GOVERNMENT PROJECTS
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- GOVERNMENT PROJECTS
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C'n 0\Z
INDIA
PROPOSED STATE HEALTH SYSTEMS DEVELOPMENT PROJECT 11
(PUNJAB)
INTERNATIONAL DEVELOPMENT ASSOCIATION
AIDE-MEMOIRE (JULY 1995)
1.
An International Development Association (IDA) team consisting of Messrs./Mme.
T. Nawaz (mission leader), S. Rao-Seshadri, K. Hinchliffe and D. Porter visited Punjab
between July 24-26, 1995 to review preparation and pre-appraise the proposal for the
Health Systems Development Project II in Punjab. The mission would like to express its
gratitude to the Chief Minister of Punjab, Mr. S. Beant Singh, and the Health Minister of
Punjab. Mr. H.S. Brar, for meeting the team to discuss key issues regarding the project.
The mission also met with Mr. A.S. Pooni, Chief Secretary', Mr. R. Kashyap, Principal
Secretary Finance, Mrs P. Khetrapal Singh, Secretary Finance and Accounts, and
Mr A. K. Dubey, Secretary' Planning, Government of Punjab. The mission would like to
thank Mr G.P.S. Sahi, Principal Secretary' Health and Family Welfare Department and his
colleagues for their cooperation and hospitality. A review meeting on the issues covered
by this aide memoire was held with Mr Sahi and his staff on July 26, 1995 in Chandigarh.
2.
This aide-memoire records the overall progress made in the preparation of the
proposed project, summarizes the main findings and recommendations of the pre-appraisal
mission, and the understandings reached with the Government of Punjab on a proposed
plan to appraise the project in October 1995.
PROJECT OBJECTIVES AND COMPONENTS
3.
Objectives: The Government and the Bank reconfirmed-that the main objectives of
the project would be to: (i) improve efficiency in the allocation of health resources
through policy and institutional development; and (ii) improve the performance of the
health care system through improvements in the quality, effectiveness and coverage of
health care services at the first referral level and selective coverage at the primary level.
The achievement of these objectives would contribute to improving the health status of the
people of Punjab, especially the poor and the underserved, by reducing mortality,
morbidity and disability.
4.
Components: It was reaffirmed that the project would have the following major
areas of investment: (i) Management Development and Institutional Strengthening
including (a) improving the institutional framework for policy development;
(b) strengthening the management and implementation capacity of institutions including
structures, procedures, management information systems, culture of service delivery,
resources and training; (c) developing surveillance capacity for the major communicable
diseases; and (ii) Improving Service Quality, Access and Effectiveness by:
(a) extending/renovating community, area and district hospitals; (b) upgrading their clinical
effectiveness; and (c) improving the referral mechanism and strengthening linkages with
the primary' and tertiary' health care levels.
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POLICY FRAMEWORK
5.
The discussions between the Government and the Bank on ke\ policy issues
continued to progress satisfactorily. The Government reiterated its commitment to
implement a policy package of health sector reforms that will include kev sectoral
development issues for the primary and secondary' levels of health care. These include the
need to: (i) increase budgetary allocations to the health sector; (ii) allocate most of the
incremental funds for the health sector to the primary and secondary levels of care;
(iii ) safeguard the operations and maintenance component of the health budget to ensure
adequate supplies of drugs and essential medical materials and maintenance of equipment
and infrastructure; (iv) set up a Strategic Planning Cell under the Health Secretary to
undertake analyses of health sector issues; (v) contract out selected sendees, especially
supporting services; (vi) enhance linkages in health care delivery with the private and
voluntary sectors; and (vii) implement service improvements and user charges. A draft
letter of Health Sector Development Policy prepared by the Government and addressing
the important policy issues noted above was discussed with the Health Secretary and his
colleagues. The Chief Minister and other senior members of the Punjab Government,
including the Health Minister and the Principal Secretary' Finance, stated that the
Government was committed to undertaking specific actions on some key issues contained
in the draft letter. This letter will be finalized by the time of the appraisal mission.
----User Charges. -It was agreed Ahat-user-fees-for-diagnostic-and-treafinent-services —
would be more widely implemented and further enhanced as rehabilitated facilities are
phased in. It was agreed that the 1994 Government Order giving notification of a new
schedule of charges, which is still pending, would be issued with a change to exempt the
population below the poverty line from the OPD registration fee. Practical methods of
identify ing and targeting the poor for exemptions were explored in detail. The mission
-agreed -with theTjovemment’s proposaLTO"usents_existmg‘sy^steTrrforndentifying^and
targeting the poor for free sendee on the basis of being eligible to hold a yellow card.
The Government reconfirmed that the funds collected through user charges would be
retained at the point of collection. It was agreed that user fees would only be used for
non-salary recurrent cost purposes.
7.
Linkages with the Private and Voluntary' Sectors. It was agreed that the
Government will contract out services to the private sector, such as laundry, cleaning
sendees, and catering wherever feasible. During the mission, the prospects for recruiting
suitable NGOs were discussed. It was agreed that the Government would work
collaboratively with both the private and voluntary sectors in general and, where
necessary', contract out the delivery of health care to the voluntary sector which has a
comparative advantage in improving access to health sendees for disadvantaged groups in
remote areas.
8.
Gender Issues and Reproductive Health. It was agreed that the proposed project
would include an IEC component to sensitize the public to the "life-cycle" approach to
women's health. The Government will continue elaborating their ideas on activities bearing
on women's health, beyond those included in the IEC component, for inclusion in the
project.
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PROJECT PREPARATION PROGRESS AND RECOMMENDATIONS
9.
Oxerall Progress. Progress with regard to project preparation activities since the
last mission has been quite satisfactory. The revisions made in the project proposal reflect
most of the points raised in the aide-memoire of the last mission. As noted in the last
aide-memoire (June, 1995), the revised proposal has targeted project investments on the
Upper Ban Doab area where the percentage of population below the povertv line, at about
40%, is much higher than the state average. How ever, three important areas of concern
remain: (i) the number of staff quarters proposed is disproportionately high; (ii) the survey
of facilities has not been initiated, although satisfactory progress has been made in
collecting information on the current equipment inventoiy; and (iii) the Government’s
proposal to set up a corporation to manage and implement the project could unduly delay
project development. This is expected to require commitment and immediate action at the
highest level of the Government. The Government and the mission agreed that these issues
would need to be given top priority for the project to be appraised in October. Details on
these aspects are provided below in the relevant paragraphs.
10.
Project Administration and Management. To facilitate health care delivery at the
first referral level, the highest levels of Punjab Government expressed to the mission their
eagerness to implement and manage the proposed project through the establishment of a
corporate set-up, much like the approach followed in Andhra Pradesh. The mission
pointed out the risks of opting for this approach since any-delay irTestabiishing a project
management structure would delay project processing at this late stage and undermine the
good progress achieved in other aspects of project development. The Government
informed the mission that work on setting up a corporate structure had already been
initiated and the Chief Minister, the Health Minister and the Chief Secretary stated that the
Government would have established a corporation and_worked_out all the details ofits.
functioning, including the legal and administrative implications, prior to the appraisal
mission planned in October.
11.
Site Survey and Preparation of Physical Works. It was agreed during the last
mission that the Government would undertake an extensive survey of all-health facilities at
the secondary level similar to the work being done by Karnataka and West Bengal. The
last mission agreed to arrange giant funds to cover part of the costs of conducting site
surveys and evaluating the existing inventory of equipment at facilities that it is proposed
to include within the scope of the project. The Government and the mission agreed that
this work needed to be undertaken expeditiously. However, progress got delayed since the
last mission both because the Health Secretary had been changed and the consulting firm,
with whom discussions had progressed on the works, reneged on the terms of the contract
at the last moment. The new Health Secretary has taken up the site survey as a matter of
urgency and informed the mission that most of the of the facilities would have been
surveyed by October. The mission agreed that given high priority, the survey could be
completed in two months in Punjab.
12.
Service Norms. A project preparation workshop involving key stakeholders in
project design and organized by the Department of Health and Family Welfare in late
April, 1995 defined the roles and functions of the various types of health facilities and
referral hospitals. The findings of the workshop have been issued by the Department of
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Health and Family Welfare and were used for revising the project. The mission reviewed
these norms in detail and agreed with the Government with regard to some modifications
1-5Analysis of Equipment Inventories. A postal survey has been undertaken to
determine the state of current inventories of equipment at project facilities. This entailed
staff at each facility completing a proforma questionnaire in which they recorded most of
the relevant data. The postal survey questionnaire did not included any request for
information on service activity data, and this matter now needs to be followed up by the
project preparation team. The previous mission had understood that the Government had
already strengthened the project preparation team by appointing a technical adviser with
expertise in management and maintenance of hospital equipment to take responsibility for
analyzing and verifying the equipment inventory' returns. In fact, this has not happened
and the work is presently being done by a non-technical officer from the Department of
Health. The mission believes it would be more effective to hire a technical expert as
originally proposed to establish what necessary' maintenance or repair work on existing
equipment and what technical specifications and volume of new equipment are needed at
each facility to bring the inventories up to agreed norms.
14.
Equipment Maintenance and Management. The Department of Health has
elaborated an action plan and the specific mechanisms to ensure state-wide coverage not
only of project investments but all current equipment and plant used by its health services.
The technical adviser recruited, along with the facility survey teamfsj, would contribute by
assessing local capabilities to provide technical support for hospital equipment including "
the possible role of private contractors. Further analysis of the maintenance and repair
coverage plan and of the detailed proposals for in-house manpower and workshop
facilities should be undertaken by this technical adviser for discussion with the appraisal
mission.
15.
Referral System. The project proposal has laid out a good plan for strengthening
the referral mechanism between the different tiers of the health system. The plan was
reviewed, including the proposed incentives to encourage patients to use the referral
mechanism. Details regarding the issuing of administrative guidelines are being developed
and will be reviewed at appraisal.
16.
Clinical Skill, and Management and Other Special Training, A training plan for
strengthening clinical skills has been developed by the Government. The mission reviewed
this plan and found it satisfactory; some minor additions were suggested. It was clarified
that some of the training would be coordinated by the district hospitals, where facilities
will be enhanced for this purpose. Training in management and other technical skills has
been discussed with the Government covering personnel policies, finance issues,
procurement policies, information systems, asset management and maintenance, IEC,
HMIS, and surveillance systems. The Government has identified institutions where such
training will be conducted.
1*7.
Management Information Systems (MIS). The MIS included in the project proposal
was reviewed and was considered appropnate. The mission suggested that details
regarding the computerization of the systems needs to be further developed.
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T 8.
Plan for Dex eloping Surveillance Capacity for Major Communicable and
Non-Communicable Diseases. A development plan for a state-wide svstem for major
communicable and non-communicable disease surveillance has been drafted and discussed
with the mission. Based on the burden of disease in the slate, a number of major
communicable and non-communicable diseases have been identified by the Government.
These diseases will be brought under the surveillance system and channels have been
defined through which information will flow. Parallel efforts will be made to improve
reporting by private medical practitioners. The surveillance system will be linked to
HMIS. A link with the Strategic Planning Cell needs to be established; community
participation in the surveillance network has been proposed and needs to be further
explicated. These issues will be discussed with the appraisal mission.
19.
