlnytoa D.C.
(U3JO , for favour of inforaat
(Fax Bo. 2024770397)
(L. ChaKrabartl)
Principal Secretary.
Annex 2
Page 14 of 17
64
HEALTH SECTOR DEVELOPMENT PROGRAM
West Bengal
Issue
Effect
Proposed Change or Action
1. Adequacy of the overall size
of the health budget to meet
public health goals and
development of a state-wide
referral system.
Allocation to public health and
medical care is about 6.1% of the
state revenue budget and about
1.10% of the GDP in 1994/95.
These budgetary allocations are
not enough to improve the
performance of the health care
system through improvements in
quality, effectiveness and
coverage of health care services at
the first referral level and
selective coverage at the primary
level.
2.
Inadequate allocation for
primary and secondary level
health care services in the
state budget.
Though the expenditure on
improvement of overall health
care services have been
increasing, investment in primary
and secondary level health care
services is inadequate to meet the
requirement.
3.
Management of construction
and maintenance.
Existing primary and secondary
level health care facilities face
operational difficulties and
function poorly, due to insufficient
non-salary recurrent funds. At
present, DOHFW does not have
much control over certain
essential operational activities,
such as civil construction and
maintenance.
Keeping in view the close
connection between allocations in
the public health sector on the one
hand and poverty alleviation and
enhancement of productivity in the
economy on the other, the
Government will ensure that in
each fiscal year during
implementation of the project, the
share of overall budget (plan and
non-plan), excluding all projects
specifically financed either
through external assistance or by
way of loan from national
financial institutions or by way of
grant/loan from the Government
of India as per award of Tenth
Finance Commision, allocated to
the health sector, shall be
maintained at least at the level
allocated in FY94/95.__________
The Government will ensure that
the share of primary and
secondary levels of health care
services out of total resources
(plan and non-plan) allotted to the
health sector shall be increased
each year throughout the life of
the project.__________________
The Government will make
adequate provision in the health
budget for operations,
maintenance, drugs and other
medical supplies and for
maintenance of equipment and
buildings. The Government will
strengthen the role of the Health
Department by providing
autonomy in managing essential
operational activities such as civil
works, construction and
maintenance.
I
Annex 2
65
I
Page 15 of 17
HEALTH SECTOR DEVELOPMENT PROGRAM
West Bengal (continued)
Issue
Effect
Proposed Change or Action
Management of district, subdivisional, state general and rural
hospitals will be strengthened and
implementation capacities
improved by: (i)
augmenting/strengthening the
administrative structure,
(ii)improving systems and
procedures, (iii) decentralizing
administrative and financial
powers, (iv) training, and (v)
improving IEC and MIS._______
A separate project component to
meet the basic health services in
the Sundarbans has been proposed
(see Annex 16).
4.
Management.
Management of health care
facilities in the state, particularly
at the secondary level, is
inadequate despite recent attempts
for its improvement.
5.
Inadequate health care
services in remote and rural
areas.
6.
Strategic planning.
Poor health indicators have been
recorded in the riverine areas of
the Sundarbans. This is due
largely to inadequate health care
services and facilities in the
region.__________________ _
Inadequate strategic planning
activity has resulted in suboptimal utilization of existing
resources.
I
I
i
7.
I
-1
I
Workforce issues.
The capacity for strategic planning
will be enhanced through the
establishment of a Strategic
Planning Cell under the
chuinnanshtp of the Secretary,
DOI 11'W
This Cell will: (i) initiate
independent research projects, (ii)
study the role of the private sector,
(iii) review the suitability of
present regulations, (iv) analyze
the burden of disease and
recommend cost-effective medical
interventions, (v) undertake the
- study of the scope and prospect of
a health insurance scheme, and
(vi) undertake a periodic review of
the training and manpower supply
situation and the clinical needs in
the state.___________
While there is no overall shortage For manning health centers and
hospitals in rcmote/rural areas, the
of staff in the health sector, there
Government will consider hiring
remains the problem of
the
services of medical
availability of medical
Annex 2
Page 16 of 17
66
HEALTH SECTOR DEVELOPMENT PROGRAM
West Bengal (continued)
Issue
8.
Role of the private and
voluntary sectors.
9.
User charges.
Effect
Proposed Change or Action
professionals in certain important
skills. Rural hospitals in
particular experience shortages of
medical officers because of the
lack of adequate facilities and
incentives. ______
Traditionally, the activities of the
private sector in providing health
care services in the state have
been limited and restricted mainly
to Calcutta and its suburbs. Of
late, there has been some increase
in the number of private hospitals,
but the charges are high and out of
the reach of the common man.
At present only 50% of
incremental charges arc channeled
back to the hospitals, with the
exception of rural hospitals. The
mechanism for user fee collection
and use has not bee effectively
implemented, resulting in a time
lag in utilization of funds collected
towards maintenance, supplies and
operation.
professionals on a contract basis.
Special incentives for doctors in
rural areas, including housing, in
service education programs, etc.
will be implemented during the
project period.______________
The Government proposes to
enhance collaboration with both
private and voluntary sectors
wherever feasible in delivering
quality health services.
User fees were last reviewed in
February, 1995. The Government
has set up a committee to examine
the scope and coverage of hospital
charges for different categories of
diagnosis, treatment and
admission. Exemption from
payment of such charges will
continue to be granted to families
with a monthly income of Rs.
1500 or less. This will be done
through the issuance of indigent
certificates.
100% of charges collected will be
retained at the district level.
i________
10. Contracting out services.
At present, contracting out
services is limited and there is
scope for its expansion._____
The Government has developed a
suitable mechanism under which
funds collected from user charges
will be retained in a separate
account to be operated at the
district level and allocated to the
hospital within the district on the
basis of need and level of revenue
collection.________________
While steps have been taken to
ensure optimal utilization of
facilities^ the Government has
Annex!
Page 17 of 17
67
HEALTH SECTOR DEVELOPMENT PROGRAM
West Bengal (continued)
Issue
T
Effect
1 1. Enhancing the quality of
private health care services.
'Ilic quality of health care services
provided by the private and non
government sector is of uneven
quality and there is a need to
ensure minimum standards of
services.
12. Poverty alleviation.
About 30.3% of the rural
population and 20.7 of the urban
population (combined 27.6% of
the total population) of the State
live below the poverty line.
Furthermore, despite some welfare
programs taken up recently,
women and SC/ST populations in
the state continue to be in a
somewhat disadvantageous
position.____________
Proposed Change or Action
decided where necessary to
contract out services like dietary,
transport/ambulance, laundry and
cleaning services as well as
services relating to waste
management to ensure costefficicncy and quality.__________
The role of both private and non
government sectors would be
continuously monitored, the
quality of services provided by
them would be assessed, and
regulations relating to service
quality would be extended. The
existing Clinical Establishment
Act of 1950 and the Rules of 1951
would accordingly be reviewed
and amended as necessary.______
Investment made in this project
will contribute to poverty
reduction by improving the
productivity and earning potential
of disadvantaged groups.
Annex 3
Page 1 of 12
68
PUBLIC EXPENDITURES ON THE HEALTH SECTOR
I
1.
The purpose of this appendix is twofold. First, it presents the past trends in selected aspects of public
finances in general and expenditures on health and family welfare services in particular in the three project
states of Karnataka, Punjab and West Bengal. As part of the exercise, total health expenditures have been
disaggregated and re-classified by level of service. This analysis then forms the base for a limited exploration
of the burden of the incremental recurrent recurrent costs of the project for each state, the resulting shifts in the
structure of health expenditure and the conditions for financial sustainability.
State Finances
2.
Trends in the level and composition of public expenditures on health and family welfare should be
seen against the backdrop of the overall developments in state government finances - both prior to the
economic and fiscal crises of 1991/92 and during the period of adjustment. Through the 1980s, overall state
government revenues grew at a slower rate than expenditures leading to the emergence of revenue deficits and
the growth and changing composition of fiscal deficits. In the more recent period, state finances have been
influenced both by the nature of macroeconomic adjustment, which affects overall tax revenues, and by fiscal
adjustment by the Central government which has affected the size of the Central governments transfers to
states, in particular the grant component.
3.
The combined gross fiscal deficit of the states was equal to 3.0 percent of GDP in 1986/87 and to
3.2 percent in 1993/94 Calculations of individual state deficits as a proportion of their own state domestic
product suggest that for the eleven most populated stales the average increased slightly from 4.2 to 4.3
percent between 1990/91 and 1994/95. Differences between states, however, arc quite substantial. Table I
presents the data for the three project states, Karnataka, Punjab and West Bengal from 1990/91 to 1993/94.
In each, the deficit has fallen as a share of state income but it has been significantly higher in Punjab than in
cither West Bengal or Karnataka.
Table 1: Gross Fiscal Deficit as Proportion of State Domestic Product
Project States 1990/91 - 1993/94
Karnataka
Punjab____
West Bengal
1990/91
-5.2
-8.5
-6.0
1991/92
"1992/93
-6.5
-4.2
-4.7
-6,3
-3.4
1993/94
-3.7
na_____
-3.8
Note : Measurement of state domestic product may differ slightly between states. This may aftect compansons between states but
not trends within states. No estimate of SDP for Punjab in 1993/94 is available.
4. The gross fiscal deficit largely reflects the combined balances in the revenue and capital accounts.
Between 1980/81 and 1986/87 a deficit on the aggregate states’ revenue account occurred in only one year.
Since then, deficits have occurred in each year. Although trends in the revenue deficit are unfavorable for all
states combined, the position of individual states again is far from uniform. Karnataka has had relatively
small revenue deficits in recent years and estimates for 1993/94 suggest a small surplus (Table 2). As a
percentage of Net State Domestic Product (SDP), the revenue deficit/surplus was -0.6% in 1991/92 and
+0.6% in 1993/94. Punjab has had more substantial revenue deficits, both in absolute terms and as a share of
SDP. In 1991/92 and 1992/93, they were equal to -2.4% and -2.2% of SDP respectively. The revenue deficits
of West Bengal have also increased since 1989/90 though not to the extent as in Punjab.
L
Annex 3
Page 2 of 12
69
Table 2: Revenue Deficit as Proportion of State Domestic Product
Project States 1980/81 - 1993/94
1980/81
1985/86
Karnataka
TT6
Punjab
+0.4
+0.1
W. Bengal
^03
+05
1989/90
1990/91
1991/92
1992/93
1993/94
-0 8
7)1
______
"TT?
-0 (>
•» 0 0
-2.4
-22
n.a.
71
77
3T
-1.5
32
Note : SDP figures taken from State Directorates of Ixonomics and Statistics; Karnataka SDP ligures from 1990/91 onwards supplied by
Govt of Karnataka.
Source: Reserve Bank of India Bulletin (various issues).
5.
As a consequence of increased revenue deficits in general, the nature of the fiscal deficit, and hence the
borrowing requirement, has changed. Whereas, previously, borrowing had been required only for covering
deficits in the capital account, by 1994/95 over a quarter of the borrowing was to cover deficits in the revenue
account.
This indicator is particularly revealing of the financial health of state governments, since it
represents the pre-emption of borrowed funds for meeting current expenditures. In Punjab, the revenue deficit
contributed over 50% of the GFD in 1992/93 and was budgeted to be about 34% in 1994/95. In West Bengal,
the revenue deficit was 43% of GFD in 1992/93 and was scheduled to rise to over 62% in 1994/95. In
Karnataka, the revenue deficit was 12 percent of the GFD in 1992/93 but made no contribution to the fiscal
deficit in the following two years.
6.
Of the three states, the overall state finances of West Bengal and Punjab seem to be most precarious.
Karnataka has a relatively comfortable budgetary position compared to the two other states. Some further
consideration is given to these issues in the final section of the annex.
Trends in Expenditure on Health and Family Welfare
7.
In all three project stales, government health and family welfare expenditures are well below the
international norm that is considered adequate to meet public health pnoritics (World Development Report
1993); and below the levels required to achieve the service norms set by the Government of India (India :
Policy and Finance Strategies for Strengthening Primary Health Care Services). Punjab spends less than 0.9%
of stale domestic product (SDP), Karnataka about 1.3% and W. Bengal about 1.1% ('fable 3). In addition,
compared to the early and mid 1980s the shares have declined in two of the three states. The decline has been
especially steep in West Bengal, where health expenditures fell from around 1.5% of SDP in 1980/81 to 1.0%
in 1992/93; and is estimated to be about 1.16% in 1993/94. In Punjab, the share dropped from around 1.1% of
SDP in 1980/81 to 0.9% in 1992/93. In Karnataka, the share is back at the same level as in the early 1980s (at
around 1.3% of SDP).
!
Annex 3
Page 3 of 12
70
Table 3 : Expenditures on Health and Family Welfare as % of SDP
80/81
85/86
89/90
90/91
91/92
92/93
93/94
R.E.
94/95
B.E.
Karnataka
1.26 ’
1.33
1.25
1.18
1.11
1.29
1.29
1.40
Punjab
1.09
1.00
1.04
0.99
0 91
0.88
n.a.
n.a.
W. Bengal
1.54
1.28
1.17
1.35
1.07
1.03
1.16.
1.10
Note: SDP figures taken from Stale Directorates of Economics and Statistics; Karnataka SDP figures from 1990/91
onwards supplied by Government ot Karnataka.
8. Per Capita Expenditures on Health. Measures of aggregate resources devoted to public sector health
programs do not convey the absolute levels of real expenditure per capita (Tabic 4). Despite the relatively
low share of public resources devoted to health in Punjab, real per capita expenditures have been the highest of
the three states and have been maintained at roughly the same level since 1980/81 (between Rs. 30-35 per year
at 1980/81 prices). Per capita expenditures which were lowest in Karnataka - between Rs 20-25 per year at
constant prices during the 1980’s have risen since 1991-92 to around Rs. 30. West Bengal displays the most
disturbing trend. The fall in real expenditures per capita has become pronounced in recent years (from Rs. 25
per year in 1980/81 and Rs. 26 in 1990/91 to Rs. 22 per year in 1993/94).
Table 4: Per Capita Expenditures on Health and Family Welfare
(in 1980/81 Rupees)
80/81
85/86
89/80
90/91
91/92
92/93
93/94
R.E.
94/95
B.E.
Karnataka
19.00
22.12
26.00
24.12
25.01
27.83
30.20
33.31
Punjab
29.13
31.95
38.06
36.18
34.12
33.60
33.30
31.16
W. Bengal
24.63
21.50
22.36
26.07
21.37
20.99
21.97
20.95
9.
Despite these differences between the three states, the per capita expenditures in all three states are
low In 1993/94, per capita expenditure at current prices was Rs. 100 in Punjab, Rs. 90 in Karnataka and Rs.
72 in West Bengal (between USS 2-3 per capita). These expenditures are well below the norms required for
the minimum package of health services as desenbed tn the World Development Report, 1993. They are also
substantially below the norms set by GOI, which would require a 50 percent increase in budgcUry allocations
over the current level (India: Policy and Finance Strategies for Strengthening Primary Health Care Services,
Grey Cover Report No. 13042-fN, May 15, 1995).
10.
Effects of Fiscal Adjustment on Health Budgets. Spending on health and family welfare grew at
around 12-13% per annum in nominal terms in the three states between 1980/81 and 1990/91. In real terms,
annual growth rates were in the range of 2.8% to 4.4%. Expenditures grew most rapidly in Karnataka,
followed by Punjab and West Bengal (Tabic 5).
11.
The consequences of the economic and financial difficulties at the start of the 1990s and the resulting
adjustment measures have differed across the three states. In West Bengal and Punjab, expenditures fell in real
terms in the first year of adjustment. While there has been a partial recovery in Punjab, the level of
1
71
Annex 3
Page 4 of 12
terms in 1991/92. ^o^le^groX^aTmwLed1 m bebregaincd- ExPenditur« fell by 16% in real
expenditures in 1993/94 was still below that of 1990/91 I p Sub*eq“ent years’ the absolute level of real
positive, but real expenditures fell by almost 4°/ Real'
nOnUnal gr0Wth rate
1991/92
agam the level in 1993/94 was (slighdy) below that in 19Q0^ r SUbsequent years was very small so that
high growth rates both in nominal^nd real terms res It
00
Other hand>
susumed
compared to those attained in 1990/91.
’
tIn8 m hlgher real expenditures in 1993/94 when
nn th l£ WHU?d appear> therefore’
1116 effects of the fiscal
dechLee°V
budgetary position of Punjab and West Bengal crisis and the consequent adjustment measures
were passed on to the health budget resulting in a
declme m real expenditures. Given the relatively low
level
of expenditures on health particularly in West
nga these trends are of concern. Special mechanisms
may be reqmred to protect and raise the level of real
expenditures on health in these two states.
statcs gef’erahy absorbed le7s thM '10% oTthTtota”smte r^ ^‘h'
been exacerbated, rather than
expenditures in all states
than health expenditures. Since
fallen farther in West Bengal (from
Wclfarc bud8ets in the three
sZtiXZp
“ ^e“cd in
• to /.2 /o) and in Punjab (from 6.6 to 5.3%).
6.6 to 5.3%).
r
1980/81-90/91
1991/92
1992/93
1993/94 R.E.
Q
Table 5: Real Growth Rates in Health Expenditures Project States 1980/81 -1993/94
_____
(annual in %)
Karnataka
Punjab
W. Bengal
4.38
4.30
2.80
-3.80
-16.23
13.36
0.50
0.41
10.57
1.12
6.95
5.66
n
61 ■»
Annex 3
Page 5 of 12
72
Table 6: Share of Health and Family Welfare Sector in Total State Revenue Budget
80/81
85/86
89/80
90/91
91/92
92/93
93/94
R.E.
94/95
R.E.
Karnataka
7.87
6.53
6.51
6.12
5.96
6.44
6.43
n.a.
Punjab
9.00
7.19
7.76
6.60
4.32
5.78
5.31
n.a.
W. Bengal
12.05
8.90
8.01
8.44
7.32
7.55
7.15
6.10
Composition of the Health Budgets
The allocation of spending between primary, secondary and tertiary level facilities and services is not
14.
readily available in state budget documents. The approximate shares can be obtained only by reclassifying
individual line items. This exercise has been undertaken in varying degrees for each state.
15..
West Bengal. The total health budget in West Bengal for the years 1989/90 to 1994/95 has been re
classified under five heads: (i) primary health care, (ii) rural hospitals and dispensaries, (iii) urban health care
facilities, (iv) items of general expenditure and (v) medical education (Table 7). Primary care comprises
expenditure on public health, family welfare, rural health services (allopathic and non-allopathic) and urban
non-allopathic services. Expenditure on Employee's State Insurance has been placed under urban health care
facilities since the scheme covers workers in the organised sector of industry, which is mainly located in urban
areas..
I
I
I
Annex 3
Page 6 of 12
73
Table 7 West Bengal: Composition of the Health Budget
(as % of total)
89/90
90/91
91/92
92/93
93/94
94/95
I. Primary care
39.66
38.19
40.30
38.55
40.53
39.24
MNpu.-
6.40
Subsidiary centres
1.73
Other
3.01
1.03
0.008
0.006
0.004
0.004
1.42
1.02
0.009
0.009
0.009
0.009
0.006
0.007
0.007
0.008
0.009
■
Rural health serv.
allopathic)
(non-
Urban health serv.
(non-allopathic)
School health scheme
Public Health
12.42
13.77
13.02
12.25
12.48
12.28
Family Welfare
12.93
12.36
13.38
13.0
14.59
13.09
PHCs
1.73
9.32
11.33
10.92
11.15
11.40
3.90
2.42
1.90
2.2
2.13
2.24
40.00
40.12
43.16
43.16
42.52
43.50
32.49
33.38
35.40
36.67
34.20
34.96
Einployces' Slate Insurance
7.5
6.74
7.75
6.98
8.32
8.54
IV. General
10.34
12.23
8.15
8.62
7.46
7.48
Direction & Admn.
3.15
3.08
3.75
3.85
3.25
3.32
Medical store depots
6.4
5 43
4 03
4.51
3.86
3.81
Other exp.
0.006
3.03
V. Medical Education and
Training
6.12
7.01
6.47
7.44
7.34
7.52
I 386.96
426.55
502.11
539.46
II. Rural Hospitals
Dispensaries
&
III. Urban facilities
Urban
hospiuls
Dispensaries
| Total (Rs. crores)
&
322.77
445.2
Source : Govt of West Bengal, Budget Documents.
74
Annex 3
Page 7 of 12
I
i
"“S
ra 43 5%-sta"for
sS^asesss
t*8r,
T110 Share of ge^ral expenditures has also decreased, from 10% to 7.5%. This is almost entirely due
the reduction m the share for medical stores and depots, which declined from 6.4% to 3 8% Thus in
addition to rural hospitals, expend.turc on drugs and other consumables has also borne the brunt' of
expenditure contraction during the period of adjustment.
19~
In order to determine the broad allocation of resources across different categories of inputs and
fferent levels of hospital services, the composition of non-plan expenditures on hospitals and dispensanes in
teiSr^"?
yCarS
eXanUned- Urban hosP‘u]s were ^vided into two^atcgones
wSlM
P
metr0p0iitan centers Md sPec‘W ^Pitals were designated as tertiary'
vUule all district urban hospitals were designated as secondary. Tnc results are presented in Table 8 The iXd
of expenditure on urban secondary and tertiary hospitals is broadly similar. Expenditure on rural secondary
hospitals is only one ninth of that on urban secondary hospitals.
a? !,
*niurban tertlary hospitals, salaries and wages account for about two-thirds of revenue expenditure
Although there was a slight reduction in 1993/94 (to about 60%), the budgeted share rose to 65% in 1994/95'
Expenditure on materials and supplies (including drugs) comprise around 9-10% of the total although again
?7o/
?P 'n ,1993/94- Machincry and equipment absorbed over 5 % of the total’in ^Z^and
1° m k
u ExpCndlture on dle£ rose from less than 6% to 9%. Expenditure on maintenance has been
negligible but this understates the overall maintenance expenditure on buildings which is included in the
budget of the Public Works Department. The remaining share of expenditure is absorbed by overhead costs
and by aid to non-govemment hospitals (about 10% and 3-4%, respectively).
21.
The expenditure pattern is broadly similar in urban secondary hospitals, with about 75% going
towards saianes. Apparently, expenditure on materials and supplies fell quite dramatically in 1992/93 (to less
than 5 /o), rising to around 9% m subsequent years. Expenditure on machmery and equipment is 2%, while
expenditure on diet has increased to about 7%. It would appear that in urban secondary hospitals the share of
saianes was protected with the budget cuts of 1992/93 borne by drugs and consumables.
22u..
In rural secondary hospitals, the share of materials and supplies fell to 1% of the total in 1992/93
wlule the share of salaries was 75%. In the following two years, however, the share of salaries and wages was
brought down drastically to less than 60%; salary expenditure actually fell in absolute terms probably
indicating that vacancies were not filled. The share spent on materials and supplies rose to over 12%
However, since the absolute expenditures on rural hospitals hardly increased in this period (and real
expenditures fell), the nse in the share docs not indicate any significant improvement in availability of drugs
and consumables though it docs indicate an attempt to restore the levels of spending attained earlier
7
Annex 3
Page 8 of 12
75
Table 8 West Bengal: Composition of Spending in Hospitals and Dispensaries
1992/3 - 1994/5 (Rs. Crores)
Urban Tertiary
Urban Secondary
Rural Secondary
92-93
93-94
94-95
92-93
93-94
94-95
92-93
93-94
94-95
Salaries and Wages
66.1
60.1
65.0
74.9
74.5
74.1
75.3
58.3
59.8
Materials & Supplies
10.2
8.7
9.3
4.6
9.5
8.9
1.0
12.7
11.9
Machinery
Equipment
5.2
4.2
4.7
1.2
1.7
2.0
2.8
4.2
4.5
Motor Vehicles
0.2
8.0
0.1
0.3
0.3
0.3
1.0
0.4
0.4
Diet charges
5.9
7.1
8.0
3.2
6.6
6.7
7.9
15.8
15.0
Maintenance
0.03
0.06
0.06
0.02
0.02
0.02
Aid to
hospitals
2.7
2.8
3.0
0.9
0.9
0.9
9.7
9.1
9.9
14.9
6.5
7.1
11.9
8.5
8.5
and
non-govt.
Office Exp & Oth.
Total (Rs. crores)
74.49
87.58 88.30 76.82 83.85
91.82
8.43
9.48
10.06
Note: Total refers to Non-Plan spending only. 1993/94 expenditures arc revised estimates and 1994/95 expenditures are budget
estimates.
Source: West Bengal, Budget Documents.
23.
Karnataka. Again, budget allocations were disaggregated and re-classified into functional activities:
primary health, family weliare, secondary' and tertiary health, medical education and training, and
administration. The percentage distributions from 1990/91 to 1994/95 arc desenbed in Table 9.
Table 9 Karnataka: Distribution of Health Care Revenue Expenditures by Level of Care
1990/91-94/95 (%)
II Function_____
Administration
Medical
Education
Secondary
&
Tertiary
! Public Health
< Family Welfare
1990/91
2.6____
9.1
1991/92
2.9____
9.8
34.3
38,3
15.7
1992/93
2.2___
10.5
1993/94
2.2____
8.7
2,1____
34.8
32.5
35.9
33.0
34,3
18.2
38.4
16.4
37,2
16.1
37.7
17.1
1994/95
10.1
Throughout the period, primary health care and Lundy welfare have absorbed around 53 percent of
24.
the total health budget. Secondary and tertiary care combined
<
have absorbed between 33 and 36 percent and
medical education and training, around 10 percent. ITic most notable change in sliarcs lias been for family
welfare. For this activity, nominal expenditures increased by 23 percent a year compared.to the lowest growth
rate of 16 percent for secondary and tertiary' care and 18 percent for primary health care. It is of interest to
note that family welfare is a 100% centrally sponsored scheme.
76
Annex 3
Page 9 of 12
I
I
I
Complicating the disaggregation of allocations in Karnataka is the substantial degree of
25.
decentralisation to the district councils (Zilla Parishads) While most of the health functions of the councils
relate to primary health care and family welfare, they also include community and some district hospitals.
From a review of the budgets of one Zilla Parishad from 1990/91 to 1994/95, the share for these facilities
appears to have fallen from 23 percent to 5 percent. If this is typical, the rural hospitals in Karnataka have
been under severe and increasing pressure similar to the apparent case in West Bengal.
Punjab. Health expenditures for Punjab were re-classified under primary, secondary and tertiary
26.
health care. Primary care was defined as including primary health centers, sub-centers, services from nonallopathic systems of medicine (apart from teaching), family welfare (apart from MCH, included at the
secondary level), disease control programs, drug control, public health laboratones and paramedical training.
Secondary care includes MCH, community health centers and district hospitals. Tertiary care covers the
teaching hospitals. The composition of health expenditures between these three levels of service is described in
Table 10. According to the breakdown, an average of 61 per cent of expenditures are allocated to primary
care, 27 percent to secondary and 12 percent to tertiary. Over the five year period, however, some changes
have occuned. The shares for primary and tertiary health care have fallen by 5 and 1.5 percentage points
respectively while the share for secondary care has increased by 6.5 percentage points.
Table 10 Punjab: Distribution of Health Revenue Expenditures by Level of Care
1990/91 - 1994/95 (%)
Function
Primary
Secondary
Tertiary
1990/92
63.5
23.0
13.5
1991/92
60.9
26.5
12.6
1992/93
1993/94
65. 9
56.9
31.8
21.8
12.3
11.3
1994/95
58,4
29,6
12.0
27.
'Hie data prepared for Punjab also allow for some analysis of items of expenditure. For each level of
care, salary items dominate. In 1994, salaries absorbed 77, 70 and 67 percent of primary, secondary and
tertiary care expenditures Materials, supplies and equipment absorbed 10, 25 and 18 percent respectively.
Over time, there are no clear trends in these distributions.
Project Financial Sustainability
1
The project’s financial sustainability depends on the ability and willingness of the state governments
28.
both to commit resources for the continuation of project activities at the end of the project period and to
support adequately those non-project activities upon which the project activities depend. The level of recurring
costs and the level, composition and trend in health expenditure will have an important bearing on financial
sustainability. Because of the size of the project in each state, some consideration of the states’ overall public
finances are required.
29.
Karnataka. The incremental recurring costs of the project, including contingencies, at the end of the
project period are estimated at Rs. 360 million. In 1994/95, total revenue expenditures in the Department of
Health and Family Welfare were Rs. 4,872 million. Since 1991/92 these have been increasing at a real rate of
9 percent a year. Over the previous decade, expenditures rose by 4.4 percent a year. Assuming continuation of
the overall trend since 1980/81 (5.2 percent), expenditures in the year following the end of the project will be
around Rs. 6,950 million. Incremental recurring costs of the project will be equal to 5.2 percent of total
expenditures of DOHFW and 100 percent of the total trend departmental incremental expenditures in that
1
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Annex 3
Page 10 of 12
year. If the incremental recurrent costs of the project were to be Rinded in addition to the ‘normal’ increase
this would imply an increased share for health of total government revenue expenditures of around 0.3
percentage points (from a current level of 6.4 percent).
30.
In practice, the incremental costs are likely to be met partly through the trend increase and partially
through additional resources allocated to the sector. While the incremental project costs are clearly sustainable
on the basis on maintenance of past trends in overall departmental expenditure, they would lead to some
restructuring of overall health allocations in the absence of a significant proportional increase in expenditures
at the secondary health level. (While not all of the project expenditures are for secondary health activities, the
majority are. The same is true for Punjab and West Bengal). An approximate calculation of expenditure on
secondary health in 1994/95 suggests a total of Rs. 848 million. Projecting this forward to the end of the
project period at a real rate of growth of 5.2 percent a year, expenditures would be Rs. 1,209 million. If
project incremental expenditures were financed in addition to the trend increase in health allocations, these
would add 30 percent to the total expenditures on secondary' health and would be equal to over five times the
normal increment in that year. (In fact, such a sharp jump would not occur in one year since part of the
incremental recurrent cost burden e.g. salaries, will be funded on an increasing basis through the project’s life
by the state). Assuming no other changes in the composition of health expenditures, the allocation to secondary
health would increase from around 17 to 22 percent of the total.
31.
Is there any reason to expect that the high growth rates of health expenditures over the past fifteen
years cannot be maintained as a result of deterioration in the states overall financial position? The revenue
account in 1993/94 was in surplus. The gross fiscal deficit is equivalent to 17 percent of revenues - one of the
smallest among the major states. Interest payments on debt accounted for 11.6 percent of total revenue
expenditures in 1992/93 rising to 12.7 percent in 1994/95. Public debt was equal to 26.3 percent of state
domestic product in 1990/91 and to 27.0 percent in 1994/95. The indicators of public finances in Karnataka
show some slight deterioration over the past few years as a result of increased borrowing for capital
expenditures but overall demonstrate a picture of reasonable strength.
32.
The financial implications of the project for the state ]government •include
. . the
. necessity to service the
loan, as well as the incremental recurring expenditure. Including contingencies the projected loan is Rs. 6,458
million - this represents 4.7 percent of the current outstanding debt of the state government. Given the
currently relatively low share of interest payments in total revenue expenditures (second to lowest among the
eleven major states) the additional burden arising from this project should be manageable.
33.
Punjab. Punjab is India’s wealthiest state with per capita income twice that of West Bengal and 1.7
times that of Karnataka. The incremental recumng costs of the project at the end of the project penod are
estimated at Rs. 150 million. Total expenditure on health in 1993/94 was Rs. 2,202 million. Through the
1980s real expenditures on health increased by an average 4.3% a year. Between 1991 and 1993 real
expenditures fell and growth since then has been marginal. Assuming that expenditure growth recovers to
1980s levels, total health expenditures in the year following the end of the project will be Rs. 2956 million.
Incremental recurring costs of the project will be equal to 5.1 percent of total expenditures and around 1.2
times the annual addition to departmental expenditure. However, the growth trend in total state government
revenue expenditure since 1990/91 has been around 5.5 percent a year. If in the ftiturc, the share of health
expenditure in total expenditures can be maintained and the latter continue to increase by the recent growth
rate of 5.5 percent a year then the total health allocation at the end of the project period would be Rs. 3,203
million with an annual increment of Rs. 176 million - almost 20 percent higher than the project’s incremental
cost in that year. If the incremental cost of the project is financed in addition to ‘normal’ increases, the share of
health in total revenue expenditures would increase by 0.2 percent (from a current level of 5.3 percent).
■
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Annex 3
Page 11 of 12
34.
If the share of health expenditures in total expenditures is maintained together with the increases in
overall expenditures at least at the trend of the 1980s, the project’s sustainability should be attainable
Financing incremental recurrent project costs through the ‘normal’ growth in allocations would, however, lead
to some change in the structure of health expenditure. Currently, secondary health services consume roughly
30 percent of the total, or around Rs. 660 million (with 58 percent for primary care). Projecting these
expenditures to the end of the project period (assuming a constant share of total expenditure for health and
continuation of the 1980s trend in total expenditures) the allocation would be Rs. 960 million with a ‘noHnal*
increase m that year of Rs. 63 million. The required project incremental expenditure would be almost two and
a half times as large. Hence the need for reallocation. Assuming no other changes in the composition of health
expenditures, the allocation to secondary health would increase from the current 30 percent to 34.5 percent.
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35.
How feasible is the assumption of overall revenue growth in the state being equal to the level of the
1980s? The deficit on the revenue account was estimated at 13.5 percent of revenue receipts in 1994/95 and
to 23 and 24 percent in the two previous years 'Flic gross fiscal deficit has been equal to 40-45 percent of
revenue receipts over the past thiee years - (he highest for any state. Interest payments on the state
government's debt as a share of total stale revenue rose from 12 5 percent in 1985/86 to 37.2 percent in
199.4/95 - die second highest among the eleven most highly populated stales. Revenue growth from state taxes
has been buoyant in recent years and well above that for all states combmed. However, additional efforts will
be required both to increase revenue receipts further and to restructure expenditures if growth in social sector
real expenditures is to revive. The relative wealth of the state suggests that increased revenues should be
possible to generate.
36.
West Bengal . The incremental recurring expenditures at the end of the project period are estimated at
Rs. 250 million. The total revenue allocation for the Health Department in 1995/96 is Rs. 5,570 million. Real
growth rates in health expenditure through the 1980s averaged 2.8 percent a year. In 1991/92 real
expenditures fell by 14 percent. Since then they have risen by an average of 2.9% a year. Assuming a
continuation of this trend, revenue expenditures in the year following the end of the project will be Rs. 6,803
million with a 'normal' increment in that year of Rs. 197 million. Project incremental recurring costs would be
just over 3.7% of total revenue expenditures on health or around 1.25 times the ’normal’ increment. However,
overall trends in government revenue expenditures in recent years have been above those in health If, in future
years, the health sector maintains its share ot total expenditures and the trend in total expenditures over the
past three years is maintained (7.9 percent), the health allocation in 2001 would be Rs. 8,790 million, with a
’normal’ increase of around Rs. 694 million. Project incremental costs would then be equal to 36 % of the
’normal’ annual increase. The incremental project costs imply an increased share of total government revenue
expenditure for the health department of 0.3% (the current share is 7.2%).
37.
In order for the project incremental expenditures to be accommodated relatively easily at the end of the
project without a sudden large increase, the share of overall health expenditures should increase at a rate at
least as fast as total revenue expenditures If that occurs, the costs should be sustainable. If the growth rate of
health sccloi allocations was to continue to be substantially below dial of overall expenditures, the question of
project sustainability would be more ambiguous.
38
'Hie project is likely to result in an increased share of health expenditures for secondary level services
(unless overall expenditures increase at a very rapid level). Expenditure on secondary health in 1994/95 was
equal to 25 percent of total1 health expenditures, around Rs. 1,400 million (with 45 percent for primary care).
Maintaining a constant share of total government expenditures at the recent trend rate would lead to an
allocation of Rs. 2,384 million at the end of the project penod. If project incremental costs were financed in
addition to the trend increase, these would add an additional 10 percent to this total and the share of secondary
services would increase to almost 30 percent of total health expenditures million. To the extent that the
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Annex 3
Page 12 of 12
incremental expenditures are financed through the normal trend increase, the share for secondary services
would increase further.
39.
How feasible are the assumptions regarding increases in health sector financing? The deficit on the
revenue account was equal to 19 percent of revenue receipts in 1994/95 (the highest ratio across the 15 major
’ states). This has increased from 14 percent in 1991/92. The gross fiscal deficit is currently (1994/95) equal to
30 percent of revenue receipts. Interest payments on the state government's debts were equal to 19.1 of revenue
expenditures in March 1995. This is slightly above the average across the major states (18.0 percent).
Outstanding debt is equivalent to 22.6% of state domestic product which is slightly below the average. Efforts
are underway to improve state public finances. The fiscal deficit in 1995/96 is anticipated to be below the
previous years’ and as a share of revenue receipts is planned to fall to 27%. Further efforts to increase
revenues and to alter the structure of expenditure obviously will be necessary to reverse the relatively weak
position of public finances in general and the deteriorating situation of finances for the health sector in
particular.
40.
The project will add 4.5 percent to the current debt of the state government (Rs. 5,969/13,081
million).
41.
Summary. The position of public finances in Karnataka and recent trends in expenditure on health
both suggest that the project’s incremental recurrent costs arc sustainable. In Punjab and West Bengal,
however, continuation of recent trends in health expenditures would not be sufficient to absorb the incremental
costs. In both cases, the rate of growth of health expenditures in recent years has been below the growth rate
of overall expenditure. If health expenditures can be maintained at least as a constant share of overall
expenditures throughout the life of the project, the risks of sustainability would decrease significantly. Punjab
and West Bengal will need to enhance their contributions to the health sector. In the case of Punjab, the
necessary resources needed to sustain this commitment can be mobilised with small increase in tax effort. In
the case of West Bengal, some reorientation of its fiscal policies may be required to ensure sustainability.
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Annex 4
Page 1 of 5
COSTS AND EFFICIENCY OF FIRST REFERRAL VERSUS
TERTIARY LEVEL HOSPITAL CARE
1.
The Annex estimates the costs and efficiency of treating patients at a first referral hospital
compared to a tertiary hospital. It deals specifically with two issues: (i) the overall unit costs related to
specific inputs for in-patients and out-patients at first referral versus tertiary hospitals; and (ii) costs
and efficiency comparisons of first referral versus tertiary level hospitals for a sample of interventions.
One of the rationales for the project from an economic efficiency point of view is that the unit costs of
treatment can be reduced considerably by providing health care services at lower level facilities where
unit costs for comparable services are lower. The analysis in this Annex will, therefore, test whether
this hypothesis is true; and if it is accurate, what would be the approximate magnitude of the cost
savings if diagnosis and treatment of conditions that are possible to be addressed at secondary level
facilities are indeed taken care of at that level, rather than at the tertiary level.
2.
1During project preparation, service norms at different level facilities throughout the system
were streamlined and rationalized in each of the three states. This will make it possible to provide
diagnosis and treatment services at an appropnate level facility in a cost-effective manner. Therefore,
the without project scenario is one in which a substantial numoer of diagnosis and treatment services
would continue to be done at tertiary hospitals’ and the “with” project scenario is one in which many of
these services can be performed at first referral hospitals.
3.
Analysis comparing cost-effectiveness between different types of hospitals is limited in India,
because of the unavailability of data. However, due to variations in the case-mix, it is difficult to
compare cost-effectiveness compansons between these categories of hospitals. Also, because more
senous and complicated cases are admitted at tertiary hospitals, the length of stay and treatment costs
tend to be higher at tertiary' hospitals. Previous analysis has shown that between 25-40% of costs could
be saved by treating patients at first referral facilities rather than at tertiary hospitals. The data used in
such analysis have been much more broad-based and have tended to overlook some of the problems
noted here. Moreover, such analysis did not compare similar services.
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4.
A preliminary analysis was undertaken during die preparation of the project and is the initial
part of a much broader study being undertaken as part of our sector work on “Comparative Analysis of
State Health Systems Reform in India " The analysis here estimates cost savings of treating patients at
a first referral hospital compared to a tertiary hospital in Hyderabad. The reason for choosing hospitals
in Hyderabad was because of the availability of accurate cost data and the comparability of the services
provided. These hospitals were the Suraj Bhan hospital, a first referral facility and the Sultan RaTaar
Maternity hospital, a tertiary hospital attached to the Osmama Medical College in Hyderabad. Both
hospitals provide antenatal, intranatal and Family Planning Services in addition to gynecological care.
The case-mix at the two hospitals is more or less similar - where a major chunk of the in-patient facility
is utilized by obstetric and family planning cases which constituted about 40% and 30% of in-patients,
respectively during the past 2 years in both the hospitals; about 11% of the in-patients were constituted
by patients’ admitted for gynecological problems and procedures; and a roughly equal proportion of in
patients had complicated obstetric care. One difference, however, was the higher utilization of out
patients at Suraj Bhan (first referral) Hospital, with a much higher number of out-patients per in-patient
(6 to 1) compared to the Sultan Bazaar Maternity Hospital (1.2 to 1).
5.
Estimation of Costs. The recurrent costs for the Sultan Bazaar Hospital were taken from the
budget books, and the recurrent costs of the Suraj Bhan Hospital were taken from hospital records and
I
Annex 4
Page 2 of 5
81
grants received from the Government. The recurring expenditure under different heads for three
financial years for both the hospitals is presented in Tables 2 and 3. Since both hospitals come under
different administrative systems, cost heads do not exactly match, and information on some heads is not
being routinely compiled by these institutions. However, at an aggregate level both data sets represent
average recurring costs.
Table 1: Recurring Expenses of Suraj Bhan Hospital
(Costs in Rs.)
Head of Account
1992-93
1993-94
1994-95
Pay Allowances
Rent rates and
Taxes____________
Water and
Electricity_________
Cleanliness
Charges___________
Stationary, imprest
& other
Contingents_______
Maintenance______
Electrical Goods
Drugs and
Medicine_________
Drugs & Supplies
Provided from
Headquarters______
Diagnostic and Lab
Material__________
Surgical
Instruments_______
Um form_______ __
1,641,124
50,263
2,397,259
80,419
2,656,855
69,214
Average
93-95
2,527,057
74,817
23,776
17,514
17,534
17,524
5,274
3,624
2,650
3,137
13,687
15,496
12,111
13,803
10,869
73,709
1,326
9,935
65,037
1,973
19,143
57,247
5,632
14,539
61,142
3,803
425,000
467,500
514,250
490,875
2,812
2,532
4,999
3,765
1,380
3,060
767
1,914
48,648
0
2,297,868
40,855
91,250
3,196.454
39,578
91,250
3,491.230
40,216
91,250
3,343,842
Diet_______________
Total
1
Annex 4
Page 3 of 5
82
Table 2: Recurring Costs of Sultan Bazaar Hospital (Rs.)
Head of Account
92-93
93-94
94-95
Pay & Allowances
Service Postage
Water and
Electricity_______
Other Office
Expenses________
Rents and Taxes
Publications_____
Machinery and
Equipment______
Motor Vehicles and
Other Expenses
Maintenance_____
Materials and
Supplies________
5,055,000
0
0
5,862,000
0
0
7,110,000
3,000
597,000
Average
93-95
6,486,000
1,500
298,500
33,000
0
90,000
45,000
70,000
15,000
172,000
29,000
50,000
1,546,000
112,000
15,000
150,000
70,500
32,500
848,000
0
157,000
0
78,500
0
1,450,000
581,000
1,397,000
9,000
1,400,000
295,000
1,398,500
Diet________________
0
6,795.000
220.000
9.M 12.000
220,000
9,706.000
220,000
9.774.000
Total
6.
Estimation of Capital Costs. Capital costs, however, were more difficult to estimate, as both
hospitals are located in old residential structures that were converted several decades ago. In addition,
the equipment is relatively old. Hence, it was not possible to arrive at precise capital costs. An
approach suggested by WHO for estimating capital costs1 was used. This included a detailed listing of
existing capital resources of both hospitals, namely building (area), equipment (major, minor and
surgical) and furniture. The current costs of these capital resources were applied to the existing
facilities of both hospitals. For each capital facility the mean duration of utility was arrived at by
obtaining expert opinion. Examples from the Indian context were taken to arrive at a capital facility
with a mean duration of use and the annual capital cost component.
I
1
Andrew Creese
David I’tukcr, Cost Analysis in 1’iunnry Health Care: A Training Manual tor Programme Managers;
WHO, Geneva 1994.
83
Annex 4
Page 4 of 5
Tabic 3: Estimation of Annual Capital Costs (Rs.)
Capital
Facility
Description
Major________
Minor________
Surgical______
@ Rs. 8720/bed
Furniture
@ Rs. 400 per
Building
Sq. Feet
Area ,
Total Capital Costs per Annum
Equipment
Current Costs
Sultan
Bazaar
4,287,100
187,000
230,000
1,395,200
Suraj
Bhan
1,050,100
90,000
67,000
436,000
15.290.0002
6,960,8003
Mean
Duration
or Use in
Years
10
5
1
10
50
Estimated Capital Costs
per Annum
Sultan
Bazaar
428,710
37,400
230,000
139,520
305,800
Suraj
Bhan
105,010
18,000
67,000
43,600
139,216
1,141,430
372,826
2
-Sultan Bazaar Hospital: Total Building Area 38,225 Sq. Feet
3
Sultan Bhan Hospital: Total Building Area 17,402 Sq. Feet
6.E$timation of Unit Costs. Since the hospitals studied provide both in-patient and out-patient services,
a comprehensive index which captures both types of services was applied to arrive at a unit cost figure.
The day equivalent method which equates the cost of one in-patient day with four out-patient visits was
used. Using the case equivalent method, the unit cost for each hospital was calculated. The results arc
shown in Table 4.
Table 4: Estimation of Unit Costs for 1993-95 (Rs.)
__________Description
Average IP____________
Average OP___________
Case Equivalents_______
Annual Recurrent Costs
Annual Capital Costs
Total Annual Cost______
Cost per Case Equivalent
Sultan Bazaar Hospital
_______ 52,516_______
_______ 62,150_______
_______ 68,054_______
9,774,000
1,141,430
10,915,430
160
Suraz Bhan Hospital
12,199
79,962
32,190
3,343,842
372,826
3,716,668
115
2 Andrew Creese & David Parker, Cost Analysis in Primary Health Care: A Training Manual for Programme Managers;
WHO, Geneva 1994.
3 Howard Barnum & Joseph Kutzin; Public Hospitals in Developing Countries, published for the World Bank by The John
Hopkins University Press.
84
Annex 4
Page 5 of 5
7.
As data on in-patients and out-patients were available only for two years (1993-94; 1994-95),
the analysis applies only to this period. The results indicate that day equivalent at the Suraj Bhan
secondary hospital is about two-thirds that of the Sultan Bazaar Maternity Hospital. The results are
similar to other studies which found that services at secondary level facilities can be provided more cost
effectively than at tertiary hospitals if it is technically possible to provide these services at the secondary
level. In other words, there can be considerable cost savings if services that can be provided at
secondary level facilities are provided at those facilities rather than at tertiary hospitals. The main
reason for this at the two hospitals studied was largely because of greater unit costs of infrastructure
and overheads at tertiary hospitals.
8.
A review of several studies undertaken by Barnum ct. ai. also concluded that within a country,
tertiary hospitals tend to have higher average costs than the less technically complex district level
hospitals. However, they did not analyze unit costs for similar types of services provided. These results
are merely indicative, and apply only for two hospitals. However, they do illustrate the fact that
streamlining and rationalization of services can result in considerable cost savings.
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Annex 5
Page 1 of 6
USER CHARGES AND COST RECOVERY
1.
The principle of implementing user charges more rigorously for both inpatient and
outpatient diagnostic and treatment services in hospitals has been adopted by the Governments of
Karnataka, Punjab and West Bengal. The Governments regard cost recovery as a way of
augmenting public resources for healthcare, though not for substituting for them. Responsibility for
meeting the incremental recurrent costs of the project has been accepted by each Government
Three-quarters of total health expenditures in India already are made directly by patients to private
doctors and hospitals. Studies show that the poor are disproportionately represented among the
users of public hospitals. Full cost recovery in the public sector is neither feasible nor desirable.
Equally, however, each government has adopted the principle that those patients who are able to
pay for services in public hospitals should do so to some degree and that revenues should be of a
size to have a significant effect on funding non-salary recurrent costs. Therefore, the system of
user fees proposed by each state is a combination of voluntary payments and targeting of the poor
for exemption.
. 2.
In summary, the guiding principles for implementing user charges will be to: (a) recover a
part of the costs of inpatient hospital services from those patients who can afford to pay, while
protecting the poorest sections of society, (b) charge all outpatients a nominal foe partly to
improve record-keeping and partly to raise moderately hospital income (Punjab and West Bengal);
(c) concentrate charges on voluntary services such as private rooms or wards and on medical
services with a relatively low cost-effectivcncss; (d) enable hospitals to retain all or part of the
revenues collected by them (Punjab) or to empower district health committees (West Bengal and
, Karnataka) to retain the revenues and redistribute them among hospitals within the district
according to both need and level of collection; (e) ensure that revenues arc used for non-salary
recunent items. In the absence of quality improvements, new or increased charges could lead to
reduced demand for hospital services with an overall reduction in revenues. Increased charges will,
therefore, be introduced in a phased manner and matched to higher quality levels of services. Some
would be appropriate immediately. Others would need to await improvement in services and
infrastructure.
3.
While the general principles are common across the three states, there are variations in the
way they will be implemented. The programs of each state are described below, followed by an
indicative example of the levels of revenue which might accrue.
Karnataka
4.
Outpatient charges. Currently no charges are made for outpatients. A recommendation is
before the Government to implement an annual Rs. 2 registration fee. The intention is both to
encourage patients to keep a record of their treatment and to raise revenues. Charges of Rs. 5 are
currently made for issuing health certificates. Half the revenue-is retained by the doctor and half
retained by the government. Such charges represented 40 percent (Rs. 41 million ) of total revenues
collected by the Department of Health and Family Welfare during 1992-93.
5.
Inpatient charges- The last revision of charges was made in 1988. Patients who are a
member of a family with an annual income of above Rs. 8,000 a year arc meant to be charged Rs.
2 per day for a bed in a general ward. Daily charges for four, two and single bedded rooms arc Rs.
5, Rs 7.5 and Rs. 15 respectively. Of total hospital beds, paying beds currently constitute only
ii-
*
«6
Annex 5
Page 2 of 6
PaS"1 (60° °UIt °f 1?500)- FCCS for mcdlcal SCrV1CCS
a150
and they are also
g aded. Patients m special wards are meant to pay fell fees while those in paying general wards
from iPh
PerCent ° 1116 fee- Patlents m generaJ wards Pay "0 fees. Average iiual revenues
S
°Ver. PeiLOd n1990’93 were
66 nulll0n - equivalent to under 2 percent “f
total DOHFW expenditure. If all the charges were in practice being levied, revenues would be
grea er than those actually collected. Recommendations are before the Government to introduce a
small registration fee (with no exemption), to revise the charges for paying beds and to increase
^ir number through the designation of 20 percent of all additional beds. Revisions of charges for
treatment will be undertaken dunng the project but the immediate priority is to increie the
collection of existing charges.
6.
____
Exemption for the
Poor. A criterion for exempting the poor has been proposed by the
Government. The Government
. 11,850 or below (i.e., the nattonally accepted norm under the JRY program) are entitled to such
gr“n cards. Comprehensive surveys of the rural population were undertaken in the past for
entifymg the beneficiaries. As of now, the rural population with an annual income of Rs. 11 850
or below has been provided with green cards. This includes special categories of underprivifeged
populations like landless agricultural laborers, village artisans, small and marginal farmers oldage pensioners, widow pensioners as well as the urban poor. The green card facility has recently
been extended to the non-noufied slums. The number of green card holders tn the state are about
5.3 million compared to the 9 milhon ration card holders of the PDS system The Government has
provided assurances dial n wdl carefully monitor die green card system as a basis for exemption
from user tecs and ensure mat leakages arc minimized.
between hospitals in the district on the basis of both need and level of revenue collection.
Punjab
8.
Qutpanent charges. Currently, a charge of Rs. 2 is made for outpatients. A Government
Order giving notification of (among other things) Rs. 5 registration fee was prepared in early
1994, butt is still pendmg. The Government provided assurances that it would implement the
enhanced outpatient charges as quality improvements are effected through the project. In addition
it has proposed to establish ‘pay clinics’ in government hospitals to-be operated after regular
hospital hours by government doctors. Of the fees, 50 percent would be retained by the doctor and
□0 percent retained by the institution.
9.
Inpatigm Charges. The Government Order also established sets of fees for inservice
med^ facilities. These included charges for special wards in district and sub-divisional hospitals
y visiting charges by doctors and for laboratory investigations such as X-ray, diathermy, ECG*
CT scan and ultra sound and for various categories of surgery. The proposed charges are higher
than those proposed in the other two states and the coverage of treatments wider
)
£
87
Annex 5
Page 3 of 6
10.
Exemption for the Poor. Exemptions to the charges noted above include state government
employees and members of families holding yellow cards which signify a family income of below
Rs. 11,850 based on the JRY norms. New lists of families eligible for these cards have begun and
will have been completed by negotiations. Total revenue raised by DOHFW in 1993/94 was Rs. 25
million or just over 1 percent of expenditure. According to the National Sample Survey 1987/88,
almost 50 percent of .hospitalized cases are in non public hospitals. The average payment per case
in these institutions was Rs. 1,200, indicating a willingness to pay among the general population.
Because of the higher income level in Punjab, the ability and willingness to pay for services is
greater than in the other two states. As a result, there exists considerable opportunity to increase
revenue collection through increased charges and better collection methods.
11 ■
Revenue administration. The Government has determined that revenues will be retained by
the institution of collection for the purpose of non-salary recurrent expenditures.
West Bengal
. 12.
Outpatient charges. A structure of hospital charges was implemented with effect from
November 1992. Among the changes implemented was an outpatient charge of Rs. 1 per
prescription slip, an OPD ticket which is used on average 3 times, for teaching and district
hospitals. In 1995, a Government Order was issued to cover all subdivisional hospitals in the
Calcutta Municipal Corporation and all polyclinics in Calcutta. There are no exemptions for these
OPD charges. Charges for most tests and diagnoses exist - in the range of Rs. 10 to Rs. 50 - but
few are collected. A review body is currently considering some new charges. The Government
provided assurances that extension of charges to state general hospitals will be considered upon
improvement of services under the project.
13.
Inpatient charges. The review of 1992 also resulted in an upward revision of charges for
private beds, diagnostic services and surgery in district and sub-divisional hospitals. Fees are
charged for 10 percent of beds (mostly in special wards). As a result of several perceived
anomalies in the structure of fees, these were again revised and extended in early 1995. Paying bed
charges in general wards are Rs. 10 a day in most tertiary teaching hospitals and Rs. 6 in state,
district and sub-divisional hospitals. Separate room charges are Rs. 30 and Rs. 16 respectively.
Charges arc made for diagnoses and for surgery for those in private beds and wards. The majority
of charges arc below Rs. 50 apart from those for endoscopy and CT scan. More recently, another
review has been initiated which, in addition to surveying the levels of charges, is attempting to
rationalize them across both the secondary and tertiary sectors. Regarding paying beds, the
Government proposes to enhance these to 30 percent of all beds at district, state general and subdivisional hospitals. A further extension to rural hospitals will also be considered. Another avenue
of user charges are the polyclinics in urban centers manned largely by doctors of teaching
hospitals. These provide mainly outpatient services and charge Rs. 16-20 per visit. In 1994/95, the
largest of the polyclinics generated almost 15 percent of recurrent costs with a similar amount
being paid to the doctors. Revenues generated by all charges are currently equal to just under 3
percent of total DOHFW expenditure.
14.
Exemptions for the Poor. The existing system for exempting the poor in West Bengal is
based on an ‘Indigent Certificate’ from the local elected representative, given to families with an
income level below Rs. 1,500 per month. The West pengal Government proposes to use this
Annex 5
Page 4 of 6
88
criterion rather than the JRY criterion because the latter does not apply to large portions of the
urban population of West Bengal.
15.
Revenue administration. Provisions exist for the Government, through the Finance
Department, to reallocate 50 percent of the incremental funds collected through user charges to the
collecting institution. The procedures, however, are said to be very tortuous and are rarely used.
The Government has provided assurances that it will take necessary actions to ensure that revenues
collected through user charges at the district, state general, sub-divisional and rural hospitals will
be retained at the district level to be reallocated amongst hospitals in the district based on both need
and level of revenue collection.
Potential Revenues From User Charges
16.
In each of the three states, review bodies to consider the structure and implementation of
user fees in hospitals exist and proposals are being actively considered. Here, an indicative
example is developed of the potential revenue that would be generated through the implementation
. of the types of user charges now being discussed and implemented. Sets of alternative assumptions
are used. The example is based on information for Karnataka.
17.
Paying beds and wards. Currently, total bed strength is 14,858 at secondary hospitals. Of
these there are around 400 paying beds in the district hospitals and 200 in the tertiary, teaching,
hospitals. The project will add 3,832 additional beds. Another 1,400 beds will be added through a
planned KFW project. Of the additional beds it is proposed that 20 percent will be paying beds. In
secondary level institutions, the total number of paying beds will increase from around 400 to
almost 1450.
As was described above, there are different bed charges depending on the number
of beds per room. Currently, the average charge is Rs. 6 per day. It is intended to increase the
charges considerably. Assuming that charges for 2 and 1 bedded rooms average Rs. 50 per day and
for 4 and 6 bedded rooms, Rs. 20 per day, that one quarter of the beds fall under the first category
and two thirds under the latter and that occupancy rates remain at around the current level of 85
percent, the increase in revenue would be:
Table 1: Project Revenue from Paying Beds and Wards
Current:
Future:
400 beds
362 beds
1088 beds
x
x
X
310 days
310 days
310 days
x
X
X
Rs. 6 = Rs. 0 7 m.
Rs. 50 = Rs. 5.6 m.
Rs. 2u = Rs. 6.7 m.
Total
Rs. 12.3 m.
Increase: Rs. 11.6 m.
«e-----------
■■
18.
Charges for Diagnostic Services and Surgery. A proposal is currently being considered by
the Government to charge a registration fee (Rs. 5) for each in-service case. The most recent
estimate, for 1992, is of 900,000 cases a year. The fee (if applied with no exemptions) would raise
Rs. 4.5 million. The charges being discussed for diagnostic services and surgery in Karnataka tend
to vary according to whether the patient is in a special ward or the general ward. It is proposed that
one set of charges would apply to all those in paying beds while those in general wards (but with
an income of over Rs. 11,850 a year) would pay half that rate. Obviously, in setting charges for
Annex 5
Page 5 of 6
89
patients in special wards care will need to be taken to ensure that the combined higher quality of
room and services can justify the additional charge. Otherwise, patients will either opt for the
general wards or for private sector treatment and the paying beds will be underutilized. Currently,
while there is a schedule of charges, last revised in 1988, few are collected owing to the lack of
institutional incentive previously desenbed. The charges in Karnataka, similar to those being
proposed in West Bengal, suggest a level of Rs. 45 for minor surgery and Rs. 100 for major
surgery. Charges for some forms of diagnosis are higher but apart from scans etc. few are above
Rs. 300.
19.
The total number of inpatient cases in Karnataka is estimated to be 900,000 a year. Those
inpatients below the defined poverty line and therefore to be exempted from charges are estimated
at 30 percent - 270,000 patient cases. Of the remaining 600,000 or so cases, six percent or 36,000
will be in paying beds. The remaining 564,000 would be in general wards. Assuming that onequarter of patients require major surgery and the rest require minor surgery, the annual revenue
from the charges would be:
Table 2: Projected Revenue from Major and Minor Surgery
Patients
36,000 in paybeds
564,000 in general
Major Surgery
Rs. 100 i
x
141,000 x Rs. 50 +■
9,000
Minor Surgery
27,000 x Rs. 45 423,000 x Rs. 23 -
Rs.
Rs.
Revenue
1.3 in.
17.0 in. wards
Total Rs. 18.3 m.
Overall, increased revenues from inpatients might be around Rs. 11.6 million for bed charges, Rs.
4.5 million for registration fees and Rs. 18.3 million for diagnostic services and surgery: a total of
Rs. 34.5 million.
fee jeovunng
(covering ayuu
a year ui
or
20.
Outpatient charges. A recommendation to charge a registration tee
until the registration card is filled up) of Rs. 2 for outpatients without exemptions is being
considered by Government. In 1992, roughly 10 million cases were registered. Revenue would be
Rs. 20 million.
21.
Other charges. Forty percent of departmental revenues are currently generated through
charges for health certificates. The charge is Rs. 5. A proposal to double the charge is being
considered. This would increase revenues from this source from Rs. 41 million to Rs. 82 million a
year.
Summary
22.
Annual recurrent expenditures for secondary health services are expected to be Rs. 1,560
million at the end of the project period. The measures desenbed above could generate around Rs.
136 million, equivalent to almost 9 percent of the total or over 29 percent of all non-salary
recurrent expenditures. This amount of additional resources could have a significant effect on the
levels of service quality provided by secondary health care institutions. In these computations, the
existing charges for treatment have been utilized. Revenues generated from these would provide
only one quarter of all revenues and are much less than those arising from increased charges for
ccitiiicatcs etc. 1 he cliargcs of Rs. 45 and Rs. 100 tor minor and major surgery respectively might
be compared to the average private expenditure on an episode of hospitalization in a rural private
L
90
Annex 5
Page 6 of 6
hospital in 1986/87 of Rs. 733 (NSSO). The estimated revenues from user charges, therefore,
should be regarded as being at the low end of the potential range. There remains considerable
opportunity to review and enhance charges for minor and major surgery, while making sure that
approprute mechanisms for protecting the poor arc in place.
23.
These calculations are mainly illustrative. While the decisions have been made in each
state both to increase the role of user charges and improve the system of implementation^
Governments have yet to implement all aspects of the levels and coverage of charges that would
yield this level of revenue. The results, however, do indicate the potential which exists to augment
government resources for health services through a few relatively simple measures. The immediate
priority is to implement the existing patterns of charges more effectively and to monitor the use an
effects of the revenues on health services.
I
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Annex 6
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PROJECT MANAGEMENT
1.
Project management arrangements in the three states have several common elements and some
differences. In Karnataka and West Bengal, the project will be managed and implemented by the Department
of Health and Family Welfare (DOHFW) which will be strengthened under the project to address increased
investment at the primary and secondary levels of health care. In Punjab, the project will be managed and
implemented by the Punjab Health Systems Corporation (PHSC), which was established as an Act and
promulgated as an Ordinance on October 20, 1995. The aim of the Corporation is to establish, expand,
improve and administer medical care at the secondary or first referral level in Punjab. Chart I of this Annex
shows the functional levels of project management that apply across all three states.
2.
The project management arrangements proposed in each state have taken account of the existing
organizational set-up of the Health and Family Welfare Department, the health programs being currently
implemented by the Department and the overall set-up of public administration in the state, especially with
regard to the nature of decentralized administration in each state. The management structure proposed in each
state would assist in implementing a health system both efficiently and effectively. This Annex describes in
detail the project management arrangements to implement the project in Karnataka, Punjab and West Bengal.
Karnataka
3.
A Project Governing Board (PGB), at the top of the management structure, includes high-level
representation from all relevant parts of the state Government that would be associated with the project. The
PGB is fully empowered to make major policy decisions and develop the broad policy outlines for the project
in Karnataka; approve the annual budget; authorize major project revisions as necessary; ratify decisions made
by the Steering Committee; formulate rules and regulations; and undertake an annual review of project
implementation and monitor overall project progress. The PGB would meet twice a year.
4.
The PGB would delegate adequate powers to the Steering Committee to carry out its functions as the
nodal body for project implementation. The Secretary, DOHFW, would be the Chairman of the Steering
Committee and the Project Coordmator. The Steering Committee will supervise and monitor project
implementation, undertake planning activities and facilitate project management activities. It will report to the
PGB (Chart 2).
5.
The Project Management Cell would be headed by an Additional Secretary, IAS cadre, who would
serve as the Project Admimstrator. This officer would report directly to the Secretary, DOHFW. An
Additional Director (Health Systems, World Bank) would assist the Coordinator and Administrator in day-today operations. Under the Additional Director, a Technical Wing would assist in carrying out project
implementation. A Joint Director (Hospitals), who would be a Senior Medical Officer, and who has
considerable field experience of working in hospitals of all levels, would be in charge of the medical and
technical aspects of the project. This official would be supported by four Deputy Directors: Deputy Director
(Training and Referral); Deputy Director (Hospiuls North); Deputy Director (Hospitals South); and Deputy
Director (HMIS). They will maintain the project profiles in respect of all 202 institutions being taken up
under the project, prepare Action Plans for each institution and be responsible for the continuous
implementation and monitoring of progress for each component of the project. The position of an Additional
Director for the Gulbarga region would be created to implement the KfW project and will be financed by the
KfW project. This officer will report to the Project Administrator to foster collaboration between the World
Bank and KfW projects and facilitate the functioning of the overall health system.
1
92
Annex 6
Page 2 of20
6.
A Design and Engineering Wing in DOHFW, headed by a Chief Engineer, would be responsible for
designing, supervising and monitoring all the facilities to be renovated/extended under the project. The budget
for civil works will be directly released by the project management to this wing, which would be fully
accountable to the project authonties. Administratively, this wing will function as part of project staff. The
Chief Engmeer would be supported by two Superintending Engineers, and an adequate complement of
Executive Engineers, Assistant Executive Engmeers and Junior Engineers in the various districts. The
Superintending Engmeer of World Bank supported IPP-IX will also report to the Chief Engineer. A Senior
Architect, specialized in hospital design, would be responsible for reviewing hospital design. He would report
to the Additional Director (Health Systems Project) for administrative purposes and to the Chief Architect of
the state for all technical issues. Equipment Management anangements incorporated in the project are
described in Annex 10.
7.
A SlrulCRiQ Planning CqII (SPC) headed by an Additional Director (Planning), would report directly to
the Secretary, DOHi-’W. The SPC would monitor the critical issues in the health sector in the state by
commissioning studies, workshops and seminars, and by directly lining consultants to facilitate these activities,
fhese issues would include monitoring the development of the private health sector; reviewing suitability of
present regulations regarding the quality of private care provision; analyzing the evolving epidemiological
profile in the states; evaluating the burden of disease and cost-effectiveness of public health interventions;
reviewing medical manpower and reviewing the implementation of cost-recovery mechanisms and sectoral
resource allocation patterns.
8.
At the distnet level, a Distnct Health Committee/Projcct Implementation Cell would facilitate
functioning of the referral system, the collection and redistribution of user charges, maintenance of equipment,
waste management, training of technical staff, quality assurance, surveillance of communicable diseases, and
the monitoring and supervision of all project activities (Chart 3). It would ensure that user charges would be
implemented more rigorously at all hospitals. A post of Resident Medical Officer (RMO) for each distnct
hospital has been created. The RMO will take over the management of the distnct hospital, thereby enabling
the Distnct Surgeon to take on an expanded set of responsibilities, including monitoring the functioning of the
referral system; planning and implementing the training component at the district level; supervising all
hospitals outside the purview of the Zilla Panshad; and managing and supervising the equipment maintenance
facility at die district level. The counterpart of the Distnct Surgeon for non-hospital health and family welfare
services at the distnct level is the District Health Officer, who will continue to implement all state and national
health and family welfare programs. The Distnct Surgeon would be supported by a social worker, mass media
officer, junior engineer and an assistant controller of finance and accounts in implementing the project at the
district level.
Punjab
9.
At die top of the management structure of the Punjab Health Systems Corporation (PHSC) would bo
the Board of Directors, whose ex-officio Chairman would be the Secretary, DOHFW (Chart 4). The Board of
Directors would consist of 13 members: 7 ex-officio members, including the Secretary, DOHFW; Special
Secretary and Managing Director of PHSC; Secretary, Finance; Secretary, Rural Development and
Panchayats; Secretary, Local Government; Director, Health Services; a Representative from the Ministry of
Health and Family Welfare, GOI; and 6 nominated members. The Board of Directors would have powers to
formulate policies for the Corporation, make regulations, borrow money and levy fee for services, and would
be responsible for overseeing the overall management of the Corporation. The Government of Punjab would
have the powers to issue directions to the Corporation in matters of policy, inspection and control, monitoring,
and accounting.
1
I
I
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Annex 6
Page 3 of20
10.
The Project Management Cell would be headed by Special Secretary, IAS Cadre, who would be the
Managing Director of the Corporation. The Project Management Cell would undertake all aspects of project
implementation, including routine management, monitor progress, maintain flow of funds and project accounts,
provide general administration and technical guidance and prepare progress reports. The Managing Director
would be assisted by an Additional Managing Director and five other Functional Directors: Administration and
Personnel; Medical Management, Medical Services, Engineering Services, M & E and HMIS and Financial
Management. The Additional Managing Director would be responsible for Administration and Personnel and
would be supported by a Manager for personnel matters relating to doctors, two Assistant Managers and four
Assistants. He will also be responsible for purchase of non-medical equipment, stationary and other office
equipment and will be supported by an accountant and an assistant in the performance of these functions.
Another Assistant would also support him on matters relating to purchase and maintenance of vehicles.
11.
The Director for Medical Management would be supported by four Joint Directors — one for referral,
quality assurance and medical audits, one for ensuring linkages with national programs, one for waste
management and surveillance of communicable diseases and one for purchase and distribution of drugs and
medical supplies. These Joint Directors would be supported in the performance of their functions by the
necessary Deputy and Assistant Directors. The Director for Medical Services would be supported by a
Manager, personnel (nurses and paramedics), a Joint Director for training, and a Joint Director for the
purchase of drugs and medical supplies. The Manager and three Joint Directors would be supported by a
number of Deputy and Assistant Directors for performing specific functions. The Director for M&E would be
supported by a Deputy Director for I EC and a Deputy Director for M&E and performance indicators. The
latter would be supported by two Research Officers/Statisticians.
12.
The Director for Engineeiing Services would be responsible for both civil works as well as equipment
management and maintenance matters, lie would be supported by a Superintending Engineer (whose level
would be that of a PWD, Building and Roads Superintending Engineer) and three Executive Engineers under
him. The three Executive Engineers would be responsible for public health (water supply, sanitation, pipes
and fitting, sewerage, anesthetic and oxygen systems), electrical matters (wiring, equipment, etc.), civil works
and building maintenance. Each of the Executive Engineers would be supported by two Subdivisional
Engineers. For civil works and building maintenance, two additional Junior Engineers and an Accountant
would also be recruited.
13.
The Director for Financial Management would be responsible for revenue, audits and accounts. He
would be supported by two Deputy Managers, one for Audit and one for Accounts/Revenues. The Deputy
Manager for Audit will be assisted by two Assistant Managers, one for Pre-Audit and one for Post-Purchase,
and by four Auditors. The Deputy Manager for Accounts/Revenues would be responsible for banking,
ledgers, user charges, flow of funds and salaries. He would be assisted by two Accountants and one Assistant.
14.
A Strategic Planning Cell (SPC) would report to the Secretary, DOHFW through the Managing
14.
Director, PHSC. The SPC would monitor the critical issues in the health sector in the state by commissioning
studies, workshops and seminars, and by directly hiring consultants to facilitate these activities. These issues
would include monitoring the development of the private health sector; reviewing suitability of present
regulations regarding the quality of private care provision; analyzing the evolving epidemiological profile in
the states; evaluating the burden of disease and cost-effectiveness of public health interventions; reviewing
medical manpower and reviewing the implementation of cost-recovery mechanisms and sectoral resource
allocation patterns.
At the district level, a District Health Committee/Project Implementation Cell (chart 5) would be the
15.
nodal implementing agency. It would facilitate functioning of the referral system, ensure maintenance of
1
94
Annex 6
Page 4 of 20
equipment, manage hospital waste, train technical staff, provide quality assurance, undertake surveillance of
communicable diseases, monitor and supervise project activities, and collect and redistribute user charges at
the district level. The Civil Surgeon would be the Deputy Medical Commissioner and Chairman. The
Committee would be composed of the District Development and Panchayat Officer; District Horticulture
Officer; Executive Engineer, Municipal Corporation; Senior Medical Officer; and Municipal Health Officer as
official members, and two members from the hospital welfare committee as non-official members. The Deputy
Medical Commissioner would be assisted by an Assistant Medical Commissioner and by a Medical
Coordinator, Administration and a Health Coordinator, Training — the former for administration, procurement,
surveillance, waste management and referral, and the latter for training, records, and HMIS. In addition, the
District Coordinator would be assisted by a Social Worker, a Mass Media Officer, a Junior Engineer, an
Assistant Controller for Finance and Accounts and a Superintendent of Office.
West Bengal
16.
A Project Governing Board (PGB), at the top of the management, will include high level
representation from ail relevant parts of the state Government that would be associated with the project. The
West Bengal structure is similar to the one in Karnataka (Chart 6). The PGB will be fully empowered to make
major policy decisions and develop the broad policy outlines for the project in West Bengal; approve the
annual budget; authorize major project revisions as necessary; formulate rules and regulations; facilitate
project management activities; and undertake an annual review of project implementation and monitor overall
project progress. The PGB would meet twice a year.
17.
The Secretary, DOHFW will be the project coordinator. The Project Management Cell would be
headed by a Special Secretary, DOHFW, who would be the Project Director. The Project Management Cell
would undertake all aspects of project implementation including routine management, monitor progress,
maintain flow of funds and project accounts, provide general administration and technical guidance and
prepare progress reports. Because of the large volume of work, the Project Coordinator and the Project
Director would receive additional support for implementing the project by two Special Officers — one for
medical and for non-medical activities. The Project Director would be supported by five Additional Directors:
Administration and Finance; Engineering and Civil Works; Health and Medical I; Health and Medical II;
HMIS and 1EC. The Additional Director for Administration Finance would be a non-medical person and be
responsible for recruitment, non-medical purchase, vigilance, financial audits, accounts and revenue matters.
The Additional Director for Engineering and Civil Works would be responsible for supervision and
monitoring of civil works and architectural designs and management and maintenance of equipment. The
Additional Director for Health and Medical I would be responsible for personnel matters, training, quality
assurance program and medical audit. The Additional Director for Health and Medical II would be
responsible for the surveillance of major communicable diseases, monitoring of the referral system, waste
management and medical purchase. The Additional Director, for HMIS and IEC would be responsible for
M&E, performance indicators and IEC activities. The five Additional Directors would be supported by a
complement of Joint, Deputy, Regional and Assistant Directors in the performance of their duties noted
above.
18.
A Strategic Planning Cell (SPC) would report to the Secretary, DOHFW through the Special
Secretary (Project Director). The SPC would monitor the critical issues in the health sector in the state by
commissioning studies, workshops and seminars, and by directly hiring consultants to facilitate these activities.
These issues would include monitoring the development of the private health sector; reviewing suitability of
present regulations regarding the quality of private care provision; analyzing the evolving epidemiological
profile in the states; evaluating the burden of disease and cost-effectiveness of public health interventions;
95
Annex 6
Page 5 of20
reviewing medical manpower and reviewing the implementation of cost-recovery mechanisms and sectoral
resource allocation patterns.
i
19.
A District Steering Committee in each district would be composed of the Sabhadhipati, Zilla Panshad
(Chairman); District Magistrate; Karmadhyakya, Jana Swastha Committee; Chief Medical Officer (CMO);
Executive Engineer; Superintendent of local hospital; and an NGO representative (Chart 7). The Committee
would meet monthly, and would review and monitor the progress of the project; coordinate activities between
different agencies involved in the project; and provide necessary administrative and technical guidance at the
district level The CMO or the District Project Officer would be the head of District Project hnolcmcntation
Cell. This Ceil would be responsible for implementing the project at the distnet level including : facilitating the
functioning of the referral system, maintenance of equipment, waste management, training of technical staff,
ensuring quality assurance, undertaking surveillance of major communicable diseases, and monitoring and
supervising other project activities. The District Project Officer would be supported by: a Deputy Project
Officer; an Assistant Project Officer for administration, procurement, surveillance, referral, waste
management; an Assistant Project Officer for training, records, miscellaneous activities and stores; a social
welfare officer; a mass media officer; an accounts officer; and an engineering cell.
Annex 6
Page 6 of20
96
Chart 1: Functional Levels of Project Management
GOVERNING BOARD/BOARD OF DIRECTORS
Major policy decisions
.
. Review progress
. Ensure coordination
. Resolve administrative bottlenecks
. Ensure flow of funds
. Approve annual budget
Authorize major project revisions
.
. Formulate rules and regulations
. Mobilize resources1
_ 1
I
I STEERING COMMITTEE1
STRATEGIC PLANNING CELL
. Evolve health ••ctor strategy
Coordinate health sector
planning
1 . SupervtM project activities
I
Muuilor project Uup4«ut«uUi(iun
1. Undertake planning activities
r
-HMdqwMwr Lev«l
l
'. Facilitate project tnaoageznexit activities
I
. Conduct studies/research
Ad rbe/recommen d
PROJECT MANAGEMENT CELL
.
Routine management
. Monitor progress
. Maintain flow of funds
. Maintain project accounts
.
Provide technical guidance
.
Provide general administration
.
Prepare progress report
L
ENGINEERING
DIVISIONS
I
' DISTRICT STEER^iG COMMITTEE3
I
I
Implementations of ail
|.
Review unit wise/com pooent progress
I
engiueenng-onented
J.
Co-ordinate activities between differenS agencies
I
projects at the district
I.
Resolve adm inht ralive problems at Districts
I
—— —• — — — _ —
I
—>
I
A
DISTRICT HEALTH COMMITTEE & PROJECT
IMPLEMENTATION CELL
.
Facilitate functioning of referral system
.
Ensure maintenance of equipment
Manage hoapital waste
Train technical staff
‘Only for Punjab
2OnJy for Karnataka
JOniy for West Bengal
.
Provide quality assurance
.
Undertake surveillance of co nun unicab la diseases
.
Monitor & supervise project activities
.
Collect and redistribute of user charges
-Diana Level
Chart 2 Karnataka Health System: Management Structure
Project Governing Board
\
Steering Committee
I
Secretary
Project Co-ordinator
I
Director
Medical Education
Director
Indian Systems
of Medicine
Chief Architect
T
T
J
Director
Health Senices
Addl. Secretary
Project Administrator
Drug Controller
I
Addl. Director
Communicable Diseases
i
Jt. Director
Govt. Med. Store
Strategic Planning Cell
Jt. Director
Hospitals
ZZZTJU__
I
I—
Jt. Director
Equipment
i
Chief Accounts
Officer
Dy. Director
Hospitals North
Dy. Director
— Equipment (DME)
Dy. Director
Hospitals South
Dy. Director
_ Equipment (DHS)
Dy. Director
Training and
Referral
Dy. Director
Training and
Referral
Dy. Director
HMIS
Dy. Director
Transport
D).
Chief Architect
Addl. Director
Karnataka Health
System (KfW)
Addl. Director
Karnataka Health
System (WB)
n
Chief Engineer
I
I
I
I
I
1
Supdt. Engineer
Bangalore
Admin. Officer
Supdt. Engineer
Dharvrad
w
o >
-4 B
2,5
w H
O O\
Chirt 3 Kimitika Health System: District Level Organization
Secretary, Health and
Family Welfare Services
—
I
~
Director Health Services
Additional Secretary
T
Project Administrator
I
I
I
Additional Director
District Health Committee
Karnataka Health Systems (VYB)
T
I
I
I
I
»
District Surgeon
District Health & F.W, Officer
• Maintenance of
- Supervision of Taluka
Equipment
- Management of Waste
- Training of Technical
Staff
-
Medical Officers'
Activities
-
Monitoring Referral
-
System
-
vo
oo
Coordination of Primary
Health Care Activities
Surveillance of
Communicable Diseases
Quality Assurance
Surveillance of
-
Monitoring Referral
System
Communicable Diseases
>0
Sodal Worker
Masi Media
Officer
Junior Engineer
Asst. Controller
finance & Accounts
° E
O
Chart 4 Punjab Health Systems Corporation: Management Structure
Chairman
(Health SecreUry)
and Board of
Directors
Managing
Director
Additional Managing
Director
Admin, and
Personnel *
(N on-Med lea I)
Director
Medical
Management
Director
Medical Services
1
L_Mafiagcr
Perseaad (dadon)
Referral/QAAfedical AudM
Dy. Dir.
~ 4 AMauU
RefefTaUQAJMcdkal Audit
Purchase I—a medv-al
I t=r
Lpwchaaa A MaMtala
Director
Engg. Services
Director
M&E and HM1S
i—Superintending Eng.
Ma oat er
Pcraoanel
j. Dirtdor
I—AM. Dir. Nunes
I—AM. Dir. Paramedics
_Eiec. Eng. (Pubbc Health)
Lj Subd. Eng (PobAc Health)
Dy. Dir.
IEC (mast media)
I—Dy. Dir. MAE
— Eaec. Eag. (DcdncU'EJcaraaici)
Natloaal Profraau
----- Jl. Director
Pub. Health Performance
I—Subd. Eag. (wmagj
Pcrformatxc Ln dicaton/
—Subd. Eng. (e^iupmcnO
MAE
Waste Mgmt ./Sure dflanet
I Am Dir. Wane Mgmt
|_AM. Mr. SwtcMU*«
Dy. Dir. Dodon
AM. Dir. Nurses/
paramedics
vo
— Dy. Manager (Audit)
l_ AM. Manager (Pre-awdtl)
'—Ant. Manager (Post-audit)
12 Audlton
— Dy. Manager (Accounts/Reveauc)
I—Accountant
Training
— Jl. Dtndor
to
Director
Ftn.
Management
G Auditors
_Jt. Wncier
eepaipmcM, aLatkmary.
other office eqaipmeat)
Ceil
r
-Jl. plr.
— 2 AM. M&aattn
I>7 hUsaftr
■I Strategic Planning
|
Eiec. Eng. (Orb V^srti)
I—J Subd. tag (Ol Worts)
-Research Off/
SlalUtkian
Ld Junior Lag (Ort Worts)
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Chart 5 Punjab Health Systems Corporation: District Level
District Health
Committee
Deputy Medical
Commissioner
Assistant Medical
Commissioner
o
o
Social Worker
Medical Coordinator, Administration
Health Coordinator, Training
(Adniinistration/Procurcment/Suneillance
Waste Management/Refcrral
(Training/Records/HMIS)
Mass Media Officer
Junior Engineer
Asst. Manager
Finance & Accounts
(Salaries/Procurement
of medicines in
emergency/revenue
collected thru user
charges/bank
claims/petrol/TA/DA)
Superintendent of
Office
10
r»
- >
O D
£.5
O
Chart 6 West Bengal: Management Structure
Governing Board
Principal Secretary
(Project Coordinator)
cr
z
o
c
Special Secretary
(Project Director)
Special Officer (Med)
A
Special Officer (Non-Med)
Strategic Planning Cell
Directorate of Health Services
o
4)
Addl. Director
Admin. & Finance
(Non Medical)
- Recruitment
- Non Medical
Purchase
- Vigilance
- Financial Audits
- Accounts
Addl. Director
Engg.
Addl. Director
Health & Medical I
Addl. Director
Health A Medical II
Addl. Director
HMIS & IEC
- Civil Works
- Architecture
- Equipment Mgmt.
- Personnel
- Training
-Medical Audit?
Quality Assurance
- Surveillance
• Performance
Indicators
-Monitoring
- IEC Activities
I
JI. Dlrtdor
Accounls/FInancial
Audit, Account
I
J|. Diractor/
Dtp. Director
Equip. Mgmt.
- Referral System
- Waste Mgmt.
- Medical Purchase
ZZZ1
|
|
Jl. Director/
Dep. Director
Civil Works,
I
I
I
Architecture
j
Reg. Director
Medical
N. Bengal
Reg. Director
Medical
Burdvran
|
|
DD/AD
|
I
~
DD/AD |
£
Reg. Director
Medical
Presidency
_
O B
T
O O\
DD/AD
Chart 7 West Bengal: District Level Organization
District Health Committee
District Project Officer
Dy. Project Officer
I
i
o
K)
Asst. Project Officer
(Administration)
Asst. Project Officer,
(Training)
Administration
Procurement
Surveillance
Referral
Waste Management
n
Social Welfare
Officer
- Training
- Records
- Miscellaneous
- Stores
II
Mass Media
Officer
Accounts
Officer
I
Engg. Cell
to
o
00
o O
C6
O O\
!'
103
Annex 6
Page 13 of 20
KARNATAKA
PROJECT GOVERNING BOARD (PGB)
Additional Chief Secretary to the Government
Finance Commissioner
Development Commissioner
The Secretary to Government, Department of Planning
The Secretary to Government, Department of Public Works (PWD)
The Secretary to Government, Department of Women’s Welfare
The Secretary to Government, Department of Social Welfare
The Secretary to Government, Department of Health and Family Welfare
(Project Coordinator)
The Additional Secretary, Karnataka Health System Development Project
(Project Administrator)
The Director of Health and Family Welfare Services
The Representative of the Government of India from the Ministry of Health and Family Welfare
(MOHFW)
PROJECT STEERING COMMITTEE
•
•
•
•
•
•
•
•
•
•
•
The Secretary to Government, Department of Health and Family Welfare
(Chairman and Project Coordinator)
The Secretary II to Government, Finance
The Additional Sccictary, Dcpaitincnt oi I Icalth and family Wcltaic
I he Sccrctaiy to (jovciiiincnl Planning
'Hie Director, Department of Social Welfare
The Director, Department of Women’s Welfare
The Director, Department of Medical Education
The Director, Health and Family Welfare Services
The Joint Director, Hospitals
The Additional Director, Strategic Planning Cell, Department of Health
The Chief Engineer, Design and Engineering Wing, Department of Health and Family Welfare
The Chief Architect, Design and Engineering Wing, Department of Health and Family Welfare
•
The Chief Accounts Officer, Department of Health
•
PROJECT IMPLEMENTATION
Technical Wing
• Joint Director Hospitals
• Deputy Director Hospitals North
• Deputy Director Hospitals South
• Deputy Director Training and Referral
• Deputy Director HMIS
• Joint Director Equipment
• Deputy Director Equipment (DME)
• Deput}' Director Equipment (DHS)
104
•
•
•
•
•
Annex 6
Page 14 of 20
Deputy Director Training and Referral
Deputy Director Transport
Joint Director Medical Stores
Chief Accounts Officer
Administrative Officer
Design and Engineering Wing
• The Chief Engineer
• Superintendent Engineers
• Executive Engineers
• Assistant Executive Engineers
• Assistant Engineers
• Junior Engineers
• Senior Architect
The organizational arrangements for the technical components of the project are described in the relevant
annexes.
DISTRICT HEALTH COMMITTEE
•
•
•
•
Chief Executive Officer, Zilla Parishad
District Surgeon
District Health and Family Welfare Officer
Lay Secretary
105
I
Annex 6
Page 15 of 20
PUNJAB: PUNJAB HEALTH SYSTEMS CORPORATION
BOARD QF DIRECTORS
•
•
•
•
•
•
•
•
•
•
•
•
The Secretary to the Government, Department of Health and Family Welfare
(Chairman of the’Board of Directors)
The Managing Director, Punjab Health Systems Corporation
The Secretary to the Government, Department of Finance
The Secretary to the Government, Department of Rural Development and Panchayats
The Secretary to the Government, Department of Local Government
A Representative of the Government of India from the Ministry of Health and Family Welfare
(MOHFW)
The Director of Health Services, Department of Health
A Representative of a Medical Institution of Excellence
Two Distinguished Experts in Professions related to medicine and health
An Experienced Professional in Systems Management
The Director of the National Institute of Pharmaceutical Education and Research
A Representative of a reputed Industrial House Manufacturing Pharmaceuticals
PROJECT IMPLEMENTATION
i
•
•
•
•
•
•
•
•
Managing Director (IAS Office, Special Secretary), the Punjab Health Systems Corporation (PHSC)
Director, Administration and Personnel, PHSC
Director, Monitoring and Evaluation and Health Management Information System, PHSC
Director, Medical Services, PHSC
Director, Medical Management, PHSC
Director, Engineering Services, PHSC
Director, Financial Management, PHSC
Other key staff of the rank of Joint/Deputy/Assistant Directors, Research Officers, and Statisticians
who will assist the Managing Director and the six Directors of the PHSC in implementing the
project
DISTRICT LEVEL
•
•
•
•
•
•
•
•
•
i
I
District Coordinator, Health Services
Deputy District Coordinator
Assistant District Coordinator, Administration (Administration, Procurement, Surveillance, Waste
Management, Referral)
Assistant District Coordinator (Training, Records, HMIS, Stores, Pharmacist)
Social Worker
Mass Media Officer
Jumor Engineer
Assistant Controller, Finance and Accounts
Superintendent of Office
106
Annex 6
Page 16 of 20
WEST BENGAL
PROJECT GOVERNING BOARD
•
•
•
•
•
•
•
The Chief Secretary to the Government (Chairman)
The Secretary to the Government, Department of Health and Family Welfare (Vice Chairman of
Governing Board and Project Coordinator)
The Secretary to the Government, Department of Finance
The Secretary to the Government, Department of Public Works
The Secretary to the Government, Department of Pandrayat and Community Development
The Director of Health Services
Special Secretary to Government, Department of Health and Family Welfare (Project Director)
PROJECT/MANAGEMENT CELL
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The Secretary to Government, Department of Health and Family Welfare
(Project Coordinator)
The Special Secretary to Government, Department of Health and Family Welfare
(Project Director)
Special Officer, Medical
Special Officer, Non-Medical
I lead of the Strategic Planning Cell
Director of Health Services
Additional Director, Administration and Finance
Additional Director, Engineering and Civil Works
Additional Director, Health and Medical I
Additional Director, Health and Medical II
Joint Director, Accounts/Financial
Joint/Deputy Director, Equipment Management
Joint/Deputy Director, Civil Works/Architecturc
Regional Director (Medical), North Bengal
Regional Director (Medical), Burdvvan
Regional Director (Medical), Presidency
Deputy/Assistant Director, North Bengal
Deputy/Assistant Director, Burdwan
Deputy Assistant Director, Presidency
DISTRICT STEERING COMMITTEE
•
•
•
•
•
•
•
Sabhadhipati, Zilla Parishad (Chairman)
District Magistrate
Karmadhyakya, Java Swastha Commince
Chief Medical Officer
Executive Engineer
Superintendent of Local I iospital
Representative of NGO
107
DISTRICT HEALTH COM;
•
•
•
•
•
•
•
•
I
Annex 6
Page 17 of 20
;e/project implementation cell
District Project Officer
Deputy Project Officer
Assistant Project Officer , Administration (Administration, Procurement, Surveillance, Referral, Waste
Management)
Assistant Project Officer, Training (Training, Records, Miscellaneous Activities, Stores)
Social Welfare Officer
Mass Media Officer
Accounts Officer
Engineer Cell
108
Annex 6
Page 18 of 20
SCHEDULE OF APPOINTMENT OF KEY HEADQUARTERS STAFF AND OTHER
PERSONNEL
L Karnataka
•
•
•
•
•
•
•
•
•
Additional Secretary
Additional Director (3), including one for K_FW Project in Gulbarga District
Joint Director (3)
Chief Engineer
Deputy Chief Engineer
Executive Engineer (2)
Assistant Architect
Chief Accounts Officer
CAO
II. West Bengal
Currently Filled
•
•
•
•
•
•
•
•
•
•
Principal Secretary (Project Coordinator)
Project Director
Strategic Planning Cell
Additional Director Engineering
Additional Director, HMIS and IEC
Deputy Director Civil Works
Deputy Director Equipment Management
Deputy Director Accounts/Financial Audit
Four Office Assistants
Secretariat staff of Project Director and other officers
Tq be Filled (by July 31, 1996)
Headquarters
•
•
•
•
Additional Director, Administration and Finance (Non-Medical).
Additional Director, Health and Medical I
Additional Director, Health and Medical II
One Regional Director, Medical
District
•
•
District Project Officer
Deputy District Project Officer
■j
I
I
109
i
I
•
•
•
•
•
Assistant Project Administration Officer (District)
Social Welfare Officer
Mass Media Officer
Accounts Officer
One designated Engineer
To be Filled (by December 31, 1996)
Headquarters
•
•
•
Special Officer/Assistant Director (Medical)
Special Officer/Assistant Secretary (Non-Medical)
Two Regional Directors
District
•
•
Assistant Project Officer (Training)
Additional officers in the Engineering Cell
III. Eunjab
Currently Filled in the Punjab Health Systems Corporation
•
•
•
•
•
•
•
•
•
•
•
•
•
Chairman
Managing Director
Members of the Board of Directors (appointed/nominated)
Director of the Strategic Planning Cell
Health Economist
Systems Analyst
Additional Managing Director (Personnel)
Director Medical Management
Director Medical Services
Director Engineering Services
Manager, Finance/Accounts
Secretary, Board of Directors
Deputy Director, Medical Management
Tq be filled (by July 3lt 1996)
Headquarters
•
•
Director, M&E and HMIS
Director, Financial Management
Annex 6
Page 19 of 20
i
110
District (17; one in each District)
•
•
•
•
•
•
Deputy Medical Commissioners
Assistant Medical Commissioners
Junior Engineers
Mass Media Officers
Manager, Finance 8c Accounts
Superintendent of Office
To be Filled (by December, 1996)
Headquarters
•
•
•
•
•
•
Jt. Director Personnel
Jt. Director Purchases
Jt. Director Quality Audit
Jt. Director Waste Management
Executive Engineers for Construction/Maintenance
Manager (Audit)
District
•
•
Medical Superintendents (remaining 150 institutions)
Medical Specialists
Annex 6
Page 20 of 20
I
111
Annex 7
Page 1 of 14
TRAINING
I
i
1.
The primary objective of the training component is to improve quality and strengthen the
services provided at first referral facilities. The strengthening of services at these hospitals is expected
to improve the referral system, provide better quality of services, and reduce the burden on tertiary
hospitals in the cities. Each state would implement a comprehensive training program for upgrading
skills at rural, sub-divisional and district hospitals.
2.
During project preparation, the DOHFW in each state set up a working group responsible for
matters related to training and skill development. The working groups are composed of experienced
clinicians from rural and teaching hospitals as well as nursing personnel, hospital superintendents and
administrators. These working groups conducted a rapid training needs assessment study, where
teams from the working groups visited a number of secondary hospitals and interacted with the medical
and paramedical staff of these hospitals. Each state then conducted a training workshop to discuss the
results of the rapid training needs assessment study and developed priority intervention strategies.
3.
'Hie working groups’ concluded that training programs are necessary for all categories of
hospital manpower, including doctois, specialists, nurses and technicians at alt levels. It was decided
that Lite progiam should include liaming of clinical skills, hospital management, use and mamtciuuicc of
equipment, hospital record-keeping and reporting, and the functioning of referral system. In addition,
the teams identified other types of training where participants would include not only hospital staff, but
other state and district level officers. These participants would receive training on IEC, health
management information system (HMIS) and on surveillance of major communicable diseases.
Additional information on specific training programs are provided in the individual annexes.
4.
The working groups considered several factors while formulating a comprehensive training
program: (a) the target group to receive training; (b) the issues/subjects that need to be addressed;
(c) the number of staff in each category to be trained; (d) the training of tramers; (e) the availability of
existing training materials versus the need to develop new curriculum and training modules; (f) the
number of trainees each year; and (g) the unit cost of training.
Clinical Training
Concept. In order to improve the quality and effectiveness of clinical services in hospitals, the
5.
states would establish periodic in-service clinical training for health professionals. The goal of clinical
training would be to upgrade skills of health professionals, in order to provide safe and high quality
services to clients. Norms for these services were defined for each type of hospital through workshops held
in each state.
Clinical training deals primarily with obtaining the knowledge, attitudes and skills necessary to
6.
carry out a specific procedure or activity. Although this training can be thought of as being effective if
it succeeds in conveying information or influencing attitudes, it will have failed if the participants are
unable to satisfactorily perform the activity assigned to them. Clinical training would therefore focus on
providing the essential facts and attitudes, as well as developing skills required for performing a specific
procedure or activity.
7.
The training provided would be competency-based training (CBT) or learning by doing. It is
based on a social learning theory which states that when conditions are ideal, a person learns most
112
Annex 7
Page 2 of 14
rapidly and effectively by watching someone (in this case the trainer) perform a skill. The participant
later performs the skill under the guidance and facilitation of the trainer. To successfully accomplish
CBT, the skill or activity to be taught must be broken down into essential steps. Each step is then
analyzed to determine the most efficient and safe way to both teach and learn it. This process is called
standardization Once a procedure has been standardized, competency-based learning guides and
checklists could be developed to facilitate learning the necessary steps and provide more objective
evaluation of the participant’s performance.
8.
Training Approach. This project would undertake the CBT approach to clinical training which
is based on demonstration, practice, feedback and assessment of the minimum level of competence in
performing a job. A combination of three modalities would be used for providing in-service training:
short courses, practical training and distance learning packages. In order to do so, responsible working
groups in each state would develop curricula suitable for each type of training. These working groups
would also design and conduct the training of trainers and develop necessary training modules.
9.
Who Will be Trained? A preliminary analysis of the categones of staff and training needs
indicates that two distinct categories of training will be provided: (a) updating the knowledge and skills
within specialty areas for those who have already had post-graduate training; and (b) updating the
knowledge and skills for those who have not received post-graduate training in the identified areas
(MBBS, nurses, lab technicians, radiographer).
10.
Curriculum Development. Since clinical training will focus on hands-on practice to improve
skills in performing procedures, a specific curriculum needs to be developed accordingly. With the
assistance of a consultant on clinical training, each state is expected to establish several working groups
and conduct workshops to develop suitable curricula for different types of training categories
(physicians, specialists and nurses). The members of the working groups would consist of experienced
clinicians who arc competent in their specialties, physicians who have experience working in rural
hospitals and some members from medical colleges. Curricula would be continued to be developed
during the early implementation phase of the project.
11.
Training Modules. The modules for clinical training would be very specific, including learning
objectives and methods, and check lists to evaluate skills. Karnataka, Punjab and West Bengal will first
review existing training materials developed by APWP in Andra Pradesh, USAID-JHPIEGO and
WHO, and adapt training materials accordingly. If necessary, the states will assign working groups to
develop the specific training modules.
12.
Training Site. To train physicians from the community, rural, sub-district and sub-divisional
hospitals, the states would assign some distnet hospitals within the states as training centers. Some of
the advantages of such an arrangement would be: (a) conditions at district hospitals are more likely to
be similar than at teaching hospiuls; (b) training rural hospital physicians at district hospitals is likely
to familiarize them with the functioning of the district hospital, thus facilitating the referral process.
Suitable district hospitals have been identified. The project will support construction of training
facilities at district hospitals, which consist of classrooms, libraries and training equipment.
For training of specialists from district hospitals, the states have assigned several teaching and
13.
tertiary hospitals as training centers. Further coordination with the staff of medical colleges will be
conducted during the first year of the project.
113
I
i
I
Annex 7
Page 3 of 14
14.
Training of Trainers. Trainers who will provide clinical training in each state need to be kept
abreast of training tcclmology and familiarized with the specific curriculum and training modules.
Training technology that they would have to acquire include: selection and use of appropriate teaching
methods for development of psychomotor skills (i.e. patient management procedures); small group teaching
methods; acquisition of desirable attitudes; and methods of assessment for evaluation of learning outcomes.