Information, Education and Communication (IEC). The IEC proposal was discussed
with the mission. The IEC component has been formulated to focus on the need to raise
public awareness of preventive measures. It will now need to be fleshed out, taking into
account the findings of the beneficiary' assessment study. Opportunities for contracting out
some of the IEC activities will be reviewed.
20.
Detailed Project Costing. Project costs have been reviewed and need further
revision incorporating the changes discussed with the mission. The main changes are with
respect to civil works component, especially the construction of staff quarters. The mission
--------was of the opinion that the'number "of stafT'quartefrpropoself under ThFpfoject was
disproportionately high. It was agreed that the Government would make substantial
reductions in this area. It was also agreed that the detailed revised cost tables will be
provided to the mission by August 20, 1995. After revision, preliminary' total project costs,
including contingencies, are expected to be approximately Rs. 400 crores or about
USS 100 million. Recurrent costs are expected to be about Rs.25 crores at project
completion. The Principal Secretary, Finance has informed the mission that the
Government will have no problem in bearing this additional recurrent cost burden.
21.
Drug List. The Government provided a drug list to the mission, which is being
reviewed. The mission suggested that the technical specifications of the elements common
with the Andhra Pradesh drug list be incorporated by Punjab since the Andhra Pradesh list
had already been cleared by the Bank.
22.
Plan for Disposal of Medical Waste. The proposal for the disposal of medical
waste has been reviewed by the mission. It has been clarified that the plan for medical
waste disposal should include all hospitals, including tertiary hospitals not included in the
project Staff at facility level who will cany out the disposal function need to be identified
from among the existing personnel. Training modules will need to be developed for staff
at different health facilities responsible for medical waste disposal. Arrangements for the
temporary storage of waste prior to disposal need to be developed and the technical
specifications of incinerators, including capacity, at various facilities need to be modified.
23.
Beneficiary/Social Assessment and Private Sector Studies. The Beneficiary/Social
Assessment and Private Sector Studies are progressing well and a preliminary draft of
phases I and II have been given to the mission for review and comment. The mission is
5
^p»-^leased to note the ven' good work being done by the Foundation for Research and
Development of Underprivileged Groups in collaboration with the Government.
24.
Performance Indicators. A list of performance indicators was discussed and agreed
upon. The Government will further refine this list, to be reviewed with the appraisal
mission.
25.
Implementation Schedule and Procurement Plan. An implementation schedule has
been prepared and reviewed by the mission. The phasing of the hardware and software
components needs to be worked out more explicitly. The Government has agreed to
provide these by August 20, 1995. Procurement plans are being developed and will be
discussed with the Bank prior to the appraisal mission.
26.
Land acquisition. Because the proposed project involves renovation and extension
of existing facilities, it is anticipated that the need for land acquisition will be minimal.
The Government has provided assurance that none of the sites where hospitals are to be
upgraded will entail involuntary resettlement of any persons.
27.
Next Steps. An appraisal mission could be scheduled in October, 1995. By that
time, the Government will need to have completed a substantial portion of the site survey
and put in place a viable structure to manage and implement the proposed project. The
Government has made good progress with regard to other aspects of the, project. It is
expected that the recommendations of the mission concerning the remaining activities will
be completed by the end of September.
August, 1995
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|PIntroduction
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This summary paper has been prepared to supplement the annual sectoral work plans of
UNICEF and the Government of Karnataka. It is hoped that this will provide an
overview of the areas that UNICEF, with its partners shall focus attention in 2001.
Piogram details can be found in the individual sector plans that have been submitted by
Unicef to the Department of Women’s Development and Child Welfare.
It is hoped that during the workplan review meeting scheduled for 24 November, that the
following can be achieved:
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Genera! agreement on the GoK/Uniccf workplan for 2001;
Identification of program priorities for January to December 2001;
Identification of program review and monitoring activities to be undertaken; and
Identify roles and processes regarding undertaking of (he mid-term review, ’
Situation Analysis of Women and Children in Karnataka State and
preparation/advocacy regarding the Special Summit for Children.
Karnataka: A Developmental Overview
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With a population of44.8 million, Karnataka is the eighth largest state in India. Ils large
SC/S I population constitutes 22 percent of the total population. Karnataka has a child0
population of 25.5 percent (aged between 0 and 14). Positive trends have included the
decline in infant mortality rate from 81 per 1,000 live births in 1981 to 53 in 1997, a decline
in child marriage and increase in age at marriage from 16.1 in 1961 to 20.1 in 1991. There
has been a r;. id increase in expansion in the primary education network along with programs
to increase literacy. Areas of concern include the 976,000 working children between the aecs
( ol_5jud.l4, thcdcduicjinlimsex rati^TrWTmFmrc^sp^
for
I Icmale^hijdre^ O^er^percenLofpregnant women are anaemic, leading to higher maternal
i deaths. Levels of malnutrition arc high for severe malnutrition and 35 percent for moderate
r malnutrition. Peri-natal deaths have increasecTTrom 43?Tm 1981 to 47.8 in 1994 The
maternal mortality rate continues to be high at 450 and life expccJ^cVjroIsTcars Underfive nioilalily is nine percent. Fifty-three infants die for every 1,000.births. Ill V/AI DS is
emerging as a challenge that requires attention.
While the stale is relatively developed, there exist sharp regional differences within the slate
The northern Karnataka has significantly lower developmental indicators than more
developed parts of the states. There have been calls for Unicef to focus assistance in the
boidci distiicts that have the weakest child development indicators.
[ GO/\LSOF ThFuNICEF programme of cooperation in 2001
UNICEF aims to promote comprehensive and holistic survival, growth and development of
children m the state of Karnataka. Integrated interventions in 2001 will aim for child survival
through improved new-born care, and foster development, protection and early stimulation of
children in the vulnerable 0-3years. It will also support enjoyable and quality education
programs at pre-school and primary levels. Extending access to clean water and a sanitary
environment and protection from child labour will be other areas of focus. Improved
____ I’W.2
A |»P.L«adiJ.’a perjb r_2001_______
Hyderabad l-icld Ollier, t'M( I t
nutritional status for proper growth and development and better childcare practices will also
receive attention in 2001.
Budget and programme Highlights
The following table summarises the present budget allocations for the state for each
sector in 2001 as well as highlights the major areas of program focus. This budget has
been set by Unicef/Delhi and can not be changed without approval from Unicef/Delhi.
Unicef/Hydcrabad has already submitted a request for a higher budget but this will not be
considered until the start of the new year. GoK program priorities should be fit within the
following budget and any budget additionality will be used support other programs
identified for the year. Unicef/Hyderabad is actively seeking supplemental funding that
would enhance program delivery in co-ordination with the Government of Karnataka for
2001. Details of activity heads of expenditure are supplied in the individual work plans.
Sector
Community
Convergent
Action
Allocated
Budget
5:59,400
Rs: 27 lakh
Program highlights
Promote integrated programming in identified districts, including: Mysore,
Chilradurga, Gulbarga, Raichur with a focus on community-based development and
monitoring. Explore potential to link IT with CCA programming. Ensure that VDCs
arc equipped with skills and back-up support for fulfilment of children's rights.
Health interventions will concentrate on implementing the sub centre strategy in the
border districts of Bidar, Richur, Gulbcrga and Bijapur. fhc sTialcgy Will tutus on
developing community H&N teams, facilitating a package of interventions including
new born care, 1MCI and maternal care as well as capacity building of sub centre
through drug supply and training of staff. Other interventions will include sustaining
and strengthening of maternal and child protection services including
immunisation, Vitamin A supplementation and health counselling.
Health
5:163,000
Rs: 73 lakh
Child
Development and
Nutrition
5: 157,700
Rs: 71 lakh
Child development initiatives for the 0-3 years will include initiating the family held
card as a tool for empowering family and community level monitoring of health
nutrition and developmental status of children. Initiatives for 3-6 years will
concentrate on qualhy impi ovcmciit of pre school education in the ICDS
Water and
Environmental
Sanitation
5: 500,000
Education
5:450,000
Major interventions being prioritised includes scaling up of support for school
sanitation to 4 districts of Mysore; Tumkur, Chilradurga and Raichur.
Support will also be extended to sector reform interventions being implemented in 3
districts and human resource development training.______________________________
I he major education intervention will continue to be (he janshahi program funded by
the Jt. UN systems which focuses on quality improvement in primary grades, and
community participation in education. Implemented in 10 blocks over 6 districts. In
addition to tin's special pilot IT initiatives in education will be explored.
During the year, will focus on sericulture and bonded labour; Promote interstate
collaboration between AP and Karnataka will ensue, thus tackling child labour in
synergistic manner and serve as a model for other interstate collaboration. Will help
ensure that there is a common approach to training on issues pertaining to child
protection.; Support HIV/A1DS prevention activities.____________________________
Focus on preparing the Situation Analysis of IFonten and Children, dissemination of
the 2nd CRC report and follow-up; Monitor the implementation of the district CRC
plans with a focus on the CCA, integrated program as well as children in dangerous
situations, infanticide and HIV/AIDS. Support advocacy activities in areas pertaining
to the Special Summit for Children.
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Setting up of the interdepartmental monitoring cell and developing the Child Info
data base, as well as the use of programme MIS in districts with multi-sectoral
UNICEF programs. Major activity will include the mid term review of UNICEF
support to Karnataka and preparation of the Situational Analysis of Women and
Children for providing inputs for the next program cycle.
Rs: 2.2 crore
Rs:2.025
crore
Child Protection
5: 35,900
Rs. 16 lakh
Communications
528,500
Rs. 13 lakh
Strategic
5:14,000
Programme
Rs:6.3 lakh
Monitoring and
Evaluation
Total
51,408,500
6.3383 crore
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A p prone
pc
Hyderabad Field (Hike, HMCIJ
’.
s ,»rt .» «e govemma« in s.n^ie panning and policy 10™*™.;
cZX™=' and8 ».nn.u..i.y based p.og—g;
:
^"S^gXXnen. of UN.CBF sapP^
I Sup port tos i r a i eg k- 1j222L——————
UN!CEF»i1.oon.ino--~^X^i,’WPlhe,*ale
in planning and
strategy fomwlation. This will be ao
Ptovifce ofdala bases, researeb and evasion da.a and —
>)
ii)
area or people specific .0 provide
workable strategies
providing of data bases or
iXkle'a b'>'se'fo .^taal decision
access information, collate or analyse1 ff
areas (o p|.cpai.c for strategic
making. This also mchulcs spccilic . ‘
ions Jn illcilKlc 1) Preparing a Suucili^il
iniplcinentations. Towards this, maj
inJ;na results of the Second CRC Report, 3)
J,,1,,;,,,., of 11'00,00 00,1 CloIJroo: 2). Dwmi"a S
, realisi„g righls „r cluldrco
Using ClolJlofo by goel
°io governmental monitoring systems so ll,al >1 can bo
4) I inking of ‘program MIS softwai
g
nrr>vi(lin2 support to a monitoring and
d y lit De artments during lhe.r reviews,
kovkoblaining data on
evaulaLtion cell; and 6) ^uct.ng
10 iinprove program strategy
the qualtty of service oolreadt and ' "8
a„d intern to assist with nmndonng
and implcntentalion. Untccfwi
, lliat njpo will be joining the Uincef office o
Xemtormg and evalnalton io 2001.