For this purpose, the state would organize appropriate short courses for staff of district hospitals and medical
colleges who will be serving as trainers in the training programs. Input for such training of trainers will be
obtained from institutions such as the National Teacher Training Centers for Medical Education and Research
(e.g. JIPMER in Pondicherry, PGIER in Chandigarh, etc.). Funds for such consultant support will be
available under the project.
15.
Distance Learning Packages (DLP). In addition to the regular training mentioned above, the
states would use DLP to improve clinical skills in various areas of specialties. DLPs are training
materials designed to be used by physicians and other health professionals to update their skills through
independent study. DLPs will help states to update physicians’ skills on a regular basis, in a costeffective way. Since there is no experience in the use of DLPs, a pilot test will be conducted in a small
area. For development of the DLP, selected training institutions will be given contracts to develop or
adapt DLP appropriate to the training needs.
■
1
16.
Fellowships. The project will provide several fellowships for trainers to improve their teaching
skills, for managers and physicians to attend several short courses outside the country.
17..
Phasing of Training Program. The training program will be implemented in a phased manner
through the life of the project. The phasing is required both for the benefit of carefiilly planned training,
as well as for avoiding service distortion which could result from many doctors being away at training
at the same time. The total cost of the training program is therefore phased out over the five years of the
project (see Annex 21).
Clinical Training: Features Specific to Each State
16.
Karnataka At government hospitals, the major cause of death of inpatients (compared to total
patients admitted) were as follow: perinatal complications (12.4 %), circulatory system disorders (9.1
%), ill-defined conditions (7.3 %), congenital anomalies (7.0%) and injury and poisoning (4.0%). The
working group has focused on improving the clinical skills of the hospital staff in these particular areas
while taking into consideration the results of the Workshop on Norms.
17.
A priority list of clinical skills for physicians and nurses of community hospitals, sub-district
hospitals and districts hospitals were identified and grouped by area of specialty. A plan outlining an
approach to updating these skills was completed in order to facilitate the preparation of training
manuals. The first priority is in the areas of obstetrics, neonatalogy, internal medicine, surgery and
anesthetics. Training for physicians of community hospital and sub-district (Taluka) hospitals will be
conducted at district hospitals. A teaching center, attached to each district hospital, will be constructed
and completed with teaching aids. Training of the specialists will be done at the teaching hospitals. The
clinical training for other areas of specialties will follow after the first priorities have been settled.
Table 1 describes the training programs for physicians and various specialties while Table 2 describes
those for nurses.
20.
Punjab. A transition in the burden of disease is currently underway in Punjab. Data from
several medical institutions (1993) showed that 76.5 % of out-patients and 85.7% of in-patients suffered
114
Annex 7
Page 4 of 14
from non-communicable diseases. Acute respiratory infections were the next frequent reported cases,
when both out-patients and in-patients were taken into consideration. The Survey of Causes of Deaths’
m rural yeas (1991) showed that apart from “fever” (24 %) which reflects infected conditions, the
other leading cause of rural deaths were circulatory system disorders (17.2 %), degenerative conditions
(U/o), trauma (11.3%) and respiratory disorders (11%). The working group focused on improving
clinical skills of the hospital staff in these particular areas while taking into consideration the result of
the Workshop on Nonns.
21
The Punjab Health Systems Corporation would give contracts to selected teaching institutions
within the state (medical colleges and nursing colleges) to assist the district hospitals in implementing
their training program. Under this contract, the teaching institutions will assist the district hospitals in
conducting short on-site courses and practical clinical training. Fourteen teaching centers will be
constructed and they will be attached to fourteen district hospitals. These facilities will consist of
classrooms and library and teaching equipment. The total number of staff to be trained is about 10,000
including specialists, physicians, dentists, nurses and technicians.
22.
During the early stages of the project, short on-site courses and some practical clinical training
will be provided at the medical colleges or nursing colleges. The trainees will later be posted at the
district hospitals to obtain hands-on practical experience under close supervision of college professors.
After the project’s initial two years, the on-site courses and practical clinical training will shift entirely
to the district hospitals. Throughout the training period selected staff from the teaching institutions will
be posted at district hospitals.
18Wes*
West Bengal
Bengal.. The major cause of death at health institutions,
institutions. as obtained from the Survey of
Causes of Death, 1987 (Model Registration Scheme), were complications of pregnancy and child birth
(22.7 %), infection and parasitic diseases (17.6%), ill-defined conditions (13.2 %), diseases of the
digestive system (10%) and injury and poisoning (8.7%). The working groups at the state level have
focused on improving the clinical skills of the hospital physicians, specialists and nurses in their
particular areas, in order to improve their clinical performance and quality of care.
24.
However, a survey on the causes of deaths carried out in the Howrah Municipal Corporation in
1993, a typical overcrowded industrial area with a sizable slum population, revealed that the major
causes of death were from chronic lung diseases, such as bronchitis, asthma and emphysema (10.5%),
cerebro-vascular diseases (8.5%), and pneumonia (7.3 %). The state will emphasize improving the
clinical skills in this area.
19.
DOHFW would select several leaching institutions within the state to assist the district
hospitals in implementing their training program. During the early stages of the project, short on-site
courses and some of practical clinical training will be provided at the teaching institutions. The trainees
will later be posted at the district hospitals to obtain hands-on practical experience under close
supervision. After the initial two years of the project, the on-site courses and practical clinical training
will shift entirely to the district hospitals. Throughout the training period selected staff from the teaching
institutions will be posted at the district hospitals. The working group has prepared a plan outlining the
clinical training program. Tabic 9-3 describes the training program for various specialties.
I
115
Annex 7
Page 5 of 14
Management Training
26.
The three states would provide management training for hospital administrators at the
secondary level and for state level officers involved with project management. For state level officers,
management training will be provided through scholarship programs within India or internationally.
20.
Hospital Management. The main objective of this training is to strengthen management
knowledge and hospital administrators’ skills. The important management issues that will be covered in
the training program are: personnel, finance, facility management, equipment management, consumable
supplies, information systems and general management. The intention of management training will be
to provide practical training to enhance the ability of administrative staff to face day-to-day problems.
Details of the program are shown in Table 4.
21..
Training Institution. Management training would be contracted to outside institutions. A
specific working group responsible for management training was established in each state during project
preparation. This group will continue to collaborate with designated institutions to work on the curricula
and training modules.
22.
Training Approach. Hospital management training will emphasize analysis of the existing
situation. The analytic steps of the process arc: problem identification, objective setting, optionsappraisal and decision-making, 'flic approach will be a continuing element in future management
activities. Case studies based on local situations will be developed for training purposes.
Management Training: Features Specific to Each State
30.
Karnataka. In order to improve the administrative capability of hospital managers, the state
will organize regular Gaining course for Civil Surgeons, Assistant Surgeons and Nursing Supervisors.
The course cumculum and content will be developed in collaboration with management institutions
specializing in hospital administration.
31.
Punjab. Considering the need for close interaction between primary care providers and other
district health officers, Punjab will conduct joint training of hospital managers and primary care
providers in addition to the regular management training to be provided under the project.
32.
West Bengal. Management training would be provided by one of several training institutions:
ATI of Salt Lake, ASCI of Hyderabad, and IIHMR of Jaipur. Up to 10 scholarships have been
proposed for state level officials to strengthen management capacity.
Implementation of Training Programs
33.
Arrangements for implementation and management of training programs in each state will
follow the overall arrangements for project management, as laid out in Annex 8.
34.
Karnataka. At the state level, training programs will be implemented and managed by a Deputy
Director for Training and Referral. This Deputy Director will be supporting the Joint Director for
Hospiuls, who in turn will be supporting the Additional Director of Health Systems with the carrying
out of project implementation. At the district level, a District Health Committec/Project Implementation
Cell would be in charge of supervising the functioning of the health system. A District Surgeon, who
1
116
Annex 7
Page 6 of 14
will report directly to the District Health Committee, will plan and implement the training programs for
technical staff.
35.
Punjab. At the state level, the implementation and management of training programs will be the
responsibility of the Joint Director for Training, who will be supporting the Director of Medical
Services.
At the distnet level, the nodal implementing agency will be the Distnct Health
Committee/Preject Implementation Cell. Within this Committee, the Assistant Distnct Coordinator for
Training will be responsible for coordinating and implementing training programs.
36.
West Bengal. At the state level, there will be an Additional Director for Health and Medical I
who will be responsible for the implementation and management of training programs. The Additional
Director would be directly under the Special Secretary/Preject Director. At the district level, the nodal
implementing agency will be the District Health Committee. This Committee will include an Assistant
Project Officer for Training, who would be responsible for supervising and implementing training
programs.
I
Annex 7
Page 7 of 14
117
Table 1 Clinical Training Program for Physicians and Specialists: Karnataka
Clinical skill practice
Duration
of training
Minimum
cases for hands
on practice
Training Center
Normal obstetrical
procedures
(rlnleli ic cmcigrm.y
pioccdurcs (section
cesarean)
MTP procedures_______
Management of obstetric
critically ill patients
one month
10
District Hospitals
•
•
•
Care of new bom
Use of incubator
Neonatology
15 days
•
Laparoscopy sterilization
•
Ultrasound Sonography
Category of
personnel:
Obstetric:
Physicians from
Community Hospital
and Sub'district
(Taluka) hospitals.
Obstetric and
Gynecology specialist
from District hospitals
5
•
•
•
•
one month
20
•
•
•
15 days
20
1 5 days
•
•
•
•
A.I.I. M.S, Delhi
Jaslok Hospital, Bombay
JIPMER, Pondichery.
Vani Vilas Hospital,
Bangalore
St. Johns, Bangalore,
St. Marthas, Bangalore
Referral Hospital, Bangalore
City Corporation
Victoria Hospital, Bangalore
Jubilee Nursing Home,
Bangalore
St. Johns, Bangalore,
St. Marthas, Bangalore
Neonatal:
Physicians from
Community Hospital
and Sub-district
[Taluka] hospitals.
Pediatricians (children
specialists) from
District hospitals
•
•
Resuscitation procedure
Management of birth
asphyxia
2 weeks
10
District Hospitals
•
Management of premature
and Low Birth Weight
babies (over 2 kg].
Use of warmers_________
Management of birth
asphyxia
Ihith uijimcs
Jaundice
Convulsion
Ncunahil uilnnivc t me
Management of premature
and Low Birth Weight
babies (less than 2 kg).
Use of incubators, radiant,
phototherapy unit
2 weeks
10
District Hospitals
2 weeks
15
Vani Vilas Hospital,
Bangalore
St Malthas, Bangalore
2 weeks
10
•
•
•
•
•
•
•
•
Vani Vilas Hospital,
Bangalore
St. Marthas, Bangalore
Annex 7
Page 8 of 14
118
Table 1 (continued)
Clinical skill practice
Category of
personnel:
Duration
of training
Training Center
Minimum
cases for hands
on practice
Internal Medicine
Physicians from
Community Hospital
and Sub-distnct
(Taluka) hospitals
•
•
•
•
Internal Medicine
specialists or
cardiologist from
District hospitals
Management of
hypertension
Management of bums
Cardio-pulmonary
resuscitation
Training on the use of
ECG_________________
Management of ICU
[Intensive Care Unit J and
ICCU [Intensive Coronary
Care UnhJ
District Hospitals
15
10
•
•
•
•
•
Management of critically
ill patients
15
5
Training on the use of
Endoscopy
10 days
5
Sri Jayadcva Institute of
Cardiology, Bangalore
Wokhardt’s Heart Hospital,
Bangalore
Manipal Hospital, Manipal
St Johns, Bangalore
•
Mallya Hospital, Bangalore.
•
•
•
A.I.I.M.S. Delhi
Jaslok Hospital, Bombay
Grant Medical Hospital,
Bombay
JIPMER, Pondichery._____
Bowring & Lady Curzon
Hospital, Bangalore
St. Johns, Bangalore
•
•
•
Surgery:
Physicians from
Community Hospital
and Sub-district
(Taluka) hospitals
General Surgeons from
Sub-district hospitals
and District hospitals
Management of injury
patients: resuscitation and
patient stabilization
before referring to other
hospital_______________
Management of head
injuries
District Hospitals
two weeks
10
Management of thoracic
injuries
two weeks
5
Management of
orthopaedics emergencies
two weeks
10
Management of critically
ill patients
15 days
Training on the use of
Ultrasound Sonography
two weeks
20
•
•
•
•
•
•
•
•
•
•
•
9
•
•
•
•
NIMHANS, Bangalore
Manipal Hospital, Manipal
CMC Hospital, Vellore
SDS Sanitarium, Bangalore
MS Ramiah Medical College
Hospital, Bangalore._______
Victoria Hospital, Bangalore
St Johns, Bangalore
JJM Hospital, Davanagere
KMC Hospital, Manipal
A.I.I.M.S, Delhi
Jaslok Hospital, Bombay
JIPMER, Pondichery_______
Victoria Hospital, Bangalore
Srinivasa Screening Center,
Bangalore
St. Johns, Bangalore
St. Marthas, Bangalore
i
Annex 7
Page 9 of 14
119
Table 1 (continued)
Category of
personnel:
Anesthesia
Physicians from
Community Hospital
and Sub-district
(Tai uka) hospitals
Anesthetists specialists
from Sub-district
(Taluka) hospitals and
District hospitals____
Radiology
Radiologist specialists
from District hospitals
*
*
*
Dental Service.
Assistant Dental
Surgeon (BDS A
MDS)
Clinical skill practice
Duration
of training
Minimum
cases for hands
on practice
Administration of general
anesthesia and regional
anesthesia for normal or
non complicated cases
Advance techniques and
the used of latest drugs
six months
10
•
one w.ek
6
•
Ultrasound Sonogaphy
Special Radiological
investigation
Spectra-photometry
one month
50
•
•
Victoria Hospital, Bangalore
Jubilee Nursing Home,
Bangalore
Management of maxi lafacial injuries and
fractures
one month
10
•
Oral Cancer Detection
Biopsy & Excision of
small lesions A follow up.
one month
10
•
Government Dental College,
Bangalore
SDM Dental College,
Bangalore______________
Kidwai Memorial Institute of
Oncology
Management of
Polytrauma cases
two weeks
10
*
20
•
*
•
Training Center
•
All teaching hospitals in
Karnataka State including
private Medical College
Hospitals.____________
All teaching hospitals in
Karnataka State including
private Medical College
Hospitals.
Orthopedics
Orthopedic surgeon
(MS or D.Ortho)
from District hospitals
•
Practice in Implant
surgeries
Tuberculosis
TB Specialist
1
•
Pulmonary test
four weeks
one month
10
•
*
Sanjay Gandhi Memorial
Accident Complex A
Rehabilitation Center,
Bangalore
Victoria Hospital, Bangalore
Mam pal Hospital, Bangalore
Sanjay Gandhi Memorial
Accident Complex A
Rehabilitation Center,
Bangalore
Victoria Hospital, Bangalore
Manipal Hospital, Bangalore
•
*
PKTB Hospital, Mysore
SDS TB Hospital, Bangalore
Annex 7
Page 10 of 14
120
Table 1 (continued)
Category of
personnel:
Clinical skill practice
Duration
of training
Minimum
cases for hands
on practice
Cataract surgery with IOL
implementation
Keratoplasty
one month
10
Training Center
Opthamology
Ophthalmologist (MS
or DOMS) from
District hospitals
•
•
•
•
•
Micro surgery
Use of operating
microscope
one month
10
•
•
•
Ear-Nose-Throat
ENT surgeons (MS or
Minto opthalmic Hospital,
Bangalore
Lion’s Eye Hospital,
Bangalore
Narayana Netralaya,
Bangalore______________
Minto opthalmic Hospital,
Bangalore
Lion’s Eye Hospital,
Bangalore
Narayana Netralaya,
Bangalore_____________
•
Bronchoscopy and remove
of foreign bodies.
three
weeks
5
•
•
SDS Sanatorium, Bangalore
St Johns, Bangalore
•
Micro surgery
six weeks
10
•
•
Basavangudi ENT Center
Chinnammal Memorial Trust
Hospital, Madras
KEM Hospital, Bombay.
DLO) from District
hospitals
•
Skin and Venereal Diseases
Dermatologist, Skin
specialist from District
hospitals
Recent advances
15
5
All teaching hospitals
121
i
Annex 7
Page 11 of 14
Table 2 Clinical Training Program for Nurses and Lab Technicians: Karnataka
Category of
personnel:
Clinical skill practice
Duration
of
training
Minimum
cases for
hands on
practice
Training Center
* "ICCU Nursing Care
15 Days
10
Sri Jayadeva Institute of
Cardiology Bangalore
*
1 5 Days
10
NURSES
Staff Nurses of
CHCs/ Taluk/
District Hospitals
Staff Nurses of
CHCs/Taluk/DistnU
Hospitals
Stall'Nurses of
CH Cs/Tal uk/D istnet
Hospitals
Pediatric Nursing
*
*
♦
OTTiaining
One
Month
JO
*
*
*
Staff Nurses of
CHCs/Tal uk/D istrict
Hospitals_________
Staff Nurses of
CHCs/Tal uk/District
Hospitals__________
Staff Nurses of
CHCs/
Tai uk/D istrict
Hospitals__________
Staff Nurses of
CHCs/
Tai uk/District
Hospitals__________
Staff Nurses of
CHCs/
Tai uk/District
Hospitals
Vani Vilas Hospital,
Bangalore
Chcluvamba Hospital,
Mysore______________
Bownng & Lady Curzon
Hospital Bangalore
K.C.G. Hospital,
Bangalore
General Hospital,
Jayanagar, Bangalore
NIMHANS, Bangalore
Psychiatric Nursing
15 Days
10
*
Anesthesia
One
Month
5
*
*
Labour Ward Training
(in use of Foetal and
Maternal Monitors)
One
Month
10
*
*
Laparoscopy
15 Days
10
*
All Teaching Hospitals in
both Govt, and Private
Sectors
Nursing Training in
Management of Poly
Trauma cases and
usage of Orthopedic
Appliances including
Splints
One
Month
10
♦
Sanjay Gandhi Memorial
Accident Complex &
Rehabilitation Centre,
Bangalore
KMC Hospital, Manipal
St.Johns Hospital,
Bangalore
KLE Society Hospital,
Bclgaum
J.J.M. Medical College
Hospital, Davanagere
♦
♦
♦
♦
All Teaching Hospitals in
both Govt, and Private
Sectors_______________
All Teaching & Hospitals
Private Hitech Hospitals
Annex 7
Page 12 of 14
122
Table 2 (continued)
Duration
of
training
Minimum
cases for
hands on
practice
Procedures of Histo
pathology
15 Days
30
Lab.Technicians
Procedures of MictoBiology
15 Days
30
Lab.Technicians
Procedures of BioChemistry
15 Days
30
Lab.Technicians
Procedures of Blood
Bank
15 Days
30
Category of
personnel:
Clinical skill practice
Training Center
I
Laboratory Technicians
All Hospitals attached to
Teaching Colleges
Including Private Medical
College Hospitals_______
• All Hospitals attached to
Teaching Colleges
Including Private Medical
College Hospitals_______
♦ All Hospitals attached to
Teaching Colleges
Including Private Medical
College Hospitals_______
• All Hospitals attached to
Teaching Colleges
Including Private Medical
College Hospitals
♦
I
Annex 7
Page 13 of 14
123
Specialty
No. of
Candidates
Phases
No. of
Candidates in
each phase
Medicine
150
5
30
Surgery
150
5
30
G&O
165
5
33
Orthopaedics
75
5
15
E.N.T.
75
5
15
Ophthalomology
90
5
18
Radiology
155
5
31
Paediatrics
75
5
15
Anesthesiology
284
9
32
Dental Surgeon
184
5
33
Endoscopy
30
5
6
Venue
NRS-10
CMC-10
IPGMER-10
NRS-10
CMC-10
IPGMER-10
NRS-11
CMC-11
IPGMER-11
NRS-5
B.C. Roy Chil-5
B.C. RoyPolio-5
NRS-3
CMC-3
RGK-3
CNMCH-3
PGMER-3
NRS-5
RIO-5
RGK-5
CNMCH-5
IPGMER-3
NRS-<>
CMC-6
RGK-6
CNMCH-6
1PGMER-7
NRS-3
CMC-3
RGK-3
CNMCH-3
IPGMER-3
NRS-9
CMC-9
RGK-7
CNMCH-7
IPGMER-4
days by rotation
R. Ahmed-12-8 days
NRS-10-3 days
CNMCH-11-3 days
NRS=3
IPGMER=3
__________________
124
Annex 7
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Table 4 Management Training Program: Karnataka, Punjab and West Bengal
Management Aspects:
Focus of training:
Facility management:
facilities planning, assist registration, planned preventive
maintenance._______________________________________________
recruitment procedures, rules and regulation, supervisory techniques,
disciplinary procedures, motivation, team building, group dynamics,
training and development.____________________________________
planning for preventive maintenance, maintenance of the building,
house keeping, monitoring of use and abuse, hospital/medical waste
management.
_________________________
government financial procedures, budget planning, accounting system
(procedures and practices), budget monitoring and control, internal
audit, management of user charges.____________________________
procurement procedures, and rules and regulations.________________
planning for the supplies, procurement, inventory management,
usages monitoring, storage.___________________________________
the use of information to improve hospital management, the
importance of patients registration, medical records and medical
reporting._____________ ________ ____________________________
the role of secondary level hospitals in supporting primary level
facilities and referral system, the role of hospital advisory committee,
the relationship of hospital with the community, etc.
Personnel management:
Maintenance:
Finance:
Procurement matters:_________
Consumable supplies (including
drugs) management:_________
Information system:
General issues:
125
Annex 8
Page 1 of 5
REFERRAL SYSTEM
Objectives of a Referral System
A well-functioning referral system is an institutional mechanism through which patients
1.
with complex health problems are identified in a timely and systematic manner and examined,
investigated and/or treated promptly at an appropriate health care facility. A multi-tier health
delivery system which combines preventive, curative and specialized care works efficiently when
the various tiers of the system are linked together through a referral mechanism. It works best
when the lowest tier (the primary care level) is easily accessible to the community and provides the
bulk of preventive care services as well as the first conuct for treating common illnesses. Each
successive level provides services that are technically more complex, the higher tier providing
technical leadership and support for the lower tiers. Under such a system, the community has
confidence in the quality of care provided and patients understand that they will be referred in
accordance with their medical needs.
The Current Referral System in the Three States
2
The rclcual system m Karnataka, Punjab and West Bengal, as in the rest of India, docs
not function well. The lower tiers arc underutilized since patients proceed directly to higher level
hospitals for minor illness, thereby overloading the hospitals. Patients perceive the lower level
facilities as providing lower quality of services. The Beneficiary Assessment study in West Bengal
found that about 2% of the patients at first referral facilities were referred from PHCs.
An effective referral system which minimizes by-passing of lower levels of health facilities
3.
is desirable, k is estimated that a third of all cases which arc currently treated at tertiary facilities
could be treated at lower cost at first referral facilities, if those facilities received adequate inputs.
Such a system would require:
•
•
•
•
•
services at each level - primary, secondary and tertiary - to be clearly defined;
service at each level to be of a quality promoting confidence among patients;
patients and the community to have the confidence that patients will be properly
referred and promptly transferred to higher levels of health care as needed;
the public to be made aware of the types of services available at each level of care; and
procedures to be implemented ensuring that patients do not by-pass lower level
facilities.
The New Referral System
Under the project, the referral system would be improved through strengthening the
4.
following activities: (i) renovating and upgrading hospital buildings to provide appropriate space
for services; (ii) upgrading and updating clinical skills of physicians and nurses through an
effective training program; (iii) providing ambulances for transporting critical patients; and (iv)
installing phone, fax, and/or radio communications. It is expected that these hospitals will become
the referral point for the primary health care level.
126
Annex 8
Page 2 of 5
5.
The project would seek to ensure that a much higher proportion of patients coming to first
referral hospitals had been seen at PHCs and referred upwards. The project would implement
several measures to strengthen the referral system. These include: (a) introducing the use of
Referral and Feed Back Cards; (b) implementing the referral guidelines that specify the "what",
when and how of referrals; (c) establishing an incentive system for patients who follow referral
procedures; (d) establishing linkages and communications between the first referral hospitals and
primary care facilities through regular training and out-reach visits; (e) conducting intensive
information, education and communication (IEC) targeted at providers and the community; (f)
forming District Health Committees that will monitor the implementation of the referral system.
Referral and Feedback Cards. A new system of Referral and Feedback Cards will be
introduced. Once a decision is made to refer a patient to a higher level facility, the patient will
receive a Referral Card. The Referral Card will provide the patient direct access to the referred
hospital. The Referral Card will contain general information about the patient (such as: name, age,
address, and gender), clinical diagnosis, purpose of referral, and medical information (such as:
examinations conducted, investigations carried out, treatment received and the condition of the
. patient). At the refened hospital, the patient could report directly to the unit or department to
which he or she has been referred, instead of going through the regular Out-Patient Department
(ORD). This card will be made available not only at the first referral hospitals but also at primary
health care facilities. Alternatively, a special counter for receiving referral patients may be a
preferred mechanism.
After completion of investigation, treatment or consultancy al the referred hospital, the
patient will be reported back to the first facility. The referred hospital will provide the patient with
a Feedback Card. This card will include: general information about the patient, final diagnosis,
procedures and treatment given, type of investigation conducted, and follow-up advice. No new
ticket will be required for patients returning from the referred hospitals.
Referral Guidelines
8.
A manual of referral guidelines will be issued to all institutions that will specify
procedures to make the system effective and acceptable to the community. It will consist of two
parts, administrative guidelines and die referral protocols.
9.
Administrative Guidelines. The administrative guidelines are expected to be completed in
the first year of project implementation and will provide the following information:
•
•
•
•
•
10.
location of hospitals within the state district in order to ensure that referral of patients
are made to the nearest hospital;
transportation facilities that could be used for referraj, in particular, the kind of
transport arrangements that could be required for critical patients;
operational hours of the referral hospitals, particularly, the opening hours of specialist
clinics, radiology department, laboratory hours, etc.;
examples ofReferral and Feed Back Cards;
incentives to the patients for following the referral procedures.
Referral Protocols. The referral protocols will be developed in a participatory manner by
a techmeal group consisting of senior clinical specialists7 It will provide information on:
127
I
i
•
•
•
•
Annex 8
Page 3 of 5
service norms that elaborate the type of services provided at each level of care. During
project preparation, each state has streamlined its service norms and rationalized the
provision of services at different level of care.
patient conditions are needed to refer patients either for investigation or treatment at
higher level facilities for each area of specialization;
procedures to be followed before referring the patients, for example, for critical
patients, procedures that would stabilize the patient;
counseling for patients and the family prior to referral (such as: purpose of the
referral, benefits from referring die patient to another hospital, location of the referral
hospital and timing of admittance, likely events at the referred hospital, cost of medical
care, and precautions and preparation to be undertaken by the patient prior to hospital
admittance).
H.
Incentives to Patients. Efforts will be made to provide incentives to patients in order to
encourage proper referral procedures. Refened patients will not need to pay an out-patient fee at
the referred hospital. They will be able to report directly to the unit or department to which they
- have been referred without going through the OPD registration window. The referring hospital will
provide transporting at a suitable fee. The Referral and Feedback Cards will serve as tickets at the
hospitals.
12.
Technical Support to Primary Level. The first referral hospitals will have closer linkages
with the primary level health facilities. Certain primary level facilities and community hospitals
will be grouped into one zone based on geographic location. An identified district or sub-divisional
hospital will be assigned responsibility for providing technical support to that particular zone.
Technical support will be carried out through:
•
•
•
•
dissemination of referral guidelines to primary level facilities;
training of staff from primary level facilities and community hospitals at the district
hospital or sub-divisional hospital;
regular meetings to discuss problems in clinical management at the primary level;
out-reach visits to provide on-the-spot consultation.
13
Strengthening Referral Management District Health Conunittces, to be established under
the project, will make the referral system operational. The members of these committees will
include: a District Surgeon, a Distnct Health and Family Welfare Officer, medical officers from
the taiuka/subdivisional hospitals level, and superintendents of teaching hospitals, if available.
These committees will have the following responsibilities:
•
•
•
•
i
identifying zones for referral, which link identified PHCs, CHCs and rural/community
hospiuls to a particular district hospital, for the purpose of serving as a preferred
referral site and providing technical back-up for lower level facilities;
monitoring the implementation of the referral system which will be done by assessing
data from referral registers. In addition, the District Health Committees will review
feedback from primary care facilities;
mobilizing transport for referral needs through collaboration between the Committee
and NGOs or other agencies; and
coordinating technical support for lower level of care, as required.
128
Annex 8
Page 4 of 5
141EC support. An extensive IEC program has been proposed to support the development of
an effective referral system. There will be two target groups. The first target will be the providers
at the primary level and the first referral facilities. This group would mainly be provided
information about the guidelines and functioning of the referral system. The second group would be
the community which would be provided with information focusing on the benefits of using the
referral system. Additional information about IEC support is described in annex 15.
15.
Training. After the guidelines have been finalized, the staff of primary level and first
referral facilities will be familiarized with these documents through training. For staff at first
referral facilities, referral training will be integrated with clinical training or management training.
Features Specific to Each State
16.KArnatakfl. I'hc state has selected the districts of Chitradurga and Hassan as pilot areas
for implementing the referral system and for introducing the quality assurance program. By the end
ol die third year, when the upgrading ol the physical structure at the first referral hospitals arc
. complete and die clinical and management training program arc in place, die referral system will be
implemented throughout the state.
17.
The state has also developed a plan to improve the linkages between primary and first
referral levels. As mentioned earlier, primary care facilities and community hospitals will be
included in one zone, and an identified sub-district or district will be assigned to provide technical
support for each zone. In Karnataka, technical support will be provided through:
•
dissemination of referral administrative guidelines and referral protocols to the
facilities;
•
regular meetings and briefings with physicians of primary level facilities to discuss
problems of clinical management;
•
out-reach visits to PHCs and CHCs by consultants from the district hospitals for
providing on-the spot consultation for selected cases and practical demonstration of
selected management techniques.
18.
For tribal communities, the state has proposed annual health check-ups to identify health
problems. Those who require treatment or further investigation will get a Referral Card to go to the
appropriate health facilities.
19.
Punjab. The state has proposed a color coded Referral Card. Blue Referral Cards will be
used by community and area hospitals, green cards by sub-divisional hospitals and white cards by
district hospitals. At the hospitals, there will be a separate counter or window for accepting
referred patients to avoid long waiting time. After registration, referred patients will be guided
directly to the concerned specialist for consultation, examination, investigation or further treatment.
Referred patients will be given preference over other patients and will be examined by the most
senior specialists available.
WgSt Bengal. Special attention will be given to establish a referral mechanism for the
Sunderbans area, where 8 Block PHCs and 28 PHCs are included in the project. The Government
will approach the Zilla Parishads to construct rest houses*for the patients and their families. These
are not accounted for under the project.
129
Annex 8
Page 5 of 5
i
21.
Regarding training for the referral system, the state’s working group has developed a
training agenda. It decided that the persons to receive training will be medical officers, specialists,
superintendents, administrators, block medical officers of health (BMOH), nursing staff, ward
masters and SWOs. Training for the medical officers, specialists, superintendents and BMOH will
be for 3 days, conducted at district hospitals and cover the following materials: service norms at
various levels of care; flow of referral mechanism; use of communication; referral guidelines; use
of Referral and Feedback Cards; and IEC and HMIS orientation. Training for nursing staff, ward
masters and SWOs will be for a day at sub-divisional hospitals and will cover the following
materials: arrangement of vehicles for referring patients; filling up Referral and Feedback Cards
and explaining to patients the importance of the referral; providing counseling and guidance; and
other relevant topics.
130
Annex 9
Page 1 of3
QUALITY ASSURANCE PROGRAM IN HOSPITALS
1.
Quality Assurance (QA) is an approach to building institutional capacity and organizational
culture that focuses on continuous improvements in service delivery and on consumer satisfaction. It is
an on-going process that monitors the shortfalls in quality and implements remedial measures to address
these shortfalls. A well planned QA program would empower m'uiagers, clinicians and technicians to
monitor the quality of care provided by their own hospitals and assist in instituting rapid remedial
measures wherever shortfalls in quality are noticed. The program will cover as many clinical activities
as possible, but will focus on a few selected aspects at the beginning of the project.
2.
Quality of care has many aspects, such as care, courtesy and comfort; technical aspects such as
safety of care; and managerial aspects such as availability of resources and cleanliness of the facility.
To implement a QA program, it is necessary to clearly define indicators for each aspect of quality in
order to monitor the improvement over time.
Objectives and Scope of the Quality Assurance Program
The states propose to implement a systematic program of quality assurance that covers several
3.
aspects of clinical quality, user satisfaction and management of resources. This program will help to
ensure that other project interventions, such as improvement of physical buildings, provision of new
medical equipment, streamlining of service delivery norms, strengthening of clinical and management
capacity and improvement of the hospital information system, will actually translate into better quality
of care.
4.
Since QA is a new program, each state will identify two districts to be the initial project sites
during the first year of project implementation. All hospitals in these two districts will implement the
QA piogiam.
The QA program would consist of the following components: First, a QA committee would be
5.
established at die state level. This committee would develop an overall policy framework for quality
improvement throughout the state. Second, several QA working groups would be assigned. These
working groups would develop guidelines and necessary tools for implementing QA program in priority
areas. These guidelines would be tested in hospitals in two selected districts chosen as pilot sites. After
a year, a comprehensive evaluation of the pilot sites would be conducted and necessary adjustments of
the guidelines would be made. A state wide implementation would start the second year of the project.
Responsible QA officials will work closely with teams responsible for clinical training, management
training and equipment provision.
6.
Quality Assurance Committee. Each state would set up a State Quality of Care committee.
The main task of this committee would be to develop a policy framework for the QA program for the
whole state. This committee will undertake the following steps:
•
•
identify influential opinion leaders from among several groups involved in health care delivery at
hospitals. This would include professional groups such as: specialists, doctors and nurses; hospital
managers, such as hospital directors or superintendents; union leaders; other managerial groups,
such as district coordinators; and representatives of the community.
plan a systematic program of consensus-building among^these opinion leaders. This would include
holding seminars to give information on the benefits and limitations of QA and workshops to
involve opinion leaders in consultative decision making regarding the development of the program.
131
•
•
Annex 9
Page 2 of3
Seminar and workshop activities would include developing or reviewing indicators, setting
standards for quality, and suggesting aspects of quality that should be monitored.
identify pnority areas. The suggested prionty areas are obstetrics, pediatrics, medicine, surgery,
orthopedics, anesthesia and nursing.
identify working groups that will work on details of the selected areas of specialty.
7.
Quality Assurance Working Groups. Several working groups will be established to work on the
details of each area of specialty that has been selected as pnority. The members of each working group
will consist of specialists in that particular area, hospital administrators and physicians who have
worked in lower level hospitals (first referral hospital) These groups will design the quality assessment
tools, conduct evaluations ol the cuiicnl quality of set vices in selected hospitals, develop guidelines for
foe implementation of QA programs, and monitor foe implementation of QA at the pilot sites.
Consultants will be appointed to assist the working groups.
Activities to be Undertaken by the QA Working Groups
•
8.
Quality Assessment. The first stage of program development is to establish procedures for quality
assessment. This involves the development of acceptable standards, key indicators and methods for regular
periodic assessment of the quality of selected aspects of care provided in hospitals. The QA working group
at the state level will define the prionty cases in the areas of medicine, pediatrics, surgery, obstetrics,
orthopedics, anesthesia and nursing in which the quality of care will be improved during the life of the project
The criteria for priority selection are foe most frequent cases admitted to foe hospital or those that constitute a
significant burden of disease. Examples include: pediatric cases, acute respiratory tract infections and
diarrheal diseases. The group will assign sub groups to work on standards of procedures and identification of
suitable indicators for monitoring foe quality of service.
9.
The steps in setting up quality assessment for the selected areas of focus are: (a) identify
suitable indicators for momtoring quality; (b) set acceptable standards; (c) pilot test methods of data
collection e.g. routine records, interviews with patients, set-up complaints mechanism, focus group
discussions with selected "clients" (women users, community leaders, tribal groups etc.); (d) review data
that has been collected and review indicators and proposed standards; (e) establish regular on-going
methods of data generation; and (f) establish procedures for reviewing the data and identifying hospitals
which have shortfalls in quality.
10.
Evaluation of the Current Quality. A detailed analysis will be conducted in selected hospitals,
to assess the discrepancies between the standards and the actual practices. Observation guides based on
accepted treatment norms would be used to document where patient care fell short of the standard
Based on the results of this analysis, each hospital would develop its own plan of action to correct
lapses in technical quality and implement the correction action through direct supervision and on-the-job
training. In applying the concept it is important to note that the evaluation process is not concerned
with results that are theoretically achievable if there were unlimited manpower, skills, money or
equipment, but rather with optimum results that can be achieved in a particular hospital given the
available resources. QA is concerned with determining the difference between an optimum achievable
result, given the available resources, and the result that is actually being achieved.
11Quality Improvement at Pilot Sites. A Quality Improvement (QI) group will be set up in each
of the hospitals. QI groups will be formed from among foe staff who are responsible for the provision
of care in the area which has a shortfall in quality. The QI groups would identify some performaneg
indicators that are easy to access, such as hospital acquired infection rate, wound infection rate and
patient complaint rate. With the assistance of foe QA Coordinator, the QI group would: (a) investigate
132
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Annex 9
Page 3 of 3
factors contributing to shortfalls in quality; (b) develop strategies for remedying shortfalls in quality and
prepare an implementation plan; (c) submit a report of the investigation and the implementation plan to
the QA Committee at the state level; and (d) implement the plan.
12.
Criteria Audit. Criteria auditing is a system to assess a hospital’s patient care management
using criteria which .have been developed by that particular hospital. By careful choice of criteria, it is
possible to determine whether a procedure was justified, whether the process of care was satis factory
and whether the outcome was as desired. A subject of study, say a disease, would be selected by staff
concerned with the subject. The enteria for screening, diagnostic, treatment and outcome would be
developed and agreed by the QI group. The entena are sunplified and where possible quantified so that
any designated hospital personnel can check whether the criteria have been met. In a case where the
criteria have not been met, the QI committee would study the records to see if any departure from the
criteria is justified.
13.
Medical Audit. In case of disputes or unexpected mortality, a medical audit would be
conducted. It examines retrospectively the clinical application of medical knowledge and compares care
. rendered to preset standard of excellence.
implementation
I
State-wide implementation of the QA program would be undertaken after the conclusion of the
14.
pilot testing, llic first step m implementation would be to tram hospital staff in quality assurance. Staff
must be aware of the principles and practical application in their discipline of quality assurance. The
training would be a short onentation course about the basic concept and approach in QA or a special
course of 1 or two weeks. The next step would be to implement the strategies or actions that will
improve the quality or overcome the identified problem.
15.
During the implementation, several approaches can be used to help identify the problems within
a hospital. Where possible, existing information would be used as part of the review and evaluation.
This information would be in the form of incident reports, mortality rates, infections and complications
etc. and would usually be generated on a continuing basis. Other information may have to be collected
through the use of patient questionnaires, observation or other methods.
Management of QA Program.
16.
Management of the QA program in each state will follow the overall management structure as
laid out in Annex 8. Specifically, in Karnataka, the Joint Director for Hospitals will supervise the QA
program at the state level, while at the district level the District Surgeon will oversee the QA program.
In Punjab, the Joint Director for Referral, QA and Medical Audit will manage the QA program at the
state level, while the Assistant District Coordinator of Administration will oversee its implementation at
the district level. In West Bengal, the Additional Director of Health and Medical I will be responsible
for supervising the QA program at the state level, while the Assistant Project Officer of Administration
will oversee its implementation at the distnet level.
17.
Project Support The project will support the activities of QA committee and QA working
groups at the state level This will include: meetings, workshops, consultants, and development of
guidelines.
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Annex 10
Page 1 of 6
MEDICAL WASTE MANAGEMENT
1.
Waste management is a part of the routine hygiene and maintenance activities of a health facility.
Basic requirements such as reliable water supply, sanitary facilities, disinfection procedures and equipment arc
vital to keep a health facility clean and at a satisfactory level of hygiene. Medical waste should be carefully
managed — from the point of generation to final disposal. In most circumstances it is appropriate to consider
an incremental approach to addressing medical waste management issues at the institutional level
2.
Inappropriate management of medical waste could cause transmission of HTV/AIDS virus. Hepatitis
B or Hepatitis C virus. This could happen through injuries caused by syringe needles or sharp instruments
that are infected by contaminated human blood. In addition to the above risks, hospital water sewage could
also transmit some diseases such as cholera to the surrounding neighborhoods.
i
3.
Medical waste may be produced in hospitals, health centers, clinics, nursing homes, laboratories,
research institutes, veterinary clinics, midwifery and other medical care conducted at home. About 85% of
medical wastes arc non-hazardous wastes, 10% are infectious and around 5% are non-infectious but hazardous
wastes. The amount of waste generated varies by type of facility. In developed countries, waste generated
from general hospitals is estimated to be about 2.5-4.5 kg per bed day, while in Latin America it vanes from
1.0-4.5 kg per bed day. A recent study estimated medical waste generated at hospitals in Bombay, Delhi and
Madras to range from 0.85 to 2.25 kg per bed day.
Classifications of Medical Waste
4.
There arc several classifications used to categorize medical waste. WHO suggests the following:
General waste:
all non-hazardous wastes, similar in nature to domestic wastes.
Pathological
wastes:
tissues, organs, body parts, human fetuses, most blood and body fluids.
Radioactive waste:
solid, gaseous waste contaminated with radionuclides generated from
diagnostic or therapeutic procedures.
Chemical waste:
solid, liquid and gaseous chemicals used in diagnostic, experimental work or
cleaning and disinfecting procedures. For the purpose of waste handling,
chemical waste should be categorized as toxic, corrosive, flammable,
reactive or genotoxic.
Infectious waste:
pathogens in sufficient concentration or quantity that could cause diseases.
Sharps:
needles, syringes, scalpels, etc.
Pharmaceutical
waste:
pharmaceutical products, drugs, chemicals that have been returned from
wards, spilled, outdated or contaminated1
.
Pressurized
containers:
those used for demonstration or instructional purposes, containing gas,
aerosol cans.
Since there is an overlap between some of the categories, it may be advisable for developing countries
5.
to use the following simplified classification for practical reasons: i) general wastes; ii) sharps; iii) infectious
waste other than infected sharps; iv) chemical and pharmaceutical wastes; and v) other hazardous hospital or
Annex 10
Page 2 of 6
134
medical wastes. Limiting the number of categones to five instead of eight will limit the number of separate
waste collection and storage channels.
The Process of Waste Management
6.
In general, the process of medical waste management at a particular hospital could be viewed as
shown in figure 1:
Figure 1: Flow of Hospital’s Solid Waste
Source of
waste
Final
disposal
Temporary
* storage
internal
transportation
external
transportation
7. .
Source of Waste, ^aste can ke generated in the patient ward, operating room, or examination room
At this stage, infectious wastes, sharps and hazardous wastes will be segregated from general wastes and put
differenced1
dlSp0Sa1' 7116 se8reSatlon of medical waste will be done by putting the waste into
8.
JInternal Transportation. Internal transportation involves transporting the waste from the point of
generation
to the place of temporary storage within the hospital.
.
.
It IS important that all colored bags arc
securely fastened with adhesive plastic rape. The trolleys or carts must have surfaces which are smooth and
impermeable, that can be easily cleaned and drained, and that allow the waste to be easily loaded, secured and
unloaded. At all times, care should be taken to maintain bags i.in an upright position to prevent leakage.
'
Temporary Storage. A temporary storage facility should be provided by designating an adequate
storage area to store the waste separately in accordance with color coded bags before finally disposing the
wastc^ If an incinerator is located within the hospital compound, the storage point should be as close as
possible to the mcmerator sue The storage room should be kept secure, so that unauthorized persons would
not have access to the waste. Also, it should be kept out of the reach of animals, such as dogs cats and
rodents.
’
°'
ILvtema1 Transportation: External transportation involves transporting the waste from temporary
storage to the final the disposal site. If the final disposal site, for example, an incinerator, is within the
hospital compound then no special vehicle will be needed. However, in certain urban areas the state
governments have decided to have one incinerator serve several hospitals, and will make the necessary
arrangements for transporting the waste.
11;
.
dlsP°sal Of Solid Waste. Medical solid waste should never be disposed into water because of the
risks of'polluting the water with chemical and microbiological materials. Therefore, solid waste should be
disposed at a land site or by the use of an incinerator.
12.
Present Practice. Due to insufficient resources and/or lack of understanding about the effects of
medical waste, safety m handling medical waste has not been a priority in the health care system in Indian
states. A study of waste disposal in a rural teaching hospital in India revealed the following practices. Normal
waste was disposed in an open ground and burnt at irregular intervals. Disposable needles and plastic syringes
were discarded along with other general waste. Used surgical dressing, pads, cotton and gauge were disposed
135
I
Annex 10
Page 3 of 6
in open ground. Biological waste was treated more carefully, by disposing to the incinerator. Liquid or fluid
waste, including blood or other body fluids, was directly discharged into the sewer and sewage system
although the hospital was connected to the general municipal waste water system. Chemical wastes from
laboratories were washed off with water and discharged into the same waste water system. All types of
hospital waste were transported from the point of generation to the main storage through hospital corridors in
small uncovered buckets. The waste was not sorted before being transported. The hospital incinerator was
operated and maintained by an operator who was not trained with respect to desired temperature, retention
time, handling procedures, etc.. In the absence of relevant guidelines, any waste that was brought to the
incinerator was incinerated without sorting through the waste. Clearly much needs to be done to improve the
management of the waste disposal system at the hospital level.
i
Project Support
i
I
I
13..
'fhc project will support the improvement of medical waste management in a comprehensive manner.
This would mean that implemcnULion of existing policies and regulations would be supported with adequate
budget, liaming and nioiiiloi mg foi coinpliam c
Following a review of the existing practices, discussions with state, district and facility level
.14.
authorities were held to formulate a better approach for medical waste management. The issues discussed
included: systems development, development of a state-wide comprehensive plan for disposal of medical waste,
and an implementation plan. Key elements of such a plan to be adopted include: segregation of waste using
color coded contamers; improvement of transportation, storage and final disposal methods; and improvement
of the handler’s knowledge and handling skill through extensive traming. By improving waste management,
the risk of affecting human health or the environment would be minimized.
Systems Development
The project will support the development of a system to improve medical waste management. At the
State level, a Waste Management Unit will be set up and led by a person who has a management background.
This unit would be responsible for medical waste and related matters for the entire state, with its main concern
being the development of waste management policy, implementation strategies, coordination and monitoring
capacity. The expected outcomes of this unit would be as follow:
15.
!
•
•
Develop state level medical waste policy in line with the environmental protection policy;
Develop a comprehensive plan for the entire state, which would include all sectors concerned with
•
•
medical waste;
Review policy;
Coordinate inter-sectoral collaboration with regard to medical waste management, particularly in
•
•
urban areas;
Develop guidelines related to medical waste handling that include segregation, storage,
tianspoi talion and tinal disposal, and
Monitor implementation.
Al die district level, the District 1 Icalth Coiiuiultee would be die nodal point. Ihc expected capacities
16
on .medical waste matters arc as follows:
•
Supervisory capacity; to make sure that other hospitals or other primary care facilities at the
district area arc implementing the waste management system;
Annex 10
Page 4 of 6
136
•
•
•
Training capacity to provide training for staff who handle medical waste. For physicians, training
for medical waste handling would be integrated with the clinical skill training;
Logistics capacity for storage and distribution of bags and other supplies; and
Coordination capacity to coordinate thej use of incinerators for several hospitals, especially in
urban areas.
17
Facility Level. Each state has prepared a plan for improvement of the medical waste disposal for its
ealth facilities. This includes all first referral hospitals, tertiary hospiuls and primary care facilities These
facilities would segregate their medical wastes at the point of generation by putting infectious wastes, sharps
and hazardous wastes into different colored containers and different channels for disposal For the purpose of
mtemal transportation, closed storage bins with wheels and wheel barrows will be provided to all hospitals
under the project For final disposal, the states have proposed to adopt three methods: incinerators for large
institutions, purolators for small institutions, and bunal method in wells or pits for primary care facilities The
plan is provided in Table 1.
Features Specific to Each State
<8
Karnataka. Community/rural, sub-divisional and district hospiuls would be provided with colorcoded closed bins with wheels as conuiners for segregating medical waste. In addition, wheel barrows will
also be provided for transporting the waste to die temporary storage area.
^A^1Lh0SP'talS
50 bedS
ab°VC W11‘ bc insullcd with incinerators. For small hospiuls such as
3°?udCSd b°Sp,tals' thc statc
ProPOsed to provtde purolators. For large cities (i.e., Bangalore’ Mysore
and Hubh-Dharwad), the government has proposed to develop spec.al landfills specifically for the disposal of
medical waste. In these cities there arc many health facilities that could share thc use of these landfills instead
ln5^ll‘n« thclr °wn ‘numerators. It is also proposed tliat at a later sUgc thc operation and maintenance of
these landfills could be financed through cost-shanng among thc users.
20.
The Government of Karnataka has included the following specifications to ensure the safe operation of
the incmerators: (i) all emissions and residues should be pathogen free; (ii) chimneys must be designed and
constructed to remove combustion gasses effectively; (iii) incinerators must be safe to operate- and (iv)
incinerator capacity and feed rate should be adequate.
or small institutions, such as PHCs and sub-center hospitlas, there is no proper provision for garbage
removal by the local authorities, even for ordinary garbage. The Government has decided that at these
institutions deep pits will be excavated in their back yards which will serve as the final disposal for medical
waste. Under the project, specific guidelines will be developed and disseminated to these facilities.
22.
Punjab. At present no first referral hospitals are provided with incinerators. With project assistance
incinerators of various capacities would be provided to all hospitals based on their bed strength and the
amount of waste likely to be generated at these institutions. 30 to 50 bedded hospiuls will be provided with
™ ”,
23
hospiul!R1
400
”,h p«and 'h°“
At the primary care facilities, including sub-centers, PHCs and CHCs, the state would construct deep
,nStItUt,°nS 7110 project vviI1 suPP°rt development of guidelines, manuals
i
137
Annex 10
Page 5 of 6
24.
West Bengal. An assessment was conducted of waste disposal methods in several Calcutta hospitals.
The assessment recommended that hospitals should make their own arrangements in dealing with waste
generated, since training of municipal staff for this purpose would be difficult. The state has accordingly
proposed to adopt methods of medical waste disposal through the use of incinerators, purolators for steam
sterilization and K-type wells for the burial system. During the first two years the project will concentrate on
first referral hospitals. However, gradually the plan will include guidelines for tertiary and private hospitals
25.
Incinerators will be made available for districts hospitals and some sub-divisional hospitals^ where the
number of beds are larger than 300. In installing these incinerators, several guidelines from the government,
especially from the West Bengal Pollution Control Board, will be taken into consideration. For rural hospitals,
the state has proposed the use of the K-type well. The K-type well is well-lined with earthen rings or concrete
rings. The well has annular concrete steimng and is plugged at the bottom. A concrete cover with locking
arrangement will be provided on the top.
I
I
26.
Training. The Government of West Bengal has developed a strategy for conducting training on
medical waste management. Training of the hospital superintendents will be incorporated in the Hospital
Management Training Program; training for doctors, nurses and technicians will be integrated in the clinical
skill training program. A program for one day training at sub-divisional and district hospitals would be
developed for ward masters and sweepers.
Table 1: Waste Disposal System
Nature of waste
1.
2.
3
F
4
5
General Waste
Paper, kitchen waste,
residential,
hospital
campus waste
Sharps,
needles,
scalpels, scissors
Infectious waste:
Waste from operating
rooms, isolation rooms,
dialysis rooms, human
tissue, maternity wards,
etc.
System
Segregation1
of
Final Disposal
DJI.
.
Remarks
S.D.II.
C.H/R.II.
Color coding
Black bin/trolley
Disposable through
Municipal
. " system
,
i
Disposable through
Municipal system
Burial in land
fill or K-type
well
Special
container
for sharps, then put
into yellow bags
Incinerators
Incinerators
Incinerators
Staff handling
this type of
waste will be
trained
Incinerators
Incinerators
Incinerators
Staff handling
this type of
waste will be
trained
Yellow bag
Chemical________ and
Pharmaceuticals:
Dnig
section
or
hospital dispensary
Expired
medicine
will be returned to
companies or
disposed in yellow
bags
Incinerators
Incinerators
Incinerators
Staff handling
this type of
waste will be
trained
Other hazardous:
Culture from laboratory
Autoclaved
at
source and pul into
yellow bag
Incinerators
Incinerators
Incinerators
Staff handling
this rype of
waste will be
trained
Note: 0 the color of the bags or containers would vary by stales
UJ
oo
to
(TO
O\
>
S
E3
o M
i
139
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Annex 11
Page 1 of 8
EPIDEMIOLOGICAL SURVEILLANCE OF COMMUNICABLE DISEASES
AND HEALTH MANAGEMENT INFORMATION SYSTEMS
A. Epidemiological Surveillance of Communicable Diseases
1.
Epidemiological surveillance is the ongoing and systematic collection, analysis and
interpretation of health data in order to describe and monitor health events. Surveillance activities
include data collection, data compilation and processing, interpretation, actions taken and feed-back
(see Chart 1). llie project will address only major communicable diseases, and the diseases to be
monitored will vary by state. Explicit entena for these communicable diseases will be defined to avoid
any ambiguity in reporting by different institutions.
!
2.
Under this project, the states will establish a comprehensive and effective surveillance system,
which would aim at describing health events over time in a simple, flexible, acceptable, sensitive, and
accurate manner. The main purpose of this effort is to strengthen the capacity of district and stale level
health administrations to monitor major communicable diseases and to prevent an outbreak or epidemic.
I he development of a surveillance capacity and response capability for major communicable diseases
will focus on the following steps: identification through education of health workers and community
involvement, indexing of cases or isolation of cases and treatment^ and tracing of contacts for
monitoring and evaluation. In the long-term, however, the surveillance system would need to be
expanded to include preventive examinations and immunization of groups most likely to be infected; and
an enhanced response capability in case of outbreaks or epidemic. This project would fill some of the
gaps in the national disease programs by linking the three elements noted above and by providing
treatment at the secondary hospital level.
3.
In order to achieve these objectives, the states will institute the following approach: (i) enhance
data collection from various facilities; (ii) promote community involvement in data collection; (iii)
define and strengthen those organizational structures at district and state levels which arc responsible
for surveillance; (iv) strengthen the capacity and capability of district level health administrator to
analyze and interpret data; (v) enhance the district level health administrator capability to provide a
rapid response to problems; and (vi) strengthen collaboration between district and state level health
administrators and various service delivery facilities.
i
4.
A working group was established in each state to conduct an assessment of the existing
surveillance system. Currently, a basic surveillance system exists at the primary health care level at
public facilities in Punjab, Karnataka and West Bengal. This surveillance system covers subcenters,
PHCs and Block PHCs. However, at the secondary or tertiary level there is virtually no surveillance
mechanism. The diseases that are reported and monitored at the primary level are mostly vaccinepreventable diseases. Communicable diseases, which are treated at the secondary level, are therefore
not monitored by any institution.
Concept
Data Collection. The comprehensive surveillance system proposed in the project will cover all
health care facilities, both public and private, throughout the states. The working group recommended
that the existing surveillance activities at the primary care level be integrated into the proposed state
surveillance system. The system will collect information on specific communicable diseases from these
facilities through regular reporting forms. In addition to the routine data collection, special efforts arc
being proposed by the states. In rural areas of Punjab, information from the community level regarding
140
Annex 11
Page 2 of 8
communicable diseases will be collected by the multi-purpose health workers (MPHW, male and
female) during their routine field visits. West Bengal will introduce a stamped red card for quick
transmission of information when a case of communicable disease occurs. The card will contain
essential data (name, age, sex, address, etc.) of every patient who suffered or died from the disease. As
soon as a case is detected, the card will be completed by the health provider and posted to the District
Surveillance Unit. In Karnataka, taluka hospitals will monitor surveillance reports from primary care
facilities within their areas. Anganwadi workers, school teachers and Gram Panchayat members would
provide community level information for the surveillance system.
6.
During project preparation, the states designed formats for daily, weekly and monthly reporting
of the incidence and prevalence of the identified diseases. Before implementing a state-wide program,
these formats will be tested in a pilot area of each state. At the hospital level, the project will
strengthen foe information system on out-patients and in-patients. In addition, foe project will introduce
a surveillance mechanism which will enable reporting of certain communicable diseases which are
treated at foe hospitals through foe regular reporting system.
7.
Strengthening District Level. At the district level, a District Surveillance Unit will be
established. This unit will receive reports from vanous facilities within the districts, process and
analyze the data, and provide information on trends of the monitored diseases. The Unit will therefore
be able to pi ovide early warning signals of epidemic outbreaks and alert the other officials within the
district about the situation. The Unit will perform the following functions:
•
•
•
•
•
•
Act as a nodal surveillance unit at the district level, receiving regular reports from private
as well as public facilities (primary health care facilities and hospitals). In addition, the
Unit will receive red cards directly from health facilities, in case any communicable disease
is identified;
Analyze the data and review morbidity and mortality trends of the monitored diseases from
time to time;
Frovide early warning signals of epidemic outbreaks and alert the health officials about the
condition;
Coordinate with other related government agencies and local bodies, such as PWD, Fishery
Department, Irrigation Department, Indian Medical Association and Zilla Panchayat.
Assist local health facilities when there are increased cases, in order to overcome the
problem and prevent spreading of the disease to other areas; and
Send regular reports to the state level and provide feedback to health facilities.
8.
These district units will be headed by an epidemiologist and consist of sufficient technical -staff
including an entomologist, microbiologist, statistician and medical officers. The units will be equipped
with a computer and specific software (e.g. Epi-Info) to process the incoming data from public and
private facilities within the district. The program will provide information on morbidity and mortality
patterns of the specific monitored diseases. In the event of an increase in the number of cases or deaths,
necessary action will be taken immediately.
9.
State Surveillance Unit. A State Surveillance Unit will be established at the state level This
Unit will become a nodal office for epidemiological surveillance of the entire state. Chart 2. shows the
flow of reports of various facilities from the district level to the state level. In West Bengal, the State
Bureau of Health Intelligence (SBHI) will be strengthened and function as a state unit, while in
Karnataka, the state has proposed to transform the Health Intelligence Unit, presently functioning in the
Directorate of Health, into the State Surveillance Unit.
141
Annex 11
Page 3 of 8
1
i
I
10.
....................
" ~
_ for the District
Additional Staff.
Table 1 shows the staffing pattern proposed by each state
Surveillance Unit and State Surveillance Unit These posts will be filled through transfer of existing
staff and new recruitment. Karnataka has proposed the establishment of 20 District Surveillance
Units. About 100 additional staff will be required for these districts. These include entomologists,
micro-biologists, statisticians, medical officers and drivers. The district epidemiologist post will be
filled by existing staff. Punjab has proposed that all hospitals with 100 beds or more have a Health
Supervisor to fill out necessary report forms and undertake any case or outbreak investigation under the
supervision of a Senior Medical Officer or District Epidemiologist.
11.
Training. An extensive training program has been designed by each state to support the
effectiveness of the surveillance system. The training for District Epidemiologist and key officials of
State Surveillance Units will be trained at the National Institute of Communicable Diseases (NICD).
Health officials from various facilities will be trained at the distnet level (Distnct Surveillance Unit)
with focus on the surveillance system and familiarization with reporting forms. For community-based
reporting the training will be conducted by the District Surveillance Unit.
Features Specific to Each State
I
12.
Karnataka. The state will transform the Health Intelligence Unit, currently functioning at the
Directorate of Health, into the State Surveillance Unit. Presently there are several Joint Directors (JD)
dealing with communicable disease, i.e., JD of Communicable Diseases, JD for Malaria, JD for
Tuberculosis and JD for Leprosy. These Joint Directors are responsible for prevention and control
activities, including surveillance of these particular diseases. It was proposed that the status of Joint
Director of Communicable Disease, within the newly structured State Surveillance Unit, will be
upgraded to that of an Additional Director post (see Chart 2 of Annex 8). At the district level,
surveillance activities related to the project will be coordinated by the District Surgeon and existing
surveillance of the vertical program will continue to be monitored by the District Health and FW
Officer.
13.
Punjab. At the state level, an Epidemiological Ceil will be created and will be under the
coordination of Punjab Health System Corporation’s Director of Medical Management. At the district
level, the surveillance activities will be headed by Assistant District Coordinator, Administration.
14.
At the hospital level, there is currently no infrastructure for conducting surveillance of
communicable diseases. It is proposed that ail hospitals with 100 beds or more have a Health
Supervisor, who will fill out necessary report forms and undertake any case or outbreak investigation
under the supervision of the Senior Medical Officer or District Epidemiologist. This supervisor is also
to provide feed-back to the peripheral workers in the lower level facilities.
15.
With regard to surveillance training, the Corporation will train State and District
Epidemiologists at the National Institute of Communicable Diseases (NICD) for one month. The
training of the SMO and MO will be arranged at SIHFW Kharar, Family Welfare Training Center,
Amritsar, for a penod of 5 working days. Health supervisors and other staff will be given training
within their distnct for about 2 days. The period of training can, however, be increased depending upon
the feed-back received.
16.
West Bengal. At the state level, surveillance activities supported by the project will be
coordinated by Additional Director Health & Medical II (see Chart 6 of Annex 8). At the district level.
142
Annex 11
Page 4 of 8
it will be under the Assistant Project Officer, Administration. Opportunities for involving the private
sector will be explored.
B. Health Management Information System
17.
The Health Management Information System or HMIS is a mechanism for monitoring health
information which assists organizational needs, program implementation and momtoring, problem
solving, and system integration. The advantage of having an HMIS is that it allows for gathering,
processing, and analyzing of health data and provides quick insight into health performance indicators.
Tins in turn assists the implementation of programs that conti ibute to the improvement of health status.
Moreover, the improved data availability and linkage throughout the health care system allows for better
management and more efficient resource allocation. It also facilitates better monitoring of performance
indicators and surveillance of major communicable diseases
18.
Under the project, the state’s HMIS will be strengthened by: i) making provisions for the linking
and sharing of health data at the three health care levels through computerization; ii) improving the
hospital information system; iii) strengthening the district level capacity to analyze data; and iv)
providing training for data analysis and computer use.
19.
Computerization of HMIS. The states will install computers at three levels: state head quarters,
district levels and at selected hospitals. Information will be passed between all three levels and in the
long run the computers themselves may be actually linked through a network. At the state level, the
project will provide a Local Area Network (LAN) with a server and several work stations. This will
data from the districts; ii) analyze the data gathered; iii) provide feedback to districts; and iv) back-up
data allow the state head-quarters to: i) act as a nodal point for the compiling of gathered. The state
head quarters will also be responsible for development of software modules for the state-wide HMIS
and function as a training center for the district level. At the district level, one or more computers will
be installed to facilitate the entry of data from hospitals and perhaps PHCs. The district level HMIS will
also have limited capacity to analyze gathered data, before passing it to the state level. At selected
hospitalsx a computer would be installed which will assist patient admission and registration, patient
and hospital accounting, management of medical records, patients care, office automation, inventory;
and overall admimstration. Synthesized hospital data will be sent on a regular basis to the district level.
20.
Improvement of the Hospital hiloiiuation System, lhe states will improve the hospital
information system through: i) development of standardized formats for in-patient records, out-patient
cards, registration and other forms; ii) revision of monthly/annually reporting format to be submitted by
hospitals; iii) improvement of storage facilities for medical iccords, and iv) training of medical records
person. The project will provide computers for selected hospitals.
21.
Strengthening of District Capacity. In addition to computers installation, HMIS staff will be
trained to perform limited data analysis. The analysis will focus on evaluating performance indicators,
such as hospital activity, and efficiency indicators of all hospitals available in the district. However,
some analysis related to diseases surveillance will also be conducted by the HMIS staff. A software
package will be available at this level.
143
Annex 11
Page 5 of 8
Management
i
22.
In implementing HMIS, each state will have its own structure arrangement as shown in Charts
2 to 6 of Annex 8. The structure will consist of two layers, district level and state level. Punjab and
West Bengal will have special directors responsible for the HMIS, while in Karnataka HMIS will be a
part of the Hospital Directorate. The following paragraphs will explain specific arrangement for each
state.
23.
Karnataka. At the district level, HMIS will be under the management of the District Surgeon.
The District Surgeon will have several responsibilities that are project related, including monitoring the
referral system, planning and monitoring training activities, and surveillance of communicable disease.
At the state level, a Deputy Director will be appointed to manage the state HMIS unit. This unit will
maintain performance indicators of 202 hospitals included in the project. The Deputy Director will
report directly to the Joint Director of Hospitals.
i
24.
Punjab An Assistant District Coordinator, Training, will be appointed al the district level to
administer several activities, including HMIS, training and medical records. He or she will report
directly to the District Coordinator as shown in Chart 5 of Annex 8. At the state level, there will be a
special director, Director ME and HMIS, who will be responsible for the monitoring, evaluation and
information system.
25.
Wc$t Bengal. At the district level, HMIS will be placed under the Assistant Project Officer for
Administration. This officer will coordinate several project activities including the improvement of
HMIS, surveillance, referral system, and waste management. At the state level, an Additional Director
HMIS & IEC will be responsible for the development of HMIS in the whole state.
I
i
Annex 11
Page 6 of 8
144
Chart 1: Surveillance Elements
Collection of Data
Compilation of Data
Processing & Analysis of Data
Investigation Required
No
Feedback
Yes
Action Taken (Inference)
Remedial Measures
Annex 11
Page 7 of 8
145
Chart 2 : Proposed Flow of Reports
Occ'urrciK'e of lien Illi Event
Diagnosis
Public
F
E
E
D
B
A
C
K
&.
D
I
S
S
E
M
E
N
A
T
O
N
Reporting Sources
I
I
I
I
I
I
I
Physicians
Laboratories
Hospitals
Schools
Vital Records
1
Reporting Process
Data Recipients
I
I
I
I
I
I
I
I
▼
Prittuiry l.tvtl
(PHCs)
Secondary Level
(District Surveillance Unit
I
I
I
I
I
I
I
i
I
I
I
I
I
I
I
I
V
Tertiary Level
(State Surveillance Unit)
I
I
I
I
I
I
I
I
D«U MaiugcniDiU
Collection
Initial entry
Editing
Analysis
Report generation
Report dissemination
Annex 11
Page 8 of 8
146
Table 1: Staffing Pattern for Surveillance Systems
Punjab
__________ Karnataka
District Surveillance Unit
Micro-biologist
Ass. Entomologist
Ass. Scientific
Ass. Statistic
Typist
Insect collector
Health Supervisor
Ass. Health
Medical officer Health
Entomologist
Insect collector
Health assistance [M &. F|
Driver
West Bengal
State Surveillance Unit
Deputy Director Malaria
Epidemiologist Malaria
Dislnct Malaria Officer
Medical Officer
Entomologist
Insect collector
Table 2: Major Communicable Diseases To Be Reported
Karnataka
2
3
4
5
6
7
Punjab
Japanese Encephalitis
Kyasanur Forest Disease
Cholera
_1_
2
Gastro-ententis
Plague_______
Tuberculosis
Malaria.
4^
_5
6_
7
3
West Bengal
Poliomyelitis______
Measles_______
Tetanus:
a. Neo-natal tetanus
b Others_________
Viral Hepatitis
Polio________
Measles_____
Viral hepatitis
2
3
£
5_
6_
7
Diphtheria
| Entenc Fever
Japanese encephalitis_______
Tetanus (neonatal and others)
Table 3: Cost of UMIS in Project States
___________ PUNJAB____________
Stale Level I Dirtnct Level | Hotpitali
Facihtv
si 00.000
Computer Equipment
S41.000
Software
S 16,000
$77,000
$30,000
Stx£T (2 yn )
Op«r /Kacux
Tiauune
S 10,000
Tool Suo-Leveli
$219,000 |
TocU Ovcrsil
1140.000
SM.000
Stale Level
WEST BENGAL
Diitnct Level I
KARNATAKA
Uosp«(ala
State Lcvei
Dutnct Lcvd
H«a*(tah
$100,000
$200,000
$102,000
$500,000
$410,000
$41,000
$60,000
$17,000
$10,000
$16,000
$10,000
$260,000
$240,000
$40,000
$140,000
$100 000
$170,000
$14,000
$41,000
$14,000
$16,000
$72,000
$72,000
$30,000
$10,000
$234 000
$757,000
».000
$10.000
S24J.OOO
$219 000
$50,000
$15.000
$104.000 |
$1.673.000
$20.000
$1,010,000
$10,000
$219,000 |
$15,000
$215,000
S1.124.00Q~
$ 10.000
S550.000
147
Annex 12
Page 1 of 3
INFORMATION, EDUCATION AND COMMUNICATION STRATEGY
1.
The information, education and communications (IEC) component of the proposed
project will serve as a vital link between the various activities of the project, such as the
referral mechanism, the tribal strategy, the gender component, and the beneficiaries of the
project. Specifically, the objectives of quality improvement and increased accessibility to
health care services require an enhanced level of knowledge and awareness amongst the
beneficiaries which can be facilitated by a well-designed and effectively implemented IEC
component. The IEC strategy, including target groups to be addressed, key messages to be
transmitted to each group, and media to be utilized, has been fine-tuned on the basis of the data
obtained from the Beneficiary Assessment studies undertaken in each state. An assessment has
also been made of the manpower and other resources required to implement the strategy, and
the administrative and management arrangements within the DOHFW and PHSC which will be
• utilized to coordinate the development and implementation of the IEC strategy. The linkages
between the IEC component and other project components which will be addressed directly by
IEC, such as the referral mechanism surveillance system, the quality assurance program and
■ the tribal strategy, have been clarified.
Objectives
2.
Improving Access to Health Services. Access to health services is dependent not only on
physical distance and cost factors, but also on the levels of awareness and confidence that exist in
the minds of the beneficiaries - particularly Scheduled Caste/Scheduled Tribe (SC/ST) and other
disadvantaged groups — with regard to the quality of services provided by the health care facility
and its staff. An important dimension of this is the sense of "care, courtesy and comfort" that
patients perceive throughout their interaction with the health care system. Enhancing the
willingness of beneficiaries to seek health care in a timely manner would be an important objective
of the project.
3.
Improving System Performance and the Quality of Services. The provision of additional
facilities, equipment and clinical as well as technical training is expected to result in a significant
improvement in the quality of service delivery. In this context, the IEC strategy will interact
closely with some of the key components of the proposed project to enhance their efficiency and
effectiveness. For example, IEC will be used to disseminate information on the functioning of the
referral mechanism to be strengthened under the project, and reduce wastage of time and resources
by directing patients to the appropriate level of care. The IEC component will also form linkages
with the surveillance system and HMIS which will be put in place under the project. This will give
the IEC agency access to vital information regarding the prevalence of communicable diseases and
other vital information in the states. Such information can be utilized to target IEC messages more
effectively. The IEC strategy will also take into account tho objectives outlined by the tribal
strategics for health in Karnataka and West Bengal It will be ensured that the design of the IEC
component assists in achieving the objectives of the tubal strategy
I
I
4.
Improving Efficiency in the Allocation and Lse of Health Resources. Since resources are
currently being used to provide free services to some people who can contribute to the costs,
allocative efficiency will be improved by increasing the health system's capacity to recover a part
of these costs. However, willingness to pay is a function not merely of ability to pay but also an
assessment of what is being paid for. The communications strategy would contribute to allocative
efficiency by raising the willingness of specific groups to pay user charges for selected services.
148
Annex 12
Page 2 of 3
Communications Strategy
5.
Six broad strategies are proposed for the component: (a) increase awareness of the
services provided by first referral hospitals, particularly among lower income and
disadvantaged groups (such as tribals), and thereby increase utilization of the system;
(b) improve access to the expanded range of all reproductive health services among women;
(c) motivate all hospital staff to maintain good standards of patient care in terms of “care,
counesy and comfort” so that the quality of services received by patients is enhanced;
(d) sensitize hospital staff to hospital equipment maintenance issues; (e) promote hospital
services to specific groups in a manner that increases their willingness to utilize these services
and, where possible, to share in the costs of service delivery; and (f) address specific public
health issues in each state such as road safety, alcohol abuse, healthy diet (particularly in
Punjab), women’s issues etc.
6.
The strategy has been developed on the basis of decisions made with regard to:
• (a) identification of target groups; (b) selection of messages; and (c) selection of media. The
rationale for each of these categories is as follows:
7
Target QrQupg. Five groups will be included in the target audience. Eirsi, government
functionaries working at the grass roots level - anganwadi workers, gram sevikas, school teachers,
agricultural extension workers and multipurpose health workers — would be targeted for
information pertaining to die availability of different types of health care al different levels within
the health care system. These workers arc likely to be seen as opinion leaders by the populations
dicy serve and dicy can be key information sources in spreading knowledge about the availability
of services and the referral system. Second, women would be considered as a priority target, since
their access to health facilities is comparatively low. They arc, in addition, managers of the health
status of the household and have demonstrated their ability as a group to mobilize the community.
Third, patients who enter the hospital system would be considered a priority target. Their word-ofmouth based on their first-hand experience will carry far more weight than any other channel of
communication. The imperative of creating satisfied customers, and thereby expanding the demand
for services, particularly in tribal areas, must be recognized for the communication strategy to
succeed. Fourth, private practitioners and NGOs would be targeted because of their potential role
in referring patients, and because they should be aware of the improved standards of care in first
referral hospitals. Fifth, the population in the Sunderban Area of West Bengal and SC/ST groups
in Karnataka will be targeted, to raise awareness in those communities of the increased access to
and improved quality of primary health care services now available to them.
8.
Messages. The content of the messages that comprise the IEC strategy will vary based on
factors such as geography, seasonality and local considerations, for example, in Punjab, where
the incidence of non-communicable diseases such as cardio-vascular disease and cancer is
particularly high, IEC will focus on prevention and treatment of such diseases; in Karnataka,
where there is a relatively high incidence of traffic accidents, IEC will focus on issues of road
safety as well as the availability of emergency facilities at first referral hospitals. In Karnataka
and West Bengal, where tribal populations are significant project beneficiaries, IEC will focus on
disseminating information to tribal groups about service availability, timing of OPD and other
facilities, user charges and the referral mechanism.
149
Annex 12
Page 3 of 3
9.
Media Selection. Media selection would depend upon the outreach of different media to the
various target groups. One of the most important media for the IEC strategy is the employees of
the health care institutions. The manner in which they treat outpatients, inpatients and visitors will
have the greatest impact of all the possible channels that may be employed. It will, therefore, be
essential to provide training on communication and education to staff on patient and visitor
handling. Training modules are being developed for this purpose. Further, training inputs will be
sustained and supplemented through penodic internal '’campaigns" to remind employees of their
role in delivering quality health care. For the potential beneficiaries, the priority medium would be
functionaries working in health and related sectors, who will be given in-house tours to enable them
to understand the changes that have been instituted within the hospitals. Such tours would also be
arranged for the elected Gram Panchayat and Zilla Panchayat representatives. The IEC strategy
would also focus on penodic waves of pnnted communication to higher levels in the Health
Department and in hospitals. Finally, the use of well-designed signs within hospitals, as well as in
PHCs, providing information on what services are available and where, would be used as an
efficient and low-cost medium.
. Implementation
10.
There is a full-fledged IEC wing functioning within the Health Department of each state.
However, they have been focusing on Family Welfare and MCH related activities. There is also a
Health Education wing functioning under the Health Department. This wing will provide support
to the IEC wing in the development and implementation of the IEC strategy. In addition,
professional communications agencies will also be used on a contractual basis to develop IEC
materials and will coordinate their activities with an official designated by the IEC wing to the
project.
11.
In Karnataka, the IEC strategy will be coordinated by the Deputy Director (Hospitals
North) and Deputy Director (Hospitals South) at the state level. At the district level, the Mass
Media officer v.ould be in charge of disseminating IEC material and would report to the District
Surgeon, who serves as the coordinator of all project activities at the district level.
12.
In Punjab, a new post of Deputy Director, IEC (mass media) has been created at the state
level. This officer would work under the Director M&E and HMIS. The Mass Media Officer at
the district level would be responsible for dissemination of IEC material in a particular district, and
would report to the Deputy Medical Commissioner.
13
In West Bengal at the state level, IEC is the responsibility of the Additional Director,
HMIS and IEC, who would report directly to the Project Director. At the district level, the Mass
Media Officer would be responsible for IEC activities in a particular district, and would report to
the District Project Officer, who would coordinate all project activities at the district level.
Timing
14.
It is proposed that communication activities will be commenced in a phased manner. Some
aspects of the IEC strategy, such as the public health and gender components, would begin early in
project implementation. More project specific aspects will be implemented after enhancement of
physical premises, equipment upgradation and manpower development steps have been completed
since prematurely initiated IEC activities can be counter-productive.
150
Annex 13
Page 1 of 5
TRIBAL AND UNDERDEVELOPED AREAS STRATEGY
1.
Introduction. In both Karnataka, with a 3.3% Scheduled Tribe population, and West
Bengal, with a 5.9% Scheduled Tribe population, tribal peoples would be substantial beneficiaries
of the proposed project. Punjab does not have a tribal population. During project preparation, a
number of workshops' were held to facilitate stakeholder identification of health care problems in
rural as well as tribal areas as well as to develop, through a process of consultation, an appropriate
tribal strategy for Karnataka and West Bengal. In addition, Beneficiary Assessment studies,
involving the informed participation of tribal groups, have been undertaken in tribal and rural areas
of Karnataka and West Bengal and have: (i) provided a social context analysis for establishing the
current distribution of and access to health care facilities in rural and tribal areas; (ii) provided an
institutional analysis to understanding the supply factors which adversely affect health care
utilization; and (iii) assessed the perception and attitudes related to health needs and health seeking
behavior of tribal populations (see Annex 17 -- Social Assessment).
2.
Health Awareness and Related Behavior Among Tribal Populations. An important finding of
the study is the low hospital utilization rates of the tribal and rural population in both Karnataka and
West Bengal. The study also focused on the following issues in the two states:
•
I
i
Physical Access. Clearly, hospital services provided by the Government are inadequate in rural
areas. Distance traveled to reach first referral hospitals seems to be an important factor in
determining utilization. Community hospitals in tribal areas are located very far from tribal
hamlets, with poor transportation and communication facilities, and often with no convenient
residential arrangements for the medical personnel. Non-availability of staff, particularly
doctors, is stated to be the most important reason for preferring private medical care over
Government hospitals. In addition, the insensitivity of medical personnel strongly influences
the community’s confidence in them. Especially in emergency situations, the easy accessibility
and ready availability of quacks or underqualified doctors is a major determining factor of
community preference for their services. Another important issue is (he non-availability of
necessary drugs and medicines at first referral hospitals, particularly for curative care, which
has been identified as a major constraint to patient satisfaction. The community, however,
seems to be willing to pay for the medicines provided by the hospital staff.
Social Access. Results from the qualitative survey conducted in the two states indicate that
tribals have a special set of social beliefs and practices which affect their health seeking
behavior. “Illness” was perceived as an inability to discharge one’s daily duties. Illness was
reported earlier amongst children than adults. Gender differentials were less common until the
age of 12, alter which it was observed that illness among girls was reported late. An estimated
30% of tribals still approach the traditional healer first, and go to a hospital only if the
treatment provided by him is ineffective. Communities seemed to be generally better aware of
causes responsible for fevers (sunstroke, mosquito bite), diarrhea, dysentery and jaundice
(polluted water and food). However, chicken pox, measles, leprosy and epilepsy were ascribed
to supernatural powers. Consequently, more money is spent on rituals and traditional healers
for the latter diseases. In the case of diarrhea, a doctor is consulted within a day or two of onset
if there is no improvement in the patient’s condition, since the community is aware that diarrhea
could be fatal. Children suffering from measles and chicken pox are kept secluded, and a paste
of neem leaves and turmeric is applied on the body- followed by a bath and rituals. Persons
151
Annex 13
Page 2 of 5
suffering from TB and leprosy are isolated since the community perceives them as being
dangerous to their health.
•
Economic Access. The data show that substantial costs ~
—
~ on
on fees,
fees, drugs,
drugs, tests
tests and
and transport
transport —
are being incurred by tribals and disadvantaged populations possibly because they postpone
treatment until the problem has become very acute.
In addition, due to the relative
inaccessibility of Government health care services, these populations are approaching the
private sector for their health care needs. However, a majority were of the opinion that,
although private hospitals offered modern equipment and convenient service, the costs of
treatment were prohibitive, and few of them could afford to consistently visit a private
practitioner. Moreover, it was felt that the private practitioners commitment to low-cost
preventive care was minimal, and that in the case of emergencies a Government hospital was
much more likely to provide efficient service.
3.
Tribal and Underdeveloped Areas Strategy. The project's tribal and underdeveloped areas
strategy in Karnataka and West Bengal is aimed at increasing the demand for hospital services in tribal
and underdeveloped areas by improving the quality of services provided; by providing effective IEC to
belter infoim tribal populations pl the benefits ol using health services at secondary hospitals; and by
providing primary care services at selected sites. I he number of beds at sub-divisional and community
hospitals located in tribal and underdeveloped areas will be increased to reflect a share of beds at
secondary hospitals dial is much more commensurate with their proportion in the overall population of
the states. In addition to increasing the bed strength in tribal and underdeveloped area hospitals, the
project would: (a) strengthen linkages between primary and secondary health care services; (b) provide
an incentive package to doctors and other medical staff in tribal and underdeveloped areas to encourage
them to accept assignment in these areas; (c) increase the appropriate utilization of non-tnbal medical
systems by the tribal population; and (d) reduce the cost to tnbals and disadvantaged populations of
utilizing the system.
4.
‘
Specific
project components have been developed in both Karnataka and West Bengal on the
basis of this information, and these are described below.
West Bengal
5.
Of the total West Bengal population of 68 million (1991), 3.8 million or 5.9% are STs. 5
large ST communities — Santhals, Oraon, Munda, Bhumij, and Kora — constitute 84% of the state’s
ST population. There are 35 other smaller groups of tribals dispersed across the state, of whom 3
have been designated as primitive tribal communities.
6.
The Government of West Bengal has had a Tribal Welfare Department looking into the
special needs of tribal peoples since 1952. This department was subsequently renamed the
Scheduled Castes and Tribes Welfare Department in 1967, and has initiated and implemented
several programs in education, including grants and scholarships; construction of schools and
hostels, provision of books, clothing and mid-day meals; economic upliftment including
development of land and irrigation facilities, supply of seeds and fertilizer, soil conservation, and
cottage industries; social sectors, including provision of medical facilities, drinking water supply,
houses and house-sites, legal aid, and provision of grants-in-aid for voluntary agencies working
with tribal peoples.
1
Annex 13
Page 3 of 5
152
7.
Access tp Health Services in Tribal Areas. According to GOI service delivery norms for
tribal areas, a sub-center is to be provided for every 3,000 population and a PHC for every 20,000
population, as against a norm of a sub-center for every 5,000 population and a PHC for every
30,000 population in other rural areas. There are now 303 sub-centers, 47 PHCs and 28 rural
hospitals located in the tribal areas of the state. The Government plans to set up additional sub
centers and PHCs to bring their numbers up to the population norms.
8.
Services provided in these health facilities include disease control, such as malaria, filaria,
tuberculosis, gastroenteritis, Japanese encephalitis and kala-azar; other preventive programs;
maternal and child health programs; and ayurvedic and homeopathic treatments.
9.
Proposed Strategy for Improving Access to Quality Health Care. The following are the
project activities in support of the tribal strategy described in para. 3:
•
.
strengthening health care delivery in tribal areas. A large section of tribal and disadvantaged
peoples still depend on traditional healers, or sometimes the local quack, since they do not have
adequate access to public health services and cannot afford a qualified private doctor. In order
to address this issue, under the Sunderban plan, all 28 rural hospitals located in underdeveloped
areas will be strengthened under the project. In addition, 17 hospitals located in areas with a
sizable tribal population will also be strengthened (see Annex 19).
•
strengthening linkages between primary and first referral health care services. The available
evidence points to the urgent need to strengthen linkages between primary and first referral
levels of health care, particularly with respect to the referral of tribal and disadvantaged
patients. Special effons would be made to disseminate referral administrative guidelines and
referral protocols to primary health centers in these areas. The Zilla Parishad would also
construct rest-houses close to the first referral hospitals for the convenience of patients and their
families who have been referred to hospitals far from home, requiring an overnight stay.
Transport would also be provided free of charge from the referring facility to those patients
who cannot afford the cost of public transport.
•
increasing incentives for medical staff in tribal and underdeveloped areas. Staff would be
provided incentives to increase their commitment to serving in tribal and underdeveloped areas
in a variety of ways. Additional staff quarters will be provided to all grades of staff with the
construction of new staff quarters in tribal areas. Other benefits, such as extra credit to doctors
and other staff for PG qualification admission and for fellowships; enhanced opportunities for
transfer to urban areas after serving in a tribal area for 4-5 years; and preference to the children
of doctors in tribal areas for admission in Government-run schools. This would encourage
doctors and staff to work in tribal and underdeveloped areas and provide quality services. This,
in turn, will increase the credibility of the health care system for tribal and disadvanuged
patients and encourage them to approach health care facilities more readily, when necessary.
•
increasing the appropriate utilization of the government health services delivery network by
tribal and disadvantaged populations. An important intervention aimed at encouraging the
health seeking behavior of tribal and disadvantaged populations is an IEC program targeted
particularly at increasing their awareness of disease. The IEC program would also increase the
awareness and sensitivity of medical staff to tribal customs and culture, as a means to
pH
IOO
^6
153
Annex 13
Page 4 of 5
improving the client-provider relationship in tribal
areas and promoting the level of comfort that
tribal peoples feel in the health facility.
"carT^sum
di*adv“nta8ed P°P“^ons of utilizing the first referral health
care system. The analysis clearly shows that the poor, including tribals, are bearing a
disproportionate burden of health care costs (see Annex 17) and they will be exempted from
user charges, particularly for drugs and tests, which constitute the major share of ex^nditures
incurred a Government health facilmes (see Annexes 5 and 17). The rest houses to be provided
by the Zilla Panshad, mentioned earlier, will also contribute in the reduction of ihe cost
burden. In addition, the Government will coordinate with NGOs, where possible, to provide
transportation and/or food to needy patients and attendants.
Karnataka
Thev , J
PuP n110" *n Karnataka is about 2
or about 3.3% of the state’s population
They are geographically d.spersed across the state, and are not a homogenous populationP Some ST
households who live in the plains are quite modern and well integrated with the rest of the
population. Such households have considerably improved their economic and social position
However, other STs are primitive tribes, many of them hili and forest dwellers. The health
indicators amongst this latter group tend to be very poor, due to their isolation and poverty.
J?
cr" 0Veural‘asseussment clear‘y indicates that there is need for special targeted interventions
b .7
L , th‘n thCSe immunities, there is a special need to improve access to and quality of
neaith care delivery for women.
7
2L U Pr°posed Slralesy for Improving Access to Quality Health Care.
The tribal and
underdeveloped areas strategy to be implemented in Karnataka will include components similar to
the ones proposed in West Bengal. In addition, the Government of Karnataka proposes to
implement a well-designed program of primary care interventions to improve the availability of
eaith services for SC/ST households residing in rural areas.
A major activity planned in this
context would be a system of annual health check-ups for all SC/ST families, which would include(a) physical exammation, includmg pulse, B.P., eyes, ears, nose, teeth, longue, skin disorders'
disabilities etc.; (b) systemic examinations, including cardiovascular, respiratory etc.; (c) simple
laboratory investigations; and (d) special examination of women, including pelvic examination and
FW services. A record of the health check-up would be maintained in a master register and each
individual would be issued a health check-up card free of cost.
Lm IrnPlementatlon Plan- The state has a large network of 7,793 Auxiliary Nurse Midwife
(ANM) sub-centers which on average cater to a population of about 3,000 persons, of which about
40 would be tribals. The medical check-up will be scheduled in Health Check-up Camps to be
organued in the ANM sub-centers according to a timetable to be drawn up by the District Health
an Family Welfare officer. A team of medical professionals consisting of the Medical Officer of
the Primary Health Center (PHC); Lady Medical Officer specially drafted for this purpose from a
Government hospital; laboratory technician; Lady Health Visitor; ANM; and one para-medical staff
would then visit the sub-center on the scheduled date. The team would carry with it such
equipment and other materials as are required for a thorough medical check-up. Doctors and other
StaHf,W0.U d ,Ut‘1Ze the PHC vehlcle where feasib'e. Where such a vehicle is not available, a vehicle
will be hired for transporting staff and equipment to the camps.
1
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Referral. Cases requiring further treatment would be referred to the nearest Government
14.
hospital where appropriate facilities are available. A referral card would be issued to the patients,
and such patients would get free treatment at referral hospitals where necessary.
15.
Information, Education and Communication (IEC) campaign. Prior to the date on which
the health check-up is scheduled in a particular village, the ANM and male health worker would
make house to house contact with each SC/ST household and provide information regarding the
venue, timing and purpose of the health check-up. A particular target for IEC activities would be
women, since they are less likely to avail themselves of the facility provided. This would ensure
that the maximum number of households attend the camp. The camps would also be a good venue
for IEC activities relating to the ci-semination of general public health issues.
16.
Dru^s and Medicine*. Based on an average ol Rs. 10 per person towards drugs and
medicines to be dispensed al die lime ol (he check up, an amount of Rs. 500 will be allotted for this
purpose to each camp.
Lady Medical Officers (LMOs). In some districts, particularly in the Hyderabad - Karnataka
17.
region, adequate numbers of LMOs are not available in the Government sector. Given the
imponance of the LMO in encouraging women in SC/ST communities to seek health services at the
camps, the services of available lady doctors in the district hospital would be utilized for the check
up. In some cases, the services of private lady doctors available at the district and sub-divisional
levels will be utilized, with the payment of an honorarium of Rs. 300.
II
18.
Pilot Introduction of the Scheme. It is proposed to introduce this scheme in the 5 districts
of Mysore, Hassan, Kolar, Bijapur and Raichur during the first year of the project. It would
subsequently be extended to the districts of Belgaum, Chitradurga, Dakshina Kannada, Gulbarga
and Bellary. Before extending the scheme to the next set of districts, an impact analysis of the
scheme on the access of SC/ST families to health care delivery, and on the improvement of their
health status would be conducted.
I
I
1
19
Monitoring and Supervision. The PHC Medical Officer will be responsible for the
implementation of the scheme. The work done by the PHC MO will be monitored by the newly
designated Taluk Level Medical Officers. A District Level Committee will be constituted with the
CEO, Zilla Panchayat as Chairman. The composition of the Committee will be as follows.
Chairman: CEO, Zilla Panchayat; Members: District Surgeon; Principal of the local medical
college; District Information Publicity Officer; Representatives of 2 voluntary organizations;
Assistant Director, Women and Child Development; and District Health and FW Officer.
20.
The Committee would: (a) review progress of the scheme on a monthly basis; (b) arrange
wide publicity for the camps; (c) secure full involvement of voluntary organizations; and
(d) approve expenditure incurred. A monthly progress report would be sent to the Joint Director
(Planning), who would be responsible for monitoring and reviewing the scheme at the state level.
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SOCIAL ASSESSMENT
1.
Background and Objectives. Between February, 1995 and October, 1995, a number of
studies were conducted as part of project preparation in Karnataka, Punjab and West Bengal.
These studies collectively comprise the Social Assessment (SA), and include the Beneficiary
Assessment and the Review of the Private Sector. The SA was undertaken in an environment of
intense collaboration between the World Bank team; local research organizations including the
Administrative Staff College of India (ASCI), the Foundation for Research on Underprivileged
Groups (FRUG), and Operations Research Group (ORG); the respective state Governments; local
Government; and representatives of NGOs and the private sector.
2.
Components. The SA had four components: (i) a social context and institutional analysis,
identifying and selecting specific areas within each state that are geographically, socially and
’ culturally distinctive, differentiating between rural and urban areas, and describing and analyzing
the organizational and legal framework of the health care network in the state, (ii) an analysis of
health needs, including an analysis of service utilization of both private and Government health
• services differentiated by income level, gender and social grouping (Scheduled Caste/Scheduled
Tribe), and an analysis of the access and coverage of both traditional and allopathic systems of
medicine in the more remote areas of the state, especially for more disadvantaged and tribal
groups; (iii) an assessment of health seeking behavior amongst women and tribal populations, and
(iv) a review of the role played by the private sector in health care provision, including the scope of
the private sector, the role of NGOs, and the opportunities for contracting-out support services to
.the private sector.
3.
Stakeholder Participation. An important aspect of the SA was the involvement of key
stakeholders
Preparation of the project devoted special attention to facilitating a sense of
ownership and commitment of those involved in the process. They included: (i) the Government of
India (GOI), state Governments and agencies responsible for project implementation; (ii) the
beneficiaries, i.e., the individuals, groups and communities who would benefit from the proposed
intervention; (iii) women, scheduled castes (SC) and scheduled tribes (ST); and (iv) others with a
vested interest in development initiatives, including other donor agencies, NGOs, religious and
community organizations, local authorities and the private sector.
4.
A number of participatory activities were incorporated into project design:
2
three
preparationi workshops, organized by GOI, involving central and state Government
officials, including the Health Secretaries of 11 participating states; representatives from
WHO; the National Institute of Public Finance and Policy; the Gujarat Institute of
Development Research; ASCI; the Indian Institute of Health Management and Research; the
All India Institute of Hygiene and Public Health; and the IDA team were held in Hyderabad in
November, 1994, in Jaipur in February, 1995, and in Shimla in June 1995, in which the group
discussed health sector issues with regard to financing and implementation and agreed on a
strategy for future activities;
•
I
beneficiary assessments were conducted in each state, with Terms of Reference agreed with
IDA, to determine the level of service availability; undertake a social context analysis of the
geographically, socially and culturally distinctive features of each state; undertake an
institutional analysis to understand the supply factors influencing health care utilization;
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determine the health needs of communities, particularly women and SC/ST populations; study
the social, physical and economic constraints to access to health care; and estimate the private
costs of seeking treatment;
•
private health sector studies were also conducted in each state, with the intensive participation
of private medical professionals, to understand the scope of private sector involvement in
health care delivery; the role of NGOs in the health sector; the coverage and cost of alternative
systems of medicine; the potential for contracting-out services, particularly support services, to
the private sector by the Government; and the cunent level of regulation and monitoring of the
private sector.
•
technical norms workshops were held in Bangalore, Chandigarh, and Calcutta to develop and
reach a consensus on service norms for the different tiers of the health system viz. the
community, sub-divisional and distnet level hospitals. Participants included officials from the
Directorates of Health of the respective states, private medical practitioners, members of the
academic community, the project preparation teams and members of the IDA mission.
Subsequently, training workshops were held in Karnataka and West Bengal involving state
medical officials, academics, and private practitioners, to determine the training needs for
medical personnel from different disciplines functioning in different tiers of the health system;
•
•
the participation of local NGOs was encouraged in all states. In Karnataka, for instance, an
NGO functioning in the tribal areas of southern Karnataka participated in discussions between
the Government of Karnataka and the IDA mission. In West Bengal, the IDA team discussed
the scope of NGO work with the Tagore Society in the Sunderban area. Similar discussions
were held in Punjab. Useful suggestions were made in all cases with regard to health care
delivery for underprivileged groups.
5.
Methodology. The studies were designed to provide answers to a scries of questions which
would enable the project preparation team to fine-tune the proposal to best serve the felt health care
needs at the community level. Some of these questions were: Who are the stakeholders? Are the
objectives of the project consistent with their needs, interests and capacities? What social and
cultural factors affect the ability of stakeholders to participate or benefit from the intervention
proposed? What will be the impact ot the project on women and vulnerable groups? What arc the
social asks which might affect the success of the project? What institutional and management
arrangements are needed for participation, and is there a plan for building capacity at the
appropriate levels?
6.
A multi-pronged strategy was adopted to gather the information required for the SA. The
basic demographic, epidemiological and socio-economic data were gathered from secondary
sources. These included the Statistical Abstract and Medical Directory of each state for data
regarding the availability of medical services, utilization of services and other hospital-based data;
National Sample Survey (NSSO) 42nd. round for discussions on rural-urban differentials in health
facilities, public-private health facilities, paying-non-paying wards and cost differentials;
Household Survey of Health Care Utilization and Expenditure (NCAER, 1995) for an
understanding of the morbidity pattern at the state level and health care utilization and expenditure;
and secondary information from selected health facilities on the availability of services, drugs and
infrastructure.
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7.
Primary data consisted of quantiutive data regarding the supply factors affecting health
service delivery, linkages between traditional and allopathic medicine, physical, social and
economic factors affecting utilization of health services, and cost of treatment; and qualitative data
regarding the relationship between health, nutrition, saniution, and hygiene, social services
currently being offered by the Govcmment/NGOs, health needs of the community, perception and
attitudes related to health seeking behavior, gender differentials in health seeking behavior, and the
cost of seeking treatment. The primary data was generated in a variety of ways: through
participatory observation, interviews, case studies, focus group discussions and rapid rural
appraisal.
8. Health Status in the Three States
Karnataka. The population of Karnataka in 1991 was about 45 million, with urban areas
accounting for about 31 percent of the population. Scheduled Castes and Scheduled Tribes
formed 16.4 and 4.0 percent respectively of the population. 40% of the population is below the
poverty line compared to about 33% for India as a whole.
•
In Karnataka, the birth rate of 26.3, death rate of 8 and infant mortality rate of 67 per
thousand live births compares to the national averages of 29.3, 9.8 and 80 per thousand live
births respectively. However, neonatal and post natal mortality and still birth rates have
increased during the late 80’s and early 90’s. In the last decade, the number of patients
admitted in government hospitals has increased by 60 percent, putting a great deal of pressure
on hospital facilities. During the period 1982-92, the increase in inpatients has been greatest
for the treatment of infectious diseases, neoplasm, endocrine, nutritional and metabolic
diseases and immunity disorders, complications due to pregnancy and puerperium, and injuries
and poisoning.
West Bengal. With a total population of 68 million, West Bengal is the most densely
populated state in India (about 770 per square kilometer). 39% of the population is below 15
years of age, and only 27.5% is urban. The large rural population is mainly agricultural, with a
predominance of small and marginal farmers. It is estimated that more than 30% of the rural
population lives below the poverty line. Scheduled Tribes constitute 5.6% of the population
and 23.6% belong to the Scheduled Caste.
I
1
•
West Bengal has a birth rate of 25.6, death rate of 7.3 and infant mortality rate of 58 per
thousand live births. The fact that more than 50% of the disease burden is attributable to
maternal and child health and communicable diseases is good reason for selecting a package of
interventions at the primary and first referral level that would cost-effectively address the
major health care needs in the state.
•
Punjab, twenty-nine percent of the population of Punjab lives in urban areas. The sex ratio of
882 females per thousand males as against the national average of 927 females per thousand
males, according to the 1991 census, is a matter for grave concern. In 1991, the per capita
income was US$554 equivalent, and 12% of the state’s population was below the poverty line.
However, as in other states, there is substantial regional variation in per capita income. The
Upper Bari Doab area, in the northwest comer of the state, has 40% and Southern Malwa has
25% of its population below the poverty line.
c
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underway tn Punjab” (Detail o^X-otg^prefil^eaS1Ste'te^n m ZS
9.
Major Findings. With a few variations between states, the main findings of the SA can be
summarized as follows:
10.