Research and Evaluation studies
^erlainfng lo/ttrem-ra-
y in Chi.radurga .“"J Ra'd" '^Ltome ofodoloscoo, oooooda and strategy response
— ofNalli KaK strategy 5) study oo
ago,oS.
women .
.
Piloting of Interventions which are area oreP“[R ’^X'i/i'srllt strategy of quality
■XSSwetbingehiidreninto schools, and
sustainable models of school sanitation.
, In ZOOlspecific strategics that wiilI be[
Bijapur and
the quality of health mterventions in the fo
win
[Q estab,ish sub centres as the
Gulberga.. Within the RCH PJ^ Hn’kages with the community so that plannmg of health
core of activities and revitalise ns
s/rategvfor supplementation of Vitamin A
-Vicoverall children between the ages of notc
along the lines ol the 1 ri
Ta2C 4
Appr<mIlL’n 1»er f<)r_201H_______
Hyderabad Field Ollice, I W 1(1 J
months and three years in a single campaign; transplanting the concept of neighbourhood
basedgroups/leaders and community monitoring from urban community development
models into rural areas, which will be tried out in two blocks each of Chitradurga, Raichur,
and Gulberga districts. A strategy to empower families and childcare workers will be
explored by adding a care dimension to early health and nutrition interventions will be
explored. Unicef will support strategies to prevent anaemia in adolescent girls which
includes covering all school-going adolescent girls (11 to 16 years) with a weekly regime of
100 mg. Iron and folic acid for 52 weeks. Resources to harness IT to support education and
CCA initiatives will be explored.
I Intersectoral CoiivergcnceTnd CoininiinitjTbasecl programming
UNICEF will continue to support interventions that strengthen the capacities ol
communities to assess and analyse their own situations, set priorities and monitor
integrated development activities. In 2001, UNICEF will focus on the convergent
programs which arc being undertaken and monitored in four districts of Karnataka. In
these districts, communities will be empowered to develop and monitor micro plans.
Program intervention will focus on ensuring that there is greater conceptual clarity
amongst government counterparts regarding concepts of CCA. 'This will be done by
hosting workshops at the stale, district and block level. UNICEF will support the capacity
of frontline workers (teachers, AWWs, literacy volunteers,) block functionaries, district
sector staff,panchayti raj members and elected representatives, community members and
children to understand and apply concepts associated with CCA.
UNICEF anticipates that by converging program interventions and actively supporting an
integrated social development planning process, UNICEF, and GoK can more effectively
fulfil rights of children and women. By focusing resources in blocks with greatest
developmental deficits, it is anticipated that UNICEF will make a greater impact in
influencing and improving developmental indicators in the states. The scope of convergence
at the district and mandal level is outlined in the table below:
Number of blocks
Karnataka
"s’
Programme
Rnicliur
Guibarga
Hcalth/BDS
Entire
district
Entire district
Mysore
C’duiga
No
1
interventions
1
2
2
ECCSGD/MCHN
intervention
T”
2
3
Joyful Learning
in A WC 3-6 yrs
Universal
Primary Edu (Jt
UN Prog) 6-9 yrs
NCLP for Edu of
children 9-14 yrs
2
2
1
2
DPEP
DPEP
DPEP
2
1
1
1
1
1
2
3
2
2
2
1
4
5
6
7
9
To
"ChTTd
Labour/Protcctio
n Initiatives
School Sanitation
INC and IIIU
operation
CCA———
1
2
__ V;v,lc_5
The Mowing process
1'iSX'
converging program aol.vmes
sc|,00,.
VDCswiU?ee^*^^a —M—»•
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>
50% of gnls in 12 rag g
opportunities;
f water and school sanitatio ,
.............. ..........
inerc-l cnroiimenr m AWCs and increased co........ ni^.s^Km
”
of ECC SOD and lire .mpo.lance o
^rtoclioning ofFAWCi
iifol and addressed wid. Vi.iago —
>
Village social priontie
Funds.
Anticip^e£
-_
-
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-ciM^EES"
• ,, realities- In 2001. UNICEF wO
> Addressing previons.y onio--jj”'S'^-empmenird
—
address some prevmusly '““^aKI ’dention than m recent y
,11'7 AIDS will re“'v,m«.E
md w.lh ^eeonnenl cmmlc pa.
will work will’ 'l’t,.1DS prevention programs m the »' ‘ v;A|DS md 3) yoo'E
work with
to more
......... of
GoK will be exp oi
rcac|I program objectives
1
‘ including radio and
cnlrfdy and
/'“opEncc edrreati.n
"n ^d sbanoe'
education and CC ■ • l lcti0Iial media for older age c
ovati011 In the WES
television as effective n
ncw opportunities for i
d
ihcrc win
education and tcachci
- bl
1(i()U p.-ogram w I I c cx|
c lol.c
>-»“aras °r
-X^XZ^nd scooi sanitation-
__
Strategy: In 2000, the field office
............................. ...
rOC',r'’sll,,,,or..nSpalln«.Sn.oree,Teenve>y-.
.
enhancing internal crEcrency. and
!(
Approstcli I’npcr for 2001
Hyderabad Held Office, UMCEr
>
-L>”c_6
Supporting partners more effectively: Towards this end UNICEF has worked towards
lour mam interventions which include 1) specific workshops to help state district level
unctionancs plan based on objectives and monitor program progress based on a clear set
ol indicators; 2) institutionalise a system of reviews every four months based on the
above to facihtate program acceleration; 3) provide a system of a supportive audit for
large programs where the budget exceeds 15 lakhs; and 4) providing a customised
software to support account keeping and reporting.
>
Enhancing internal efficiency: includes the organisations ability to respond with greater
speed and sensitivity to the needs and requests from its partners. Specific interventions
include 1) holding of program-wise supply workshops to draw up a supply plan for each
piogiam to ensure speedy processing of supply requirements; 2) ensuring that requests for
cash assistance are processed within ten days of a proper request; 3)setting up a system to
alert and follow up all advances that are over three months old; and 4) Identifying a team
of two persons per district who will be responsible for trouble shooting and responding to
[[Conclusion
11
Ilus approach paper provided an overview of the programs and areas of focus of the
Hydcmbad F.eld Office in 2001. The paper has presented the proposed goals and focus olf
he office as well as plans for enhanced intersectoral convergence. Anticipated programmatic
c lallengcs and proposed responses, as well as priority management and organisational
development priorities also been presented.
H IS hoped that upon review, a clear idea of program priorities will be established for 2001
and lead to a spirit of close collaboration and communication during the coming year.
Paper III
^-5'3^
- 7--
Analysis of Expenditure on
Medical & Public Health, Family Welfare
Dr. S. Subramanya
Karnataka a federal state in India is located in the south-west part of the
country. It is bounded, in the clockwise direction, by the States of Goa, Maharashtra,
Andhra Pradesh, Tamil Nadu, Kerala and the Arabian Sea. The area of the State is
191,791 sq. km. and constitutes 5.38 percent of the area of the country.
Demographic Trends
The population of the State in 1991 was 44.98 million and accounted for 5.31 percent
of the population of India. In terms of population size and geographic area, Karnataka
ranks eighth among the States. Kannada is the mother tongue of 65.7 percent of the
population. The compound annual growth rate of the population of Karnataka was
1.93 percent in the decade 1981-91. The decline in population growth rate has been
more rapid in Karnataka than in India. In 1991, the urban population accounted for
30.91 percent of the population of the State as compared to 25.71 percent for India.
The Crude birth rate (CBR) for Karnataka was estimated at 25.5 for the year 1993.
2. Morbidity Pattern
2.1 Morbidity Pattern among Users of Go^nment Facilities
According to the Forty Se^nd Round of National Sample Survey conducted
in 1986-87, 40.3 persons per thousand population suffered from some ailment or other
during 30 days preceding the date of interview and 89.6 percent of them consulted a
doctor. Those who were admitted as inpatients during the preceding 365 days
accounted for 21.8 per thousand population.
The estimates of outpatients and inpatients per thousand population per year
for the government hospitals derived from the results of the Forty Second Round of
National Sample Survey conducted in 1986-87 were 168.2 and 12.0 respectively.
These estimates are close to those estimated from data on morbidity compiled from
returns submitted by hospitals in the government sector for the year 1992. The
average number of registrations in outpatient department is 176.8 per thousand
population and for inpatient it is 12.3 per thousand population.
Between 1982 and 1992 there has been, in the government hospitals, an
overall increase in outpatient consultations as well as admission as inpatients. The
outpatients have increased by 47 percent and the inpatients by 65 percent while, the
increase in total population has been 21 percent. The increase in outpatients and
inpatients at government hospitals between the years 1982 and 1992 may be due to
increase in morbidity level or in utilisation of hospital services or both. It may also be
due to increase in cost of medical care in the private sector.
*
Project Administrator, Karnataka Health Systems Development Project (KHSDP), Government of
Karnataka
E\KHSDP\Sarma\Health-~2.doc
1
Paper III
The increase in treatment as outpatients for the respiratory, digestive, genito
urinary systems, complications due to pregnancy and the puerperium, and injuries and
poisoning has been above the average of all diseases. The increase in inpatients for
treatment of infectious diseases, neoplasm, endocrine, nutritionals & metabolic
diseases and immunity disorders, mental disorders, diseases of circulatory system,
diseases of genito-urinary system, complications due to pregnancy and the
puerperium, diseases due to injuries and poisoning, has also been higher than the
increase in total hospital admissions.
2.2 Causes of Death
During the decade 1981-91, the share of deaths due to parasitic diseases declined
while that due to diseases of the circulatory system increased. The share of deaths
among females due to complications of pregnancy and child birth declined. In 1991.
diseases of the circulatory system constituted the single largest cause of deaths
(23.5%) followed by infectious and parasitic diseases ( 19.6%). Injury and poisoning
took the third place (14.6%). The fourth place was taken by conditions originating in
the perinatal period (8.8%), Diseases of the respiratory system and diseases of the
nervous system came fifth and sixth, accounting for 7.8% and 6.1% of deaths
respectively. These six diseases accounted for 80.4 percent of deaths.
Analysis by age revealed that infant deaths formed 12.9 percent of total deaths. The
major causes of infant deaths were slow foetal growth, foetal malnutrition and
immaturity (28.7%), hypoxia, birth asphyxia and other respiratory conditions (20.2%)
and all other causes originating in the perinatal period (17.6%). The age group 15-34
accounted for 28.4 percent of deaths of females due to all causes as compared to 16.3
percent in case of males. (Annual, 1991)
Objectives of the State
In Karnataka like any other state of India, the health sector is characterized by :
• A Government sector that provides publicly financed and managed health services
throughout the state from Primary Health Centres to hospitals where free curative
and preventive health services like ante-natal care, immunisation are made
available to a large section of the population.
• A private sector comprising of mainly fee for service practitioners and a few
hospitals with in-service facilities.
-ft
The Government sector is expected to be targetted towrads these weaker section of
the society. There are a few reports in which attempts have been made to analyse
Government expenditure on health services (Panchamukhi 1993; Reddy 1992;
Tulasidhar 1993, Bhaskar Rao et al., 1993). There are limitations in analysing the
health care expenditure on a national scale on account of the lack of disaggregated
data (Burman 1997). In addition health care expenditure is incurred by the state
Government and hence analysis of health care expenditure at state government level
presents proper function. Narayana and Reddy (1993) and Mahopatra (1996) have
analysed the expenditure incurred by Andhra Pradesh Government on health care
during 1980s.