Socio-economtc Characteristics. On average, the distribution of users by caste, literacy level
place of residence (urban/rural) are comparable to the average distnbution of these
popu ations m the state as a whole. However, the proportion of patients who arc literate
urban residents, and higher caste and income groups tended to increase in higher level
facilities indicating that the most disadvantaged and needy sections of society have limited
access to district hospitals.
Nature of Ailment. About half the users visited the hospital for treatment of acute medical
co^ittons such fever cough, diarrhea etc. A larger proportion of patients at the community
hospital level suffered from acute medical conditions compared to the district hospital level
District hospitals were preferred for chronic medical, surgical, obstetric and orthopedic cases'
while sub-divisional hospitals were used predominantly for injuries.
Distance Traveled. More than two-thirds of respondents resided within a distance of 10 kms.
0 e ospital utilized, and about a third of the respondents were within walking distance The
proportion of users within walking distance was highest in primary and community health
centers, and decreased in higher level hospitals.
•
Referral Mechanism. Less than 2% of those interviewed at secondary hospitals reported either
consulting or being referred by the staff at a Pnmary Health Cegter, indicating that the referral
system is functioning very poorly. Two thirds of those interviewed had consulted a private
medical practitioner, particularly for chrome ailments. A large number had either approached
the hospital of their own accord, or been advised to do so by relatives.
Profile of First Referral Hospitals
Physical Access. Although, in general, patients are within 10 Kms. of a first referral hospital
there
ere arc pockets in
m all the states where physical access is an important issue. The SundcTban
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area of West Bengal, for example, consists largely of swamps, tidal estuaries and dense forest.
Transport and communication networks are inadequate, and riverine transport between the
network of 54 islands is unreliable. This area poses special challenges in the health sector,
since cases of snake bite, shark bite, crocodile bite and tiger mauling are not uncommon. In
addition, the population in the Sunderban consists largely of poor and marginal fanners, 40%
of whom belong to scheduled castes and scheduled tribes (SC/ST). In the case of Karnataka,
the northern districts of Bidar, Bijapur, Gulbarga and Raichur have historically been neglected
in terms of health sector development and health indicators tend to be poor in these areas.
There is a special need to strengthen health care networks in these areas, and to encourage the
development of the private and NGO sectors to provide outreach services which the public
health services are unable to provide.
Social Access. According to hospital sources, the proportion of hospital users belonging to
SC/ST groups is commensurate with their proportion in the general population. However,
considering the poor socio-economic condition of these groups, and their low nutritional level,
the morbidity and mortality in this population is greater and warrants a higher utilization of
secondary hospital services. An additional issue is the low utilization of health services by
women. In Karnataka, for example, the NSS survey indicates that the sex ratio among
hospitalized cases is 786 females per 1,000 males, whereas the sex ratio in the population is
960 females per 1,000 males. The average household expenditure per illness was found to be
lower for women and girls as compared to their male counterparts. Given the results of the
NCAER survey (1993), which reports that the morbidity among females aged 15-59 is 10%
greater than among men in the same age group, there appears to be a significant bias against
females in both hospitalization and intra-houschold allocation of health resources.
•
Services Available. There arc no norms for the provision of services at the different level of
first referral hospitals (community, sub-divisional and district). Basic specialist services i.c.
medicine, surgery, gynccology/obstctncs, and pediatnes arc available at all first referral
institutions. In addition, at district hospitals, other specialist services such as orthopedics,
£P4T, ophthalmology', skin and S.T.D. and blood bank arc available. Dentistry services are
available at some district level hospitals, but not at others. Hence, there is considerable
overlap between the first referral hospitals, and inconsistency between different regions within
each state.
•
Personnel. While there is not a general shortage of trained medical and para-medical staff,
there is a shortage of medical personnel in rural and remote areas of all the states. Moreover,
the absence of certain specialties at sub-divisional and district hospitals was reported
repeatedly. In Karnataka and Punjab, for example, the presence of a gynecologist at the subdivisional hospital was found to be of special importance. In Punjab, a need was expressed for
more pediatricians at district hospitals. There is considerable difficulty in placing doctors in
rural and remote areas in both West Bengal and Punjab.
Maintenance. At present, approximately 2% of the original cost of construction is allocated
annually towards the maintenance of the hospitals in each of the states. This sum is grossly
inadequate. There are additional problems created by the fact that maintenance of secondary
hospitals is in the charge of the Public Works Department (PWD) rather than the Health
Department. Leaking roofs and peeling plaster are arommon sight in most hospitals.
i
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and Vehicles. Some of the major equipment at secondary hospitals is noncuonal A shortage of well trained technicians was reported to be a significant problem
There is also a lack of regional workshops at the district level, which could ewedite equipment
and vehicle repair and maintenance
In the absence of such subsidiary workSopC all
maintenance jobs need to be handled at the central level, leading to overload 2^d delays.
’
Only baSiC lab0rat0ry SerV,CeS are avaiIab,e even at
district hospital
ho ’t
1T
8eS m reasents’ anti8ens and other equipment. At sub-district level
hospitals, laboratories are under-equipped and laboratory techmcian posts are vaX Sth ±e
»
, r ,°KT“S ar'
>« taafa „d Punjab, the,
for the post of pathologist in any of the hospitals.
provision
Training. Most in-service training programs are oriented towards
on-going national programs,
such as CSSM, UIP and Blindness Control. No in-service
training is offered to update the
clinical skills of medical and para-medical personnel on a
regular basis, except in'West Bengal
where a training program for doctors at district hospitals
is in place. Hospital administrators
also reported a need for training in managenal skills to better fblfill their duties.
Awarene:i-S and R-elated Beha™r Among Tribal and Disadvantaged Pnn„htinneP11Sri CO7P07nt Of!the SA dealS SpecificaJI>' 'V’th health seeking behavior aLng tribal Sd
disadvantaged populations m Karnataka and West Bengal. Punjab has no tribal popubtion
important finding of the study is the low hospital utilization rates of the tribal population.
Physical Access. Clearly, hospital services provided by the Government are inadequate in
inadequate in
rural areas. Distance traveled to reach first referral hospitals seems to be an important factor
in determining utihzahon. Community hospitals in tribal and underdeveloped areas arc located
very far from the village, with poor transportation and communication facilities, and often with
no convenient res.dent.al arrangements for the med,cal personnel. Non-availability of staff
particularly doctors, ,s stated to be the most important reason for preferring private medical
care over Government hospitals. In tnbal areas, the msens.tivity of medical personnel strongly
acSsCfrft?6 Community’s COnfidencc in them- Especially in emergency situations, the easy
facto blflty and ready avallabll,ty of q,Jacks or underqualified doctors is a major determining
°
COr7lllnity Prcfcrence for uieir services. Another important issue is the nonava.iab.lity of necessary drugs and medicines at first referral hospitals, particularly for
curative care which has been identified as a major constraint to patient satisfaction 7The
eormnunity, however, seems to be willing to pay for the medicines provided by the hospital
30»/
t’n? I
u
31 ilIneSS amons girls was reP°rted late- A" ^tunated
trtt
t
/J I auP
traditional healer first, and go to a hospital only if the
treatment provided by him .s ineffective. Communities seemed to be generally better aware of
Solluld^T5 H ^iCVuS (sUnStrokc> mostlulto b,tc). diarrhea, dysentery and jaundice
polluted water and food)^However, chicken pox, measles, leprosy and epilepsy were ascribed
to supernatural powers. Consequently, more money is spent on rituals and traditional healers
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for the latter diseases. In the case of diarrhea, a doctor is consulted within a day or two of
onset if there is no improvement in the patient’s condition, since the community is aware that
diarrhea could be fatal. Children suffering from measles and chicken pox are kept secluded,
and a paste of neem leaves and turmenc is applied on the body followed by a bath and rituals.
Persons suffering from TB and leprosy are isolated since the community perceives them as
being dangerous to their health.
Economic Access. The data show that substantial costs - on fees, drugs, tests and transport are being incurred by tnbals and disadvanUged populations possibly because they postpone
treatment until the problem has become very acute. In addition, due to the relative
inaccessibility of Government health care services, tribal populations are approaching the
private sector for then health caic needs However, a majority wcic ot the opinion that,
although piivale hospitals olfcied iihmIciii equipment and convenient service, die cosU ot
treatment were prohibitive, anil lew ot them could ailord to consistently visit a private
practitioner Moreover, it was fell that the private practitioners commitment to low-cost
preventive care was minimal, and that in die case of emergencies a Government hospital was
much more likely to provide efficient service.
•
13.
Causes for the Under-Utilization of First Referral Hospitals
•
Shortage of Staff. Non-availability of staff, particularly doctors, is stated to be the most
important reason for preferring private medical care over Government hospitals. Most
laboratory technician and supervisory cadre posts arc either vacant, or the posted persons are
on prolonged deputation at the district headquarters. In tribal areas, the insensitivity of
medical personnel strongly influenced the community’s confidence in them. Especially in
emergency situations, the easy accessibility and ready availability of quacks or underqualified
doctors is a major determining factor of community preference for their services.
•
Shortage of Medicines. Non-availability' of necessary drugs and medicines at first referral
hospitals, particularly for curative care, is identified as a major constraint to patient
satisfaction. The community, however, seems to be willing to pay for the medicines provided
by the hospital staff.
•
14.
•
Poor Access. Accessibility of first referral hospitals seemed to be an important factor in
determining utilization. Some district hospitals are located such that they are inaccessible to a
large proportion of the district’s population. In fact, some residents preferred to visit the
neighboring district hospital, since it was more accessible than their own. Similarly,
community hospitals arc located in remote areas, with poor transportation and communication
facilities, and often with no convenient residential arrangements for the medical personnel.
The RqIc of the Private Sector:
The private sector in health care delivery is unorganized, and is operated by a mix of qualified
and unqualified practitioners. The private sector is relatively better developed in Karnataka
and Punjab, particularly around urban centers, than in West Bengal. Services are provided
mainly through small clinics and nursing homes. Most private practitioners dispense allopathic
medicine, although homeopathy and ayurved arc also widespread. Both preventive and
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curative services are provided, while emergency and medico-legal
cases are generally referred
to Government first referral hospitals.
The main advantage of the private sector health facility is its easy accessibility. Not only are
private clinics better located in urban areas, there is also the facility of round-the-clock
availability of a specialist on the premises, unlike in the case of a Government hospital where
doctors are available only for a fixed number of hours every day. In addition, due to better
maintenance and sanitation, and more courteous treatment by the medical personnel, private
hospitals are perceived to be providing better services than Government hospitals.
•
■
•
A majority of patients visiting private clinics belong to the middle and upper socio-economic
classes since the costs of private treatment are very high when compared to a Government
hospital. In West Bengal, for example, it was found that, of out-patients visiting a pnvate
pracutioner, 58% spent about Rs. 100, 23.9% spent Rs. 100-300, and 6.9% spent more than
Rs. 300 on medicines in the preceding three months. By comparison, the figures for those
visiting a Government hospital are 28.3%, 12% and 5.4% respectively. In other words only
about 10% of out-patients are spending less than Rs. 100 in the pnvate sector, as against
almost 55 of out-patients visiting Government hospitals.
Of those belonging to the low-income and tribal groups, a majority were of the opinion that,
a lough private hospitals ofiered modern equipment and convenient service, the costs of
treatment were prohibitive, and few of them could afford to consistently visit a private
practitioner. Moreover, it was felt tliat the private practitioners commitment to low-cost
preventive care was minimal, and diat in the case of emergencies a Government hospital was
much more likely to provide efficient service.
Actions Recommended
b.
The SA has made an important contribution to the overall effort to assist the stotes of
Karnataka, Punjab and West Bengal to design a cost-effective and sustainable health system. The
broader sectoral policy reforms such as improvements in health planning capacity, management
effectiveness, allocation of public resources for health, and enhanced role of the private sector
would increase the efficiency of the health sector by improving the environment in which the health
sector operates and by optimizing resource use. The technical and quality improvements, including
operations and maintenance functions, at the institutional and health facility levels will enhance the
effectiveness and efficiency of health care services by encouraging patients to seek timely care
resulting in higher cure rates at lower costs. The strengthening and upgrading of selected aspects of
the primary health care system for implementing the various priority health programs and provide
basic health care in rural areas would have a direct impact on improving the health status of the
people by reducing mortality, morbidity and disability. The SA has contributed to developing the
following strategies and project design issues:
‘6
^eamlining of Norms In order to increase the efficiency and effectiveness of the
functioning of the different levels of the first referral hospital network, to reduce overlap in the
services provided at such hosp.tals, and to reduce wastage of resources, technical norms
workshops were held in each state The puqiose of this workshop was to reach a consensus on
services that would be provided in die different tiers of the health system viz. the community subivisiona and district level hospitals. Based on the service norms that were developed in each state.
163
I
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the participants subsequently developed staffing and equipment norms, equipment maintenance
plans, referral system, training needs assessments, and management systems. The implementation
of these recommendations will help reduce both the duplication of services and wastage of
resources that characterize health service delivery. Preliminary estimates show that, when
implemented, this streamlining and rationalization will result in considerable efficiency gains.
Estimates in Andhra Pradesh have suggested that as much as 33% of cost could be saved by
treating patients at first referral facilities rather than at tertiary level health facilities.
17
Referral System. An adequately functioning referral mechanism would improve the
effectiveness of the primary health care level and encourage a greater participation of the private
sector in health care. In reality, the referral system in these states, as in the rest of India, does not
function well. The different tiers do not complement each other, the lower tiers arc underutilized
and institutional and technical linkages between the lower and the higher tiers are weak. Moreover,
. less than 2% of the patients at first referral facilities are refened from PHCs.
18.
The project would seek to ensure that a much higher proportion of patients coming to first
- referral hospitals had been seen at a Community/rural hospital and referred upwards. Likewise,
for those patients going to tertiary' hospitals, the project would implement several measures to
strengthen the referral system and improve the quality of care at the first referral level. These
include: (a) strengthening the management of the referral system; Cd) implementing the referral
protocols that specify the "what", "when" and "how" of referrals; (c) implementing clinical
management protocols that specify the essential processes of clinical management by
manage common conditions without the direct supervision of relevant specialists; and (d)
establishing an incentive system (explained below). Special attention would also be given to
establishing mechanisms to improve access for remote and disadvantaged groups and tribal
communities. The project would establish linkages and communications between the first referral
and primary health care levels. The first referral hospitals would provide clinical and technical
support to the PHCs; clinical skills at secondary facilities would be updated and upgraded;
technical support for the primary level of care and community hospitals would be strengthened;
referral mechanisms between community, subdivisional and distnet hospitals would
strengthened; and mechanisms to provide greater access to secondary and higher levels o£hea^th
care would be formulated by making the referral system more timely, effective and client-friendly.
The Governments of Karnataka, Punjab and West Bengal would strengthen the referral system by
establishing an incentive system with differentiated user fees for users and non-users and allowing
patients to by-pass waiting lines when they carry a referral slip.
19
Selective Investments in Primary Health Care, especially fpr Wgmgn and SQ/ST
Populations. The project's tribal and underdeveloped areas strategy is aimed at increasing the
demand for hospital services in tribal and underdeveloped areas by improving the quality of
services and providing effective IEC to better inform tribal and disadvantaged populations of the
benefits of using health services at secondary hospitals. The number of beds at sub-divisional and
community hospitals located in tribal and underdeveloped areas will be increased to reflect a share
of beds at secondary hospitals that is much more commensurate with their proportion in the overall
population of the states. In addition, to increasing the bed strength in tribal and remote hospitals,
the project would: (a) strengthen linkages between primary and secondary health care services; (b)
provide an incentive package to doctors and other medical staff in tribal and underdeveloped areas
to encourage them to accept assignment in these areas; (c) increase the appropriate utilization of
1
164
Annex 14
Page 10 of 14
non-tnbal medical system by tribal population and reduce the cost to the poor, including tribals, of
utilizing the system (see Annex 16).
20.
In addition, the project would provide much greater access to women, particularly rural
women, and improve the quality of services they receive. More specifically, by strengthening the
referral mechanism and linking die community hospitals widi primary health centers, the project
would assist in providing timely access to emergency obstetric care. The project would also
promote a life-cycle approach to women’s health, taking into account some of the main
recommendations of the Cairo Conference on women’s reproductive health, such as screening for
reproductive tract infections (RTIs) and sexually transmitted diseases (STDs), providing
appropriate information, education and communication (IEC) to promote the value of the girl-child,
and increasing women’s awareness of their options in terms of health care.
21.
Specific components included in the project to address these issues are: Upgrading of
Primary Health Centers in the Sunderban Areas of West Bengal. The Sundarban area in southern
West Bengal, with a population of about 3.1 million people, is among the poorest regions in the
. state and is most lacking in adequate health facilities. It is therefore proposed that the project
would upgrade all PHCs and block PHCs in the region. In addition, three floating medical units
will be set up to deliver effective health care in the riverine areas and would be supported by
wireless connection. A wireless communication system will also link up the 36 PHCs and block
PHCs with the gram panchayat office. Increasing Access to Primary Care Services Among SC/ST
Population in Karnataka . A system of annual health check-ups is proposed under the project for
the SC/ST population of Karnataka, which account for nearly 20% of the population. The medical
check-ups will be made available in health check-up camps to be organized at the headquarters of
every auxiliary nurse midwife (ANM).
Means-tested Cost Recovery. Previous sector work indicates that the revenue collected in
the three states from user charges vanes between 3% and 7% of the health budget of the states.
International experience in developing countries with somewhat higher per capita income than
India, and where the performance of the public health sector has been relatively better, show that
revenue collected from user charges accounts for about 15-20% of the health budget. The
Governments of the three states recognize the importance of increasing revenue collection through
user charges for the sustainability of the sector. The strategy with regard to the implementation of
user charges takes into account both the willingness of most people to pay something towards
services rendered, given improvements in the quality of basic services and infrastructure i.c.
voluntary payment, and the need to adequately exempt the poorest sections who simply cannot
afford to pay. In order to encourage greater volunUry payments of user charges, the state
Governments have stated that user charges would be more widely implemented in a phased manner
for treatment and diagnostic services, after the improvements in quality have been implemented.
Fees for services such as paying beds, cabins, and charges for a range of diagnostic services and
outpatient registration fees would be more widely implemented. User fees would be used
specifically for non-salary recurrent cost purposes, particularly to purchase drugs and medical
supplies. The Governments would institute adequate administrative mechanisms for collecting user
fees and enhance the Governments’ resource generation capacity through the appointment of key
staff in its Finance and Audit unit. (See Annex 5 for details on exemptions for the poor).
23
Iffgreasing the Scope fpr Private Sector Involvement in Service Delivery. Contracting-out
Selected Services. Private contractual services are often more efficient and effective than direct
165
Annex 14
Page 11 of 14
labor. In view of the difficulties of employing government staff, such as slow recruitment and
absenteeism, contracting-out certain services, especially support services, becomes even more
attractive. It has been confirmed that there are no legal barriers inhibiting the use of contractual
services for support functions and that the Contract Labor Regulation and Abolition Act (1970),
which prohibits certain institutions from contracting-out perennial services, exempt hospitals and
health care facilities. In order to cut costs and increase efficiency, the Governments of Karnataka,
Punjab and West Bengal would review and propose implementation of private contractual services,
especially supporting services.
24.
Linkages with the Private and Voluntary Sectors. The state Governments have proposed
to enhance the participation of the voluntary sector, especially for improving access to primary
health care and first referral services in remote and underdeveloped areas of the Sunderban in West
Bengal and for disadvantaged groups, particularly SC/STs in Karnataka. The state Governments
arc also exploring opportunities for contracting out the delivery of health care in remote areas to
tiie voluntary sector which has a comparative advantage in improving access to such health
services for some disadvantaged groups. On matters of ensuring the quality of health care
. provision, state Governments would also play a more pro-active role, through legislation such as
tiic Nursing Home Registration Act which is pending Parliamentary clearance in Karnataka and
Punjab.
25.
Decentralization of Management and Administration. Retention and Use of Revenue
Collected. To provide incentives to hospitals for collecting user charges, all three states have
proposed to implement a system that would ensure that revenue collected through user charges
would not go back to the state treasury in Karnataka and West Bengal. The revenue collected
through user charges would be retained at the district level to be reallocated by district level health
authorities amongst hospitals in the district, based on both need and level of revenue collection. In
Punjab, revenue collected would be retained at the point of collection.
26.
Project Management. During preparation the Government stated that the DOHFW did not
have the capacity to implement a project of this scope. In addition, a project preparation workshop
held in Chandigarh recommended that an independent agency would be more suitable to implement
the proposed project. Therefore, a model similar to the APWP was adopted. The IDA mission
recognised the implication of the proposed management structure and the initial start-up problems
this would entail. However, the benefits of this approach, namely, the independence to carry out
project work more efficiently, implementing user charges and being more self-sustaining in the long
run, outweigh the possible associated risks.
27.
Civil Works and Maintenance. Due to the scope of the civil works component and the
need to ensure adequate maintenance of assets, the Health Department s role in Kumataku and
West Bengal would be strengthened by providing it with enhanced management and supervision
responsibilities of essential operational activities including construction and maintenance activities
in collaboration with local government. These responsibilities now he with the Public Works
Department which would be unable to adequately fulfill its obligations to the Health Department
due to the diverse functions it is called upon to perform. A Design and Engineering Wing would be
set up in the Health Department at both the state and district levels, and flow of funds would be
channeled through DOHFW. In addition, a maintenance cell will be established in each large
hospital to manage day-to-day emergent maintenance works. In Punjab, the establishment of a
Health Systems Corporation with substantial autonomy in carrying out essential operational
166
Annex 14
Page 12 of 14
activities would facilitate implementation of the project at both state and district levels, and the
flow of funds would be channeled through the Corporation.
28WQLtforce I?sue$. There is currently no acute shortage of professional staff overall, but
there is a shortage of some medical specialties and nurses. The first step would be to improve
recruitment and prompt filling of job vacancies by improving the main procedures. The states will
put appropriate regulations in place so that state Governments have the authority to: (i) advertise,
appomt’ Promote and Ransfer staff internally; (ii) post staff as needed, especially in tribal areas; '
(iii) introduce appropnate incentives to retain staff in remote areas including: provision of staff*
quarters, bonus at the end of a specified period of posting, educational allowance for children of
staff posted in remote and tribal areas, additional leave eligibility and extra weightage for doctors
and other staff for PG qualification admission and for fellowships; and (iv) relax service rules as
necessary to maintain service when appropriately qualified staff are unavailable.
29Information, Education and Communication. Six broad strategies are proposed for this
component: (a) increase awareness of the services provided by first referral hospitals, and the
. functioning of the referral system, particularly among lower income and disadvantaged groups
(such as tribals), and thereby increase utilization of the system; (b) improve access to the expanded
range of all reproductive health services among women; (c) motivate all hospital staff to maintain
good standards of patient care in terms of ‘care, courtesy and comfort’ so that the quality of
services received by patients is enhanced; (d) sensitize staff to hospital and equipment maintenance
issues; (e) promote hospital services to specific groups in a manner that increases their willingness
to utilize these services and, where possible, to share in the costs of service delivery; and (f)
address specific public health issues in each state such as road safety, alcohol abuse, healthy diet
(particularly in Punjab), and women’s issues.
30.
Five groups will be included in the target audience. First, government functionaries
working at the grassroots level — anganwadi workers, gram sevikas, school teachers, agricultural
extension workers and multipurpose health workers - would be targeted for information pertaining
to the availability of different types of health care at different levels within the health care system.
These workers are likely to be seen as opinion leaders by the populations they serve and they can
be key information sources in spreading knowledge about the availability of services and the
referral system. Second, women would be considered as a priority target, since their access to
health facilities is comparatively low. They are, in addition, managers of the health status of the
household and have demonstrated their ability as a group to mobilize the community. Third,
patients who enter the hospital system would be considered a priority target. Their word-of-mouth
based on their first-hand expenence will carry far more weight than any other channel of
communication. The imperative of creating satisfied customers, and thereby expanding the demand
for services, particularly in tribal areas, must be recognized for the communication strategy to
succeed. Fourth, private practitioners and NGOs would be targeted because of their potential role
in referring patients, and because they should be aware of the improved standards of care in first
referral hospitals. Fifth, the population in the Sundcrban area of West Bengal and SC/ST groups
in Karnataka will be targeted, to raise awareness in those communities of the increased access to
and improved quality of primary health care services now available to them.
167
Annex 14
Page 13 of 14
Poverty Aspects
31.
In India the public health system is utilized predominantly by the lower income groups,
especially at the secondary level. Those who can afford to pay usually prefer using private
hospitals. Country-wide health sector studies have shown that the public sector hospital care seems
well targeted to the poor, with over seventy percent of public hospital users being from the lower
forty percent of income distribution. These findings are confirmed by the beneficiary assessment
for Karnataka, which includes an analysis of secondary hospital patients by family income. This
analysis found that in Karnataka over 45 percent of the patients have an annual income below Rs.
15,000 (close to the official poverty line), and over 90 percent of the patients have an annual
income below the taxable level of Rs. 50,000.
32.
General Poverty Impact. By improving health service quality, access, and effectiveness at
• the secondary level, this project will disproportionately benefit the poor and underprivileged
segments of the states’ population. Beneficiary studies in the project states have shown that while
the poor are the major users of these public health facilities and would therefore benefit from any
improvements within the secondary health system, perceived quality, access and effectiveness of
health interventions at this level are major barriers faced especially by the poor. This project will
also focus on addressing these bamers and thereby increasing the utilization of these services by
the poor.
33.
Special Poverty Interventions/Areas of Emphasis. In addition to having the overall aim of
improving secondary health services for the poor, each state has undertaken special initiatives
under this project in order to reach the most vulnerable and poor: In IVesf Bengal, where 44
percent of the people arc below the poverty line and rural poverty averages around 48 percent,
poverty in the Sunderban Areas lies yet above this average. In addition to including some of the
poorest populations of the state, the Sundcrban face the additional problem of being remote,
difficult to access, and having low availability of even primary health care services Illis project
will seek to redress the problems that the poor in these remote areas face in accessing health care,
by upgrading all primary health centers in the Sundcrban Areas. In addition, three floating medical
units supported by a wireless communications system will be set up in order to enable effective
primary health care deliver in these remote, riverine areas.
34.
In Karnataka, where the percentage of people in poverty at 38 percent is close the all-India
average, the main issues of the poor’s access to health services center around increasing access to
primary and secondary health care services for the scheduled caste and scheduled tribe populations
of the state. Beneficiary assessments have shown that these are the people with the highest
percentage of poverty and often with the least access to public health services. In order to reach
out to these populations, heighten their awareness of the types of services available, and to improve
their health indicators, Karnataka will institute a system of annual health check-ups for the entire
SC/ST population. These health check camps would serve as a early screening forum for
preventive health care, would enable direct IEC to communicate the levels of health care services
and facilities available, and would above all increase basic health care delivery to some of the
poorest segments of the population.
I
35.
In Punjab, the percentage of people below the poverty line is the lowest in the country, at
12.7 percent. This figure, however, masks great regiQnal differences within the state. In the
poorest region of the state, the Upper Bari Doab area, 30 percent of the overall population and 40
168
Annex 14
Page 14 of 14
of the rural population live below the poverty line. In the next poorest region. Southern Malwa,
rural poverty is 25 percent. Since this project focuses on first-referral hospitals, which are usually
located in the rural areas, it is these high rural poverty rates in the two regions of Punjab that are of
real concern. To address the issue of access and equity faced by the rural poor in these two
regions, 57 percent of the first-referral hospitals to be upgraded will be located in these poorer,
rural areas. Moreover, 61 percent of the total cost of hospital upgradation in Punjab will be
allocated to hospitals in the Upper Bari Doab and Southern Malwa areas. By focusing the project
on the areas with a greater percentage of people below die poverty line, Punjab aims to redress the
current difficulties of quality and access to health care services faced by the poor.
Exempting the Poor from User Charges- Although the implementation of user charges in
order to contribute to the long-term sustainability of the first referral health system is justified,
there is a very valid concern regarding the targeting of poor people for exemptions from user
charges. Given the differences in management and administration, income levels and underlying
structure of the economy in the three states, it is proposed that different income criteria by state be
applied for exempting the poor from user charges. Details of an appropriate exemption mechanism
. to be implemented in each state are provided in Annex 5.
Annex 15
Page 1 of24
169
PROJECT COSTS
Table 1: Cost By Component
(US1 MUUm)
IRuqx MOB—>
Far^i
Coapooeot
Local
Focrita
Total
c*—
Tac^i
tool
I. .Maaafomrat OcvwiopiiMot & taMiiutional Str«D(tb<nknc
58.3
16.4
74.7
1.7
.5
2.1
221
11
lb * Strengthen Management k Implementation Capacity
667.5
105.4
772.9
19.2
3.0
22.2
14%
6%
Ic - Develop Surveillance Capacity
60
IO
Z2J.
U
LI
12%
1*
789.6
137.1
926.7
22.7
3.9
26.6
13%
7%
4,085.9
740.8
4.826.7
117.4
21.3
138.7
39%
0%
114.4
41.1
155.6
43%
0%
LU
308.2
16%
0%
la - Improve Insntunorul Framework for Policy Dcvclpment
Subtotal
2. Improv* S*rvic* Quality, Acxea and E/Tectivena
la - Rxrwviu A Eaicnd Community. Area Jc District Hospitals
2b • Upgrade ClincaJ Effectiveness
2c - Improve Referral Mechanism
Subtotal
1
Toui BASELINE COSTS
Hiysicai ContinfancMt
ha Contingencies
Total PROJECT COSTS
I
3.982.7
1.431.8
5.414,5
202 8
8.271.4
2S0.Q
2.452.6
482.8
10.724.0
237.7
LQ
70.5
611 0
233 8
B44 9
17 6
6.7
24.3
7%
0%
9.672.1
2,823.5
12.495 6
277.9
II.I
359.1
100%
0%
u
OX
890.5
279.6
1.170.1
25.6
1.0
33.6
9%
0%
2.340.9
664.9
3.025.7
18.5
5.4
24.0
7%
0%
12.903.5
3.788.0
16.691.4
322.1
94 6
416.7
116%
0%
Annex 15
Page 2 of 24
170
Table 2: Cost by Categories of Expenditure
(USS
(Rupe* Mdlwal
FarWc
« Tsui
Ban
C-M
Lood
Local
For«t<«
To<«l
1.131.1
199.6
1.330.7
32.5
5.7
38.2
15%
11%
13.9
92.5
15%
26%
4%
Investment Costs
Civil Works (Renovation)
Civil Works (New Const/ or Extension)
Professional Services
2.737.3
483.0
3.220.3
78.7
356.1
89.0
445.1
10.2
2.6
12.8
20%
1.0
9.7
10%
3%
40.4
60%
11%
304.7
33.9
338.5
8.8
Major Medical Equipment
562.7
844.1
1,406.8
16.2
24.3
Minor Medical Equipment
43.3
10.8
54.2
1.2
.3
1.6
20%
20.3
101.3
2.3
.6
2.9
20%
1%
21.9
5.5
27.4
20%
8%
4%
Funuiurc
Medical Equipment - Surgical Packs
81.0
Equipment (Other)
763.1
190.8
953.8
Vehicles
109.9
329.8
439.7
3.2
9.5
12.6
75%
Medical Lab Supplies
127.9
32.0
159.9
3.7
.9
4.6
20%
1%
Medicines
401.5 •
401.5
803.0
11.5
11.5
23.1
50%
6%
Other Supplies
550.3
550.3
15.8
15.8
208.3
4.5
6.0
220 5
66.7
6.3
6.3
1.9
1.9
61.8
.2
1.5
1.5
.5
MIS/IEC Materials
156.2
52.1
Local Training
220.5
Studies
66.7
Fellowships
6.2
Workshops
51.5
51.5
Consultants
12.4
12.4
NGO’J
18.7
18.7
5
221.3
55.6
1.5
1.6
1.8
300.1
4%
25%
2%
2%
1%
90%
26%
84%
7.701.0
2.742.4
10.443 4
Operational Expenses
473.5
52.0
526.1
13.6
1.5
15.1
10%
4%
Building Maintenance
69.4
7.7
77.1
2.0
.2
2.2
10%
1%
Surgical Pack Mattuenance
2.9
.2
3.1
.1
.0
.1
5%
Total Investment Costs
Recurrent Costs
Salaries of Addiuorui Sulf
78.8
10%
35.2
35.2
Vehicle Maintenance
15.6
1.7
17.4
.4
.0
.5
10%
Equipment Maintenance
170 2
18 9
189.1
4 9
.5
5.4
10%
2%
Furniture Maintenance
14 3
14 3
Total Recurrent Costs
1.971.1
81.1
2.052.2
56.6
2.3
59.0
4%
16%
Total BASELINE COSTS
9.672.1
2.823.5
12.495.6
277.9
81.1
359.1
23%
100%
Physical Contingencies
890.5
279.6
1.170.1
25.6
8.0
33.6
24%
9%
Price Conttngencics
2.340.9
684.9
3.025.7
18.5
5.4
24.0
23%
7%
Total PROJECT COSTS
12.903 5
3.788.0
16.691.4
322.1
94.6
416.7
23%
116%
Annex 15
Page 3 of 24
171
Table 3 Project Totals: Expenditure Accounts by Years - Base Costs
Karnataka, Punjab and West Bengal
Costs in Rs. Millions
Base Cost in Indian FY
98/99 99/2000
2000/01
Total
Foreign
Exchange
*
Amount
96/97
97/98
Civil Works (Renovation)
186.4
248.2
412.1
376.0
107.9
1.330.7
15*
199.6
Civil Works (New Constr or Extension)
490.7
802.7
964.3
747.1
215.5
3,220.3
15*
483.0
Investment CimU
Professional Services
67 9
102.6
133.0
109 0
32.7
445.1
20*
89.0
Furniture
29.2
81.2
98.8
67.0
62.2
338.5
10*
33.9
Major Medical Equipment
104 I
323.1
412.9
299.1
267.6
1.406.8
60*
844.1
Minor Medical Equipment
5.4
10.8
16.2
10.8
10.8
54.2
20*
10.8
Medical Equipment - Surgical Packs
10.1
20.3
30.4
20.3
20.3
101.3
20*
20.3
Equipment (Other)
103.2
234.9
258.4
189.2
168.1
953.8
20*
190.8
Vehicles
91 2
148.7
82.2
61.4
56.3
439.7
75*
329.8
Medical Lab Supplies
8 4
20.1
30 4
410
59.9
159.9
20*
32.0
Medicines
49 0
110.7
166.2
204.4
272.7
803.0
50*
401.5
Other Supplies
46.7
81.0
131.9
144.2
146.4
550.3
MIS/1EC Materials
24.7
107.1
44.8
22.9
8.8
208.3
25*
52.1
49.3
48.1
220.5
90*
55.6
26*
2.742.4
52.6
Local Training
20.5
48.5
54.0
Studies
15.4
14 8
14.2
12.4
9.9
66.7
Fellowships
8 9
17.8
19.5
7.9
7.7
61.8
Workshops
7.1
U.2
13.3
11.2
8.6
51.5
3.7
3.9
0.9
0.7
12.4
5.0
5 5
5.9
1.3
1.0
18.7
1.277.2
2.393.0
2,892.5
2.375.4
1.505.3
10.443.4
Salaries of Additional Staff
91 1
209.5
272.4
307.1
345.0
1.225.2
Operational Expenses
27.1
68.1
121.8
139.9
169.2
526.1
10*
16.8
37.0
77.1
10*
7.7
0 3
4 J
23.3
0.9
4 7
1 8
4.7
3.1
17.4
5*
10*
0.2
1.7
10*
11.9
Consultants
NGO’s
Total Investment Costs
Recurrent Costs
Building Maintenance
Surgical Pack Maintenance
Vehicle MauucrwKC
1
00
Equipment Maintenance
o 1
4 8
J 2
5.4
26 2
56.1
96.6
189.1
Furniture Maintenance
0.7
1.4
2.4
4.2
5.6
14.3
Total Recurrent Costs
123.8
287.6
444.7
536.2
659.8
2.052.2
4*
Sl.l
Total BASELINE COSTS
1.401.1
2.680.6
3.337.2
2.911.6
2.165.1
12.495.6
23*
2.823.5
Physical Contingencies
133.3
253.2
315.3
272.3
196.0
1.170.1
24*
279.6
Price Contingencies
52.7
361.2
774.4
940.0
897.5
3.025.7
23*
684.9
Total PROJECT COSTS
1,587.1
3.295.0
4,426.9
4,123.9
3.258.5
16.691.4
23*
3.788.0
Taxes
84.4
179.9
235.5
215.3
173.1
888.1
Foreign Exchange
350.6
797.2
994.4
880.5
765.2
3.788.0
Annex 15
Page 4 of24
172
Table 4 Karnataka: Expenditure Accounts by Years — Base Costs
Costs in Rs. Millions
96/97
Total
Foreign
Exchange
%
Amount
40.2
251.6
15%
37.7
171.8
954.4
15%
1431
22.1
Base Cost in Indian FY
97/98
98/99
99/2000
2000/01
Iflvestmeni Costs
Civil Works (Renovation)
90 6
62.9
Civil Works (New Constr or Exiension)
286.3
267.2
Professional Services
35.4
29.9
Furniture
3.1
34.3
1110
Major Medical Equipincru
57.9
229.0
26.5
28.1
84 9
110.6
20%
20.8
17.7
104.1
10%
10.4
75 I
55 5
326 5
60%
195.9
65 5
22.7
13 7
121.3
33.7
49 2
327.7
20%
19 7
151.4
75%
18.8
Minor Medical Lquipmciu
Medical Equipment • Surgical Packs
72 I
27 2
21 2
75 3
24.4
8.1
25.0
108 1
MIS/IEC Materials
32 8
9 I
5 I)
12 5
5 8
8.7
Local Training
2.0
25.0
Studies
3.5
2.6
4.1
4.1
10.2
10.2
Equipment (Other)
Vehicles
Medical Lab Supplies
> Medicines
Other Supplies
Fellowships
Workshops
Cottsuiiants
2.1
2.9
72 7
11 7
46 0
17.4
9.7
5.5
24.0
3.9
2.6
5.6
51 2
124 8
20%
163.1
418.2
50%
65 5
113.5
25.0
209.1
34.8
116.1
25%
8.1
90%
25J
28%
855.7
0.3
32.3
24.0
100.1
3.9
19.5
2.4
28.0
3.0
21.5
5.1
5.6
2.8
2.8
8.4
12.7
43
4.2
4.2
506.7
824.4
706.6
M5.2
424.7
3.107.6
Salaries of Additional Staff
5.7
86.2
126.4
160.9
195.3
574.6
Operational Expenses
3.0
30.2
66.4
90.5
301.7
10%
30.2
16.1
18.9
111.6
22.4
57.4
10%
5.7
0.6
11.3
19.6
28.0
59.5
10%
5.9
NGO’s
Total Investment Costs
Recurrent Costs
Budding Maintenance
Surgical Pack Maintenance
Vehicle Maintenance
Equipment Maintenance
Furniture Maintenance
Total Recurrent Costs
8.8
116.9
220.2
290.0
357.3
993 2
4%
41.9
Total BASELINE COSTS
515.5
941.3
926.7
935.2
782.1
4.100.7
22%
897.5
Physical Contingencies
50 6
87 5
83 9
67.0
372.8
24%
88.5
300 9
322 4
984 5
22%
2196
1.3199
1.171.4
5.458.0
22%
1.205.6
Price Contingencies
20 6
126 3
84.0
214 3
Total PROJECT COSTS
580 0
1.155.1
1.225.0
Taxes
30.2
63.0
62.1
67.3
58.8
281.3
Foreign Exchange
99 I
294 6
264.7
283.1
264.1
1.205.6
Annex 15
Page 5 of 24
173
Table 5 Punjab: Expenditure Accounts by Years — Base Costs
Costs in Rs. Millions
Total
Foreign
Exchaafe
*
Amount
15.6
156.4
15*
233
115.6
1.156.0
15*
173.4
13.1
131.2
20*
26.2
65.2
10*
6.5
397.5
60*
2313
3.5
Base Cost in Indian FY_____
2000/01
98/99
99/2000
96/97
97/98
46.9
31.3
31.3
Civil Works (New Const! or Extension)
31 3
115 6
346.8
346.8
231.2
Professional Services
14 4
39.4
38.1
26.2
Lnrtsunenl Costs
Civil Works (Renovation)
Furniture
Major Medical Equipment
Minor Medical Equipment
Medical Equipment - Surgical Packs
Equipment (Other)
Vehicles
. Medical Lab Supplies
Medicines
Utlicr Supplies
MIS/1EC Materials
Local Training
Studies
Fellowships
Workshops
Consultant*
NGO*
Total Investment Costs
9 I
35 8
1.8
2.3
18.9
47 6
10
18 4
2 5
13 4
12.4
10.3
5.0
2 8
02
0J
13.0
18.3
12.4
12.4
75.5
123.2
87.4
75.5
3.5
5.3
3.5
3.5
17.5
20*
4.6
6.9
4.6
4.6
23.2
20*
4.6
157.5
20*
313
63.7
33.1
37.4
45.7
29.9
29.9
84.9
75*
1.5
28 6
2.5
20*
2.2
50*
102.0
25*
27.9
90*
IS.9
0.6
4.0
71 4
15 5
3.3
12.4
2.8
2.7
1.5
0.2
0.3
11.0
204 0
06
2.0
)<> 7
II 5
29.0
10.7
5.3
5.5
1 5
04
06
343 I
715.9
718.5
5263
386.5
2.6903
27*
722.4
54.1
60.9
71.1
74.5
77.8
338.4
123
15.6
18.0
26.2
82.0
10*
8.2
0.7
2.9
10.9
14.5
10*
1.4
0.0
0.1
0.2
0.4
0.7
5*
0.0
4.4
16.4
10*
10*
1.6
4.0
00
53 5
10.7
7.5
5.0
1.9
04
46 9
14 5
123
13 0
5.3
2.7
1.5
04
50 0
111.4
59.2
31.2
21.0
9 I
I 6
2.4
Recurrent Costs
Salaries of Additional Staff
Operational Expenses
9 8
Building Maintenance
Surgical Pack Maintenance
Vehicle Maintenance
0.2
3.0
4.4
Equipment Maintenance
4.8
5.9
9.5
14.7
39.7
Furniture Maintenance
48
0.7
0.9
0.9
l.l
1.5
5.0
Total Recurrent Costs
69 6
81.8
98.7
110.7
135.9
496.6
3*
153
Total BASELINE COSTS
412.7
797.7
817.2
637.0
522.4
3.186.9
23*
737.7
Physical Contingencies
37.5
75.8
77.2
47.5
297.1
734.7
25*
72.1
216.8
23*
161.7
786.7
4,218.8
23*
979.2
Price Contingencies
14.9
107.8
189.6
59.1
205.6
Total PROJECT COSTS
465.1
9813
1.044.1
901.7
23.9
52.0
56.0
45.2
40.4
217.3
246.1
199 8
191.1
979.2
Taxes
Foreign Exchange
1
117.7
224.4
Annex 15
Page 6 of 24
174
Table 6 West Bengal: Expenditure Accounts by Years — Base Costs
Costs in Rs. Millions
Base Cost In Indian FY
Foreign
Exchange
%
Amount
96/97
97/98
98/99
99/2000
20007 01
64.6
138.4
323.0
304.5
92.3
922.8
15%
131.4
Civil Works (New Const/ or Extension)
88.8
188.7
388.5
344.1
99.9
1.110.0
15%
166J
Professional Services
18.1
33.3
68.4
63.9
19.6
203.3
20%
40.7
Furniture
16.9
33.8
52.4
33.8
32.1
169.2
10%
16.9
Major Medical Equipment
68.3
136.6
204.8
136.6
136.6
682.8
60%
409.7
Toui
Investment Costs
Civil Works (Renovation)
Minor Medical Equipment
3.7
7.3
11.0
7.3
7.3
36.7
20%
7.3
'Medical Equipment - Surgical Packs
7 8
15.6
23.4
15.6
15.6
78.1
20%
15.6
Equipment (Other)
51.6
93.7
140.6
93.7
89.1
468.7
20%
93.7
54.9
38.6
36.6
203.4
75%
152.6
Vehicles
34.6
38.6
Medical Lab Supplies
2.4
4.8
7.2
4.8
4.8
24.1
20%
4.1
Medicines
18.1
36.2
54.2
36.2
36.2
180.8
50%
90.4
Other Supplies
38.4
57.6
96.1
96.1
96.1
384.3
MIS/IEC Materials
2.6
43.9
7.8
5.2
5.2
64.6
25%
16.2
Local Training
6.1
12.9
18.4
12.2
11.6
61.2
Studies
1 6
3.2
4.8
3.2
3.2
16.0
Fellowships
1.3
2.6
3.8
2.6
2.6
12.8
90%
UJ
Workshops
2.1
4 2
6.3
4.2
4 2
Consultants
02
04
05
0.7
0.7
0.5
1.1
05
0.7
20.9
2.4
0.7
3.6
427 4
U52.7
1.467.4
1.203.9
694.1
4.045.5
25%
1.164.3
Salaries of Additional Staff
31 2
62.4
74.9
71.8
71.8
312.2
Operational Expenses
14.2
25.6
39.9
31.3
31.3
142.5
10%
141
1.5
3.8
5.3
10%
0.5
0.2
0.7
1.4
2.3
5%
0.1
0.2
0.2
0.2
1.0
10%
0.1
9.0
27.0
54.0
89.9
10%
9.0
0.6
1.6
3.1
4.1
9.3
NGO’s
Total Investment Costs
Recurrent Costs
Building Maintenance
Surgical Pack Maintenance
Vehicle Maintenance
0.2
Equipment Maintenance
Furniture Maintenance
Total Recurrent Costs
45.5
88.9
125.9
135.6
166.6
562.4
4%
24.0
Total BASELINE COSTS
472.9
941.6
1.593.3
1.339.5
860.7
5.208.0
23%
1.1U.3
Physical Contingencies
45.2
90.0
154.1
129.3
81.5
500.1
24%
111 J
Price Contingencies
17.2
127.0
370.4
4334-
358.3
i.306.5
23%
296.6
Total PROJECT COSTS
535.4
1.158.7
2.117.8
1.902.3
1.300.5
7.014.6
23%
1.603.2
Taxes
Foreign Exchange
30.4
65.0
117.4
133.8
278.2
483.6
102.8
397.6
73.9
310.1
389.5
1.603.2
Annex 15
Page 9 of 24
177
Table 9 Punjab: Expenditure Accounts by Years - Base Costs
Costs in USS Millions
96/97
Base Cott in Indian FY
97/98
98/99
99/00
2000/01
Tool
Foreign
Exchange
%
Aminsnf
laTtsUnent Cotts
Civil Works (Renovation)
Civil Works (New Cornu or Extension)
Professional Services
Furniture
Major Medical Equipment
Minor Medical Equipment
Medical Equipment - Surgical Packs
Equipment (Other)
Vehicles
Medical Lab Supplies
• Medicines
Other Supplies
MIS/IEC Materials
Local Training
Studies
Fellowships
Workshops
Consultants
NGOs
Total Investment Costs
09
3.3
0.4
0.3
1.0
0.1
0 I
1.3
10.0
l.l
0.4
0.5
1.4
00
05
0.1
0.4
0.4
0.3
0.1
0.1
0.0
0.0
2.2
0.1
0.1
1.0
l.l
0.0
0.8
0.2
1.5
0.3
0.2
0.1
0.1
0.0
0.0
99
20.6
1.6
0.9
10.0
l.l
0.5
3.5
0.2
0.2
1.3
0.9
0.4
4.5
6.6
3.3
33.2
0.8
0.4
0.4
0.4
2.2
0.1
0.1
0.9
3.8
0.1
1.1
0.1
1.3
0.3
0.4
0.8
0.3
2.5
0.1
0.1
0.9
1.9
11.4
0.5
0.7
4.5
2.4
15%
15%
20%
10%
60%
20%
20%
20%
75%
20%
50%
0.7
5.0
25X
0.1
90%
0J
0.8
0.2
6.9
0.1
0.1
0.9
1.8
0.1
0.3
0.4
0.1
2.1
0.4
0.1
0.4
0.4
0.2
0.2
0.0
0.0
0.0
0.2
0.1
0.0
0.0
0.0
0.1
0.1
0.0
0.0
0.0
1.7
0.9
20.6
15.1
11.1
77.3
27%
20.1
1.8
2.0
0.4
2.1
0.5
0.1
0.0
0.1
2.2
0.4
0.8
9.7
2.4
10%
0.2
0.3
0.4
0.0
10%
5%
10%
10%
0.0
0.0
0.0
0.1
5.9
1.4
3.2
0.6
2.9
0.3
0.0
0.1
Recurrent Costs
Sahrta of Additional Stiff
Operational Expenses
0.3
0.0
Building Maintenance
0.0
0.0
0.0
0.1
0.1
Equipment Maintenance
0.1
0.1
0.3
0.4
Furniture Maintenance
0.0
0.0
0.2
0.0
0.0
0.0
0.0
0.5
1.1
0.1
Total Recurrent Costs
2.0
2.4
2.8
3.2
3.9
14.3
3%
0.4
Total BASELINE COSTS
11.9
22.9
23.5
18.3
15.0
91.6
23%
21.2
Physical Contingencies
2.2
l.l
2.2
1.5
1.7
1.5
1.4
1.4
8.5
25%
Price Contingencies
1.1
0.4
5.9
23%
2.1
U
Total PROJECT COSTS
13.4
26.2
27.2
21.5
17.8
106.1
23%
24.6
5.5
24.6
Surgical Pack Maintenance
Vehicle Maintenance
0.1
Taxes
0.7
1.4
1.4
1.1
0.9
Foreign Exchange
3.4
6.0
6.2
4.8
4.3
Annex 15
Page 10 of 24
178
Table 10 West Bengal: Expenditure Accounts by Years — Base Costs
Costs in USS Millions
Base Cost In Indian FY____
97/98
98/99
99/00
2000/01
Total
Fortipi
FvHiwige
%
Ainouat
26.5
31.9
5.8
4.9
19.6
l.l
2.2
15%
15%
20%
10%
60%
20%
20%
20%
75%
20%
50%
0.1
2.6
15%
0J
90%
0J
lavesunem Costs
Civil Works (Renovation)
Civil Worts (New Constr or Extension)
1.9
2.6
05
0.5
2.0
0.1
0.2
4.0
3.4
2.7
2.9
0.6
0.9
3.9
2.7
Vehicles
Medical Lab Supplies
. Medicines
Other Supplies
MIS/IEC Materials
Local Training
Studies
Fellowships
Workshops
Consultants
NGOs
1.5
1.0
0.1
0.5
l.l
0.1
0.2
0.0
0.0
0.1
0.0
0.0
9.3
11.2
2.0
1.5
5.9
0.3
0.7
4.0
1.1
0.1
1.0
1.7
1.3
0.4
0.1
0.1
0.1
0.0
0.0
1.6
0.2
1.6
2.8
0.2
0.5
0.1
0.1
0.2
0.0
0.0
l.l
0.1
1.0
2.8
0.1
0.4
0.1
0.1
0.1
0.0
0.0
0.3
0.1
0.1
0.1
0.0
0.0
13.5
5.8
0.7
5.2
11.0
1.9
1.8
0.5
0.4
0.6
0.1
0.1
Tola! Investment Costs
12 3
24 5
42.2
34.6
19.9
133.3
23%
33J
0.9
1.8
0.4
0.7
2.2
1.1
0.3
0.8
9.0
4.1
0.2
0.1
0.0
2.6
10%
10%
5%
10%
10%
0J
0.0
0.0
0.1
2.1
0.9
0.1
0.0
0.0
1.6
0.1
0.4
0.0
2.1
0.9
0.0
0.0
0.0
Professional Services
Furniture
.