E\KHSDP\Sarma\Health~2.doc
2
Paper III
The primary objective of this assignment is to arrive at sector-wise expenditure,
evaluate, & compare these expenditures on Primary, Secondary, and Tertiary Sectors
over the years.
The secondary objective is to find out the proportional expenditure on Health &
Family Welfare out of the total expenditure of the state over the years and derive ai
the trends.
In addition to the above objectives, it also envisages to find out and analyse
expenditures on some important heads of account individually.
The estimates of expenditure are documented by Government of Karnataka mainly
contain abstracts of expenditure on different Heads of Account. These Heads of
Account are classified into Major Head, Sub Major Head, Minor Head, Group Head.
Sub Head, and Object Head. Each year's document (i.e., volume IV) contains Account
Expenditure (Plan & Non-plan) for last-but-one year, Budget Estimate (Plan & Non
plan) and Revised Budget Estimate (Plan & Non-plan) for the last year, and Budget
Estimate (Plan & Non-plan) for that year.
However, the documents for Medical & Public Health, and Family Welfare do not
provide any break-up on sector-wise allocation. It is important to have sector- wise
break-up to know the way in which these expenditures are growing over the years in
order to effectively plan development activities relating to health services. Hence, it
becomes necessary to analyse these documents to arrive at sector-wise spending.
It is equally important to know the proportionate allocation of the total expenditure of
the state to Medical & Public Health, and Family Welfare to have a clear picture about
the trend of health services expenditure. Further, it becomes necessary to have item
wise expenditures to facilitate future decision making regarding usage of funds.
Hence, this analysis is presented to facilitate the decision-makers in planning and
implementation of policies.
This paper attempts to examine the issues in expenditure on health and health related
areas in the past 30 years to relating to allocation of funds.
3.
Methodology
For this analysis, data from three sources is considered. First the annual financial
statements of the state for the years 1990-91 through 1996-97. Second the detailed
estimates of expenditure of Medical & Public Health and Family Welfare for 1990-91
through 1997-98 volume IV. Third, the Zilla Parishad Link documents for 1990-91
through 1997-98.
From the annual financial statements, the receipts and disbursements of the state are
obtained. From these the per capita income and expenditures both at current prices
E\KHSDP\Sarma\Health-2.doc
Paper III
and constant prices (1980-81 prices) are calculated. In addition, the share of Services
Sector in the total income and expenditures of the state, the share of Social Services,
and Health & family welfare sector in the Social Services expenditure are calculated.
The Zilla Parishad link documents provide breakdown by account head the budget
allocation for a given year. On the other hand, the volume IV presents consolidated
figure of grant budgeted for the current year, revised estimate for the preceding year
and the actual amount disbursed two years ago. The ratio of actual amount disbursed
to amount budgeted, for the year is used to deflate the disaggregated data presented in
link document and replace the lump sum grant indicated in Part IV.
From the documents of detailed estimates of expenditures, various heads of accounts
are sorted into three broad categories viz., primary, secondary, and tertiary. Further,
the secondary sector is divided into two sub groups (teaching hospitals &others). To
arrive at this sector-wise expenditure, first, the heads of accounts under each sub
group are summed. These sub groups are then assigned to any of the three sectors (viz.
primary, secondary, and tertiary) based on certain assumption mentioned in the
following section.
The sector-wise expenditures are obtained and then compared over the years to
understand the trends in the spending and to evaluate the primary objective. The
actual expenditure on these sectors was also compared with the budget estimates to
know the extent of utilisation. Also expenditure on some major items / heads of
accounts were compared over the years individually to know the variations in
spending. This analysis was carried out for the years 1990-91 through 1997-98.
4.
Assumptions
1. The following assumptions are made while doing the above analysis:
• All heads of account under the major head "Family Welfare" and "Public
Health" are assigned to primary sector.
• All heads of account under the sub major heads "Research", "Education", &
"Training" are assigned to tertiary sector.
2. The following hospitals are taken into tertiary sector:
• National Institute of Mental Health and Neuro Sciences.
• The Bangalore Accidents Rehabilitation and Other Services Society.
• Kidwai Memorial Institute of Oncology
• Development of District Hospital, Raichur (OPEC).
• Indira Gandhi Institute of Child Health
3. All hospitals attached to teaching institutions are taken into a separate group under
secondary sector. These hospitals are:
• Victoria Hospital, Bangalore.
• College Hospital, Mysore.
• College Hospital, Bellary.
• KMC, Hubli.
• District Hospital, Belguam.
E\KHSDP\Sarma\Health-~2.doc
4
Paper III
•
•
•
District Hospital, Gulbarga.
Chigateri General Hospital, Davanagere.
Head Quarters Hospital, Mangalore.
4. The heads of account relating to hospitals attached to teaching institutions are also
taken into the separate group under secondary sector. These are:
• Special improvements to buildings(Teaching Hospitals),
• Provision of equipment to teaching hospitals,
• Provision of ambulance to teaching hospitals,
• Intensive care units and cardiac care units in teaching hospitals,
• Modernised blood banks for teaching hospitals.
• All other major hospitals, district hospitals and tuberculosis institutions are
assigned to secondary sector.
5. KHSDP is considered for secondary sector.
6. DoH&FW, Administrative unit (ESI), Other Expenditure (ESI), Medical Stores
Depot, Other Expenditure (Buildings), Director of Indian System of Medicine are
considered common to all three sectors. These are later apportioned on the basis of
percentage ratios of each sector.
7. Hospital unit (ESI), establishment maintenance units for hospital equipment, and
repairs to hospital equipment are considered common for both secondary and
tertiary sectors. These are later apportioned on the basis of percentage ratios of
each sector.
8. The following are assigned to the Primary Sector.
9. Block assistance to Zilla Panchayats and Gram Panchayats is assigned to primary
sector.
10. ICDS projects (Health Component) are assigned to primary sector.
11. All centre-sponsored schemes are assigned to primary sector.
5. Results:
5.1 Growth of Net Domestic Product
The Net Domestic Product of Karnataka at factor cost is given in Table #5.1.
Table # 5.1 Net State Domestic Product of Karnataka at Factor Cost
90-91
91-92
Net Domestic Product (Crore Rupees)
At Current Prices
20,550 26,736
At 1980-81 Prices
9,112 10,270
Per Capita Income (Rupees)
E\KHSDP\Sarma\Health~2.doc
92-93
93-94
94-95
R.E
95-96
Q.E
96-97
29,132
10,482
33,794
11.275
39,158
11,728
43,422
12,361
47714
13053
5
Paper III
At Current Prices
At 1980-81 Prices
4,598
5,888
6,315
7,214
8,237
9,004
2,039 ________________________________
2,262
2,272
2,407
2,467
2,563
R.E: Revised Estimate, Q.E: Quick Estimate, @: Anticipated
Source: Directorate of Economics and Statistics, Bangalore.
9758
2669
The Net Domestic Product at current prices increased at the annual compound growth
rate of 15.1 percent between 1990-91 and 1996-97. During this period, the per capita
NDP increased at an annual compound rate of 13.4%. Adjusting for inflation, the
NDP grew at an annual compound growth rate of 6.2 percent and per capita NDP
grew at an annual compound rate of 4.6 %.
5.2.
State Revenue and Expenditure
5.2.1. Receipts
The total revenue of the State increased from Rs. 4,775.5 Crores in 1990-91 to Rs.
6938.1 Crores (at 1990-91 prices) in 1997-98 representing an annual compound
growth of 8.6 percent. Tax revenues accounted for an average 59.1 percent of total
revenues followed by States Share of Union Taxes at 17.9 percent and Services at
12.5 percent and grants in aid at 10.6 percent. Out of the total income from Services
80.8 percent is contributed by Interest and Economic Services, 12.3 percent by
General Services, and 6.9 percent by Social Services.
Table 5.2.1 State Revenue Income at 1990-91 Prices and Share by Source
90-91
Revenue Receipts Rs. Crore
3,892.2
State Tax Revenue
Non-tax Revenue
States Share of Union taxes
Grants-in-aid from Central Govt.
59.9
13.3
17.0
9.8
91-92
92-93
93-94
95-96
96-97
97-98
Revised Budget
4,137.0 4,399.5 4,759.0 4,706.9 5,485.0 6,351.0 6,938.1
____ Percent of Gross Revenue
60.7
57.1
60.3
60.0
59.9
57.2
59.0
13.0
14.8
11.6
12.2
14.5
12.7
10.1
19.4'
16.4
17.2
16.1
18.7
17.9
18.4
9.9
10.9
12.0
6.9
11.8
10.0
12.5
94-95
5.2.2. Expenditure
Table # 5.2 presents the Revenue and Capital expenditure for the period 1990-91
through 1997-98 at 1990-91 prices. The total revenue expenditure of the state
increased from Rs. 3,971 Crores to Rs. 7,055 Crores at a compound annual rate of 8.6
percent. The expenditure on General Services grew at a faster rate (9.9 percent per
annum) as compared to the other Sectors. The expenditure on Grants & Contributions
grew at 8.3, that on Social Services at 8.5 percent, and that on Economic Services
grew at 7.2 percent. This also indicates that the share of Social Services expenditure
out of total expenditure is nearly constant at about 38 percent.
E\KHSDP\Sarma\Health~2.doc
6
Paper III
Table # 5.2 Revenue & Capital Expenditure by Sector at 1990-91 Prices
Crore Rupees
Revenue
90-91
91-92
92-93
93-94
94-95
95-96
General Services
Social Services
Economic_____
Grants &
Contributions
Total_________
Capital_______
General Services
Social Services
1 174.6
1538.9
1 159.3
98.3
1231.9
1639.7
1318.0
1433.3
102.1
1379.3
1689.7
1367.4
101.2
1789.7
1355.1
93.2
1554.2
1860.0
1393.5
99.2
3971.1
4291.8
4537.5
4671.4
1 1.4
17.7
625.8
654.9
11.8
28.2
640.9
680.8
15.5
31.4
Economic______
Total
591.4
638.3
97-98 i Annual
Budget , Growth
1714.3
2086.7
1570.0
73.3
96-97
Revise
_____ d
1968.3
2379.7
2158.3
129.8
!
2273.3 I
2726.7 ■
1883.5 I
171.9
%__
9.9
8.5
7.2
8.3
4906.9
5445.0
6636.2
7055.4 I
8.6
17.3
15.0
39.2
46.3
706.5
767.9
15.9
52.8
727.7
796.4
13.7
38.7
508.3
560.8
9.4 |
59.6
518.8
587.8
-2.7
18.9
-2.6
-1.5
837.3
893.8
The share of General Services in revenue expenditure increased from 29.6 percent in
1990-91 to 32.2 percent in 1997-98 while that of Economic Services declined 29.2 to
24.4 percent. The share of Social Services increased marginally from 38.8 percent in
1990-91 to 39.9 percent in 1997-98.
Share of Different Sectors
40.0
30.0
s 20.0
Q
<D
ci-
10.0
0.0
General
Services
Social Economic Grants-in
Services Services
'Aid
1990-91 ■ 1997-98
5.3.
Expenditure by Sector
5.3.1. Expenditure on Social Services
Table # 5.3 presents the Revenue Expenditure on Social Services Sector. This
increased from Rs. 1,596 Crores to Rs. 2,727 Crores (1990-91 prices) at an annual
compound rate of 7.9 percent. The annual compound growth rates for the other
components of social services are 7.8 percent for Health & Family Welfare, 23.1
percent for Water Supply & Sanitation, 25.4 percent for Housing & Urban
Development -4.3 percent for Nutrition and 6.7 percent for Other Social Services.
E\KHSDP\Sarma\Health~2.doc
7
Paper III
Table # 5.3 Revenue Expenditure on Social Services Sector
Crore Rupees (at 1990-91 prices)
Education_______________
Health & FW__________
Water Supply & Sanitation
Housing & Urban
Development__________
Nutrition_____________
Other Social Services
Total
90-91
91-9
92-93
93-94
878.6
270.7
58.2
44.2
832.9
255.9
70.2
78.7
890.8
292.3
77.7
52.4
961.7
' 294.4
89.2
49.1
64.4
67.5
334.7
1639.8
24.7
351.8
1689.7
376.1
1789.7
280.3
1596.4
96-97
1197.0
374.1
161.3
165.8
97-98
1314.7
459.2
249.4
215.7
25.3
37.1
42.8
345.1
372.0 438.7
1860.0 2086.7 2379.7
440.6
94-95
978.1
309.2
121.9
80.4
19.2
95-96
1093.3
318.8
141.9
123.7
47.2
2726.8
The expenditure on each component increased at different rates. The growth in
expenditure on water supply & sanitation and housing increased at a faster rate. This
resulted in a decline in the share of education has from 55.0 to 48.2 percent over the
seven-year period while the share of water supply & sanitation increased from 3.6 to
9.1 percent and housing from 2.8 to 7.9 percent.
Trends
in
Components of Social
Expenditure on
S e r v ic e s
6 0.0
... : • ?
5 0.0
ZZZZ-i
ZZTZZ
.•
4 0.0
I
3 0.0
------ -
2 0.0
__ t
•
--rr
T
.3- < .■ ■■ ■
’
;•
.
10.0
-
**
•
■
-
o .0
9 0-91
9 1-9
9 2-93
9 3-94
—•— Education
—— W ater Supply &
9 4-95
9 5-96
9 6-97
9 7-98
H e a 1th & F W
Housing & Urban Development
O ther Social Services
S a n ita tio n
—*<— N u tr it io n
5.3.3. Public Expenditure on Health Related Items
Table 5.3.3.1 presents the trends in Health Related Services. The expenditure on
Health related items grew in real terms at the rate of 7.9 percent per annum. There has
been considerable variation in growth rates between different components. The
expenditure on nutrition declines in real terms at the rate of 4.3 percent per annum.
The expenditure on General Education increased at 6.0 percent per annum while that
on Health & Family Welfare services increased at an annual rate of 7.8 percent. The
expenditure on Water supply and Sanitation as well as that on housing grew at over 23
percent.
The per capita expenditure on health in 1997-78 has been Rs. 712 at current prices and
that on Health & Family Welfare Rs. 154. The Health Related items account for 30
percent of total revenue expenditure of the sate and the Health & Family Welfare
E\KHSDP\Sarma\Health~2.doc
8
Paper III
account for 6.5 percent ot States revenue expenditure.
The Expenditure on Health Related items forms 6.0 percent of State Domestic
Product.
Table 5.3.3.1 Trend in Expenditure on Health Related Items
Item
91-92 | 92-93 | 93-94 94-95 | 95-96 | 96-97 9“-98
Expenditure in 1990-91 prices: Crore Rs.
General Education
827.0 786.7 844.0 911.1 924,7 1034.8 1136.9 1245.7
Health & Family Welfare
270.7 255.9 292.3 294.4 309.2 318.8 374.1 459.2
Water Supply & Sanitation_____________
58.2 70.2 77.7 89.2 121.9 141.9 161.3 249.4
Housing
20.1
79.7 77.7 28.3 48.4 50.9 79.5 117.1
Nutrition___________________________
64.4 67.5 24.7 19.2 25.3
37.1
42.8 47.2
Total Health & Related Services________ 1240.4 1259.9 1316.4 1342.2 1429.5 1583.5 1794.7 2118.6
Per capita Expenditure on Health Related
281.1 323.3 353.8 372.0 444.2 507.9 587.7 712.1
Services at current prices Rs.______
Per capita Expenditure on Health & Family
61.3
87.9 78.6 83.7
96.1 102.2 122.5 154.3
Welfare Services at current prices Rs.
Expenditure on Health Related Items as
31.2 29.4 29.0 28.7 29.1
27.0 30.0
29.1
Percent of State's Revenue Expenditure
Expenditure on Health & FW Services as
6.8
6.0
6.4
5.6
6.5
5.9
6.3
6.3
Percent of State's Revenue Expenditure
Expenditure on Health Related Items as
6.0
5.4
5.6
5.4
5.7
6.1
5.3
Percent of SDP________________
Expenditure on Health &FW as Percent of
1.3
1.1
1.2
1.2
1.2
1.1
1.3
SDP_____________________________ _
Per capita Expenditure on Health Related
281.1 323.3 353.8 372.0 444.2 507.9 587.7 712.1
Services Rs.__________________
Per capita Expenditure on Health & Family
61.3
87.9 78.6 83.7 96.1 102.2 122.5 154.3
| Welfare Services
90-91
During 1986-89, The per capita expenditure on health related items in Karnataka are
marginally less than that for India. A comparison among the.southern states shows
that Karnataka stands third and its expenditure on health related items is about 70
percent of that spent in Kerala and Tamil Nadu.
State
Per Capita Expenditure
at 1988-89 Prices
63.73
67.94
86.74
95.62
68.91
Andhra Pradesh
Karnataka_____
Kerala________
Tamil Nadu
India
E\KHSDP\Sarma\Health~2.doc
9
Paper III
5.4.
Expenditure by Primary, Secondary and Tertiary Sectors
Table # 5.4 Expenditure Primary, Secondary & Tertiary
Crore Rupees (at 1990-91 prices)
Year__________
90- 91
91- 92__________
92- 93_______ __
93=94__________
94-95_______ __
95=96________ _
96-97_______ __
97=98__________
Growth % 1990-97
_________ 1990-98
______ Sector
Primarvl Secondary
147.09
150.73
179.20
177.71
192,03
199,04
227.56
248.94
6.4
7.8
68.31
70.01
74.40
82.41
79,16
83,34
105,11
154.03
6.3
12.3
Tertiary
27,62
33.75
39.14
34.11
37.88
36.35
41.47
56.23
6.0
10.7
243.02
254.49
292,73
294,22
309.07
318.73
374.13
459.19
6.4
9.5
The expenditure on primary sector had the highest annual growth rate 6.4 percent
followed by the Secondary sector with 6.3 percent. The growth of expenditure on the
Tertiary sector was only 6.0 percent.
The expenditure on the Secondary sector in 1996-98 is due the launch of Karnataka
Health Systems Development Project. During 1997-98 the provision for Medical
Education, Research and Training was Rs. 22.0 crores more (or 50 percent more) than
the preceding year resulting in a higher growth of 10.0 percent per annum.
The share of primary sector shows a decline in 1997-98 due to the initiation KHSDP
for strengthening the secondary sector. However, the combined share of the primary
and the secondary sectors remains unchanged at 88 percent.
Share ofDifferentSectors .
70.0
60.0
-w
40.0 -
O
cu
30.0
20.0
■®Bil
E\KHSDP\Sarma\Health~2.doc
10
Paper III
Expenditure by Item
The expenditure by item of expenditure is presented in Table # 5.5.1.
Table # 5.5.1. Revenue Expenditure by Sector and Item for 1997-98
And Share of each item in a sector
Item of Expenditure
Salaries
Travel Expenses
Office Expenses
Drugs & Chemicals
Hospital Necessities
Diet Expenses________
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Others
Grants
Lump Sum
Total 1997-98
_______ Crore Rs.(at 1997-98 prices)
Primary Sector Secondary Sector
Tertiary Sector
All Sectors
Amount % Share Amount % Share Amount % Share Amount % Share
100.91
24.10 104.64
39.25
40.21
43.03 245.76
31.56
1.75
0.42;
0.60
0.22
0.25
0.27
2.59
0.33
3.15
0.75
10.01
3.75
2.12
2.27
15.28
1.96
26.33
6.29
33.37
12,52
1.08
1.16
60.79
7.81
0.00
0.00
5.44
2.04
1.34
1.44
6.79
0.87
0.29
0.07
8.73
3.28
0.24
0.26
9.26
1.19
0.00
0.00
1.27
0.48
0.00
1.27
0.00
0.16
29,02
6.93
6.97
2.62
9.98
10.68
45.98
5.90
1.82
0.43
0.04
0.01
5.28
5.65
7.13
0.92
18,26
4.36
0.00
0.00
0.00
18.26
0.00
2.35
2.66
0.64
0.00
0.00
0.00
2.66
0.00
0.34
11.76
2.81
4,21
1.58
15.96
0.00
0.00
2.05
0.97
0.23
0.19
0.07
1.24
2.41
31.90
0.31
187.96
44.89
10.38
3.89
29.81
2.02 228.15
29.32
33.84
8.08
80.77
30.29
1.89
1.33
115.85
14.89
418.70 100.00 266.61
100.00
93.45
100.00 778.77
100.00
There is no break up by item of expenditure is available for amounts disbursed as
Grants as well as amount budgeted/accounted under Lump Sum. The amount for
which break up is not available by item of expenditure is 53 percent for the Primary
Sector, 34 for the Secondary Sector and 32 percent for the tertiary sector for the
current year (1997-98). The lump sum provision of Rs. 75 crores KHSDP accounts for
bulk of provision under the head "Lump Sum". In case of the Tertiary Sector grants to
autonomous institutions account for major portion of expenditure under this head. The
details of expenditure are available from the financial accounts of individual
institutions and need to be analysed to get a better picture of item wise expenditure in
this sector.
Salaries and allowances form the major component of expenditure (31.5%) followed
by Drugs & Chemicals (7.8 percent) and Equipment and Apparatus (5.9 percent).
Table #5.5.2 presents the breakdown of expenditure for 1990-91 at 1997-98 prices by
item of expenditure and sector as well as the compound annual growth rate between
1990-91 and 1997-98.