Major Medical Equipment
Minor Medical Equipment
Medical Equipment - Surgical Packs
Equipment (Other)
1.0
1.0
3.9
0.2
0.4
8.8
9.9
1.8
1.0
3.9
0.2
0.4
2.7
0.2
0.4
2.6
1.1
0.1
1.0
2.8
0.J
4.0
4.8
1.2
0J
11.8
0J
0.4
2.7
Recurrent Costs
Salaries of Additional Suff
Operational Expenses
Building Maintenance
Surgical Pack Maintenance
Vehicle Maintenance
Equipment Maintenance
Furniture Maintenance
0.0
0.0
0.0
0.0
0.0
0.3
Total Recurrent Costs
1.3
2.6
3.6
3.9
4.8
16.2
4%
0.7
Total BASELINE COSTS
13.6
27.1
43 8
38.5
24.7
149.7
23%
34.1
Physical Contingencies
Price Contingencies
1.3
0.5
2.6
1.3
3.7
24%
3.4
3.1
2.3
2.3
14.4
3.0
10.2
23%
2.4
Total PROJECT COSTS
13.4
31.0
33.2
43.3
29.4
174.2
23%
39.9
09
1.7
7.4
3.0
12.1
2.4
1.7
9.7
9.5
7.0
39.9
Taxes
Foreign Exchange
3.8
Annex IS
179
Page 11 of 24
Table 11 Project Totals: Karnataka, Punjab and West Bengal
Disbursement Accounts by Financiers
Total Cost in USS Millions
5<a« Skarw
IDA
22.8
15%
129.4
85%
152.2
Cocuultanu. SiudMa. Brof Services. NGOa
1.8
10%
16.3
90%
III
Funucurc
1.1
10%
10.2
90%
11.4
Vehicles
1.5
10%
13.1
90%
14.6
Equipment
8.4
10%
76.0
90%
Medicines. Lab and Other Supplies
5.1
10%
46.0
90%
10%
MIS/IEC Matenals
0.7
0.0
Salaries .
13.8
6.7
Furniture Maintenance
Equipment Sl Vehicle Maintenance
- Operational Expenditures
Building
Total
Calculation of IDA Share
(Net of Tax and Duties)
22.1
121.1
3.0
15.1
84.5
51.1
6.2
90%
6.9
100%
10.7
35%
25.5
65% /a
39.3
38%
11.1
62% /a
17.8
1.4
46%
1.7
54% /a
3.2
46%
3.8
54% /a
3.1
7.0
66.7
16%
mo)
350.0
84%
Tbm
37%
4%
3%
4%
20%
10.7
0'416-7)
d«*m a
Kjk>.
Aiuai
Civil Work*
Training <Sc Workshops
(U.
Totti
AaMwat
Ammia*
1.4
1.1
9.4
10.9
2J
1.5
35.8
42.7
5.9
12%
14.7
33.1
3.2
2%
3%
9%
4%
1%
, 2%
1.7
4.7
0.5
1.8
8.9
1.8
39.3
14.1
1.2
0.3
0.7
2.6
0.2
5.8
0.5
100%
94.6
299.9
0.1
i
V
88.7* !
416.7 -22.2
-------------- T
NOTES:
/a Disbursements on Recurrent Costs are on a declining basis: Years 1-2 at 90%. Year 3 al 75%. Year 4 at 60%. Year 5 at 40%
1
Annex 15
180
Page 12 of 24
Table 12 Karnataka: Disbursement Accounts by Financiers
Total Cost in USS Million
Cort o/ Kamaiaka
AimxiH
%
IDA
Total
Amotial
Aokouai
Local
(EkL
OvdM A
Taxw)
Ta—
2.2
Civil Woriu
6.0
15%
34.1
85%
40.1
29%
5.9
31.9
Consultants, Studies, Prof Services. NGOs
0.5
10%
4.5
90%
5.0
4%
0.7
4.3
Furniture
0.3
10%
3.1
90%
3.5
3%
0.3
2.9
0.2
Vehicle*
0.5
10%
4.5
90%
5.0
4%
3.8
0.8
0.5
Equipment
2.2
10%
19.7
90%
21.9
16%
8.8
11.6
1.5
Medicines. Lab and Other Supplies
2.2
10%
20.1
90%
22.3
16%
8.0
12.9
1.5
MIS/IEC Materials
Training de Workshops
O.l
10%
1.0
90%
100%
1.1
4.8
0.3
0.7
0.1
4.8
0.8
4.0
Salaries
7.2
4.2
11.3
6.0
61% /a
59% /a
18.5
Operational Expenditures
39%
41%
1%
4%
14%
10.2
8%
1.0
8.5
Building <Sc Furniture Maintenance
0.8
44%
1.1
56% /a
1.9
1%
0.2
1.6
O.l
Equipment 5c Vehicle Maintenance
0.9
46%
l.l
54% /a
2.0
2%
0.2
1.7
O.l
25.0
18%
III.3
136.4
100%
30.1
99.3
7.0
Total
0.0
82%
18.5
NOTES:
/a Disburse me mi on Recurrent Costs are on a declining basis: Years 1-2 at 90%. Year 3 at 75%, Year 4 at 60%. Year 5 at 40%
0.7
Annex 15
Page 13 of 24
181
Table 13 Punjab: Disbursement Accounts by Financiers
Total Cost in USS Million
Gort oi Punjab
Amount
%
IDA
Amount
Tool
AmoaxU
For.
Exck.
Loot
(Exd.
Tim)
Dvtiai
Tim
2.4
Civil Works
6.6
15%
37.3
85%
43.9
41%
6.6
34.9
Consultants. Studies. Prof Services. NGOs
0.6
10%
5.0
90%
5.6
5%
0.9
4.7
Furniture
0.2
10%
2.0
90%
0.2
1.8
0.2
Vehicles
10%
2.5
90%
2.2
2.7
2%
0.3
3%
2.1
0.4
0.3
Equipment
2.0
0.9
0.4
0.0
10%
18.0
90%
20.0
19%
9.4
1.4
10%
10%
90%
90%
100%
9.0
3.7
8%
4%
3.5
0.9
2.8
3%
0.6
3.4
32%
8.1
3.3
2.8
7.4
9.3
4.8
10%
36%
49%
1.8
69% /a
64% /a
10.8
10
0.3
51% /a
2.8
0.7
3%
1%
0.3
0.1
2.3
0.6
0.2
0.0
38%
1.2
63% /a
1.9
2%
0.2
1.6
0.1
15%
89.7
85%
106.1
100%
24.6
76.0
5.5
Medicines. Lab and Other Supplies
MIS/IEC Materials
Training de Workshops
Salaries
Operational Expenditures
. Building Jc Furniture Maintenance
Equipment de Vehicle Maintenance
Total
0.3
0.7
16.3
2.5
2.2
0.6
0.3
10.8
NOTES:
/a D&bursemenu on Recurrent Cosu are on a declining basis: Years 1-2 a( 90%. Year 3 at 75%. Year 4 at 60%. Year 5 at 40%
Annex 15
Page 14 of 24
182
Table 14 West Bengal: Disbursement Accounts by Financiers
Total Cost in USS Million
Conor WB.
Awount
*
IDA
%
Tout
AuouM
For.
Exci.
Ucai
(EmL
Taxa*)
Mn A
Tn.
3.8
Civd Work
10.2
15%
58.0
85%
68.2
39%
10.2
54.2
Consulunu, Studies. Prof Services. NCOs
0.8
10%
6.8
90%
4%
1.4
Furniture
0.6
0.7
10%
90%
0.6
0.4
90%
6.8
3%
4%
6.2
4.7
10%
5.1
6.1
7.6
5.7
1.0
0.7
Medicines. Lab and Other Supplies
4.3
2.0
10%
10%
38.3
17.8
90%
90%
42.5
19.8
MIS/IEC Materials
0.2
10%
3.0
1.1
0.2
Vehicles
Equipment
Training
Workshops
0.0
24%
5.1
17.7
11%
3.2
21.8
15.5
1.5
1.9
90%
2.1
1%
0.5
3.0
100%
3.0
2%
0.4
6.8
68% /a
10.0
6%
2.7
Salaries
3.2
Operational Expenditures
1.6
32%
3.3
68% /a
4.9
3%
0.5
4.0
0.3
Building <Sc Furniture Maintenance
0.2
48%
0.3
52% /a
0.5
0%
0.0
0.4
0.0
Equipment &. Vehicle Maintenance
1.6
50%
1.5
50% /a
3.1
2%
0.3
2.6
0.2
25.3
15%
149.0
174.2
100%
39.9
124.7
9.7
Total
32%
86%
10.0
NOTES;
/a Diibur$cmcnu on Recurrent Co»u arc on j declining basis: Years 1-2 at 90%. Year 3 at 75%. Year 4 at 60%. Year 5 at 40%
J
Annex 15
Page 15 of 24
183
Table 15 Project Totals: Karnataka, Punjab and West Bengal
Expenditure Accounts by Project Components
Costs in USS Millions
CmaMadJ *
lipruri forvtai QuaMr. ‘ ■■M and
KrTMIrmwa
Mcunu r
(Mprove
laMUMMiaal
Fraewwrvk
fiv Pnlicv
Su’caftkra
Dr»«fc^
Muhoo *
lnyinWKMM SurvolUnca
Cjpac inr
Coacev
LuttU
Ciwiaey.
Area A
Duma
HcaoiuU
Upgrade
Cluucd
E (Tea i venaa
lin prill
AeMM
M BaaM Hmk*
ServicM
PbyMMd
C ■■juric
Iwprnu l
ReWral
TOTAL
Smem
Amomk
2.9
38.2
iOS
3.1
15.5
0.9
3.1
tos
9.3
ns
0.1
0.6
IOS
IJ
9.0
0.2
92.5
12.1
9.7
IOS
1.0
Ma/or Medical Equipmenr
40 0
0.4
40.4
IOS
4.0
Minor Med cal Equipmenc
1.5
2.9
0.1
1.6
IOS
0.2
0.1
IOS
0.3
0.4
IOS
2.7
IOS
1.3
0.5
2.3
1.6
0.6
0.3
0.2
0.1
0.1
0.0
0.0
Civil Woriu (Rxnovwoc)
0.0
Civil Woriu (N«w Co«tf or Externno)
Profoaioad Service*
Funuurc
0.0
3.0
02
0.0
03
0.1
35.3
Mcdcal Equipmcw - SurgKal Pack!
EqugHncM (Other)
0.1
44
Vehicles
0.1
I 5
05
0.3
0.3
0.0
0.0
0.0
0.0
2.9
27.4
12.6
4.6
23.1
15.1
6.0
6.3
1.9
l.l
1.5
0.4
0.1
0.0
0.1
0.5
IOS
5S
5S
5S
5S
111 4
11.9
20.1
300 I
IOS
293
0.6
2.1
5S
1.6
IOS
IQS
IOS
IOS
IOS
l.l
1.5
0.2
00
0.0
0.5
0.0
Other Supplies
0.0
0.1
0.0
20.1
0.3
1.6
15.2
14.6
MIS/IEC Maxcruh
00
0 3
0.1
4.0
Local Trauung
0 1
0.5
0 4
0 I
0.0
5.5
0.1
1.2
0.6
1.9
Medral Lab Suppica
MedtciMU
FeJiowib^
0.4
Workshop*
02
Contuiunu
0.1
06
0 1
03
0.2
NCO'i
0.1
03
I 6
II 7
12
Sahrm o< AddiiMMui Sulf
0.5
0 1
70
3 2
0.1
Opcraiionaj Expenaca
Studua
T*ttl Imv0(bm*< Costa
0.0
134 6
10.
0.4
3.0
7.9
0.5
0.9
0.1
0.6
0.7
0.2
0.0
0.1
IOS
IOS
IOS
IOS
5S
lnwr— CmU
00
00
0.1
0.0
04
00
49
0.1
Fur Mure Mamw nance
00
00
00
0.4
00
35 2
15.1
2.2
0.1
0.5
5.4
0.4
Te«a4 IUc«rr«s< Cwu
06
10 5
10
4 1
37.1
2.0
3.5
390
7S
4.1
Tatal BASEUXE COSTb
2.1
22.2
2.3
131.7
155.6
13.9
24.3
359.1
9S
33.6
RiysKal CxMUageiKi
0.1
l.l
0.2
13.9
13.9
1.4
2.4
0.1
1.5
0 1
1.9
10.7
0.8
l.l
33.6
24.0
OS
Pro CtMUageacia
9S
2.1
Tetai PROJECT COSTS
2.4
25.5
2.6
161.5
110.2
16.0
21.5
416.7
9S
33.7
1.2
24.7
9.5
1.4
9.3
l.l
7.9
22.2
94.6
9S
10
41.1
9S
u
0.1
00
BuiMing Maimenance
26.4
2.0
2 2
MainuraiKM
0.0
00
0 I
Ftbk Meimenank*
Vehicie MaiManance
5 4
Tmm
0.0
II
0.1
Foreign Exchange
0.5
35
0.5
0.4
0.0
IOS
Annex 15
Page 16 of 24
184
Table 16 Karnataka: Expenditure Accounts by Project Components
Costs in USS Millions
QmumcM-I *
Mteepii—I Di'Hiyit A
bnprowt
Surnetrkca
Fnawwtvk
fur Pule;*
ImptaneaMiMM
Imprwe
laprOT Strata QuaMy. AcnM
Efftl-rwi—
Strvuetbwe
CuMMMury.
Aru A Duna
HiHouaii
l'p<TW*e
ClMMcai
EfNctiventM
R^k^Ci ■ lyurr
I of
ie Me rt—Mk
Service*
KanoviM A
Eaatne
Ratemi
TOTAL
CmU
a?
7 2J
IO«
Civd Work* (New Como or Exicnsioto
0.89
23.62
0.91
27.42
10*
17
ProfeMKXUl Serve**
0.03
3.06
009
3.18
10*
0.3
2.86
2.99
10*
9 38
9 38
10*
0.)
at
7.2J
Civil Work* (RenovaiKMi)
Fu/nuw*
0 01
0 09
004
Mafor Medical Equipment
0*
Minor Medical Equipment
0*
Medical Equipment • Sutjcai Pack*
Equ>pmen< (OtherI
0 03
4 21
0 21
Vehicle*
0 04
I 12
0.12
I 'M
1 94
0.23
2.8
9 42
10*
Of
4 33
10*
0.4
0.4
ModicaJ Lab Suppitc*
0 60
2.98
3.39
10*
Medic me*
4 31
7.70
12.02
10*
1.2
0.01
Other Suppl ie*
M1S/IEC Material*
0 23
Local Traiainf
3.01
0.05
0.26
3.33
10*
0.3
0.32
0.03
0.57
0.93
to*
0.1
2.42
0.06
0.17
2.88
5*
0.36
10*
o.i
o.i
Sojdica
0.36
0.20
Fci lowth ip*
0.37
0.43
Workshops
0 13
0.36
Corauliants
007
NGOi
Total laveament CmU
0.10
3*
0.0
0.11
0.62
5*
0.0
0 17
0.00
0.24
3*
0.0
0 to
0 26
0.00
0.36
3*
0.0
I 16
7 07
11.70
89 30
10*
8.7
13.10
0.38
16.51
3*
as
2.21
1 92
8.67
10*
0.9
1.65
10*
0.2
0 37
37.83
28.09
306
0*
Rccurrrot CooU
Salanc* o( Addiinnai Sulf
0.18
2.17
0 47
OperaiKMtai Eapcnaca
0 03
2.43
0.10
1.96
1.63
Building Maintenance
0*
Surgical Pack Maintenance
0*
Vehcle MaiMcnance
Equipment Mainonance
001
0 31
1.71
I 38
2.50
28 34
7*
2.0
3 06
14 20
117.84
9*
10.7
3 66
0.30
1.38
10.71
0*
3.13
0.18
1.12
31.60
3 34
16.70
2 23
II 66
0 33
2.43
1.10
3 69
Total Racurrot CoaU
0 23
4 91
0 57
3 61
16.69
Total BASEUNZ COSTS
1 40
11.99
0.94
41 45
44 78
fhyiKal Continue new*
0.10
I 06
007
4 13
Ft ica CoMMfenciee
0.09
0 80
006
1*3
Total mQJECT COSTS
I 39
13.85
1.08
48.03
0.02
04)
0.77
2.47
004
2.33
7 22
F«raifn LuAaa«a
0.2
0*
Furniture Maintenance
Tu«
10*
0 17
8*
0.6
136.39
8*
11.4
7.04
30 08
9*
a<
9*
2.7
Annex 15
Page 17 of 24
185
Table 17 Punjab: Expenditure Accounts by Project Components
Costs in US$ Millions
CwaoLl ■
Mfiliam CW»i(ifui A I—tJtml—W
'XrwrtCTHI
QgaMMMj *
lipreve SarHee QuaMy. trrm and
t/Ttctk—et
p»r*c*r
la
HmMA
Raauvtta A
Impnwe
InumaoMuJ
Frwnewvk
StrenfUMa
A
uiuoru
Cxwuev
Dcvefop
Exwmt
C in—jary.
SurveSlaM
Ca—cev
Area A Duma
Huwah
Upmdi
Iwpwi'•
amcri
Retard
Effucttvcanr
Sv—
TOTAL
%
lavcauneat Coau
Civil WorU (Ranovmon)
4 49
Civil Worka (New Coiuu or LiteniKMU
3J 22
33.22
10%
3.2
Profcuional Scrvica
3 77
3.77
10%
0.4
0.2
Furniture
0.4
I 77
i n
10%
Madk.al Ka|uiym»n4
II 4J
II 48
10%
1.1
Minur Mtdu.ai tquipineiM
0 30
0 30
10%
0.1
0 67
0 67
IO«
0.1
4 30
4 32
IOS
0.3
10%
0.2
Medical H^wipment
001
0 06
0 04
Surgical Kauki
bjuipment (Othar)
•
IO»
VthKiM
0 III
0 01
U 01
0 12
2.1
Medical Lab Supplies
0.32
0.32
10%
0.0
Mcdcina
3.86
5 16
10%
0.6
Other Suppl ics
1.44
10%
0.1
3.20
10%
0.3
I 62
1.70
0.03
0.42
0.90
3%
10%
0.1
0.03
0.37
0.60
0.13
0.26
3%
5%
0.0
0.0
Consultants
003
0.03
NGO't
0.07
0.07
3%
3%
0.0
77 31
10%
7.6
MLS7IEC Materials
1.44
001
Ideal Training
Studio
0 0)
0 23
0.05
2.34
003
0.02
0.42
Fcllowihipi
Workshops
Total lamtmcnt Coau
0 I)
005
0 95
0 39
Salina of Additionai Stiff
0 I]
I 34
0 32
7 94
OpcruKXtal Eipcma
001
0 58
0(M
1.61
41 48
31.61
0.37
2.76
Rccurrral Coou
0.0
0%
Building Maintenance
0.11
0.42
Surgical Pack Maintenance
Vehicle Maintenance
0.1
0 02
0 01
0 01
006
0.39
9.72
3%
0.3
2.36
10%
0.2
0.42
10%
0.0
0.02
10%
0.0
0.47
10%
0.0
Equipment Maintenance
004
I 10
1.14
10%
0.1
Furniture Maintenance
000
0.14
0.14
10%
0.0
Total Rccarrtal Coau
0 14
I 98
0.4)
0 42
10.81
0.30
14 27
7%
0.9
Total BASELINE COSTS
0 20
2.92
0.82
41.90
42.49
3 26
91.31
9%
IJ
Physical Contingenciea
001
0.22
006
4 19
3.73
0.33
154
0%
Prea Contingencies
0 01
0 19
0.04
2.69
2.90
0.12
3 93
9%
QJ
Total PMOJLCT COXT1
0 11
1 U
0 92
41 74
49 II
>71
106.07
9%
9.0
I 1AM
0 (JU
o oa
0 04
1 43
1 3C
0 33
9%
0.3
Fwaign
0 01
0 14
0 24
7 49
14 66
2 06
9%
2.2
Annex 15
186
Page 18 of 24
Table 18 West Bengal: Expenditure Accounts by Project Components
Costs in USS Millions
rMinw T •
Cl—Mf 1 •
Sw-rtct Qu^My, Aecea aad
SlrolhxMic
laHewtuM
Frweewurt
fir Pnlfc»
■ lift A
Eawed
SirMfOMe
Mwaewawra A
UnfUMMMtme
Cjoecey
!
I
i
Aom
Effeerjrt—m
Sarviaa
Uwer**»
Ouuca
SurveUUMM
C^euev
Am A Dutna
HuieeaA
0.02
23.59
2.91
26.52
10»
26.62
3.13
31.90
10%
3.2
5.02
0.60
3.44
10%
0.6
TOTAL
Efhcowmii
I
larestBeai Cueu
Civil Woriu (lUnovauoa)
Civil WorKa (New Conatf or Exicnaion)
2.14
Profeunoal Scrvces
0.21
0.00
0 16
0.04
Funuture
0.03
Major Medical Equipment
2.7
4.42
0.21
4 16
10%
0.3
19.24
0.39
19.62
10%
2.0
Minor Medical Equgjmcm
1.00
0.03
1.03
10%
0.1
Mad cal Equipment - Surgical Packa
2.19
0.06
2.23
10%
0.2
0.4]
13.47
10%
1.3
0.41
5.44
10%
0.6
Equipment (Ohcr)
• Vehciea
0 03
0.11
005
0.32
0.21
12.62
5.06
Mcdcal Lad Supplica
0.64
0.06
0.69
10%
0.1
Medicinal
4 99
0 20
3.19
IOS
0.3
Other SuppiiM
0 01
MIS/IEC Materiala
0 09
0 0]
10.16
0.46
0.29
11.04
10%
II
0 03
0.03
1.34
0.29
0.13
1.16
10%
0.2
0.03
Local Trauuag
0.06
0 12
1.50
003
1.76
3%
0.1
Stud tea
006
0 14
0.23
003
0.46
10%
0.0
P«llvwthip«
0 0)
0 09
0 16
009
0 37
3%
0.0
0.16
0 14
Workxhopa
006
0 22
003
0.60
5%
0.0
Conauitaau
001
0 01
0.05
0.07
3%
0.0
NGO*
002
002
007
0.10
5%
0.0
0 36
3 67
90S
133.49
10%
13.2
Salvia of Addiuoaal Suff
0.16
3 4J
5.36
Operational Expcnaea
002
0.14
1.33
Total U*aUB«*i Coau
0.47
55.23
51.61
6.04
i
i
0%
Rtturre** Caau
0 12
002
Building Maintenance
1.51
Surgical Pack Maintenance
007
Vchcie Maintenance
1.97
5%
0.4
019
4 09
10%
0.4
001
0.13
10%
0.0
000
0.07
10%
0.0
0.03
0.03
10%
0.0
Equ^nwni Maimcnanca
000
0 01
004
2 43
0 06
2.34
10%
0.3
Furniture M&anicaaocc
000
0.01
000
0.24
001
0.27
10%
0.0
Tatai Racwrmt Cam
0 19
3 63
0.03
0.12
964
1.31
1.03
16.16
7%
1.2
Total •AhELTiZ COSTS
0.53
7 30
0.32
35 33
64.32
7 33
10.01
149.63
10%
14.4
Physical Contingencies
004
0.33
0.03
3.53
6.47
0.74
1.00
14.37
0%
Price CootuigcncKa
004
041
0.04
3.71
4 64
0.50
0.69
10.20
9%
0.9
Tetal PROJECT COITS
062
1.31
0.60
64 66
79 47
4.79
11.77
174.23
9%
15J
Tuca
001
0.22
0.04
3.24
4.73
•0.76
0.66
961
9%
Foreign Exchange
0.09
0.47
0.09
10.00
21.12
4.77
2.26
39.90
9%
0.9
3.6
I
I
I
Annex 15
Page 19 of 24
187
Table 19 Project Totals: Karnataka, Punjab and West Bengal
Expenditure Accounts by Project Components
Costs in Rs. Millions
TiaimbTMuipaiil
di,am A llMwiiaA
Inarin i Sarrtce QuaJMp. Amm aari
DTirttvi—
rfcyioiCi II |ini: II
■Mtc HaaM
Imwvvm A
EjUMd
i
XllflM A
FrwMwort
fur
Dewta*
C—ey.
Am A Owna
Cjmow
Optra*
Oaac^
EffacUWIMll
low****
TOTAL
lavwuaeai Cmu
Civil Warti (Rcnovauoe)
0.13
. Pro&MMQMi Servcea
Furiucure
I 34
1.33
0.09
10.32
4 21
412.29
Major Modical
Muaor Marini Equqxara
. Marini EquiqawM - Surf icai Padu
Equ<>incM (Ober)
2.75
133 67
17.07
Vchclca
J 57
31 50
II.10
101.10
1J 30.70
10%
133.1
31.12
101.90
3J2O.3O
10%
322.0
44.5
1^21.73
2.974.01
103.30
Civil Worti (New Cowa ar Eittrnne)
67.3
3.11
21.00
445.11
10%
314.74
7.42
331.50
10%
33.9
1.393.34
13.43
1.406.77
10%
140.7
32.33
1.13
34.16
10%
34
W 22
2.07
101.29
10%
lO.I
14 11
953.13
10%
95.4
I4.H
4)9.69
10%
44 0
691.02
1.71
349 93
M«lnl Lab Suppiia
34 12
105.71
139.90
10%
16.0
MadKUKS
327.16
273.13
102.99
10%
KJ
Ocher Supplies
0 30
3 30
1.02
301.34
17.76
19.11
330.30
!0%
33.0
MIS/IEC HMcnals
023
9.04
2.90
140.52
31.20
24.40
201.31
10%
20.1
Local Traaui«<
200
14 09
2.61
192.72
2.00
7.00
220.49
5%
11.0
Sxudica
13 70
1930
1.00
29.30
1.00
66.70
10%
6.7
FcilowihqM
14 00
3.13
1.00
40.70
3.00
61 13
3%
3.1
WariubofM
7 20
12.00
22.33
1.73
1.00
31.41
3%
16
CooMdtana
2.10
6 40
1.60
0.04
1 60
12.44
3%
0.6
NGO’»
4 20
9 60
2.40
0.06
2 40
11.66
3%
0.9
54 31
406 10
4.121.91
412.74
722.16
10.44) 44
10%
1.026.1
ToLW Iavau*«»4 CmU
42.69
4.612.63
0%
Racwrcnt CoaU
Sahrm o( AddKMN«ai Suit
16 30
242.26
27.36
OperaiMMal EapenaM
2.17
109 71
4 91
116.33
56.36
73 92
0 7)
Be44»f MauueiWflM
911.49
61 II
3 00
Swgicai Pack Munewei
20.34
1.223.13
5%
61.3
97 61
326.13
10%
32.6
0 47
77.14
10%
7.7
0.06
3.06
10%
0.3
Vchcle Mauiunanca
0.11
0 29
2.23
0.96
17 36
10%
1.7
Equ^oMM MauMiuaca
060
12.34
1.33
171.39
2.12
119.01
10%
11.9
Fimaura MaMMsnanca
001
0.30
0.13
13.16
0 40
14.27
10%
1.4
T«ul iUaMTtM Cmu
20.23
366.05
36.43
144 10
1.292.39
70.04
122.73
2.052.19
7%
144.0
TMjU BASELINE COSTS
74.74
772.13
79.14
4.126.73
3.414.30
412.71
144 19
12.495.63
9%
1.170-1
13.61
Phywcai CoMiafeacics
3.14
62.91
6.33
412.67
412.33
47.39
12.17
1.170.06
0%
Price Coouafeacia
16.77
IU.9I
11.31
1,062.23
1.399.11
91.39
240.91
3JQ5.73
9%
237.6
TaUl PROJECT COSTS
96.63
1.024.74
104.07
6.371 63
7.296.91-
621.76
1.161.67
16.691.44
9%
1.427.7
Tua
1.29
42.94
4 71
323.01
313.14
33.12
72.52
111.13
9%
n.7
Forvifn ExcHaaoi
20.64
139 97
19.37
973.09
1.943.33
361.12
321.25
3.717.99
9%
341.4
I
Annex 15
Page 20 of 24
188
Table 20 Karnataka: Expenditure Accounts by Project Components
Costs in Rs. Millions
r------—i.
la^rw*
* nri
urwk.iM
la
f-iaaiioo^
M-mwcvm A
Roao^ A
ElMOd
CaaooMMy.
Fmaowork
fur PtMuv
liwyii—■■miiio
Atm A Dans
iMpr^o
Hwaa
SarrtMB
UerW.
a—Mi
Ertaarrmru
TOTAL
lUtenl Srw
Lavaauacac Coau
Chrd Worts (Raaovauoa)
231.35
Ctvd Worts (Now Coutu or Exhoskm)
ProfoaMoaaJ Sarvicaa
FurnKMro
0 J4
231.53
10%
23.2
JO 90
191 63
Jin
954 33
10%
95.4
I 09
106.J2
J.II
110.39
10%
ll.I
99 JI
104.01
10%
10.4
J26.47
326.47
IO«
316
J 06
I.JO
Ma/or Madicai
Miaor Mod cal E^M^naas
0%
■ Sorgeal Packs
Madcal
Equipaseas (Ohar)
’Vchctes
0%
I 73
141 77
7 27
I 43
J9 04
4 30
67.3
102.37
1.71
Mcdcal Lab Supplts
Medicxaa
MLS/1LC Maaenals
Local Truttaf
1.00
131.37
10%
13.1
103 71
124.71
10%
12.3
311
261.13
411.20
10%
41.1
104.12
1.73
9.11
116.03
10%
11.6
11.10
1.20
20.00
32.30
10%
3.2
M.I2
2.00
6.00
100.12
5%
3.0
150.07
0 JO
10%
97.71
21.00
Other
327.67
SoaiMa
12.30
7.00
19 30
10%
10
Fellowib^*
1300
13.00
21.00
3%
1.4
Workshops
3 20
12.30
3.73
21.43
3%
l.l
Coaauitaaa
2 40
600
0.04
1.44
3%
0.4
NGO'i
3 60
9 00
0.06
12.66
5%
0.6
40 22
246 20
12.17
407.09
3.107 31
10%
302.2
Sahnca o( Additaxtal SaZf
6 30
73 31
16.41
435.13
20.34
374 35
5%
21.7
OporttKMal Expenses
1.17
14 32
J 4|
76.97
66 61
301.70
10%
30.2
37.41
10%
3.7
Taud
CmU
1.317.01
977 61
106.31
RaorrvM
0%
6oiMtA< MaiMonanca
61.11
37 41
Suri cal Pack MaiMenanca
0%
VohKie MsiaMnanca
Ex<v5>nwn< MaiRMnanca
0%
0.30
10 9J
39 49
41 06
PumKurw MaMMananca
10%
3.9
0%
TauJ Racarraat Caata
167
171 03
19.96
123 39
380. U
Tatal BAIILCVI COfTl
4| 19
417 23
32.13
1.442 60
IJ3I49
106.31
17.02
993.13
7%
70.6
494.U
4.100.73
9%
372.1
PkysKal C4MKia<sacM8
3.36
36.79
2.46
144 26
127.41
10.37
41.09
372.11
0%
Prica Coaua(«acia
10.64
104 32
1.70
259.09
423.19
22.63
133.20
964.47
1%
n.7
Tacai mQJlCT COSTS
62.19
551.33
43.99
1.143.95
2.111.13
139.37
695.41
5.451.01
1%
433J
Taiaa
0.62
J0U
1.71
91.11
90.94
•13.04
43.97
211.33
9%
23.6
Far«<a Eachanfa
16.66
9104
6.13
276.93
473.33
96.40
237.39
IJQ5 63
9%
106.3
Annex 15
189
Page 21 of 24
Table 21 Punjab: Expenditure Accounts by Project Components
Costs in Rs. Millions
Q^aaMcaLl *
Milium* Di'diRU * l—wi—1
£mAAAtJ-
Iwaraa Wva. O-Ay. Ams aad
UflrtWM
PfryMCdC
If inw
MmM
Hi—'i— a
Lurat
Cumm-T.
Aim A Ut—r—i
SuvnfAaa
mmu-m a
Improv.
farHaa
O—Mt
■r^uiiwM
lUUrra Ip-
LiiMaiU Cu*U
136 40
Civd WixU (RatwvMKM)
1.134 00
Cl»d WtwU (N*w Cumw ur luianamn)
Fu/IUIIMC
0 20
: oo
I 50
Ma^or Medical Equipment
Minor Medical Equipment
Medical Equipment • Surreal Facts
'Vehicles
0 25
1.17
MIS/IEC Materials
0 25
Local Trauuac
Studies
1.20
397.41
10*
39.7
17.31
17.51
10*
1.1
D. 16
23.16
10*
2J
157.45
10*
15.7
14 92
to*
u
11.02
11.02
10*
1.1
204 02
204.02
10*
20.4
50.00
10*
5.0
111.41
10*
It.I
59.17
5*
3J
31.20
10*
3.1
21.00
5*
1.1
9.10
5*
0J
1.70
It.42
I.SO
0.15
56.52
Fcllowsh^M
1.00
14.50
1.00
20.00
20.00
4.60
4 50
WarUhops
1.60
CoMuiiaats
2.40
NGO’i
Total I>»caUDcn( CoA*
6J
397.41
1.04
14 50
1.90
32.91
13 55
I.44J 64
13.1
10*
50.00
Other Supplies
113 6
10*
76.00
MedcuKS
13.6
10*
65.24
7 50
Mcdcai Lib Supplies
10*
13124
156.55
0 40
Equ^xnent (Other)
134.40
1.154 00
61.54
111 14
PrulMtwod i4/vi£«4
TUTAL
1.102.32
96 00
1.60
5*
0.1
2.40
3*
0.1
2.690.32
10*
2S4.4
0*
Rcoumu Costs
Silanes of Additional Staff
4 50
46 66
Operational Expenses
0 30
20 23
276.15
11 OS
56.20
I 50
14 41
Buildinf Maintenance
0.72
Surgical Pack Maintenance
VehKle Maintenance
3.73
0.11
0.29
13.61
2.25
Etju^xneat Maintenance
I 39
31.26
Funutura Maintenance
0.16
4 15
331.41
5*
16.9
11.96
10*
1.2
14.41
10*
1.4
0.72
10*
0.1
16.40
10*
1.6
39.65
10*
40
3.01
to*
0J
14.41
376.11
7*
3X7
61.73
14 13
496 63
4.98
17.41
Total RacMTvat Co«s
21.31
1.431.12
1.471.50
3.IM. 95
297.1
101.66
9*
6.81
113.41
TAai BASELINE COSTS
2.19
143.11
129 79
0*
7 32
397.11
0 46
11.34
Phy»«al CiMMinfencMS
322 II
369 40
13 30
734.74
9*
623
3396
Pnca CvMinfantiMa
I 31
23 07
3 M
33 92
1.926.04
1.977 69
131.05
9*
8 86
132 24
4JI1.79
tma ntojiCT com
96.73
12.31
9*
191
3 25
1 33
217.33
0 12
103^9
Taaas
74.71
M0
Fomin Eachan<«
7 II
9*
0 39
979.16
I 89
295 96
392.03
Annex 15
Page 22 of 24
190
Table 22 West Bengal: Expenditure Accounts by Project Components
Costs in Rs. Millions
farm Qwat?, Am
Mmmw* Oil lilfll A ilMli—V
tuwmiiMf «
_____ Aum
faww A
lv*—
UnfRiii
Imin—i
frwwxi
ft*
Di^
A O»«3
r
Qmi
EffaUWMM
I fra i
fafarrn Irw
TOTAL
t
Uvmum*< Caau
Gvd Warki (IUaowmmi)
O.M
Civd Wort* (N«w Gmmt or ExMauxi)
74 60
ProfaM«Mui Sorvea
7 46
0.09
3 46
1.41
120. K
101.10
92X73
10*
913
926.43
IM.90
1.109.93
10*
111.0
20.3
174.73
21.00
203.21
10*
133.12
7.42
169.11
10*
16.9
"Maior Modcal Egoywa
669.39
13.43
642.12
10*
64.3
Mow Modsai E^rmn
>4 12
1.13
36.63
10*
3.7
Mani E^oywat - Sw(icai Pacfa
76.06
2.07
71.11
10*
7.1
14 II
464.71
10*
46.9
14 ||
203.40
10*
20 3
22 10
2 00
24 10
10*
14
nj.n
700
110.77
10*
III
FunuEurc
E^uyMM (OUw)
1.00
I 00
4 00
I 19
II 23
9 10
439.10
176.13
Mam L«» faym
OUmt fayoa
0 50
MIS/1EC Mvacuh
3 00
I 02
333 72
16.01
10.00
364X3
10*
34.4
I 00
1.20
41.00
10.00
440
64 60
10*
6.3
1.13
52.M
1.00
61.20
3*
1.00
16.00
10*
3.1
1.6
12.13
3*
0.6
1.00
20.93
3*
1.0
Local Truaug
2 00
4 29
SO«dM*
2 00
3 00
1.00
3.70
3.00
3.43
3.00
F«1 iowiAy
I 00
Wort*hop»
2.00
7.50
CommA^ao
040
0 40
1.60
140
5*
0.1
NGQb
060
060
2.40
3.60
3*
0.2
12 39
127 69
313.07
4,643.33
10*
439.3
Silvia of AddiiKxtai Su/f
3 70
120 00
116.49
Opcrwonai Expcoa
0.70
4 96
33.11
16.27
1.921.91
2.041.99
210.16
0*
R4C*rm< CmU
32.63
31119
3*
13.6
31.00
14147
10*
142
0.47
3.23
0.06
134
096
0.96
EduywM Maintmaca
0 10
0.22
I 33
13.27
1C
19.94
FunMMro MaiMtmacB
001
0.34
0 13
1.31
0.40
9.26
10*
10*
10*
to*
10*
TatW Rawrm C—u
6.31
126 27
I 66
4 03
333.33
32.63
33.71
362.41
7*
40.6
T«tai BASEUNZ COSTS
11.97
233.96
17.93
1.926.01
2J77.32
26179
330.71
3J07.96
10*
300.1
Boddiaf MunttMJO
0 73
4 03
Swrgcal Pack MaiM*aaac<
2.21
VckKio MauttCMACB
0J
0.2
0.1
9.0
0.9
Riytcai CoounfcacKa
1.31
11.60
1.70
192.60
223.27
13 11
34.71
300.14
0*
Pra Coouac«ncia
462
61.39
4 33
411.03
604.39
62.47
17.71
IJ06.54
9*
114.4
T«ul PROJECT COSTS
24.90
334.13
24.16
2J99.64
3J07.3I
331.14
473.24
7,014.63
9*
614.6
Tua
036
111
1.47
130.10
I9I.3U
30.46
26.35
319 47
9*
33.4
Fortin Exchanf*
337
34 79
3 63
402.21
171 13
119 94
9016
1.603.19
9*
143.1
Annex 15
Page 23 of 24
191
Table 23: Project Components by Year
Base Costs in Rs. Million
96/97
Bax Cot in Indian FY
97/98
98/99
99/2000
2000/01
Total
1. Management Development & Institutional Strengthening
la - Improve Institutional Framework for Policy Develpment
9.4
18.7
20.4
13.3
12.9
74.7
lb - Strengthen Management <Sc Implementation Capacity
78.6
175.1
184.2
176.8
158.1
772.9
1c - Develop Surveillance Capacity
10.2
m
IO
1L1
LLQ
Z2J.
Subtotal
98.3
213.0
221.2
206.2
188.0
926.7
706.4
1,112.0
1.431.1
1.178.4
398.8
4,826.7
457.3
1,086.2
1.378.6
1,214.3
1,278.1
5,414.5
2. Improve Service Quality, Access and EfTectivenes
* 2a - Renovate
Extend Communiry, Area <St District Hospitals
2b - Upgrade Clinical Effectiveness
ZU1
2,347.0
22J
2,909.0
69 4
2,467.8
1,746.4
482.8
10,724.0
48.9
120.7
207.0
237.7
230.7
844.9
Total BASELINE COSTS
1,401.1
2.680.6
3.337.2
2,911.6
2.165.1
12.495.6
Physical Coniinjcncics
133.3
253.2
315.3
272.3
196.0
1,170.1
Pncc Conungencics
52.7
361.2
774.4
940.0
897.5
3.025.7
Total PROJECT COSTS
1.587.1
3,295.0
4,426.9
4.123.9
3.258.5
16,691.4
84.4
179.9
235.5
215.3
173.1
888.1
880.5
765.2
3.788.0
2c • Improve Referral Mechanism
Subtotal
3 - Improve Access to Basic Health Services
Tues
Foreign Exchange
90.3
148-8
1,253.9
350.6
797.2
994 4
r
Annex 15
Page 24 of 24
192
I
Table 24: Project Components by Financiers
Total Costs in USS Millions
GO!
!DA
.kxnoaM
AAMMiai
Ejck.
Lacai
(X-d.
Tum)
Tua
0.0
1. Management Development 3c Institutional Strengthening
la * Improv« Losucuuoaal Framework for Policy Dcvelpmeni
0.3
13.8%
2.1
86.2%
2.4
0.6%
0.5
1.9
lb • ^rv-n^rx-n Maaa(cmczx &. ImpicmcDtauoa Capacity
5.8
22.7%
19.7
77.3%
25.5
6.1%
3.5
20.9
1.1
QJ
21.9%
Q6%
QJ
LQ
QJ.
6.7
21.9%
23.8
78.1%
j0.5
7.3%
4.5
24.7
U
24 8
15.4%
136.6
84 6%
1.41.3
38.8%
24.7
128.5
8.2
43.2%
48.1
122.5
9.3
L2A
11
lc • Develop Survedkocc Capaoty
Subtotal
78.1%
L Improve Service Quality, Access and EfTectivenes
2a • fUaowe A Fn*™* Coaunuaoy. Area 4c Duma Hotpiuls
2b • Upgrade Claucal EffccuvaKM
• 2c • Improve Referral Mcchanttni
Subtotal
3 * Improve Access to Basic Health Services
28 7
15.9%
151.5
84 1%
n
13 1%
86-9%
£1
13
55.6
15.6%
LL2
302.1
84.4%
^7.7
85.8%
82.1
256.4
19.2
4.3
15.3%
24.1
84.7%
3.5
6.8%
7.9
18.8
1.8
66.7
16.0%
350.0
84 0%
4^4.7 100.0%
94.6
299.9
22.2
:»2
i
Total Disbursement
t
iV-
i
A
B
£
Annex 16
Page 1 of30
193
SUMMARY OF CONSTRUCTION PROGRAM
Karnataka: List of Hospitals to be Extended/Renovated
Code Place
Type of Health Facility
Karnataka State
Bangalore District
I
104 Anekal
103 Bangalore
102 Bangalore
101 Bangalore
105 Knshnanijapuraiii
106 Ycllahanka
Taluk Hospital
HSIS Women Sc Children
Epidemic Diseases Hospital
Vanivilas Hospital
Taluk Hospital
Taluk Hospital
Bangalore Rural District
201 Channapatna
202 Dcvanhalli
203 Doddaballapur *
204 Hosakote
205 Kanakapura
206 Magadi
207 Neiamangala *
208 Ramanagaram M
Taluk Hospital
Taluk Hospital
Sub-Division Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Sub-Division Hospital
Belgium District
302 (Mhni
301 Belgaum #
303 Chikodi
304 Nipani *
305 Gokak
306 Huken
307 Khanapur
308 Saundatti-Yeilamma
309 Yargatti
310 Ramdurg
311 Raybag
312 Baiihongai
313 Kittur
Taluk Hospital
Distnct Hospital
Sub-Division Hospital
Community Health Centre
Taluk Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Community Health Centre
Taluk Hospital
Taluk Hospital
Sub-Division Hospital
Community Health Centre
Bijapur District
Taluk Hospital
Community Health Centre
Sub-Division Hospital
Taluk Hospital
District Hospital
Taluk
Hospital
606 Biigi
Taluk Hospital
607 Hungund •
Community Health Centre
608 llkal
Sub-Division Hospital
609 Indi
Community Health Centre
610 Tadavalaga
Sub-Division Hospital
611 Jamkhandi
Community Health Centre
612 Rabkavi Banahatti
Community Health Centre
613 Kalgi
Taluk Hospital
614 Muddebihal
Community Health Centre
615 Talikota
Community Health Centre
616 Mahalingpur
# Casualty Ward to be strengthened/provided
602 Badami
603 Guledagudda
604 Bagaikot
605 Basavana Bagevadi
601 Bijapur *
Bed Strength
Existing Proposed Additional.
14858
18690
3832
131
972
1103
34
16
50
0
120
120
128
0
128
0
605
605
6
94
IOO
9
91
100
390
59
J31
94
100
6
30
28
2
4'7
50
3
7
30
23
0
50
50
30
0
30
50
38
12
47
3
50
162
1220
1058
32
50
18
0
740
740
37
50
13
20
30
10
10
40
50
0
30
30
2
28
30
47
3
50
6
30
24
22
50
28
24
30
6
0
50
50
6
30
24
1260
379
881
18
30
12
30
5
25
0
150
150
40
10
50
0
440
440
20
10 • 30
20
30
50
50
30
20
50
40
10
24
30
6
. 50
100
50
14
30
16
*6
24
30
20
50
30
16
30
14
0
30
30
Annex 16
Page 2 of30
194
SUMMARY OF CONSTRUCTION PROGRAM
Karnataka: List of Hospitals to be Extended/Renovated
Code Place
Type of Health Facility
Existing
Bed Strength
Proposed Additional.