E\KHSDP\Sarma\Health~2.doc
11
Paper III
Table # 5.5.2 Expenditure in 1990-91 at 1997-98 Prices and Annual Growth Rate
Between 1990-91 and 1997-98 by Expenditure Item and Sector
Item of Expenditure
Primary Sector
Secondary Sector
Crore Rs. (at 1997-98 prices)
Tertiary Sector
All Sectors
Amount Growth Amount
Salaries
Travel Expenses
Office Expenses
Drugs & Chemicals
Hospital Necessities
Diet Expenses________
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Others
Grants
Lump Sum__________
Total 1990-91
Growth Amount Growth Amount Growth
%
%
%
61.74 ____ 7.8
20.59
10.0
143.19 ____ 8.0
0.80
-4.1
3.19
0.23 ____ L2
-2.9
19.97
-9.4
3.54
-7.1
26.49
-7,6
8.70
21.2
0.14
34.4
22.29
15.4
0.72
33.5
0.11
43.0
4.58 ____ 5.8
4.43
10.2
0.17 ____ 4,7
9.97,
-1.0
0.05
60.9
0.00
-100.0
0.05
60.7
5.39
3.7
11.57
0.53
52.0
21.8
0.20
-21.7
1.65
18.0
3.03
13.0
*
0.11
-100.0
0.00
8.60
11.4
*
*
0.00
0.00
4.03
-5.8
*
*
0.00
0.00
9.06 ____ 8.4
7.8
0.10
10.0
0.50
1.13 ____ 7.9
9.09
1.9
17.62
1.1
127.89 ____ 8.6
4.56
50.8
14.0
37.09
1.75
18.2
412.14
115.85
46.84
10.4
12.6
9.5
%
60.87 ____ 7.5
2.15
-3.0
2.98 ____ 0.8
13.45
10.1
3.74 -100.0
5.36
-34.1
*
0.00
5.64
26.4
1.18
6.4
8.49
11.6
4.03
-5.8
9.06
3.8
0.53
9.0
101.18
9.3
30.78
1.4
249.45
7.7
Note: Growth °o is compound annual growth rate between 1990-91 to 1997-98
Table #5.5.3 presents trend in expenditure by sector and item.
Table # 5.5.3 Expenditure by Sector and Item at 1997-98 prices
Item of Expenditure
Salaries
Travel Expenses
Office Expenses
Drugs & Chemicals
Hospital Necessities
Diet Expenses
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Others
Grants
Lump Sum
Primary Sector Total
Salaries
Travel Expenses
Office Expenses
Drugs & Chemicals
Hospital Necessities
E\KHSDP\Sanna\Health~2.doc
Crore Rupees at 1997-98 prices
1990-91 1991-92 1992-93 1.993-94 1994-95 1995-96 1996-97 1997-98
60.87
51.79
63.78
55.50
58.41
61.59
90.66 100.91
2.15
1.96
1.82
1.41
1.51
0.84
0.99
1.75
2.98
3.79
2.97
2.71
1.96
1.82
1.26
3.15
13.45
7.48
13.71
20.27
16.69 ' 18.73
20.65
26.33
3.74
0.00
0.08
0.03
0.00
0.00
0.00
0.00
0.18
5.36
0.07
0.08
0.04
0.12
0.24
0.29
0.00
0.00
0.00
0.00
1.26
0.00
0.00
0.00
5.64
8.33
9.27
16.33
19.92
18.31
26.08
29.02
1.18
2.67
4.65
1.30
1.91
1.18
1.56
1.82
8.49
9.35
11.39
10.94
13.29
17.39
18.26
11.16
4.03
3.64
2.49
4.61
1.46
2.66
2.66
1.98
9.06
8.22
12.89
12.42
11.11
9.19
11.76
11.01
0.53
4.74
0.73
0.97
0.58
0.99
0.66
0.65
101.18
114.15
138.92 134.61
172.56 187.96
144.31
156.99
30.78
35.31
38.93
40.80
45.64
33.84
50.97
35.98
249.45 251.61 301.69 298.01 323.12 333.80 380.41 418.70
61.74
59.25
67.32
104.64
71.52
91.39
69.69
61.61
0.80
0.57
0.41
0.36
0.65
0.49
1.00
0.60
19.97
22.89
22.43
21.47
11.12
11.23
10.01
20.33
8.70
8.06
16.87
12.09
28.47
19.26
JJ.J /
17.37
0.72
0.78
0.61
0.74
0.49
0.50
5.44
1.04
12
Paper III
Diet Expenses
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Others
Grants
Lump Sum
Secondary Total
Salaries
Travel Expenses
Office Expenses
Item of Expenditure
Drugs & Chemicals
Hospital Necessities
Diet Expenses
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Grants
Lump Sum
Others
Tertiary Total
Salaries
Travel Expenses
Office Expenses
Drugs & Chemicals
Hospital Necessities
Diet Expenses
Linen
Equipment & Apparatus
Training
Schemes
Compensations
Buildings
Others
Grants
Lump Sum
Grand Total
4.43
4.74
6.06
7.30
4.67
5.95
4.99
8.73
0.’9
0.05
0.45
0.14
0.77
0.78
0.16
1.27
5.39
2.72
5.47
3.34
2.73
13.32
5.46
6.97
0.20
0.29
0.12
0.04
0.10
0.25
0.36
0.04
0.11
0.37
0.00
0.00
0.00
0.08
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
3.14
2.79
0.74
2.54
2.48
2.13
4.21
0.10
1.37
0.00
0.10
0.33
0.13
0.13
0.19
9.09
8.86
11.65
10.20
9.07
9.56
9.91
10.38
4.56
5.84
3.04
6.71
28.29
2.46
29.69
80.77
115.85 119.26 128.71
144.64 138.34 146.42 185.26 266.61
20.59
20.03
22.04
21.69
21.05
16.31
29.60
40.21
0.23
0.38
0.13
0.22
0.26
0.10
0.21
0.25
3.54
2.84
3.52
3.41
2.91
2.93
1.32
2.12
1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98
0.14
0.14
0.38
0.57
0.58
0.80
0.95
1.08
0.11
0.15
0.21
0.19
0.21
0.16
0.17
1.34
0.17
0.17
0.16
0.22
0.22
0.23
0.21
0.24
0.00
0.00
0.04
0.00
0.00
0.00
0.00
0.00
0.53
0.20
0.32
0.48
0.27
0.47
0.35
9.98
1.65
2.96
2.19
2.74
3.28
4.17
2.69
5.28
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.50
5.72
0.45
0.88
1.18
0.88
0.66
1.24
17.62
24.99
32.94
25.17
25.07
26.93
26.38
29.81
1.75
3.12
2.92
1.54
5.88
10.20
4.69
1.89
46.84
60.71
65.31
56.61
60.32
68.82
62.69
93.45
143.19 131.08
153.14 148.70 149.15
139.52 211.65 245.76
3.19
2.91
2.37
2.28
1.94
2.26
1.56
2.59
26.49
29.52
28.92
27.09
25.00
16.01
14.37
15.28
22.29
15.68
26.18
34.13
36.68
40.71
49.69
60.79
4.58
0.93
0.90
0.96
0.65
0.67
1.25
6.79
9.97
5.02
6.18
5.04
5.24
6.41
7.75
9.26
0.05
0.45
0.18
0.77
1.42
0.78
0.79
1.27
11.57
11.25
12.32
30.13
25.65
24.13
29.90
45.98
3.03
5.92
6.94
4.29
4.96
4.59
5.77
7.13
8.60
9.72
11.40
10.95
13.37
11.16
17.39
18.26
4.03
3.64
2.49
4.61
1.98
1.46
2.66
2.66
9.06
11.36
15.68
13.16
13.59
13.55
11.32
15.96
1.13
11.83
1.17
1.79
1.97
1.63
1.78
2.41
127.89 148.00
183.52 169.98
180.32
191.63 208.85 228.15
37.09
44.27
44.32
45.38
63.56
84.13
70.36 116.49
412.14 431.59 495.71 499.26 524.16 540.54 634.49 778.77
The Salary revision was implemented in 1996-97. Consequently the expenditure by
way of salaries showed a sudden spurt. Earlier there was a ban on recruitment, which
resulted in a marginal decline in salaries during 1994-95.
5.6.
Conclusion
As mentioned earlier the grants and lump sum account for over a third of the
expenditure. The breakdown of this by item of is available with the concerned
E\KHSDP\Sarma\Health-2.doc
13
Paper III
department or the Zilla Parishad but are not captured by individual item in the
accounts. It is recommended that the data be from different departments should be
collected and reflected in the books of account.
The transfer of drugs, supplies and equipment is effected without raising a transfer
invoice. Due to this, expenditure on these items had to be allocated on the basis of
total expenditure on remaining items. It is recommended that transfers should be
effected only after raising a transfer invoice and reflect such transfers in the books of
account.
J
j 1. State Finances, Health Finances and Efficiency : Three key issues with regard to
public sector finances at the state level need to be addressed. First, the overall
fiscal situation in many states has deteriorated sharply since the early 1990s. with
a rise in the fiscal deficit, an increase in interest payments as a share of total
revenues, and an increase in debt outstanding as a share of state domestic product.
The deterioration in the overall financial situation faced by the states has had a
deleterious effect on the health sector. The share of health and family welfare in
the total state revenue budgets has declined since the early 1990s, suggesting that
past declining trends of health sector’s share in the budget has been exacerbated,
rather than reversed. The decline in the health sector’s share occurred despite a
rise in real per capita expenditures in all states up to 1991, indicating that total
government expenditures rose faster than health expenditures. Total government
spending is about USS 2-3 per capita for health services and is inadequate to meet
the government’s stated objectives. To achieve the government’s objective of
funding a basic package of health services, substantially more resources for health
care are required, but the overall state finances noted above pose a serious
problem. Second, within the health sector in most states, resource allocation in
the public sector is skewed in favour of tertiary care services relative to needs at
the primary and secondary levels, particularly rural and community hospitals.
Third, much of the resources are absorbed by salary costs. The recurrent budget
for operations and maintenance is chronically under-funded and the programs are
not fully effective?^
2: Alternative Methods of Health Care Financing : The resource constraints faced in
the health sector will required alternative methods of health care financing to
supplement budgetary allocations. Alternative methods of financing health care,
such as cost recovery, social and private insurance, and participatory schemes, are
limited. Reported revenue data indicate that cost recovery in the health sector is
about 3% on average in India, although there are problems in estimating the level.
(Some of the problems faced with cost recovery include : (a) lack of an appropriate
mechanism within the government to review user charges; (b) weak administrative
mechanism for collecting user fees; (c) difficulty in targeting the poor for
exemption from user fees; and (d) constraints to greater retention of funds
generated through user charges at the point of collection?^ Based on international
experience it should be noted, however, that a cost recovery rate of 15-20% in the
health sector is about the most that can be expected in the public sector. In the
long run, issues such as private insurance and managed health care will need to be
addressed, as the industrial and urban sectors in India expand, and cost
containment becomes increasingly important?^
E\KHSDP\Sarma\Health~2.doc
14
Paper III
3. Implement Cost-Recovery Mechanisms
Develop an Institutional Framework for Periodic Review of User Charges. The
states should set up an institutional framework to review the structure of user fees and
pricing policy periodically, and recommend revisions as necessary. The Strategic
Planning Cells established in the health departments in the four states studied provide
a viable institutional arrangement for this purpose.
Strengthen Collection Mechanisms and Target Vulnerable Groups for Exemptions
: Analysis shows that substantial increases in revenue can be gained by concurrently
strengthening the mechanism for collecting user charges and periodically revising
them. State governments should increase cost recovery in the health sector from an
average of about 3% to about 15-20% in the next 3-5 years. In addition, adequate
targeting mechanisms to identify the poor should be implemented both in rural and
urban areas. Due to the administrative costs involved, it is preferable to strengthen the
existing system for targeting the poor rather than create a new mechanism.
Retain Revenues at the Point of Collection. Hospitals and health facilities should be
allowed to retain all of the revenues collected. Alternatively, district health
committees or health systems corporations (e.g., as in Andhra Pradesh and Punjab)
could be empowered on their behalf to retain such revenues and redistribute them
among hospitals within the district according to both need and level of collection.
Utilize Revenue for Non-Salary Recurrent Expenses : Revenue collected should be
used for non-salary recurrent expenditure items such as drugs, essential supplies and
record keeping. A modest fee could be charged for out-patients, as is currently being
done in West Bengal and charges concentrated on diagnostic and other services, as
well as on voluntary services such as private rooms or wards and on medical services
with a relatively low cost-effectiveness. Increased charges should be introduced in a
phased manner and matched with higher quality of service.
E\KHSDP\Sarma\Health~2.doc
15
Paper III
Bhaskara Rao, N., M.E. Chan, And C.V.S. Prasad. 1993. "The Planning Process and
Government Health Expenditure Patterns in India in the Early 1980s." In P.
Berman and M.E. Chan, eds., Paying for India's Health Care, pp. 91-120. New
Delhi, India: Sage.
• 1995. "Resource Allocation for Public Hospital in Andhra Pradesh. India."
Health Policy and Planning 10(1) : 29-39.
Narayana, K.V., and Nagi Reddy. 1993. Public Expenditure on Health in Andhra
Pradesh. Hyderabad, India : Center for Economic and Social Studies.
Panchamukhi, P.R. 1993. "Public Financing of Family welfare Program in India : An
Appraisal." In P.Berman and M.E. Chan, eds., Paying for India's Health Care,
pp. 121-40. New Delhi, India : Sage.
Reddy, K.N. 1992. Health Expenditure in India. Working Paper no. 14. New Delhi,
India : National Institute of Public Finance and Policy.
Tulasidhar, V.B. 1993. "Expenditure Compression and Health Sector Outlays."
Economic and Political Weekly (November 6):2473-78
E\KHSDP\Sarma\Health~2.doc
16
Improving Access to SC / ST Population
Yellow Card Scheme
Status Report: November, 1999
State Profile:
The southern Indian State of Karnataka incorporates the erstwhile state of Mysore and
the adjacent Kannada speaking regions. It is the eight largest state in India in terms of area and
population. It has a population of 45 millions (1991 Census) and a sex ratio of 960. The SC /
ST population of 9.0 millions makes up 20% of the total population. The literacy rate in the
general population is 56%, where as the SC / ST population has a comparatively low literacy
rate. The Infant Mortality Rate in the state is 81.
Administratively, the state is divided into four divisions - Bangalore, Mysore, Gulbarga
and Belgaum. There are T1 districts with 175 talukas. Bangalore is the state capital.
Background of Scheme:
The SC / ST population in rural Karnataka, especially the women and children suffer a
higher morbidity and mortality compared to the general population as revealed by the survey
done in 1995. Factors such as illiteracy, poverty and continuing trends of social discrimination
in the community have attributed to this status. Improving access of available health facilities
to these under privileged communities will help change the trend. The Government of
Karnataka decided in 1995 to introduce a scheme in which health facilities in rural areas are
extended to the door-steps of the SC / ST populations and issued G.O. No. HFW 16 CGM 95
on the subject.
One of the broad objectives of KHSDP is to improve healthy facility access to these
disadvantaged section of the rural community. This objective is being met through a special
target intervention called ‘Yellow Card Scheme’. In this scheme*, disadvantaged Schedule
Caste (SC) and Schedule Tribe (ST) population in rural areas-are being medically screened
through bi-annual health check-up camps being held in all the subcentres of the state. A team
of doctors, nurses, laboratory technicians, dispenser and health educators, senior and junior
health assistants, examine the beneficiaries, detect ailments that may be present and treat them.
Special feature of the out-reach health camps is that a Lady Medical Officer of the team
examines the women in the age group 35-60 and screens them for cervical and breast cancer.
These camps are being held as per a calendar drawn by the district health authorities for the
year.
The Pilot Scheme:
Karnataka Health Systems Development Project began implementation of Yellow Card
Scheme as a pilot scheme in Nov 1996. Two PHCs each in two talukas of the five districts of
Mysore, Hassan, Raichur, Bijapur and Kolar were chosen for this purpose. Health check-up
camps were held at subcentre level in all these PHCs.
lmprv-acess-2
The health check-up team consisted of Medical Officer of the PHC, LMO, LHV, ANM,
a lab technician and a dispenser. The table below provides data on beneficiaries examined in
two districts.
District
Taluka
Mysore
T. Narsipura
Nanjangud
Hassan
Holenarsipura
Arsikere
SC/ST
Population
SC/ST
Screened at
Camp
SC/ST
Treated
at Camp
Mogaru
9,676
655
~ 655
Talkadu
4,722
950
915
Hosakote
7,436
4,879
2.591
Tagaduru
3,994
1,621
1,458
Padavalhippe
6,757
3,861
Bakenahally
3,817
2,170
Dodda Metta
5,353
4,039
Javagal
10,217
1,313
PHC
A rapid evaluation was conducted in Dec ’96 by a team from the Central Planning Cell
using the facilities at the population centre with an aim to evaluate the process and to decide if
scheme needs modifications. The District Health and Family Welfare Officer, a sample of
Medical Officers of PHCs, ANMs of subcentre where camps were held and beneficiaries were
interviewed on 23-12-96.
The results of this survey are summarised as follows :
1. The scheme is welcome by the community and will positively benefit the SC/ST
population.
2. The health check-up team should be more broad-based and include health educators.
3. Drugs, laboratory chemicals, stationary, referral cards and yellow cards should be
available in adequate quantities in the camps. Vehicles should be provided at taluka
and PHC levels.
4. District Health and Family Welfare Officer should be released funds to meet expenses
for fuel, hiring of transport and other incidental expenses.
5. Local village Panchayat leaders should be involved in the scheme.
6. In order to derive maximum benefit, the Medical Officer of PHC should be entrusted
with the responsibility of planning and implementing these camps with the support of
the Taluka Administrative Medical Officer who will be the nodal officer at taluka level.
7. Organisation should be set up at district, taluka, PHC and subcentre level to steer and
implement the programme.
First Phase of Implementation :
Having seen the need for the scheme and successful implementation of the pilot
scheme, the KHSD Project extended the Yellow Card Scheme to all the PHCs of the five
districts in March ’97. Baseline beneficiary data was collected from these five districts. More
health check-up camps were held in all subcentres of the district and beneficiaries examined,
investigated and treated. Patients who needed treatment at a higher facility were referred using
a reterral card for the purpose. By May 1997, the coverage in these five districts was as
follows:
District
Beneficiary
population
Examined /
Screened
Beneficiaries
Treated
Mysore
6,13,225
7,105
5.519
Referred to
Hospital
105
Hassan
2,83,881
12,258
6,735
35
Kolar
6,37,971
4,898
3,152
12
Raichur
5,78,000
9,656
6,545
12
Bijapur
5,35,416
18,158
7,356
68
26,48,493
52,075
29.307
232
Total
All the five districts of first phase were allocated funds as follows :
1. POL Expenses
: Rs. 1,00,000 per district
2. Vehicle hire cheques
: Rs. 1,50,000 per district
3. Honorarium for LMOs
: Rs. 2,00,000 per district
An amount of Rs. 37.8 lakhs was allotted for purchase of drugs for yellow card scheme
for these districts.
Operationalisation and Progress in Financial Year 1997 - 98 :
The Steering Committee approved an operationalisation plan to extend the Yellow Card
Scheme to all the districts of the State in its meeting held on 16-06-97 at an estimated cost of
Rs. 54.1 million which was sanctioned in G O No. HFW (PR) 429 WBA 97 dated 25-07-97.
Accordingly, the scheme was launched in all the remaining 15 districts in Aug - Sept ’97 after
district level workshops were held to train the Medical Officers of district and taluka levels.
The programme was put into operation for only 3-4 months as it was suspended at the end of
January 98 on account of ensuing parliamentary elections. Drugs, laboratory chemicals and
Yellow Cards were procured and distributed to the districts. Districts were also given funds to
meet operational expenses such as POL, honorarium for LMOs, camp arrangements, stationary
and training. A total amount of Rs. 9.0 million, was spent for drugs, while the expenditure on
laboratory chemicals was about Rs. 1.0 million. Sixteen lakhs Yellow Cards were distributed
at a cost of Rs. 1.6 million. As the scheme worked for only 4 months and because of other
constraints only Rs. 11.3 million could be utilised during the year.
Progress in Financial Year 1998 - 1999 :
Implementation of annual health check-up camp at subcentre levels continued in this
year also. The Project Management Unit (PMU) has continued district support to the scheme
by distributing more Yellow Cards and referral cards, new implementation manual with new
camp dates for each subcentre, more drugs, chemicals for laboratory testing and IEC materials
like brochures, pamphlets and posters. The PMU conducted a review of the scheme in January
’99 to assess the performance of the districts. Details of the outcome of review are given
separately. Out of a total, budget of Rs. 61.7 million for the Financial Year 1998-99, the
scheme utilised approximately Rs. 17.8 million towards purchase of drugs, Yellow Cards, POL
for hired vehicles, honorarium for LMOs and incidental expenditures in camps.
Table 3 : Expenditure on Yellow Card Scheme : FY 1997-98 and FY 1998-99
Item of Expenditure
SI. No.
Expenditure (Rs. million)
18-90
L
Drugs
7
Laboratory chemicals
3.29
2
Hiring of vehicles and POL
0.72
4.
Honorarium for Lady Medical Officers
0.22
5.
Training
1.10
6.
Information, Education, Communication (IEC)
0.56
7.
Printing Cards
a) Yellow Cards
3.60
b) Referral Cards
0.05
8.
0.64
Contingency
Total
29.10
Progress in Financial Year 1999 - 2000 :
. There has been a fairly good progress in Yellow Card. Scheme this year also. All
districts in the state have continued to conduct health check-up camps at subcentres as per an
action plan which the districts themselves have prepared. The Project Management Unit
(PMU) continued support to the districts by distributing drugs worth Rs. 75 lakhs and money
for camp expenses. About 7.5 lakh yellow cards are being printed and distributed before the
end of November 1999. Each district has been given Rs. 2 lakhs for camp related expenses
such as hiring vehicles, services of Lady Medical Officers and so on.
Coverage of Target - Present Status :
The health check-up camps have been held for about 2 years since inception. Reports
from districts received upto September 1999, show a coverage of 20,63,285 SC/ST population
(23.3%) out of the total target population of 88,62,958. In the present financial year (April 499
- Sept ’99), the coverage has been 4.8%. The northern Karnataka division of Belgaum and
Gulbarga have shown a good performance with a coverage of 6% and 9.7% respectively, while
the division of Bangalore and Mysore have achieved only 2.9% and 1.3% respectively. In the
overall target coverage, Belgaum division has recorded the highest (33.9%) while Bangalore
division has recorded the lowest (18.2%). In all, 1810 camps have been held in this year with
Gulbarga division holding the highest number of camps. So far, 12,153 camps have been held
in the state with an average attendance of 170 beneficiaries per camp. Gulbarga division has
attracted highest number of beneficiaries (231). Table 4 gives division-wise coverage.
Table 4 : Division-wise Coverage in Health check-up camps upto Sept. 1999
Beneficiary
No.