Bijapur District Continued
Taluk Hospital
617 Mudhol
Taluk Hospital
618 Sindgi
Chikmagalur District
Women &. Children Hospital
702 Chikmagalur
District Hospital
701 Chikmagalur *
Community Health Centre
703 Birur
704 Kadur
Taluk Hospital
705 Koppa
Taluk Hospital
706 Mudigcrc
Taluk Hospital
707 Narasimharajapura
Taluk Hospital
708 Snngcn
Taluk Hospital
709 Tankcrc *
Sub-Division Hospital
Chitradurga District
802 Challakerc
Taluk Hospital
903 Nayakanahatli
Community Health Centre
804 Parasurainpura
Community Health Centre
805 Bharamasagara
Community Health Centre
801 Chnradurga *
District Hospital
Taluk Hospital
806 Singcre
807 Davangre
Women &. Children Hospital
808 Davangre
Sub-Division Hospital
809 Hanhar
Taluk Hospital
Taluk Hospital
810 Hiriyur *
811 Holalkere
Taluk Hospital
812 Hosdurga
Taluk Hospital
813 Jagalur
Taluk Hospital
814 Molakalmuru *
Taluk Hospital
Dakshina Kannada District
903 Bantval
Taluk Hospital
904 Bcltangadi
Taluk Hospital
905 Karkal
Taluk Hospital
Community Health Centre
906 Nine
907 Kundapura *
Suo-Division Hospital
Weniock District Hospital
901 Mangalore *
Lady Goshen Hospital
902 Mangalore
Community Health Centre
908 Mulki
Sub-Division Hospital
909 Puttur *
Taluk Hospital
910 Suiya
911 Shirva
Community Health Centre
912 Udupi
Taluk Hospital
913 Udupi
Women &. Children Hospital
Dbarwad District
1002 Byadgi
1001 Dharwad
1003 Gadag
1004 Gadag
1005 Akki Alur
1006 Hangal
Taluk Hospital
District Hospital
Women & Children Hospital
Sub-Division Hospital
Community Health Centre
Taluk Hospital
* Casualty Ward to be strengthened/provided
io
12
651
88
274
56
51
36
64
18
14
50
170J
30
0
30
6
391
30
100
850
50
50
30
36
50
50
1592
30
30
120
6
100
705
234
44
80
30
21
100
92
1872
30
170
42
60
18
28
30
50
816
100
300
56
100
50
100
30
30
50
1870
50
30
30
30
400
30
100
850
50
100
50
50
50
50
1695
30
30
120
30
100
705
250
50
(00
.. 50
30
100
100
2255
30
250
50
100
30
30
20
38
165
12
26
0
49
14
36
12
16
0
167
20
30
0
24
9
0
0
0
0
50
20
14
0
0
103
0
0
0
24
0
0
16
6
20
20
9
0
8
383
0
80
8
40
12
2
I
Annex 16
Page 3 of30
195
SUMMARY OF CONSTRUCTION PROGRAM
Karnataka: List of Hospitals to be Extended/Renovated
Code Place
9
J
Type of Health Facility
Dharwad District Continued
1007 Haven 8
Sub-Division Hospital
1008 Hirekerur
Taluk Hospital
1009 Chitaguppa
Community Health Centre
1010 Hubli H
KMC Hospital
1011 Kalghatgi
Taluk Hospital
1012 Kundgol
Taluk Hospital
1013 Lakshemcshwar
Community Health Centre
1014 Mundargi
Taluk Hospital
1015 Nargund
Taluk Hospital
1016 Navalgund
Taluk Hospital
1017 Rarubcnnur
Taluk Hospital
1018 Rambcnnur
Taluk Hospital
1019 Gajcndragarh
Community Health Centre
1020 Ron
Taluk Hospital
1021 Savanur
Sub-Division Hospital
1021 Shig£aon
Taluk Hospital
1023 Shirhatu
Taluk Hospital
Hassan District
1202 Alur
Taluk Hospital
1203 Arkalgud
Taluk Hospital
1204 Konanur
Community Health Centre
1205 Arsikcrc
Taluk Hospital
1206 Bclur
Taluk Hospital
1207 Channarayapatna *
Taluk Hospital
1208 Hirisave
Community Health Centre
1209 Dudda
Community Health Centre
1201 Hassan a
District Hospital
1210 Halli Mysore
Community Health Centre
1211 Holcnarasipur
Taluk Hospital
1212 Saklcshpur *
Sub-Division Hospital
Kodagu District
1302 Madiken
Women Children Hospital
1301 Madiken #
District Hospital
1303 Kushalnagar
Community Health Centre
1304 Sanivarasame
Community Health Centre
1305 Somvarpct
Taluk Hospital
1306 Gonikoppal
Community Health Centre
1307 Kutta
Community Health Centre
1308 Polibetta
Community Health Centre
1309 Siddapura
Community Health Centre
1310 Virajpct
Taluk Hospital
Kolar District
1402 Bagepalli
Taluk Hospital
1403 Bangarapct
Epidemic Disease Hospital
1404 Bangarapct
Taluk Hospital
1405 Bangarapct
KGF Hospital
1406 Bangarapct
Women Children Hospital
1407 Chikballapur
Sub-Division Hospital
1408 Batlahalli
Community Health Centre
* Casualty Ward to be strengthened/providcd
Bed Strength
Existing Proposed Additional.
‘XI
30
45
740
10
6
21
o
20
18
50
22
21
6
30
30
10
821
10
30
15
97
10
50
10
6
344
16
100
133
953
210
200
34
30
112
27
28
27
45
240
1027
50
24
28
150
67
87
30
loo
50
50
740
30
30
30
30
30
30
50
30
30
30
50
50
30
1150
30
50
30
100
50
50
30
30
500
30
100
150
9K2
210
200
50
30
112
30
30
30
50
240
1274
50
24
30
150
l(X)
100
30
10
20
5
o
20
24
9
30
10
12
0
8
9
24
20
20
20
329
20
20
15
3
40
(I
20
24
156
14
0
17
29
0
0
16
0
0
3
2
3
5
(I
247
0
0
2
0
33
13
0
Annex 16
Page 4 of 30
196
SUMMARY OF CONSTRUCTION PROGRAM
Karnataka: List of Hospitals to be Extended/Renovated
Code Place
Type of Health Facility
1409 Chintamani
1410 Gaunbidanur
1411 Gudibanda
1401 Kolar *
1412 Malur
1413 Mulbagal
1414 Sidlaghatta
1415 Snmvaspur
Manilla District
1502 Knshnarajpct
.1503 Kalamuddanadoddi
1504 Maddur
1505 Malavalli
1501 Mandya #
1506 Nagamangala
1507 Pandavapura
1508 Shrirangapattana
Mysore District
1604 Chamarajnagar
1605 Chamarajnagar
1606 Gundulpet H
1607 Kabbahaili
1608 Heggadadevankotc
1609 Huruur *
1610 Kollcgal *
1611 Krislmarajanagara
1612 Sahgrama
1601 Mysore
1602 Mysore
1603 Mysore
1613 Nanjangud
1614 Piriyapatna
1615 Bannur
1616 Talakad
1617 Tiramakudal-Narsipur
1618 Yelandur
Shimoga District
1902 Bhadravati
1903 Channagiri
1804 Honnali
1805 Hosanagara
1806 Sagar #
1807 Shikarpur
1808 Siralkoppa
1801 Shimoga #
1809 Sorab
1810 Kannangi
1811 Tinhahalli
Taluk Hospital
Taluk Hospital
Taluk Hospital
District Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Community Health Centre
Taluk Hospital
Taluk Hospital
District Hospital
Taluk Hospital
Sub-Division Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Taluk Hospital
Community Health Centre
Taluk Hospital
Sub-Division Hospital
Taluk Hospital
Taluk Hospital
Community Health Centre
Cheluvanba Hospital
Epidemic Disease Hospital
SMT Maternity Hospital
Sub-Division Hospital
Taluk Hospital
Community Health Centre
Community Health Centre
Sub-Division Hospital
Taluk Hospital
Community Health Centre
Taluk Hospital
Taluk Hospital
Taluk Hospital
Sub-Division Hospital
Taluk Hospital
Community Health Centre
District Hospital
Taluk Hospital
Community Health Centre
Taluk Hospital
Bed Strength
Existing Proposed Additional.
0
50
50
0
110
110
15
30
15
140
400
260
18 *
50
32
26
50
24
0
50
50
0
50
50
306
720
414
20
30
10
24
30
6
50
10
40
50
100
50
150
400
250
18
30
12
10
50
40
24
30
6
413
1430
1017
8
50
42
30
100
70
26
50
24
18
30
12
0
50
50
0
50
50
43
150
107
35
100
65
20
30
10
0
400
400
13
50
37
8
50
42
70
100
30
0
30
30
24
30
6
24
30
6
70
100
30
24
30
6
241
1040
799
0
50
50
0
50
50
24
30
6
20
50
30
0
100
100
22
50
28
24
30
6
71
500
429
32
50
18
6
30
24
42
100
58
Annex 16
Page 5 of 30
197
SUMMARY OF CONSTRUCTION PROGRAM
Karnataka: List of Hospitals to be Extended/Renovated
Code Place
Type of Health Facility
Tumkur District
1902 Chiknayakanhalli
Taluk Hospital
Taluk Hospital
1903 Gubbi
l<X)4 Koctttagcrc
Taluk Hmpitai
Taluk Hospital
1905 Kunigal
Sub-Division Hospital
1906 Madhugin
Taluk Hospa.ii
1907 Pasagada
Taluk Hospital
1908 Sira
1909 Tiptur
Sub-Division Hospital
1901 Tuinkur H
Distnct Hospital
Taluk Hospital
1910 Turuvckcrc
Uttara Kannada District
Taluk Hospital
2002 Ankoia
Taluk Hospital
2003 Bhatkal
Community Health Centre
2004 Dandcli
Taluk Hospital
2005 Haliyal
2006 Honavar it
Taluk Hospital
2001 Kanvar #
Distnct Hospital
Sub-Division
Hospital
2007 Kumta
Community Health Centre
2008 (Tibetan) Mundgod
Taluk Hospital
2009 Mundgod
Taluk Hospital
2010 Siddapur
Sub-Division Hospital
2011 Sirsi *
Taluk
Hospital
2012 Supa (Joida)
Taluk Hospital
2013 Ycllapur
# Casualty Ward to be strcngthcncd/providcd
Bed Strength
Existing Proposed Additional
860
J!7
59J
44
6
50
14
16
30
17
M
50
50
3(1
20
100
50
50
20
30
50
30
50
20
KM)
65
35
400
325
75
X
30
22
.401
549
950
28
50
22
io
40
50
50
4
46
0
30
30
0
50
50
400
170
230
50
19
31
0
50
50
24
6
30
30
0
30
44
100
56
24
30
6
24
6
30
Annex 16
Page 6 of30
198
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
DistrictiAmritsar
—
Hospital/
Community
Health
Centre
Number of Beds
Population of
Town (1 fig.
- 1994 &2fig.
Sanctioned Functional To be made Additional Total
Remarks
2000 AD)
functional Required Required
Sub-Divisionai Level
Tam Taran
50
60
51972
60192
N. Highway
Rly. Line
10 Trauma Beds
Pani
50
50
31413
38133
20 km from
N. Highway
Ajnala
50
50
N. Highway
Rly. Line
Baba Bakala
50
50
5 km from
N. Highway
Community Health Centres
Lopoxe
30
10
______
Majitha
30
30
Tarsika
30
10
Jandiala
(Manawala)
30
30
Ghariala
30
30
20
20
30 km from
N. Highway
N. Highway
20
20
20 km
N. Highway
20512
22528
N. Highway
Rly. Line
30 km from
N. Highway
Khem Karan
30
13
Sur Singhwala
30
30
Sirhali
30
23
7
7
N. Highway
Naushera
Pannuan
30
8
22
22
N. Highway
Mian wind
30
10
20
20
10 km from
N. Highway
Total
500
404
106
106
17
17
Rly. Line
30 km from
N. Highway
I
Annex 16
Page 7 of 30
199
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District:Bathinda
Hospital/
Community
Health Centre
Children Hospital
Bathinda
Population of
Town (1 fig.
1994 & 2 fig. Remarks
Functional To be made Additional Total
functional Required Required 2000 AD)
Number of Beds
Sanctioned
100
100
100
100
171973
192653
N. Highway/
Rly. Line
District Level
Civil Hospital
Bathinda
N. Highway/
Rly. Line
Sub-Divisional Level
Rampura Phul
50
50
Talwandi Sabo
30
30
20
20
Area Hospitals
Civil Hospital
B hue ho Mandi
6
6
19
19
C.H. Maur Mandi
25
25
Civil Hospital
Raman Mandi
10
10
36855
39291
N. Highway/
Rly. Line
278932
32914
15
15
N. Highway/
Rly. Line
20 km from N.
Highway
N. Highway/
Rly. Line
18402
20484
Rly. Line
1U27
12447
2849
3059
N. Highway/
Rly. Line'
N. Highway/
Rly. Line
20 Km from N.
Highway_____
Community Health Centres
Gotuana
30
30
Sandal
30
30
30
30
Rhagta
30
30
Total
441
441
20 Km from N.
Highway
54
54
Annex 16
Page8 of 30
200
SUMMARY OF CONSTRUCTION PROGRAM
Punjub: List of llospituls to be Extcndcd/Rcnovuted
DistrictzFaridkot
Hospital/
Community
Health Centre
Number of Beds
Population of
Town (1 fig,
Sanctioned Functional To be made Additional Total
1994 <£ 2 fig.
i functional
Required Required 2000 AD)
Sub-Divisional Hospitals
Faridkot
50
50
Mai out
38
35
3
12
Mukauar
50
44
6
50
Moga
100
100
C.H. Jaito
10
10
C.H. Kotkapura
50
50
C.H.Gidarbaha
50
25
Remarks
65926
79414
N. Highway
Rly. Line
15
63471
75531
N. Highway
Rly. Line
56
72922
84964
N. Highway
Rly. Line
125923
156991
N. Highway
Rly. Line
29956
31876
Rly. Line
68581
79903
N. Highway
Rly. Line
31056
33042
Rly. Line
Area Hospitals
40
40
25
25
30
30
22
22
30
30
N. Highway
Community Health Centre
Mana
30
Nihal Singhwala
30
Baghapurana
30
Dhudhike
30
20
10
10
N. Highway
Daroli Bhai
30
4
26
26
5 km from
N. Highway
Chak Sherewala
30
15
15
15’
16 km from
Rly. Line
Badal
30
20
10
10
N. Highway
Doda
30
14
16
16
Total
N. Highway
588
395
193
I
102
295
4 km from
Rly. Line
16 km from
Rly. Line
Annex 16
Page 9 of 30
201
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District:Fatehgarh Sahib
[Hospital/
i Community
: Health Centre
Population of
--------Town (1 fig.
Functional To be made Additional Total
1994 & 2 fig.
functional Required Required 2000 AD)
Number of Beds
Sanctioned
Remarks
District Hospital
50
Fatehgarh Sahib
I
50
50
50
25
25
25
25
25
25
4
4
Sub-Divisional Level
C.H. Amloh
C.H. Bassi
Pathana
C.H. Khamano
-
21
21
10976
13064
6 km from
N. Highway
19324
21541
Rly. Line
N. Highway
Community Health Centre
CHC Gobindgarh
50
50
Total
154
154
N. Highway/
Rly. Line
96
96
Annex 16
Page 10 of 30
202
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
Dis trict: Firozpur
Hospital/
Community
Health Centre
Number of Beds
Population of
------- Town (1 fig.
Sanctioned Functional To be made Additional Total
1994 &2fig. Remarks
functional Required Required 2000 AD)
District Hospital
C.H. Firozpur
100
112
86417
99641
N. Highway/
RJy. Line
Border Area 12
for Trauma
50
64330
75970
N. Highway/
Rly. Line/ 6
beds for Trauma
Sub-Divisional Level
C.H. Fazilka
50
56
C.H. Zira
50
28
22
22
25270
28114
N. Highway
Nehru Hospital
Abohar
106
100
6
6
116447
131815
N. Highway/
Rly. Line
21759
30613
RJy. Line
11628
13900
Rly. Line
50
Community Health Centres
Jalalabad
36
36
Mam dot
30
4
26
26
Firozshah
30
8
22
22
Guruhar
30
30
Dhabwaia Kalan
30
Situ Gunno
30
30
Khui Khera
30
4
26
26
Koc Ise Khan
30
8
22
22
Total
552
416
154
30
30
30 km from N.
Highway
36 km from N.
Highway
50
204
15 km from N.
Highway
8601
10425
N. Highway
Annex 16
Page 11 of 30
203
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District:Gurdaspur
Hospital/
Population of
______Town (1 fig.
Functional To be made Additional Total
1994 & 2 fig.
functional Required Required 2000 AD)
Number of Beds
Community
Sanctioned
Health Centre
Remarks
District Hospital
Civil Hospital
Gurdaspur
’
i
100
100
60296
70376
N. Highway/
Rly. Line
104847
125982
N. Highway/
Rly. Line
134486
145918
N. Highway/
Rly. Line
21381
23901
Rly. Line
Sub-Divisional Level
Civ^l Hospital
Batala
50
50
' Civil Hospital
.Pathankot
100
100
50
50
Community Health Centres
Qadian
30
25
5
5
Kot Santokh Rai
30
25
5
5
Kahn u wan
30
30
6 km from N.
Highway
Kalanaur
30
30
28 km from N. Highway
Fateh&arh
Chunan
30
12
Bham
30
30
Char ota
30
8
Bungai Badham
30
30
N. Highway
Naroc Jaimal
Singh
30
30
20 km from
Kathua
Total
520
470
25 km from
N. Highway
—
i
18
18
11743
12943
20 km from
N. Highway
30 km from
N. Highway
22
22
50
50
100
3 km from N.
Highway
Annex 16
Page 12 of 30
204
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District: Hoshiarpur
Hospital/
Community
Health Centre
Population of
_____ Town (1 fig.
1994 &2 0g. Remarks
Functional To be made Additional Total
2000
AD)
functional Required Required
Number of Beds
Sanctioned
District Hospital
C.H. Hoshiarpur
200
155
45
45
137629
164079
N. Highway/
Rly. Station
12666
14334
N. Highway/
Rly. Station
Sub-Divisional Level
C.H: Garhshankar
50
50
C.H. Balachaur
30
30
20
20
C.H. Mukerian
50
50
50
50
C.H. Dasuya
50
50
N. Highway
18855
20775
N. Highway/
Rly. Station
19811
22511
N. Highway/
Rly. Station
Community Health Centres
CHC Bhunga
30
30
N. Highway
Saroya
30
30
20 km from
N. Highway
Mand Mandher
30
30
25 km from
N. Highway
Buxdhabar
30
10
20
20
12 km from
N. Highway
Hajipur
30
26
4
4
N. Highway
Tanda
30
20
10
10
Mahal pur
30
30
Total
590
511
79
70
149
19894
21922
N. Highway/
Rly. Station
Annex 16
Page 13 of 30
205
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District: Jalandhar
Hospital/
Community
aHealth Centre
Population of
Town (I fig.
sanctioned Functional To be made Additional Total
1994 &. 2 fig Remarks
functional Required Required 2000 AD)
District Hospital
Jalandhar
400
400
546273
N. Highway/
604740
RJy. Line
Sub-Divisional Level
50
C.H. Nawan
64
31184
N. Highway/
Shahr
33344
14 beds for
Trauma & PP
Unit
C.H. Phiilaur
50
80
22254
N. Highway/
24642
Rly. Line
C.H. Nakodar
56
68
29873
12 beds including
32435
for Trauma <fc PP
Unit/ Rly. Line
Area Hospitals
Number of Beds
C.H. Noor Mahal
25
25
C.H. Shankar
25
25
11695
12697
25 km from N.
Highway
18 km from N.
Highway
Community Health Centres
bi
CHC Banga
30
25
5
5
Kala Bakra
30
8
22
22
Kartar pur
30
30
Mukandpur
30
8
22
22
ShahkcX
30
16
14
14
Bandala
50
50
BadaPind
30
8
22
22
Total
836
807
85
85
19453
22639
N. Highway
N. Highway/
Rly. Line
22328
24608
N. Highway/
Rly. Line
20 km from N.
Highway
11594 t
14054
40 km from N.
Highway
25 km from N.
Highway
4 km from N.
Highway
Annex 16
Page 14 of 30
206
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District:Kapurthala
Hospital/
Community
Health Centre
Population of
___ Town (I fig.
1994 & 2 fig.
Sanctioned Functional To be made Additional Total
functional Required Required 2000 AD)
Number of Beds
Remarks
District Hospital
Kapurthala
1
125
70528
79726
N. Hi&hway/
Rly. Line
50
93080
101419
N. Highway/
Rly. Line/ 6 beds
for Trauma &
CPP unit______
14239
15109
Rly. Line
125
Sub-Divisional Level
50
C.H. Phagwara
50
56
C.H. Sultanpur
Lodhi_________
50
20
30
30
IS
IS
Community Health Centres
CHC KALA
sanghia
30
12
Begowal
30
40
Panchhax
30
S
Tibba
30
12
IS
Total
345
273
88
12 km from N.
Highway
10 beds for
Trauma Ward
22
22
18 km from N.
Highway
IS
50
138
26 km from N.
Highway
-T-
207
Annex 16
Page 15 of 30
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extendcd/Rcnovatcd
District:Ludhiana
Hospital/
Community
Health Centre
Number of Beds
Population of
------Town (1 fig.
Sanctioned Functional To be made Additional |Total
1994 & 2 fig.
____________________ functional Required
Required 2000 AD)
Remarks
District Hospital
Ludhiana
100
100
100
100
1227457
1608035
N. Highway/
Rly. Line
16719
20031
N. Highway
56
79705
93955
N. Highway/
Rly. Line
50
22639
25543
N. Highway
20
50312
55736
N. Highway
42
6120
6540
6 km from
N. Highway
Sub-Divisional Level
C.H. Samrala
50
50
C.H. Khanna
106
50
56
C.H. Raikot
50
C.H. Jagraon
50
30
20
C.H. Payal
30
8
22
22
20
Community Health Centres
CHC Sahnewal
30
8
Malaud
30
30
Pakhowal
30
8
vianupur
30
30
22
N. Highway/
Rly. Line
30 km from
N. Highway
22
22
8 km from
N. Highway
10 kin from
N. Highway
vtachhiwara
30
30
Sidhwanbet
30
30
Gurusar Sudhar
30
8
22
Total
546
382
164
15345
18597
8 km from
N. Highway
5 km from
N. Highway
22
170
334
N. Highway
Annex 16
Page 16 of 30
208
SUMMARY OF CONSTRUCTION PROGRAM
i
Punjab: List of Hospitals to be Extended/Rcnovated
District:Mansa
Hospital/
Community
Health Centre
Population of
_____Town (I fig,
1994 & 2 fig. Remarks
Sanctioned Functional To be made Additional Total
functional Required Required 2000 AD)
District Hospital
C.H. Mania
Number of Beds
100
Sub-Divisional Level
30
Budhladha
Jhunir at
Sardulgarh
30
60073
68384
100
I
RJy. Line / 5 km
from N. highway
!
i
i
i
30
20
20
30
20
20
Community Health Centre
30
30
Kiola Kalan
190
190
[Total
19808
21830
RJy. Line
I
N. Highway
N. Highway
40
40
i
i
i
I
I
i
L
209
I
Annex 16
Page 17 of 30
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
District:Patiala
Hospital/
Community
Health Centre
Mata Kaushalya
Hospital Patiala
Number of Beds
Population of
___ Town (1 fig.
Sanctioned Functional To be made Additional Total
1994 £2 fig. Remarks
functional Required Required 2000 AD)
200
200
274354
307213
N. Highway/
Rly. Line
75612
84132
Proposed addition
of 50 bods for
Trauma Hospital/
N. Highway/Rly.
Line
57769
63973
Including 32 beds
of women hospital
18 for Trauma PP
unit/RJy. Line
38573
42799
N. Highway
Sub-Divisional Level
A.P. Jajn Hoiptial
Rjypura
50
50
C.H. Nabha
100
150
C.H. Samana
25
25
50
25
50
25
Community Health Centres
CHC Model Town
Patiala
30
10
20
20
Doodhan Sadhan
30
25
5
5
15 km from N.
Highway
Kalomajra
30
13
17
17
N. Highway
DeraBassi
30
8
22
22
Ghanaur
30
25
5
5
13 km from N.
Highway
Bhadson
30
8
22
22
N. Highway
Badshahpur
30
18
12
12
12 km from N.
Highway
Shauana
30
20
10
10
N. Highway
Total
615
552
113
75
188
10506
12174
N. Highway
F
210
Annex 16
Page 18 of 30
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Renovated
i
DistrictxRupnagar
Hospital/
Community
Health Centre
Number of Beds
Population of
Town (1 fig.
Sanctioned Functional To be made Additional (Total
1994 & 2 fig
functional Required Required 2000 AD)
Remarks
District Hospital
C.H. Rupnagar
100
100
43600
53860
N. Highway/
Rly. Line
11601
13398
27733
30709
N. Highway/
Rly. Line
Sub-Divisional Level
C.H. Anandpur
Sahib________
30
25
C.H. Kharar
30
50
5
20
25
50
20
20
50
150
150
i
Excess of 20
adjusted as
rtquirea
N. Highway
Area Hospital
SAS Nagar
(Mohaii)
96183
130699
Proposed addtioa
of 150 beds for
Dental Training
Units to take
work load of
PCI at
Chandigarh/
N. Highway
!
Community Health Centres
Cham Kaur Sahih
30
30
Nurpur Bedi
30
20
20 km from N.
Highway
10
10
25 km from N.
High way
Kurali
30
25
5
Total
300
300
20
5
190
19826
23942
N. Highway/
Rly. Line
Ib
!
210
!
I
211
Annex k
Page 19 of 30
SUMMARY OF CONSTRUCTION PROGRAM
Punjab: List of Hospitals to be Extended/Rcnovated
District:Sangrur
Hospital/
Community
Health Centre
Number of Beds
Population of
— Town (1 fig.
Sanctioned Functional To be made Additional Total
1994 & 2 Cg.
__________ _______ functional Required
Required 2000 AD)
District Hospital
C.H. Sangrur
100
120
Remarks
61030
69154
N. Highway/
Railway line
Sub-Divisional Level
C.H. Bamala
100
100
96554
139465
N. Highway/
Railway line
C.H. Malerkoda
100
100
95346
10729S
N. Highway/
Railway line
C.H. Sunam
50
50
50
50
46711
52061
N. Highway/
Railway line
20
20
42052
505S4
N. Highway/
Railway line
26 km from
N. Highway
10 km from
N. Highway
Community Health Centres
I
1
CHC Dhuri
30
44
Bhadaur
30
7
23
23
15356
16334
30
10
20
20
16922
19442
Lon^owal
30
30
Bhawaiugarh
30
14
16
16
15707
19043
Dhanaula
30
20
10
10
16551
18191
Amargarh
30
1
22
22
Ahmadgarh
30
6
24
24*
Kauhrian
30
30
Total
620
539
10 km from
N. Highway
N. Highway
N. Hi&hway
N. Highway
29339
36239
N.High^y
15 km from
N. Highway
115
70
185
Annex 16
212 [
Page 20 of 30
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
Buh-Di visional/
District Hospitals
Rural Haapilala
Stats GsnL Hospitals
CsAs
Ma.
NtM W IMS
rsLstis<
Actual
tatotla<
Astasl
Lristla4
Aataal
PepaUttea al
B«4s
Opwedeaal
Bats
OpsvaUaaal
B^a
Of srsllsssl
Us DUtriat
Bs^
da LaiUs)
| Mssrist
J___
B^s
01
KoocMbtAar
400
400
4M
4M
X
X
02
JihWi
• 10
• 10
325
3X
203
2A5
27^9
03
DsOssUnf
2sa
300
•M
7M
UO
110
13J5
04
UUM Dtnsjpur
138
350
U
68
70
70
ia.57
33
73
12.71
238
238
26X7
03
Dakshtn Dtastpur
300
300
06
MsMs
500
500
07
MunMdsBa4
616
• 18
7X
750
273
273
47.40
08
NsSM
473
473
1027
1054
240
240
38.32
08
Non* 24-Pars>aas
306
500
1642
1702
233
2X
72^2
10
South 24 PvpsM
800
800
381
708
4ft3
525
37.15
II
HesaMy
500
550
870
870
223
223
4X53
12
Hssn
SOI
800
864
686
ITS
173
37X0
13
MdMpart
541
341
1044
1240
465
480
83JI
255
3X
IK
IK
28.05
68
66
IX
IX
22.25
684
9X
270
270
K5I
14
•sAtoura
15
PuruMs
16
OurOwan
17
Dir
506
I
I
i
I
506
I
TOTAL
I
I
I
3W
5X
236
373
ITO
170
25 X
67*4
7344
8520
10807
3848
3748
63CJ8
Cast Ln Lacs af Rup««e
District : Kaachbshsr (01)
Cads Na.
I
!
Naaas af ths
Haspital
Bads (aumbsrw)
BaacUaaedl
I
I
01 101
I
Koochbchar
DiaUict Hospital
400
Actual
Oparaliaaal I
Staff Quartan
___________ Building
Rsnavatian l
Eatsnslaa i Rsaavatiaa l
I
N.-
|
Conita.
400
IOO OO
Naw
Caastn.
1 16.02
6.65
19.44
SinkDlVlSIONAL HOSPITAL
01201
Malhabiianip
120
120
34.57
82.48
20.72
01202
Mskhlldungs
120
120
29.80
70.98
18.31
01203
Toolan<An<<
68
68
25.27
70.9H
18.24
73.98
30.00
01204
DiAhaxa
180
180
46.64
8.27
RURAL HOSPITAL
01301
Haldxban
30
30
10.74
38.95
12.10
TOTAL
916
918
246.82
453.39
104.02
27.71
i
Annex 16
Page 21 of 30
213
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
Cost La Lacs of Rupees
District : JALPAIGITRI (02)
Name of the
Code No.
Hospital
Beds (numbers)
Sanctioned!
Actual
___________ Building
Renovation i
Operational i
J al pal gun
Diet. Hospital**
02101
610
Stag guaxters
Extcasion > Rcnovatloa
New
Coasta.
New
Coasta.
610
54.77
155.52
8.26
19.44
SUB-DrVTSlONAL/STATE GENERAL HOSPITAL
02201
Alipurduax**
225
250
61.31
85 98
11.77
'/2JU2
Uli pare
IO)
KXJ
10 1/
ill
I I 3
MUM7U. IIOariTAl.
02301
FaUksta A
30
50
8 82
85.95
13.25
8.27
02302
IOO
IOO
I 4 34
42.70
15.22
8 27
02303
Mai*
Mamagun *
60
60
4 83
39 25
50.76
4 86
02304
luijgunic
25
23
4 36
34 95
3 68
4 86
02305
Dhupgun
30
30
9.70
30.05
I 1.10
4 86
02306
Dhauban
20
20
12.87
25 60
8.18
TOTAL
1200
1245
201.57
601.58
136.72
50.56
- 25
o 1220
I
I
1
Cost la Loes of Rupees
District : DAJUK6UNG (03)
Code No.
Nuae of the
Hospital
Beds (numbers)
Sanctioned
Actual
. Operational
300
___________ Building__________________ Stag Quarters
Renovation i
Extension
Renovation i
New
New___________________ | Qaastn.
Conatn.
1
136.17
3.10
19.44
15.46
97.48
8.89
14.58
37 89
73.73
8.94
70.98
7.48
50 67
03101
Dar)ccling
Di st. Hospital
258
03201
KaLmpon<
370
370
03202
Kurscong
76
76
03203
Sdlguri
250
320
71 80
03301
Khan ban *
30
30
15.68
41.35
9.00
03302
Nakaalban *
50
50
19.35
27.45
20.30
03303
Bijanban
30
30
15.97
39.60
H).3l
1064
1176
226.62
466.76
66.02
SUB'DfVISlONAL HOSPITAL
14.58
RURAL HOSPITAL
I
J
i
TOTAL
63.16
70
■ 1 106
NOTE :
extra bed space m required lor Sihgun S D I lospnal as mere is alreadv space for 70 Nos. beds.
Rml hosptials located m Integrated Tnbal Project areas.
Biol hospitals with a uxcable tnbal population ia the cauhmcnt area
Annex 16
Page 22 of 30
214
SUMMARY OF CONSTRUCTION PROGRAM
I
West Bengal: List of Hospitals to be Extended/Renovated
Cast ia Lac» af Kupaai
DUtrtct : UTTAR DD1AJFUR (04)
I
Code Na.
■ Name of the
_____ Bada (numbers)
_________ Bttllding
‘ Haapital
Sanctioned)
Actual
| Operational I
Renovation
04101
Raifunie
Dial Hospiul
04201
lalampur"*
158
350
Staff gnaxtan
Naw
Extanaiaa ■ Rcaaaatlaa i
Naw
i Caaata.
Caaaia.
|
185.92
13.85
29.56
19.44
20.42
8.27
SUB DIVISIONAL HOSPPTAL/STATZ GENERAL HOSPITAL
68
68
6.75
92.48
RURAL HOSPITAL
04301
KaHa(unge
TOTAL
70
70
7..40
64.05
12.70
296
488
28.00
342.45
tlU
Dia«rt«l ! DAJL8HD1 DlNAJrUR (06)
Ga4« Na.
Num af Uia
Haapllal
27.71
Gael la Laaa af Rupaaa
'______ (numbara
Actual
|6aaeUaaa4
OparaUaaal
RuUdln|(
!
Btafl yuartera
Eataaaiaa i Raaaaatlaa
Naw
Naw
Caaaia.
Caaata.
I
05101
Bai ux that
DUl HoaptuU
300
300
05301
Gan<araznpur *
30
50
25.00
38.35
05302
Hill?
25
25
10..60
TOTAL
353
373
45.88
10.28
85.82
10.70
19.44
49.85
2.70
4.88
174.02
13.40
24.30
RURAL HOSPITAL
Rml hufaub loraiari in kucgraicd Tribal Proyact arcaa
Rml bospob wuh a axcabk tnbal populauca m the cairhmcni area
I
Annex 16
Page 23 of 30
215
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
DUlrtat : MAX-DA (O«)
CM« No.
Hum
Cost la Loos of Rupsaa
the
Hospital
Beds (numberal
^Soaotloaod
Building
Renovation
Extension
New
Cons tn.
Actual
Operational I
I
06101
Maida**
Diet. Hoaptul
500
500
113.89
Stag Quarters
Renovation I
New
I Constn.
85.22
9.18
19.44
RURAL HOSPITAL
06301
ChonciuU
68
68
22.87
29.45
8.26
06302
HonschAnd ra pur
65
65
7.70
31.60
9.90
06303
ManAkchak
25
25
6.10
27.70
9.50
06304
5amAA<oU *
25
25
4.27
40.95
6.31
06305
Habibpur *
25
25
3.45
35.45
8.83
06306
Caxo4< *
30
30
13.00
26 25
6.45
TOTAL
738
738
171.28
286.62
58.43
Coat la Loco of Rupees
DUlrlct : MurskMaksk (07]
Co4s No.
Naaae e( the
Has pl tai
19.44
B«da (nuflBberel
' taacUsaeO I
Actual
OpsraUoaal !
I
616
_________ Building________ •______ Stall Quarters
Reaavation i Extension | Renovation l
New
| Cnnata.
I
Now
Constn.
62.56
101.12
12.70
106.21
76.96
21.32
32.00
91.63
7.42
17.78
61.48
9.85
24
18.45
4
29
3.45
3
60
61
3.45
15
30
30
13
Sadikhandiar
25
25
31
28.45
I slampur
30
30
33
3.45
Bckianaa
30
30
29
TOTAL
1641
1641
438.57
07101
tier ham pur
DUl. Hospital
616
07201
Jan pur
250
250
07202
Kandl
250
250
07203
LalbacN**
250
250
07301
KfUhrvapur
50
50
07302
Amtala
50
50
07303
Khar<ram
60
07304
Sa<arti4hi *
07305
07306
07307
19.44
SUB-DIVISIONAL HOSPITAL
RURAL HOSPITAL
81—I hoaptub locaiad ui busprat Tnbal Projsa area*.
Uml bospttals with • air—Me tnbal populauoa m (ha catchment area.
7.02
■4
« 3
5
2
397.36
87.29
26.46
?
Annex 16
Page 24 of 30
216
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
Coat to Loca of Rupaaa
DUtrlat : NADIA (O«)
Co4a No.
Beda (number)
Naoaa of tha
Hoapital
___________ Building
iSaactlnned)
Actual
Operational I
Renovation I
New
i
475
06101
Kruhnanagar
DUL Hoapital
475
08201
08202
Ranaghat
Kalyaru kl.N.MI
171
550
08203
San u pur
131
131
08204
Chakdah
50
50
08205
Nabadwip
125
125
Stafl Quart era
I
Eatenalon iRenovatiani
I Conatn.
j
I
Conatn.
82.50
I
New
131.82
34.65
19.44
SUB-DIVISIONAL HOSPITAL
200
65.28
104.28
33.00
550
155.97
82.38
36.00
43
23.00
3
39.28
76.28
3.30
35.36
92.28
12.84
STATE GENERAL HOSPITAL
I
RURAL HOSPITAL
08301
08302
0A3O3
08304
08305
08306
08307
60
30
25
25
50
25
25
60
27
39.45
2
.10
13
29.45
2
25
29
23.45
2
25
29
28.45
3
50
21
4.45
4
25
32
28.45
25
29
28.45
2
3
1742
1771
601.39
692.19
140.79
Bcthuadahan
Ba<u^
Hannghau*
Chapra
Kanmpur
Kaligunge
Kruhnacunte
TOTAL
Coat Id Lac a of Rupaaa
Di a tri ct : North 24*PargaAaa (09)
Coda No.
Bcda (oumbcra)
Nama of tha
Hoapiud
Banctlooad I
09101
Baraoai
Dial. HaMMtal
304
09201
09202
09203
Baairhal
Barrackpur
Bongaen
200
200
230
09204
09203
09206
09207
09206
09209
09210
09211
09212
Baranaaar
Aaehena«tf
Bhatpara
Naihau
Panthau
SagardullalKatnamaul
Balaram Seva ManduSalt Lake
Habra
100
30
I 19
131
ISO
131
100
100
131
00301
09302
09303
09304
09305
09306
09307
Bacda
Minakhar^
Badurta
SandeahXhaU*
Takl
Sera pul
Madhya mtrani
30
25
60
25
50
15
30
I
TOTAL
19.44
2163
Actual
Optra tian al i
two
Renovation i
I
/o aa
•u*-d<visional iioarrral
230
42.92
230
24.70
300
31.95
•TATE GENERAL HOSPITAL
46
100
30
91
119
40.70
58.00
131
61.50
ISO
99
131
100
36
22.37
131
108
RURAL HOSPITAL
30
55
25
36
24
60
61
25
50
6
30
42
30
8
too
2342
Staff (^uartere
___________ Building
966.39
Eaten»lon i Renovation i
Na1
New
| Conatn.
I
I
Conatn.
ias
ai oo
IV 44
65.36
89.93
11 I 48
11.20
66 40
27.50
3.41
26.96
26.96
68.88
65.83
65.83
21.98
62.48
33.83
26.98
3
3
112.00
26.40
26.40
2*
3.45
34.45
39.45
34.45
4.45
34.45
3.45
2
5
7
2
2
4
3
1026.M
406.90
24.00
26.40
2
7.2
30.13
7.02
•7.04
Rml ho«ptal« located ia laicgraied Tribal Projeci arcai.
Run! boaptula with a tumble tnbal popuiauon in the caxchmcnt area.
I
1
fc
Annex 16
Page 25 of 30
217
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
Cost La Lacs of Rupees
District : SOUTH 24-PAKGANAS (10)
Beds (number*! I
Actual
Operational I
Code No. I Name of the
1 Sanctioned
Hospital
I
Building
Renovation i
600
______ Staff guarters
Exteaslon i Renovation I
35.00
1
I Caasta.
Consta.
I
I
108.42
33.00
19.44
172.98
35.82
14.58
10101
M. R. Bangur
Dial Hospital
600
10201
Diamond Harbour
125
SUB DIVISIONAL HOSPITAL
250
22.30
10202
10203
10204
Vidyaaa<ar
Bl|oys<arii
Ua<hajaun
256
100
100
STATE GENERAL HOSPITAL
256
40.00
IOO
30.00
100
23.95
81.78
39.30
35 80
26.40
1000
Cannm( *
Joynagar
Sagar
Kakdwip
Mathurapur
Nimpith
Muchisa
Padmarnat
Am tala
Raidiiihi
V)
23
50
25
25
100
60
30
15
15
50
50
RURAL HOSPITAL
27
50
J2
25
42
50
21
25
17
30
10
100
57
60
26
30
4
30
29
30
14
50
31
50
IH 45
18 45
4 45
28.45
0.10
3.45
3 45
18.45
3.45
34.45
4.45
18.45
5
r
7
8
2
4
3
2
4
2
2
3
TOTAL
1676
1636
394.33
169.62
IO >UI
10302
10303
10304
10305
10306
10307
10308
10309
10310
10311
10312
llMuipur
461.23
I I 101
13.40
34.02
Cost La Lacs of Rupees
District : HAORA (HI
Code No.
New
New
Nams o( the
Hospital
Howran
Dial Hospital
Stag guAxters
_________ Building
Beds (numbers!____
New
Renovailon i Extension (Renovation!
SancUoaedi
Actual
Constn.
| Operstlooal >
|
Constn.
I
I
i
I
506
600
16.70
19.44
144.92
13.98
92.23
17.26
70.98
0.00
SUB DtVlSLONAL HOSPITAL
250
62.11
11201
Ulubcna
216
11202
Bciur
10
11203
Gabbena
118
118
55
8.98
I 1204
South Haora
10
10
37 33
53.73
15.65
Lduah (TUI
260
260
101.00
• 22.60
I 1205
64 28
11206
Udaynarayanpur
50
50
49
8.98
Batnan
40
40
24
18.45
2
I I JOI
Ja^atballavpi
t>O
20
26.45
4
9.72
I 1302
60
Dornjur
25
20
4
7 02
I 1303
18.45
3 45
4
512.50
93.49
STATE GENERAL HOSPITAL
13.48
10
RURAL HOSPITAL
I 1304
25
Amra<un
50
50
27
TOTAL
1345
1473
433.12
fhnl
located in hufiaied Tnbal Project areas.
Rurai hocpuali with • nzeabk tribal popuhuoa m the catchment ana.
38.18
I
Annex 16
Page 26 of 30
218
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
DUtrtct : HOOGKLY (12)
Code No.
I
12101
Coat la Loes of Hupoos
Beds (numbers)
Actual
Operational I
Naau of ths
Hospital
Sanctioned I
Chlnaurah
500
550
Building
Renovation
112.75
Stag guarters
Extension i Renoeation i
New
New
| Constn.
Constn.
i
115.52
44.40
19.44
S.27
Out Hospital
SUB-DIVISIONAL HOSPITAL
12201
12202
12203
Arambath
Chandannafar
Srtrampur
250
250
266
12204
U liarpara
204
12301
12302
Chanditala
Slngur
Jangipara
Dhamakhali
Pandua *
Khanakul
30
60
60
25
250
24.77
94.35
250
266
26.80
66.18
12.00
80.48
6.70
14.50
8.27
60.50
37.90
STATE HOSPITAL
204
75.00
RURAL HOSPITAL
12303
12304
12305
12306
24
26
57.45
3
60
39.45
8
60
39
39.45
3
35
26.45
4
5
25
25
25
25
lews
1743
30
25
TOTAL
49
26.45
66
28.45
5
4&O.32
040.01
139.77
DlsUtst l MWNAPORX (13)
Cods No.
Name of the
Hospital
Cost in Lass of Ruo««*
______ Beds (nuxabsrsl
_________ Building
i______ Staff Quarters
Sanctioned i
Actual
Renovation I Extension i Renovation i
New
Operational i
New
I C instn.
i
Constn.
i
I
13101
Minds poet
DtsL HusptUl
541
13201
13202
Comal
C haial
Jhargram a*
Tamluk
Haldu
125
13203
13204
13205
13206
13207
Dt<ha
13301
Bhagawanpur
Binpur *
Chandrakona
Daspur
Debra "
E«ra
Garbcta^
Hi|U
Sa bang
Salbocu
tea para
13302
13303
13304
13305
13306
13307
13306
13309
13310
13311
13312
13313
Kharagpur
tfohpur A
Basu Us_____
TOTAL
37.71
131
265
125
100
50
250
15
25
60
25
25
60
60
60
25
25
25
30
___ 30
2082
541
62.00
BUB-DTVIStONAL HOSPITAL
125
11.80
150
27.86
265
33.28
300
12.25
100
8.25
FIATT GENERAL HOSPITAL
50 36.84
250
14.00
RURAL HOSPITAL
30
40
25
63
60
33
25
47
25
39
60
104
60
29
60
47
25
30
25
38
25
33
30
49
_______ 30
35
2261
843.30
Rural bospuab located m Uucfraud Tribal Project areas.
Rural hosptial* wuh a socabk tnbal popuiauon m the caichmexu area.
107.42
7.73
66.46
76.26
91.66
169.93
5.47
7.28
23.00
6.10
57.12
5.00
70.98
26.42
6.40
6.27
4
30
15
IS
7.02
7.02
55.52
29.45
29.45
39.45
29.45
23.45
39.45
39.45
39.45
3.45
29.45
29.45
3.45
1037.44
It.44
5
2
8
9
5
30
7.02
16
5
237.40
41.77
Annex 16
Page 27 of 30
219
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
DUUict : BANKUKA (14)
C«4« No.
■
Nana of th a
Hospital
Cost in Laca of Rupaca
Bada (oumtunl
_________ Building_________
Stag guanars
;Sanctlanadi
Actual
Naw
Renovation I Extension i Renovation
I
New
Oparatiooal I
Can at a.
I
Coaatn.
I
SUB DIVISIONAL HOSPITAL
14201
Biahnupur
14202
Khaura
230
230
6.40
103.68
4.25
25
100
36.64
133.28
26.42
RURAL HOSPITAL
14301
KoCoipux
60
60
4
14.45
2
14302
Raipur *
30
30
16
3.45
3
14303
Taldan<ra *
30
30
16
4.45
4
14304
Sonaxnukhi
30
30
3
3.45
2
14305
Amarkanan
30
30
3
7.45
4
43S
530
65.24
TOTAL
267.31
Cat* La Laaa af Ruptaa
DitUlat : PURULXA (131
Oda Na.
i Nama a( tha
| Haapilal
Bada (oumbaral
SaAsUaaadl
Actual
Ruilrtiatf
Raaavailaa
| Oparatlanal i
15101
PuruUa
45.67
506
506
75.71
ExteaaloR
Naw
Coaatn.
Stag Quart era
Renovation I
Now
I CoMta.
I
94 55
14.22
70.98
8.42
19.44
Diet Hospital **
6TATK GKNKRAL HO6PITAL
I
15201
Ra^hunai/ipur
68
68
15.90
RURAL HOSPITAL
13301
Mantxa*/ *
30
30
30
15302
Harmadi
30
30
II
3.45
3
15303
Bana<ara/i
30
30
10
4.45
3
15304
Hura*
30
30
15
3.43
2
15305
KotaUa *
30
30
10
3.45
3
TOTAL
724
724
167.61
164.76
36.64
(bral bcspuali located u> Imcfraiad Tnbai Project areas.
Riaal hoaptials with a sucabk tnbal popuhuoa m the catchment area.
1
3
16.44
Annex 16
Page 28 of 30
220
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
DUUict : Burlw (10)
CMi Na.
I Naase of the
J Hospital
Cost la Laea •( Rup««a
______ Bede (numbersI
_________ Building_________ I
•t*n Quarters
Actual
Baiseiloned
Renovation I Extension i Meaavatlaa I
New
Operational |
Ceaain.
I
I
Cousin.
I /•’ :
I
BUB DIVISIONAL. HOSPITAL
10201
Aaansoi **
203
330
20.35
174.18
28.20
14 30
16202
Dur
104
200
30.00
103.98
29.40
4.80
16203
Kaloa
133
200
50.30
150.&3
17.00
8.27
16204
Katwa
180
180
33.00
124.98
18.00
8.27
16301
Metnan
60
GO
32
4.45
10
16302
Stfifoi
50
50
152
3.45
5
16303
Bhaxar
50
50
44
4.45
5
16304
Snrampur
30
30
8
3 45
5
I63O3
Mankar
30
30
8
1G300
Balia vpur
50
50
41
3.45
4
TOTAL
934
1200
367.65
307.47
123.40
pur
RURAL HOSPITAL
3
District : BIXBMUM (17)
Code No.
. Name of the
; Moepltal
Cost la Lacs of Rupsss
Beds (numbers)
Saactioncdi
Actual
I Operational i
Building_________ i_____ Stag guan era
New
.ion i Extension i Renovation I
New
I
Cans tn.
Constn.
I
R<
I
17101
Sort
33.90
320
320
90 40
194.52
35.15
19.44
127.56
70.38
18.83
37.00
8.27
Diet Hospital
SUB DIVISIONAL HOSPITAL
17201
17202
Ram pur ha
Boiepur **
131
125
17301
Murar al
30
30
66
4 43
10
17302
Samuua *
60
60
39
18.43
20
17303
Labpur*
30
30
15
3.43
15
17304
Dubcajpur
30
:k)
10
4.45
15
1065
333.35
423.20
131.00
250
125
30
82.95
RURAL HOSPITAL
TOTAL
940
27.71
- 129
> 936
NOTK
No extra bed space to required for Rampurhat S.l). Hospital as there is already exaung space for 119
beds.
Rural hoapiuls located m Intcgraicd Tnbal Project areas.
Rural boapitali with a sucablc tnbal population in the catchment area.
Annex 16
Page 29 of 30
221
SUMMARY OF CONSTRUCTION PROGRAM
West Bengal: List of Hospitals to be Extended/Renovated
• intDARAA/l
District : North
Code No.
Name of the
Hoe pitai
Cast in Lacs of Ruposs
;______ Beds (numbers)_____
| Sanctioned I ' Actual
| Operational i
Building_________ I______ Stag Quarters
Renovation
Extension i Renovation i
New
New
Caasta.
Co ns tn.
15
10
15
15
26
26
36
36
7
09402
B.P.M.C.
Haros
Sandelerhil
7
14
14
09403
Ghosh pur
10
15
28
36
11
14
6
6
6
6
18
a
to
a
10
6
21
19
ia
27
18
5
19
6
9
18
18
8
7
7
09401
09501
09502
09503
09504
OW5O5
09506
09507
09508
09509
09510
0951 I
09512
P.H.C.
Go pal pur
Kamaxtantht
Nimichi
Bhawampur
Ghoia
Barunhat
Sahcbkhah
Hinjalfun)
2
6
2
2
6
2
Jo(nhtan)
Haibach hi
Naxat
Korakau
a
a
a
13
18
Name of the
Hospital
7
14
17
4
6
23
18
a
7
18
10
14
17
5
3
8
8
7
10
23
23
13
6
20
13
4
6
6
6
23
Dlscrtct : South 24-ParfSAaa
Code No.
7
6
7
6
a
6
Coot la Lace of Rupees
Beds (numbers
Sanctioned!
Actual
| Operational .
Building
R<
li
Stag Quarters
New
Extension i Renovation i
New
| Cons ta.
I
Cooatn.
10401
Madhabna<ar
10
25
28
36
13
21
10402
Goaaba
10
23
29
36
13
21
10403
Baaanu
10
25
29
36
13
21
10404
Namkhana
Dwankana<ar
15
25
30
36
10
21
10405
Machcrdi^hi
10
10
28
24
9
14
P_H.C.
1
10501
Brajaballavpur
14
14
19
13
14
6
10502
Gadaxnathura
10
10
17
13
12
6
10503
Indrspur
6
6
11
13
8
6
10504
ChotomoiUkhali
10
10
16
13
7
6
10505
D halunrad h s na < □ r
2
6
11
17
7
6
10506
Kalkhali
a
6
10
12
7
0
10507
Bhubancsv'an
6
6
25
18
3
7
Annex 16
Page 30 of 30
222
SUMMARY OF CONSTRUCTION PROGRAM
Weil Bengal: Lilt of Hospitals to be Extended/Renovated
District : SOUTH 24 PAKGAJ<AS
Coda No.
I
Coat Ln Loo of Mupeoa
Name of the
______Beds (numbsr)
Hospital
Sanctioned!
Actual
Operational I
Stag Quarters
Building
Now
Ext enston i Renovation
New
Coaatn.
Consuu
Renovation
I
10508
10509
.
Kanuunan
S
6
25
18
3
7
KAnUWtxna
• 4
10
13
17
7
8
10510
BagdAAfa Mouaumi
2
6
23
23
3
7
10511
Fr**erfinj
2
6
14
17
7
8
10512
Harenaranagar
4
6
13
17
12
8
10513
Ramchand ranagar
4
6
20
23
2
7
10514
KuciuiaXahai
2
6
25
23
3
7
10515
Naigora
2
8
25
23
2
7
10516
Chuuarsnanf
4
10
25
22
3
7
SUNDARBAN
Coda
No.
»yp* •«
Hoapllxd
•< lb«
DU trie I
I
I
Aaialtug
B«da
Addlllnaal Bad
Space required
! PepulaUoa of
Tfce District
35
10
2.7I.OOO
|
I
094CM
North 24 Pacanaa
ISundarPan I
B P.H.C
09300
North 24 t'AXt'inaa
ISu ndax Dan I
H H.C.
i>O
20
- do -
10400
South 24-Parganaa
, ISundarbanl
B.P.H.C
55
55
21.29.000
P.HC.
86
34
-do-
I
10500
South 24-Parganas
(Sundarixanl
I
Annex 17
Page 1 of 1
223
PROCUREMENT ARRANGEMENTS
Total Costs in USS Millions
iMaraauaaal
Ciaaaxiti^e
■ l44ia<
Prwocwanet M«<had
.NaUeaal
Lecai
CaaMUU^
BMUia«
OtlMe
MaM /■
Tmai
110
(15.3)
152.2
(129.4)
CIVIL WORKS
I
4
Civil Worki
1342
(114 I)
/b
1.5
(7.7)
/c
GOODS
Furniture
Equipment
54 9
(49 4)
Vetucic*
12.7
(11.4)
42
(3.1)
14 J
(12 9)
2.1
(2.6)
11.4
(10.2)
12.7
(11.4)
14 5
(76.0)
0.3
(0.3)
14 6
(13.1)
Medical Lab Supplies
2.7
(2.4)
04
(0.3)
2.3
(2.1)
5.4
(4.9)
MedKinc*
22.0
(I9D
1.5
(1.3)
3.7
(3 3)
27.2
(24.5)
Other Supplies
74
(6.7)
III
(100)
11.5
(16.7)
MIS/IEC MatenaU
3 2
(4 7)
1.7
(1.6)
6.9
(6.2)
CONSULTANCIES
Protect Prcparanon It ImplemenutuM
(incl Training. Workshops. Fellowships!
Institutional Development (includes
Local Consultants. Studies. Professional
Services Fees. NGO Fees)
10 7
(107)
10 7
(10.7)
II I
(16 3)
III
(16.3)
39 3
(25.5)
39 3
(25.5)
MISCELLANEOUS
SaImms of Addiuonal Sulf
3.1
Building Maimcnance
Equipment Maintenance
Total
17.1
(II.I)
17 I
(III)
Opcrauonai Expenditures
(1.7)
3.1
(IT)
7.0
(3-1)
(3.1)
70
69 2
192.7
6.1
52.5
96.2
416.7
(62 3)
(1661)
(5 5)
(42.3)
(73 3)
(350 0)
Notes:
/a "Other’ methods include Force Account. Direct Contracting and Consulting Services
/b Figures in parenthesis are the repecuve amounu Financed by IDA
/c Figures may not appear to add exactly due to rounding
Annex 18
Page 1 of 13
224
i
i
I
IMPLEMENTATION PLAN
Table 1: Project Implementation Plan
• Coamruts RGB A
Steennf
Corxuninee
• Set-up Ceaail
PUaunf Cell &
Fngineennt wing
• Set-up Dinnct
1W7-98
L9%-97
W5-96
• Recruit project
managetDcot staff
• Recruit hospital staff
to bridge extsong gaps
• Recruit ms true nance
.engineers
• Invite tenders and
Health
award conmct for
Camnunrcs
civil works for first
• Recruit hospital stiff
prefect wut
• Enjat* d«»i(n
I
year construcaon
program
• Assign design works
MIUMdUMU IM
fui sm.ui«1 year
p«*p«ua UmJ
tUlUUM.lMU piugiatu
docucMoa tor
ctvd works
• Engage MIS
fnnailnnn
• Prepare bid
documena for
•quqxncix. esc.
• Set-up working
groups for
developing cl jural
equipping bospiuls to
be
renovaied/expandcd in
first year
• Roat lenders for
equxprncnt
mamec nance
workshop
• Develop trammg
• Recruit hospital staff
to fill posts in
to fill posts in
staff » fiU posts in
hospitals
hospitals
hospitals
hospitals
renovated/expanded in
renovated/expanded in
renovated/expanded in
renovamd/expanded
the first year
the second year
the third year
• Recruit A train
• Recruit and train
• Recruit A train
equipment
equipment
equipment
maintenance
maintenance
maintensnr**
teciuucians
technicians
technicians
award contract for
award contract for
cauxxNnc toywareit
civil worts for second
civil works for third
civil worts for fourth
toba
year construe non
year construction
year conscrucoon
renov atad/aapandad
pitigiain
l>Higiein
piugians
• Assign design wort
• Heal icndari fur
for third year
for fourth year
•quipping hospuals to
construcoon program
be
providing health
renovaied/cxpanded in
care to SC/ST A
fourth year
women in aalacaad
• Roat tenders (or
• Host tenders for
equipping hospitals to
equipping bosptfals to
be
ba
renovated/expanded in
renovated/expanded in
impicmcacBQoa of
second year
third year
providing health care
modteal and
to SC/ST A women m
pare mad ail aa/T
• Review
• Extend
• Extend
impicmcnacioa of
impicmcnaxwn of
ncfeml rywctn. QA.
providing health care
• Extend
implcmenaooa of
trammg modules
equrpmeot
Kbctncs for SC/ST A
selected distncts
referral rysaun A QA
ma intem nr*
women
coutmi (or cquipmcQi
QA
oiawfica&Qcc cngmocn
• Conduct
• Implement
workshops A
Survcdlancc Scheme
prepare detailed
at headquarters and m
plans for
aelacwd disencu
surveillance
schema
• Impicmeat referral
sysaem A QA m
• Develop plana for
Mfocaad dutnea
ptuvtdmg health
• Conduct onananon
care b SC/ST A
programs for Gram
women
Panchayat members to
• Procure
aqugKnaxn.
fiummre.
fovolva dvm m health
• Rxvtcw MIS
• Procure A install
in remaming distncts
• Eiicnd
nrirmn of
year
• Cotumuc mining of
medical A
paramedical staff
• EvaJuate and extend
• Conduct oneacaoon
rcfcml sysara A QA
programs » Gram
in Klecood distncts
Panchayat members to
cqutpmcol m hospitals
renovated in the firn
dismets
a Condmaa onining of
selected distncts
io SC/ST A women m
• Conduct mi runt
la fourth year
• BxwQd
coruoucuon program
wd hc&ith catc
Referral Sy Mem A
technicians
• Hoax tenders for
• Invite tenders and
programs for
workshops on
xwiinwwfif
award contracts for
prtMDCols A
• Conduct
in the fourth yaar
• Recruit A train
• Invite tenders and
• Assign design wuik
• Roat lenders tor
• Recruit hospital staff
MOO-Ol
• Recruit bospioi
to fill posts in
• Invite tenders and
• Rccrun Ley
im-oo
199S-99
• Conduct orseoiaooQ
programs for Gram
Ranchayat memben to
involve them us health
care programs
• Extend MIS to
Midsdonal hospitals
involve them m health
care programs
• Exsend MIS u
remairung bo^ucals
• Continue training of
medical and
paramedical staff
surveillance acheoM n
ocher distncts
• Cogoibm training of
nadkal and
pari medical saff
care programs
• Procure equipment
vehicles, esc. for
and nnpicmexx MIS
core staff
on axpcnmraal basis
• Start trammg courMS
tut mrulk ai umeara
and puamcdscal staff
I
I
225
Annex 18
Page 2 of 13
Table 2 West Bengal: Civil Works Implementation Plan
Activity
PHASE - I (42 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys
Soil tests17
Recruitment of Consultants27
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Pcnod
Responsibility
Starting Date
Completion Date
Private Firms
Not required
Private Firms
Engineering College/
Private Firms
DOH1'
Private Firms
Private Firms
Private Firms
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
Contractors
Contractors
July 95
October 95
October 95
October 95
November 95
December 95
October 95
January 96
February' ‘96
April ‘96
May ‘96
July ‘96
September ‘96
November ‘96
January’ ‘97
January' ‘99
December 95
March 96
June ‘96
July ‘96
July ‘96
October ‘96
December ‘96
February ‘97
April *99
April ‘2000
Private i inns
Not required
Private Firms
Engineering
Collcgc/Pnvatc Firms
Private Firms
Private Firms
Private Firms
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
Contractors
Contractors
July 95
October 95
December ‘95
January' ‘96
January ‘96
March ‘96
February ‘96
April ‘96
July ‘96
August ‘96
November ‘96
January ‘97
April ‘97
June ‘97
June ‘99
April ‘96
September ‘96
PHASE - II (54 Hospitals)
Survey of Existing Hospital
Sues Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
October ‘96
November ‘96
March ‘97
May ‘97
July ‘97
September ‘99
September *2000
i/
Soil tests wall be conducted on vacant lots and in coordination with preliminary layout of new extensions.
Recruitment of consultants to follow Bank Guidelines. During the second half of 1996, additional batch
of consultants will be recruited for the preparation of designs and drawings pertaining to Phases III &. V.
J/ DOH = Department of Health
2/
N.B.: Details regarding the management and maintenance systems for equipment and buildings in each
state at first referral facilities are attached to the Minutes of Negotiation as Attachment 2.
Annex 18
Page 3 of 13
226
Table 2 (continued)
Activity
Responsibility
Starting date
Completion Date
PHASE - III (68 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys
Soil tests
Private Firms
Not required
Private Firms
July ‘95
October ‘95
April ‘96
July ‘96
July ‘96
Recruitment of Consultants
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
Engineering College/
Private Firms
DOH
Private Firms
Pri.ace Firms
Private Firms
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
Contractors
Contractors
April ‘96
September ‘96
January ‘97
March‘97
June ‘97
August ‘97
October ‘97
December ‘97
February ‘98
April ‘98
April ‘2000
November ‘96
April ‘97
August ‘97
September ‘97
November ‘97
January ‘98
March‘98
May ‘98
September ‘2000
September ‘2001
July ‘95
October ‘95
August ‘96
August ‘96
November ‘96
November ‘96
May ‘97
August ‘97
November ‘97
January ‘98
March ‘98
May ‘98
August ‘98
October ‘98
October ‘2000
January, ‘98
February ‘98
Apnl ‘98
July ‘98
September ‘98
December ‘98
March ‘2000
March ‘2002
PHASE - IV (42 Hospitals)
Survey of Existing Hospital
Sites Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Penod
Guarantee Period
1
I
Private Firms
Not required
Private Firms
Engineering
Collcgc/Pnvatc Firms
Private Firms
Private Firms
Private Firms
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
DOH, West Bengal
Contractors
Contractors
October ‘97
Annex 18
Page 4 of 13
227
Table 3 Punjab: Civil Works Implementation Plan
Activity
Responsibility
Starting Date
Completion Date
PHASE - I (16 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys
Soil tests17
Recruitment of Consultants27
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
Private Firms
Not required
Private Finns
Private Firms
PHSC1'
Private Firms
Private Firms
Private Firms
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
Contractors
Contractors
July 95
October 95
October 95
October 95
October 95
January 96
February ‘96
April ‘96
May ‘96
July ‘96
September ‘96
November ‘96
January ‘97
January ‘99
November 95
December 95
December 95
March 96
June ‘96
July ‘96
July ‘96
October ‘96
December ‘96
February ‘97
April ‘99
April ‘2000
Private Firms
Not required
Private Firms
Private Firms
Private Firms
Private Firms
Private Firms
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
Contractors
| Contractors
July 95
October 95
December ‘95
January ‘96
February ‘96
April ‘96
July ‘96
August ‘96
November ‘96
January ‘97
April ‘97
June ‘97
June ‘99
January ‘96
March *96
April ‘96
September ‘96
October ‘96
November ‘96
March ‘97
May ‘97
July ‘97
September ‘99
September *2000
PHASE - II (38 Hospitals)
Survey of Existing Hospital
Sites Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
1/
Soil tests will be conducted on vacant lots and in coordination with preliminary layout of new extensions.
Recruitment of consultants to follow Bank Guidelines. During the second half of 1996, additional batch
of consultants will be recruited for the preparation of designs and drawings pertaining to Phases III & V.
v PHSC = Department of Health System Corporation
2/
i
TT&
Annex 18
Page 5 of 13
Table 3 (continued)
Activity
Responsibility
Starting date
Completion Date
PHASE - III (60 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys
Soil tests
Recruitment of Consultants
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Penod
Guarantee Penod
Private Firms
Not required
Private Firms
Private Firms
PHSC
Private Firms
Private Firms
Private Firms
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
Contractors
Contractors
July ‘95
October ‘95
April ‘96
April ‘96
September ‘96
January ‘97
March ‘97
June ‘97
August ‘97
October ‘97
December ‘97
February ‘98
Apnl ‘98
April ‘2000
July ‘96
July ‘96
November ‘96
April ‘97
August ‘97
September ‘97
November ‘97
January ‘98
March ‘98
May ‘98
September ‘2000
September ‘2001
July ‘95
October ‘95
August ‘96
August ‘96
May ‘97
August ‘97
November ‘97
January ‘98
March ‘98
May ‘98
August ‘98
October ‘98
October ‘2000
November ‘96
November ‘96
October ‘97
January, ‘98
February ‘98
April ‘98
July ‘98
September ‘98
December ‘98
March ‘2000
March ‘2002
PHASE - IV (36 Hospitals)
Survey of Existing Hospital
Sites Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Penod
Guarantee Penod
I
Private Firms
Not required
Private Firms
Private Firms
Pnvatc Firms
Private Finns
Private Firms
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
PHSC, Punjab
Contractors
Contractors
I
I
Ann** 18
Page 6 of 13
229
Table 4 Karnataka: Civil Works Implementation Plan
Activity
Responsibility
Starting Date
Completion Date
PHASE - I (45 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys •
Soil tests17
Recruitment of Consultants27
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
Private Firms
Not required
Private Firms
Private Firms
DOH17
Private Firms
Private Firms
Private Firms
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
Contractors
Contractors
July 95
October 95
October 95
October 95
October 95
January 96
February ‘96
April ‘96
May ‘96
July ‘96
September ‘96
November ‘96
January ‘97
January ‘99
November 95
December 95
December 95
March 96
June ‘96
July ‘96
July ‘96
October ‘96
December ‘96
February ‘97
April ‘99
April ‘2000
July 95
October 95
December ‘95
January ‘96
February ‘96
April ‘96
July ‘96
August ‘96
November ‘96
January ‘97
April ‘97
June ‘97
June ‘99
January ‘96
March ‘96
April *96
September ‘96
October ‘96
November ‘96
March ‘97
May ‘97
July ‘97
September ‘99
September *2000
PHASE - II (53 Hospitals)
Survey of Existing Hospital
Sites Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Period
Guarantee Period
Private Firms
Not required
Private Firms
Private Firms
Private Firms
Private Firms
Private Firms
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
Contractors '
Contractors
Soil tests will be conducted on vacant lots and in coordination with preliminary layout of new extensions.
Recruitment of consultants to follow Bank Guidelines. During the second half of 1996, additional batch
of consultants will be recruited for the preparation of designs and drawings pertaining to Phases III & V.
17 DOH = Department of Health
Annex 18
Page 7 of 13
230
Table 4 ( continued)
I
I
Activity
Responsibility
Starting date
Completion Date
PHASE - III (61 Hospitals)
Survey of Existing Hospitals
Sites Acquisition
Topographical Surveys
Soil tests
Recruitment of Consultants
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Penod
Guarantee Penod
Private Firms
Not required
Pnvatc Firms
Private Firms
DOH
Private Firms
Private Firms
Private Firms
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
Contractors
Contractors
July ‘95
October ‘95
Apnl ‘96
April ‘96
September ‘96
January ‘97
March ‘97
June ‘97
August ‘97
October ‘97
December ‘97
February ‘98
April ‘98
Apnl ‘2000
July ‘96
July ‘96
November ‘96
Apnl ‘97
August ‘97
September ‘97
November ‘97
January ‘98
March ‘98
May ‘98
September ‘2000
September ‘2001
July ‘95
October ‘95
August ‘96
August ‘96
May ‘97
August ‘97
November ‘97
January ‘98
March ‘98
May ‘98
August ‘98
October ‘98
October ‘2000
November ‘96
November ‘96
October ‘97
January, ‘98
February ‘98
Apnl ‘98
July ‘98
September ‘98
December ‘98
March ‘2000
March ‘2002
PHASE - IV (42 Hospitals)
Survey of Existing Hospital
Sites Acquisition
Topographical Surveys
Soil tests
Preliminary Designs
Final Drawings
Site Development Plans
Completion of Bid Documents
Floating of Bids
Evaluation of Bids
Contract Signing
Construction Pcnod
Guarantee Pcnod
Pnvatc Firms
Not required
Pnvatc Firms
Private Firms
Pnvatc Firms
Private Firms
Private Finns
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
DOH, Karnataka
Contractors
Contractors
I
I
1
I
Table 5: State Health Systems II Civil Works Implementation Plan
ID Task Name_______________ Duration
1235d
PHASE I Civil Works (Hos
1
Start
7/17/95
J5
1096
1997
1998
1999
2000
2001
2
Q3|Q4 Ql|Q2|Q3|Q4 Ql|Q2|Q3|Q4 Ql|Q2|Q3|Q4 2l[Q2|Q3|Q4 Ql|Q2|Q3|Q4 Ql|Q2|Q3|Q4 Ql|Q2
Finish
4^/00 ^"“P HASE I Civil Works (Hospitals In this Phase; W.B; - 42. Kan^ 1235d
I
i
2
Survey of existing Hospita
14w
7/17/95
10/20/95
3
Sites Acquisition (not Req
Id
10/23/95
10/2V95
4
Topographical Surveys
4w
10/24/95
11/2(V95
[[ Topographical Surveys
5
Soils Tests
12w
10/2/95
12/22/95
6
Recruitment of Ccr^sutant
12w
10/2/95
12Z22/95
(j ] Soils Tests
I
,
[]"] Recruitment of Consultants
7
Preliminary designs
12w
12^5/95
3/15/96
[~1~| Preliminary designs
8
Final drawings
20w
3/11/96
7/26^6
9
Site Development Pans
16w
5/6/96
8^ 3^6
10
Completion of Bid Docum
12w
6/3/96
8/2 3/96
11
Tendering of Bids
16w
7/29/96
11/15/96
12
Evaluation of Bids
16w
9/30/96
1/17/97
13
Contract Signing
16w
11/25/96
3/14/97
14
Construction Penoc
118w
1/6/97
4/9/99
15
Guarantee Period
64w
1/18/99
4/7/00
1 4] Survey of existing Hospitals
i
LU
i 161 Tendering of Bids
[~lT| Contract Signing
17
Survey of existing hcsprta
14w
7/17/95
10/20/95
10/23/95
Topographical Su-vtys
4w
12/1/95
12/28/95
20
Soils Tests
lOw
1/1/96
3/8/96
J Construction Period
I
Guarantee Period
Mw
118w
9/29/00 p
19
I
r-4
| 16 | Evaluation of Blds
7/17/95
Id
l
| 1 | Completion of Bld Documents
1360d
Sites Acquisition (not Req
Final drawings
16 | Site Development Plans
PHASE II Civil Worts (Ho
18
1
20'
16
10^2 3/95
1
| Sites Acquisition (not Reqd)
■
I
PHASE II Civil V5|orks (Hospitals in this Phase; W.B.-54, Karnatak^- 1360d
111] Survey of existing Hospitals
I
Sites Acquisition (not Reqd)
I
Topographical Surveys
,
I
1| Soils Tests
to
INDIA: State Health Systems II
CIVIL WORKS IMPLEMENTATION PLAN
11/21/95
Task
j
Critical Task |
I
Progress
Summary
<jq
oo
o
>
□
□
M
oo
L
Table 5:
ID
Task Name___________
Duration
21
Preliminary designs
12w
State Health Systems II Civil Works Implementation Plan (continued)
Start
Finish
2/5/96
4 26.-96
22
Final drawings
24w
4/fi/9€
S23.Sc
23
Site Development Plans
16w
7/8/96
10?SSt
24
Completion of Bid Docum
16w
8/12/96
II^SSc
25
Tendering of Bids
19w
11/18/96
3/2 8/9 7
1/13/97
5/30/97
26
Evaluation of Bids
20w
27
Contract Signing
15w
4/14/97
7/25/97
28
Construction Period
118w
6/9/97
S'10^9
29
Guarantee Period
68w
6/14/99
S 29/00
as
1996
1997
1998
1999
2000
Q3O4[Q||Q2|Q3|Q4 Ql|Q2|Q3|Q4 QI |a2|Q3|Q^[Ql |Q2|Q3|Q4|qi |Q2|q3|q
[ 1 j Preliminary designs
200?
|Q2|Q3|Q4|qi|Q2
jig'I1
I ^*041 drawings
'
| 16 j Site Development Plans
i'
I
I
I 15.* Completion of Bid Documents
i
|j9 j Tendering of Bids
I
Evaluation of Bids
| is| Contract Signing
I I!?*
1
i
] Construction Period
I ??? ‘
I
30
PHASE III Civil Works (Ho
1620d
7/17/95
S/28/01
31
Survey of existing Hospita
14w
7/17/95
ia20/95
—I
1
I
. 14 Survey of existing Hospitals '
32
Sites Acquisition (not Req
Id
10/23/95
1323/95
| Sues Acquisition (not Reqd) j
I
I
33
Topographical Surveys
4/10/96
5-7/96
[] Topographical Surveys
I
34
Soils Tests
4/10/96
&1&/96
lOw
I'
I
J
r
| Guarantee Penod
'
I________________
PHASE III Civil Works (Hospitals In this Phase*
; W.B. - 68, Karnataka
I
1
NJ
LU
NJ
I
i—i
I 1| Soils Tests
I
35
Recruitment of Consultant
16w
9/2/96
l22tV96
36
Preliminary designs
12w
1/20/97
4/11/97
If-]
I
I 1 | Preliminary designs
37
!
i
Final drawings
2Ow
3/24/97
8/8/97
38
Site Development Plans
14w
6/23/97
*26/97
39
Completion of Bid Docum
16w
8/4/97
11/21/97
40
Tendering of Bids
16w
10/13/97
1/30/98
I
I
I 20w| Final drawings
I
I
I 161 Completion of Bid Documents
Tendering of Bids
I
I
INDIA: State Health Systems II
CIVIL WORKS IMPLEMENTATION PLAN
11/21/95
Task
J
Progress
Critical Task [
1
Summary
es
>
O r»
M
GJ M
TableS: State Health Systems II Civil Works Implementation Plan (continued)
95
ID Task Name_________
41
Evaluation of Bids
Duration
16w
Start
12/8/97
2/2/98
1998
1997
1996
42
Contract Signing
16w
43
Construction Period
130w
4/6/98
9/29/00
44
Guarantee Period
78w
4/3/00
9/28/01
5/22/98
i
PHASE IV Civil Works (Ho
1733d
7/17/95
46
Survey of existing Hospita
14w
7/17/95
1070/95
47
Sites Acquisition (not Req
Id
10/23/95
10/23/95
48
Topographical Surveys
4w
6/12/96
9/6/96
49
Soils Tests
lOw
8/12/96
ICV18/96
50
Preliminary designs
20w
5/15/97
10/1/97
51
Final drawings
24w
8/7/97
I | 16 | Contract Signing
1
*
~
i
j 130w
i
.
i
] Construction Period
| Guarante
1
IE Survey of existing Hospitals
I Sites Acquisition (not Reqd) {
i
(] Topographical Surveys
[j] Soils Tests
| 20w| Preliminary designs
I
1/21/98
_!
[ 24w | Final drawings
14w
11/6/97
2/11/98
53
Completion of Bid Docum
16w
1/1/98
4/22/98
54
Tendering of Bids
16w
3/12/98
7/1/98
55
Evaluation of Bids
20w
5/14/98
9^V98
56
Contract Signing
20w
8/6/98
12/23/98
57
Construction Period
128w
10/8/98
3/21/01
pilaw
3/6/02
i
10/5/00
i
i
3/6/02 L PHASE IV Civil Works (Hospitals In this Phase; W.B. - 42. Karnataka - 42. Punjab -36)
Site Development Plans
74w
2
I________________________________________________ .
52
Guarantee Period
2001
I
'
45
58
2000
1999
Q3|Q4 Ql[Q2|Q3|Q4 Ql|Q2|Q3|Q4 Ql|Q2|Q3|Q4 Q1 |Q2|Q3|Q4|Q 1 |Q2|Q3|Q4|Q 1 |Q2|Q3|Q4|Q 1 |Q2
Finish
3/27/98
I
I
| 161 Evaluation of Bids
I
I
GJ
i
14| Site Development Plans |
I
16 | Completion of Bid Documents
| 16 | Tendering of Bids
| 20w| Evaluation of Bids
i
I
20’ I Contract Signing
I
I
1 Construction Pe
I
| 74w
771Gu
*0
10
CTO
INDIA: State Health Systems II
CIVIL WORKS IMPLEMENTATION PLAN
11/21/95
Task
]
Progress
Critical Task [
]
Summary
O
>
n
3
o
_ n
M
QO
Annex 18
Page 11 of 13
234
Table 6: Recruitment Plan
Recruitment of Project Management Staff
Strategic Planning Ceil
Project Management Project Office
Oistnct Project Office
Dittnct Engineering Oyukxi
Recruitment of Project Manpower
Preparatory Worti
Fineuzauon of Recmitment Rutte
Arrangement tor Recruitments
Recruitment lor 112 Begins
Recruitment tar 112 Complete
Jotung of 112 Staff
jiKi
Fl
Fl
E
Recruoment tor Next 288 Begm
Recruoment tar Next 288 Complete
Joeung of Next 288 Staff
Recruitment Process Starts tar 579 Staff
Recruitment for 579 Staff Completed
f
Joeung of 579 Staff Completed
Recruitment of Next 584 Staff Starts
Recruitment process tor 584 Staff Completed
Joeung of 584 Staff Completed
1
*
i
Annex 18
235
Page 12 of 13
Table 7: Implementation Plan for Software Activities1
1999
1998
1997
1996
2000
2001
Q31 Q4 QI | Q21 Q3 [ 04 QI | Q21 Q31 O4~ QI | Q21 Q31 04 QI | Q21 Q31 Q4 QI | Q21 Q31 Q4
Quality Assurance
Interaction & Policy Decision - QA Committee
QA Woriung Groups
4^^
| <I
Piot Testing r» 2 Districts
H
Evaluation ol Pdot Sites
Development ol QA Guideline
QA Training
1*1
H
• State Wide Implementation
Referral System
interaction & Polcy Decision
Issuance of Ralerrai Guidelines
Preparaoon of IEC Materials
iawiMiiitM
I IBMIWIMMIIMI |
|
Preparation of Refen al Malonais
i
n
HokSng referral Worunops
Developmeni of District Keaitfi Committee
Holdmg Referral Trameig
1*hm
Dasemmation of Referral Materials
i
IEC Activities
MKU3
Clinkai Training
Curriculum Development
Modules Development
Trareng of Tramen
Traevng of Speoaksts
Training of General Docton and M8SS
Tranmg of Nunes
Tranng of other Technicians
BBO 00000 00000 00000 mao
_ B 0 0 BOD BOD BBS
BOD 00 0 0 0 0 BIB. J
BD 0
00 0
BO 0
BB B
Development of Distance Learning Package
FekMShip
1
B 0
0
0
0 0
0 0
I 0
Agreed service, equipment and staffing norms for first referral facilities were developed at workshops held in each state,
they are attached to (he Minutes of Negotiation as Attachments 1 and 4.
I
I
Annex 18
Page 13 of 13
236
Table 7: Implementation Plan for Software Activities (continued)
Survaillance & HMIS
Oevtioomant 0/ CanU/Focmi
itor- Wf*]
Development of Guidelines
Disseminabon of Cards 4 Guidelines
I
Training
I
j
-
E3Z2ES23i
Estabksnment of Dutnct Surveillance Unit
i
Provision of Computers
Implementation
Medical Waste Management
Interacnon of Pofiqr Deoswn on Waste Managemen
Development of Guidelines tor Hospitals
e Kunese]
Training
Provision of materials (bags, contamers. etc)
Impfemantaoon at Hospitals
Development of Guidelines tor Primary Care FaabOe
Implementaoon at Primary Care FaoiiOes
1
OSCiMiilillMVMMM
n
— llHI'IIRfc |
[Oliewii muji
d
PERFORMANCE INDICATORS1
Table 1: Physical Completion Targets
Hospital Upgradation
HospacaJ
Upj radauoQ
Bull Advcrnicd
Planned
Actual
%
Bdi EvaHaicd
Planned
Ph«K I
Dumct
Subdivujonal
Communxy/
Rural
Actual
*
Coacr»cu Sorted
Coruxnjcoon San
Planned
Planned
Actual
Actual
X
Pbyiicd Completion
Planned
Actual
X
No. of Bedi
Baseline
Planned
Actual
B1»K II
Duma
SubdivtuoaaJ
Comtnuairy/
Rural
NJ
GJ
Pha^fT]
Diana
r
-
Subdtvuiooal
Conunuairy/
Rural
I
t
PhaK |V
Dismci
SubdivUioaal
ConunuMy/
Rural
•V
(TO
>
EJ
n
o X
X,
O \0
1 Baseline data from each state arc available on file.
I
Annex 19
Page 2 of 10
238
1
1
c
2
&
2
t
5
.8
o
6
Z
3i
a
3
O
*
3
o
e*
M
H
c
o
i 1
I I
£
o
Q. U
H
5 »=
*wi
O.
c>
I I
iS
i |1
*
cd
H
1
3
w
c
j
iu
I
Ia
5
*
•a
9
M
s
cl
I?
O' *
51
1
I
a
o
I
i
i
_==i>
■qUHILIL
=
1
_ _ =5£>
c 1X1XX
a
jj
a
2
J
i
239
Annex 19
Page 3 of 10
Table 3: Hospital Activity Indicators
Baseline
1. Bed Capacity
2. Cumulative inpatient days during
past 6 months
3. Admissions during past 6 months
4. Outpatient consultations (new and
repeat)
5. Turnover rate
6. Bed occupancy rate
7. Average length of stay
8. Outpatient per bed day
I
i
I
Previous
Current
Percent Change
Current/Previous
Percent Change
Current/Baseline
Annex 19
Page 4 of 10
(
240
Table 4: Hospital Efiiciency Indicators
Baseline
I
Previous
Current
Percent Change
Current/Previous
Clinical Services
ji
1
Percent Change
Current/Baseline
i
»
K of major surgeries
% of major surgeries to admission
f of deliveries
% of deliveries to admission
Emergency Service Index
Emergency OP ratio1
Emergency entry ratio2
Diagnostic Services
ft of imaging and elecuo medical tests
% of imaging and electro medical test
to admission
If of laboratory test
% of laboratory test to admission
I
Non Clinical Services
I
If ol post-mortems
% of post-mortems to admission
% of post-operative case fatality
% of infection acquired in the hospital
(nosocomial infection)
fl of referred cases received
If of cases referred to other hospitals
1 Emergency outpatient ratio is the ratio of emergency outpatients to total outpatients.
2 Emergency entry ratio is the ratio of admissions during emergency hours to total admissions.
241
Annex 19
Page 5 of 10
i
Table 5: Quality, Access, and Effectiveness Indicators
Biselinc
bpaaem waianf amc (nun)
»
Oucpaacnx waiong time (nun)
Paocnr satufacnon with docton and other medical
staff raong (scale of 1-7)
Patient utxsfaction with services offered rating
(scale of 1-7)
Pauani Musfacuon wiife tacdiucs avadable ratma
(scale of 1-7)
Hospital c.lasnlin<t> raiing (u a|« <t( | />
Quality Auunocc Program
! of disciplines that have implemented QA in DH
/ of indacaxon unplemeaxed
% of invuogiaam comply
% of remedial acoons reported
!££
* of $ spent agamu targets (or ouunals
* of awareneu among target groups of fint referral
services
% awarcoua ux»a< tnbal population of Krvicct
provided
% awareness of services available amongu target groups
in Sundartians arra
% awareocas of services available amongst SC/ST
populaooaa in Karaaaaa
* awareness of user charges among outpanenu
% awarcocM of uacr charges among inpaocou
% awartoeu among doctors of referral symm:
PIIC lu MtrnnaiuMy hospitals
CuuMMumsy huspuals w subdlviaismal buspisafe
Sub-divutonal hospitali tu diatnci huspiials
Previous
Currcai
r
f1
I
Annex 19
Page 6 of 10
242
»
Table 5 (continued)
r
Baseline
PrtvHMjj
Current
1
♦
mi:
I
% of uhucudom where sundardizcd system is introduced
i
f of supervisory reports based on MIS data received from
hospitals
Cost Recovery
I of beds delineAted as paying beds (only DH <Sl SDH)
% of beds delineated as paying beds to total beds at
facility (only DH A SDH)
Amount ot tDoacy recovered from paying beds
Amount of money recovered from other charges
Amo uni of money collected from outpauent fee
Amount of money received from distnct level as a share ol
CQllccied amount
______
(
i
i
Table 6: Quality, Access and Effectiveness Indicators
Selective Few Instruments
Furniture, Equipment and Other Appliances
DH
SDH
CH/RH
PHC/BPHC
Type of Hospital
Type of
Equipment,
Furniture and
Other Appliances
No. Proposed to
be Installed
No. Purchased/
Supplied
No. Installed A
Operationalized
% Provided as
per Norm
(1)
(2)
(3)
(4)
(S)
(6)
i)
ii)
iii)
i)
ii)
iii)
i)
")
iii)
i)
ii)
iii)
NJ
I
fia
" a
B
o M
Xj
o \©
Table 7: Quality, Access and Effectiveness Indicators
Availability of Drugs
Type of Drug
No. of Institutions with Adequate Quantities of Drugs
as per Requisition
Total
(1)
(3)
Dll
___________ (2)__________
Below 50% of Requisitions
SDH
CH/RH
PHC/BPIIC
DH
50-75% of Requisitions:
SDH
CH/RH
PHC/BPHC
DH
Above 75% of Requisition:
SDH
CH/RH
PHC/BPHC
1. Essential Drugs
2. Emergency Drugs
3. Others
A
1. Essential Drugs
2. Emergency Drugs
3. Others
1. Essential Drugs
2. Emergency Drugs
3. Others
’“0
co
(TO
>
oo
o
X) «
M
o
Table 8: Quality, Access and Effectiveness Indicators
Availability of Staff (DH, SDH and CH/RH)
Citegory of StafT
1
Doctors
2
Nurses
No. Sanctioned Under the
Project
No. Appointed
(2)
(3)
% Provided as per Norm
3. Group > C
4. Group - D
Table 9: Quality, Access and Effectiveness Indicators
Maintenance of Equipment, Furniture, OT (DH, SDH and CH/RH)
Type of Equipment,
Number Installed
No. in Working Condition
LA
% Not Functioning
Furniture, OT & Other
Accessories
_L
2.
3.
4
•-0
p
s
VO 3
O
I
►—
O VO
Table 10: Quality, Access and Effectiveness Indicators
Training
Type of Training Course
__________ (1)
No. of Training
Course Sanctioned
No. of Courses Held
During the Quarter
No. of Courses Heid
Since Inception
No. of Persons
Proposed to be
Trained During the
Quarter
No. of Persons
Proposed to be
Trained Since
Inception
(2)
(3)
(4)
(5)
(6)
1. Clinical______
2. Management______
3. 1EC_____________
4. MIES________ __
5. Maintenance_____
6. Referral_________
7. Waste Management
NJ
.u
O\
Noj of Targeted Persons
Trained During the
Quarter
(7)
No. of Targeted
Persons Trained
Since Inception
Percentage of
Targeted Workers
Trained Since
Inception
(9)
ns
to
OQ
□
O H
o
2, M
►—
O 'O
247
Annex 20
Page 1 of 4
SUPERVISION PLAN
General Routine Supervision
•
The core of the routine supervision process wiU be the six-monthly Bank supervision missions
Co™
C
Ji ’n*
s,x‘monthJy
reP°rt ‘o be submitted by the Health Systems
of“X
m
r
Department of Health and Family Welfare in Karnataka and West Bengal
of d ie commorudity of the program m the states of Karnataka, Punjab and West Bengal as wed as tfSt of Andhra
to
^e states to share their implementation experience. Dunng project
UUtlaIIVe
UnJ°n Mnustly of
to bring the states together worked very
This
S Sl“u d COr7lue to 86 fostered dunn8
implementation penod as well. Pus will result inconsiderable
cross-fertilization of implementation expenence across the project states and learning from each other The Bank
nrennmr
*
ZZT
a “V? “ ac“"“’8 “s pr'“=
tbsuii
savings of supervising a project of this size since we can eliminate a number of repetitious tasks in each state.
X'00 Fr^.uencV-Schedulln^ Programs. Regular Bank supervision missions will visit the project
y ‘XI1* mOnthS' pr°jeCt ‘S launched 111 May-June 1996, supervision missions w<Lld be
di'eXi
r" Xber-November> 1996 a**! between Apnl-May, 1997. Apart from two main missions dunng
the first year of implementation, a number of other interventions may be necessary from our side including short
?nn'
proi“
m™
3.
On each supervision mission the project coordinators in Karnataka, Punjab and West Bengal will present a
six-monthly progress report on the status of implementation for review and discussion. The Chief Engineer of the
construction wing of the Health Department m Karnataka and West Bengal and the Health Systems Corporation in
Punjab will also make presentations about the progress of civil works component to be incorporated in an overaU
progress re^rt. The Secretary, and in hrs absence, the Additional/Joint Secretary of the Department of Health and
ramily Welfare will update the mission on die progress on policy issues of the project.
4.
Each supervision mission will include field trips visiting a sample of different district, subdivisional and
ruraVcommunity hospitals The mission will lie appropriately staffed as discussed below Tnbal areas in Karnataka
and West Bengal will be visited at least once every year wluch will uiclude a tribal specialist who will visit a sample
oi project sites and facilitate the six monthly supervision missions.
5’
Cympojition pf Missions. The missions wiU be led by the Bank task manager and will include as
appropriate ax the tune, specialists in hosp.tal management, pubhc health, hospital cqmpment
economics
general management training, EC and tnbal issues, HMIS, surveillance and medical waste management’ Specialists
may also visit the states separately and individually by poor arrangement between the task manager and the Health
Systems Corporation m Punjab and the Department of Health, Medical and Fanuly Welfare in Karnataka and West
Bengal. In addition, requ.red specialists in other areas may occasionally be mcluded in missions as needed.
6.
Ad^nonal Missions. In addition to the above, the task manager may visit the three stales with or without
spec^t colleagues, in between routine supervision missions as needed for trouble-shooting or emergencies or
unng the first year of the project in order to help ensure that project implementation gets off to a smoothXt The
task manager may also, by poor arrangement with the concerned agencies in the states, authorize individual
specialists to make separate between-mission visits. Every effort will be made dunng supervision nussions to ImkX
supervise of activities in other Health and Family Wel&re projects in the stales which are interlinked w^thL
1
I
I
248
Annex 20
Page 2 of 4
project. Supervision of other projects may also be requested to follow-up on selected activities of State Health II
based on the concept of state-based supervision.
Supervision of Policy Reforms: Six monthly supervision will monitor compliance of the Policy Reform
7.
program. An economist and a managemcnt/institutional specialist will be assigned responsibility during supervision
missions to monitor compliance and progress on policy matters.
8.
Supervision of Software Aspects: In addition to the technical specialists that will accompany the Bank
supervision team as appropriate, contacts have been established with the WHO team in Delhi to assist in the
supervision of the technical aspects of the project. The Bank team will continue to bring in experts in the areas of
public health, hospital and equipment management, IEC, HMIS, surveillance and waste management.
Special ArninwmKntS for Civil Works Tlw civil works component is complex and costly and covers more
than 201 hospitals in Karnataka, 150 hospitals m Punjab and 170 hospitals in West Bengal of varying sizes in
addiuon to 28 PHCs and 8 Block PHCs in West Bengal. It therefore cannot be adequately supervised in the field by
an architect visiting twice a year foi a couple of weeks. A pyramidal, locally-based system of field monitoring for
this .component will therefore supplement the supervision arrangements desenbed above. In addition, the civil works
component will be covered by a special extra system of locally based supervision undertaken by the construction
wing of the implementing agency in each state. There will be three layers, as follows:
r
I
9.
(a)
The first layer will be the maintenance of a civil works archive in the Human Resources Unit of the
Bank's Delhi office, under the day-to-day supervision of one of the staff members. The
implementing agencies in the three states will send to this archive particulars of each hospital for
renovation and extension for which construction will be undertaken. This will include final as-built
drawings and contracts entered into for renovations and extensions.
(b)
The second layer will consist of local consultant architects who will report to the project task
manager and will:
(c)
(i)
review new arrivals in the archives once a month or once every two months as necessary
depending on the volume of arrivals, and screen them for any departures from criteria or
other features agreed upon at appraisal;
(ii)
in some cases, just prior to the regular Bank supervision missions and under a briefing
from the mission leader, visit the state to: (a) discuss cases departing from criteria set out
in the technical manual with the Chief Engineer of the Construction Wing and the Project
Coordinators in each state; and (b) make site visits to an appropriate sample of district,
subdivisional and rural/community hospitals departing from criteria;
(iii)
after these visits, report findings to the Project Coordinator and Chief Engineer and to the
regular mission architect at the start of the supervision mission, as well as filing a report of
tiie findings in the project archives.
I
The third layer will consist of the regular supervision missions. At the start of each mission, the
mission architect will review the reports of the local architect consultants and discuss them with the
implementing agencies. The architect will then make site visits, in the state visited by the mission,
to any identified problem buildings plus a random sample, drawn by him/her, of the buildings
reviewed by the local consultants during the previous six months.
L
249
Annex 20
Page 3 of 4
The Mid-Term Project Review
agencies
°Ut by “
«d s0b™^B IDA app«y
My 1999. T,
general XZe wi*k
Lues
12. .
prKeM shou,'d
nUSSIOn and
iraplementing
t0
d“n”g ,he “M "S”1" S“P«™S»" mission This mission wuld ta hdd n
aS'°C'" “
Dep“ °f “-k
Famdy Wedhra in
„
The principal aim of the Mid-Term Review will be to determine if there are any major problems or issues in
for a nrelZ^5'^
the °ri8inal ProJe«
and making mid^ourse corrections. It also may
bemused for a preliminary evaluation of the impact of the project, if the project has progressed suffic.ently to expert
13.
nroonZ Mld'Tcnn Rcv,cw W111
“ ‘^™1 stocktaking from the project records and MIS of the
progress of Project acUvmcs as measured against tin: original program and time schedule set out in the SAR iud
X rfStin1 7 r
21) PlUh OPl“,Ul ‘UjtbtlO‘U1 P3,U 35 aPProPnaIC- Notes should be included on tte
nroi«°
f
Pr°J,Xt agrCancnt5
on the results of the evaluation of a management review
p jects policy reforms aspects such as cost recovery polices, and on progress with the strategics for improving
services to tribal groups. Ihc stocktaking may also include indicators of the burden of disease and^pidcmiol^y.
U.
A final Mid-Term Review Report will be submitted to IDA and discussed with the following supervision
ZX, f
f
maJ°r PrOblem5’ ‘SSUe5’
°r
bi the project execution and the
prospects for resolving them and completing the project on time.
15.
The Mid-Term Review may be extended beyond those issues discussed above if this is considered
agencies would dead: upon the foil review content, in consultation with
IDA, at the beginning of planning for the review. Further elements of the review could include:
(a)
a management review of the organizational structure in each state;
(b)
pr^Eri^thC
(c)
special in-depth evaluadve studies of the private health sector, workforce issues etc.;
(d)
reviews of project progress by an external agency. However, this would be at the discretion of the
implementing agencies.
50031 assesstrent
training needs carried out as part of project
i
250
Annex 20
Page 4 of 4
Role of the Resident Mission
16.
The human resources group of the New Delhi office has been strengthened to carry out an increasing share
of the supervision work for human resources projects in India. This group will play an important role in this project.
First, our senior public health adviser in Delhi may be asked to follow-up on fundamental issues. Our local public
health specialist in Delhi will help monitor the project on a regular basis, follow-up on key implementation issues,
and trouble shoot in the field, as needed. He/she will be assisted by a local staff specializing in the administration of
projects. Procurement issues and guidance will be handled by the Delhi Office Procurement and Accounting Group.
That same group will handle accounting, auditing, disbursement, and flow of funds issues. These actions will be part
of the overall supervision program noted above.
!
I
I
f
Annex 21
Page 1 of 1
251
FORECAST OF EXPENDITURES AND DISBURSEMENTS
Table 1: Forecast of Expenditures and Disbursements
Disbursements /b
Expenditures
IDA Fiscal Year
Semester
Cumulative
Semester
Cumulative /c
Cumulative
as % of
Total
Semester
From Appraisal
Date
MIS Million
FY97
1st (Jul 96 - Dec 96) /a
2nd (Jan 97 - Jun 97)
22.8
22.8
22.8
45.6
5.0
19.5
5.0
24.5
1%
7%
1
2
44.1
44.1
89.7
133.7
19.5
38.4
44.1
82.4
13%
24%
3
4
55.6
55.6
189.3
244.9
38.4
35%
48%
5
47.5
120.8
168.3
49.1
49.1
294.0
343.1
47.5
40.2
215.8
255.9
62%
73%
7
8
36.8
29.4
379 9
40.2
296.1
85%
409 3
26.9
323.1
92%
9
10
7.4
416.7
21.6
•5.4
344 6
98%
100%
11
11
FY98
1st (Jul 97 - Dec 97)
2nd (Jan 98- Jun 98)
FY99
1st (Jul 98 - Dec 98)
2nd (Jan 99 - Jun 99)
6
FY2000
1st (Jul 99-Dec 99)
2nd (Jan 2000 - Jun 2000)
FY2001
1st (Jul 2000-Dec 2000)
2nd (Jan 2001 • Jun 2001)
FY2002
1st (Jul 2001 - Dec 2001)
2nd (Jan 2002 - Mar 2002)
350.0
Closing Dale: March 31. 2002
u/:
Including Special Account and Retroactive l inancmg
b/:
c/:
Figures may not appear to add due to rounding
Disbursement projections take into account the Regional Profiles for similar type projects
252
Annex 22
Page 1 of2
DOCUMENTS AVAILABLE IN PROJECT FILE
Project Proposal: Karnataka Health Systems Development Project; January 1995.
Project Proposal: Karnataka Health Systems Development Project; July 1995.
Project Proposal: Karnataka Health Systems Development Project; September, 1995.
Project Proposal: Punjab Health Systems Development Project; January 1995.
Project Proposal: Punjab Health Systems Development Project; July 1995.
/”
Project Proposal: Punjab Health Systems Development Project; September, 1995.
Project Proposal: West Bengal Health Systems Development Project; January 1995.
Project Proposal: West Bengal Health Systems Development Project; July 1995.
Project Proposal: West Bengal Health Systems Development Project; September, 1995.
Proceedings of Workshop on Norms for Hospital Services and Facilities, Karnataka. Department of
Health and Family Welfare, Karnataka; 1995.
Proceedings of Workshop on Norms for Hospital Services and Facilities, West Bengal. Department of
Health and Family Welfare, Punjab; 1995.
I
Proceedings of Workshop on Norms for Hospital Services and Facilities, Punjab. Department of
Health and Family Welfare, West Bengal; 1995.
Proceedings of Workshop on Strengthening Secondary Level Hospital Services. Depanment of Health
and Family Welfare, West Bengal; Calcutta; 1995.
Proceedings of Workshop on Policy and Finance Strategies for Strengthening Primary Health Care
Services. Union Ministry of Health and Family Welfare; Jaipur; 1995.
i
IDA Preparation Mission: State Health Systems Development Project II, Back-to-Office Report;
November, 1994.
IDA Preparation Mission: State Health Systems Development Project II, Back-to-Office Report;
March, 1995.
IDA Preparation Mission: State Health Systems Development Project II, Back-to-Office Report; June,
1995.
IDA Prcappraisal Mission: Slate Health Systems Development Project 11, Back-lo-Olficc Report;
August, 1995.
*1
253
Annex 22
Page 2 of 2
IDA Appraisal Mission: State Health Systems Development Project II, Aide-Memoire, October, 1995.
Karnataka: Site Survey of First Referral Hospitals.
Punjab: Site Survey of First Referral Hospitals.
West Bengal: Site Survey of First Referral Hospitals.
Beneficiary Needs Assessment in Karnataka. ASCI; 1995.
Review of the Private Sector in Health Care in Karnataka. ASCI; 1995.
Beneficiary Needs Assessment in Punjab. Foundation for Research and Development of
Underprivileged Groups (FRDUG); 1995.
Review of the Priv9te Sector in Health in Punjab. FRDUG; 1995.
Beneficiary Needs Assessment in Wes; Bengal- Operations Research Group (ORG); 1995.
Review of the Private Sector in Health in West Bengal. ORG; 1995.
Burden of Disease and Cost-Effectiveness Study in Andhra Pradesh. The Administrative Staff College
of India (ASCI); 1995.
!
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