Division
(No. of
districts)
Population
1997-98
Coverage No. (%)
19991998-99
2000
Total
1997
-98
No. of camps held
1998
1999Total
2000
-99
1
Bangalore (7)
32,19,971
1,14,804
(3.6)
3,77,436
(11-7)
94,655
(2.9)
5,86,895
(18.2)
1163
2489
539
4191
2
Mysore (8)
19,41,358
2,00,194
(10.3)
2,43,508
(12.5)
25,898
(1.3)
4,69,600
(24.2)
715
2716
63
3494
3
Belgaum (7)
15,26,721
1,75,898
(H-5)
2,49,765
(16.3)
91,543
(6.0)
5,17,206
(33.9)
506
1493
355
2354
4
Gulbarga (5)
21,74,908
18,662
(0.8)
2,600,79
(H.9)
2,10,843
(9.7)
4,89,584
(22.5)
113
1148
853
2114
State (27)
88,62,958
10,22,913
(69%)
11,30,788
(12.7)
4,22,939
(4.8)
20,63,285
(23.3)
2497
7846
1810
12,153
si.
About 70% of the SC/ST people who visited the health check-up camps had health
problems which needed treatment. About 3% of the sick needed referral to a higher health
facility. A total of 12,153 health check-up camps have been held so far.
Table 5 : Health Status of Beneficiary
No. Examined
No. Treated
(% of no. Examined)
No. Referred
(% of no. Treated)
5,86,895
4,00,910 (68)
16,314(4)
2 . Mysore (8)
4,69,600
2,78,885 (59).
6,830 (2.5)
3
Belgaum (7)
5,17,206
4,27,870 (83)
8,056 (2)
4
Gulbarga (5)
4,89,584
3,18,079 (65)
6,311 (2)
State
20,63,285
14,25,744 (69)
2.6% of those treated
SI.
No.
Division
(No. of districts)
1
Bangalore (7)
Districts have been sending reports of camp activities and yellow card scheme every
month. In the first year of the scheme, the reporting was irregular, but now, most of the
districts send the reports regularly. Age and sex based beneficiary data on treated and referred
cases, laboratory tests carried out and important diseases identified are being collected.
An analysis of eleven important diseases/symptoms shows that fever from any cause
(11%), upper respiratory infections (URI) (10%), worm infestations (8%) and anaemia are
common health problems among the SC/ST population. Scabies (2.3%) appears to be a
prevalent skin disease. In spite of preventive interventions. Vitamin A deficiency has been
*
observed in 0.8% of the beneficiaries. Diabetes mellitus and hypertension have been detected
in 0.6% and 0.5% respectively, of the treated beneficiaries. The analysis also refiects that
diarrhoea is not any more the highest reported disease/symptom. A district-wise analysis
shows that some districts show much higher percentage of patients than the state average, eg.,
Fever cases - Tumkur (46%), Bagalkote (17%) and Hassan (16%), Diabetes in Kolar (1.2%\
Tumkur (2.9%), Bidar (3.5%). These data help interventions in terms
t---- of early treatment of
patients and long term strategies for preventive and promotive care.
Data pertaining to drug utilisation is also being captured. Analgesics like aspirin,
paracetamol, diclofenac, anti-infectives like furadantin, ampicillin, tetracyclin, de-worming
medicine and Vitamin A capsule are being utilised.
Programme Review :
The Project Management Unit (PMU) reviewed the performance of the districts in
January 1999 in terms of coverage, training, expenditure of funds, organisation and
sensitization. The performance of six districts viz., Bidar, Bellary, Dharwad, Raichur,
Bangalore (Rural) and Bangalore (Urban) were found to be less satisfactory. A group of
officers from the PMU evaluated the performance of these districts through interaction with
district, taluk and PHC medical officers, beneficiaries and through field visits. Based on the
feedback from these districts and shortfalls noticed in other districts the following activities
have been incorporated into the new action plan for the FY 1999-2000.
1. The District Health & Family Welfare Officer and the District Surgeon, although
well sensitized to the programme, should work unison.
2. The District Health & Family Welfare Officer ensures completion of organisation at
all levels and monitors their functions.
3. The district health systems committees meet atleast once a month and discuss issues
related to yellow card scheme.
4. Action plan for re-training and health check-up camps will be prepared and
submitted atleast two months in advance.
5. The District Health & Family Welfare Officer submits the district reports on yellow
card scheme regularly.
6. Districts intensify IEC activities to increase awareness among staff as well as
beneficiary population.
7. The PMU will augment support to the districts through more frequent supplies of
yellow card, drugs and laboratory chemicals. A manual on syndromic approach to
identify common diseases will be distributed to all junior health workers to enhance
their skills in screening the beneficiaries.
Some of the activities incorporated into the action plan for the year 1999-2000 have
been implemented :
1. There is better coordination between District Health & F W Officers and the
District Surgeons.
2. The District Health System Committees are meeting regularly to allot funds for
yellow card activities.
3. The districts have been regularly sending reports on yellow card scheme
4. A community need based IEC strategy is being developed and districts have been
provided with guidelines to develop locally, IEC materials and distribute suitably.
5. A syndrome approach to disease identification by junior health workers at subcentre
level has been developed in vernacular and is being distributed. This will help the
workers in early identification of diseases and prompt referral.
The developmental objective of improving health facility access to the disadvantaged
rural sections in Karnataka is being met. In the ensuing years the project will concentrate more
on better monitoring inputs, IEC activities and follow up services to those diagnosed sick in
these camps through better linkages of PHcs with higher health facilities. More involvement of
NGOs and other non-health government functionaries in training and IEC activities is
envisaged.
•k
If • - '
■ 1 I
Hti*
-1 L I
Project Agreement
hl'
dated
• 0 i .^7
r- :t £ • <!
between
KREDITANSTALT FUR WIEDERAUFBAU
t?t
1
and the
GOVERNMENT OF KARNATAKA
<■
s
'
for
-
DM 23.000,000.00
- Upgrading Secondary Level Health Care Facilities in Karnataka, Phase I -
if
J:'L3A1UUEN\9566944V2VERTRAG\STIL0612.DOC
-2^
Project Agreement
f
between
KREDITANSTALT FUR WIEDERAUFBAU, Frankfurt am Main
C’KfW")
r
and the
GOVERNMENT OF KARNATAKA
acting by its Governor,
represented by the
Health and Family Welfare Department
(’’Project-Executing Agency")
By the agreement dated
......................
("Financing Agreement") KfW has
extended to India ("Recipient") a Financial Contribution not exceeding
DM 23,000,000.00.
On the basis of this Financing Agreement the Project-Executing Agency and KfW conclude the
following Project Agreement:
!
7
1
■
-3-
Article 1
purpose of the Financial Contribution
I
' 1.1
The financial contribution channelled in full as grant to the Project-Executing Agency
shall be used exclusively for the financing of the costs, primarily the foreign exchange
costs, for the rehabilitation, extension and modernization of secondary level hospitals
in the Gulbarga Division as well as for drugs, consumables and vehicles; construction
of and equipment for four maintenance workshops; construction of staff housing units
and waste disposal facilities as well as consulting services ("Project"). Retroactive
Financing would be effected from December 1995.
The Project-Executing Agency and KfW shall determine the details of the Project and
the goods and services to be financed from the financial contribution by a separate
agreement.
1.2
Taxes and other public charges to be bome by the Project-Executing Agency and
import duties shall not be financed from the financial contribution.
-4-
Article 2
r-
t
! Disbursement
I
2.1
KfW shall disburse the financial contribution through Government of India to the
Project-Executing Agency in accordance with the progress of the Project and upon
request of the Project-Executing Agency. By a separate agreement, the Project-
Executing Agency and KfW shall detenmine the disbursement procedure, in particular
the evidence proving that the withdrawn funds are used for the stipulated purpose.
2.2
I
I
I
■
KfW shall have the right to refuse to make disbursements after December 30, 2002.
-5Article 3
J. Contractual Statements and Power of representation
" 3.1
The Secretary of the Health and Family Welfare Department of the Project-Executing
Agency and such persons as designated by him or her to KfW and authorised by
specimen signatures authenticated by him or her shall represent the Project-Executing
Agency in the execution of this Agreement. The powers of representation shall not
expire until their express revocation by the representative authorised at the time has
been received by KfW.
*
3.2
Amendments of, or addenda to, this Agreement and any notices and statements
delivered by the contracting parties under this Agreement shall be in writing. Any such
notice
or statement shall have been received once it has arrived at the following
address of the corresponding contracting party or at such other address of the
corresponding contracting party as notified to the other contracting party:
For KfW:
For the ProjectExecuting Agency:
Kreditanstalt fur Wiederaufbau
Postfach 11 11 41
60046 Frankfurt am Main
Federal Republic of Germany
Telefax: (069) 74 31-29 44
Telex: 4 15 2560 kwd
Government of Karnataka
Health and Family Welfare Department
III Stage (First Floor) Multistoreyed Buildings
Dr. B.R. Ambedkar Road
Bangalore - 560 001
India
Telefax: 0091-80-2252499
-6-
Article 4
tThe Project
4.1
The Project-Executing Agency
a)
shall prepare, implement, operate and maintain the Project in conformity with
sound financial and engineering practices and substantially in accordance
with the Project concept agreed upon between the Project-Executing Agency
and KfW;
b)
shall engage independent, qualified European consulting engineers working
in cooperation with local consultants to assist in the preparation and
supervision of the Project and shall assign the implementation of the project
to qualified local firms;
c)
shall award the contracts for the consulting services to be financed from the
financial contnbution direct and the contracts for the goods and all other
services to be financed from the financial contnbution upon pnor competitive
bidding which may be limited to firms domiciled in India, or upon prior
international competitive bidding, as the case may be;
d)
shall maintain, or cause to be maintained, books and records unequivocally
showing all costs of goods and services required for the Project and clearly
identifying the goods and services financed from this financial contribution;
e)
shall enable the representatives of KfW at any time to inspect said books and
records and any and all other documentation relevant to the implementation
I
of the Project, and to visit the Project and all installations related thereto and
f)
shall furnish to KfW any and all such information and records on the Project
and its further progress as KfW may request.
4.2
I
The Project-Executing Agency and KfW shall determine the details pertinent to
Article 4.1 by a separate agreement
-7-
Article 5
Miscellaneous Provisions
5.1
If any of the provisions of this Agreement is invalid, all other provisions shall remain
unaffected thereby. Any gap resulting therefrom shall be filled by a provision
consistent with the purpose of this Agreement.
5.2
The Recipient and the Project-Executing Agency may not assign or transfer, pledge or
mortgage any claims from this Agreement.
5
?
5.3
This Agreement shall be governed by the law of the Federal Republic of Germany.
The place of performance shall be Frankfurt am Main. In case of doubt as to the
interpretation of this Agreement, the German text shall prevail.
5.4
The legal relations established by this Agreement between KfW and the Project-
Executing Agency shall terminate with the end of the useful life of the Project but not
later than fifteen years after the signing of this Agreement.
5.5
For the amount of DM 3.0 million this Project Agreement shall not enter into force until
the Government Agreement on which this amount is based has entered into force.
I
I
■■
■
■■
Ur
-8-
Done in four originals, two in German and two in English.
1 Frankfurt am Main,
Bangalore,
/G
or- W
this
this
kreditanstalt fur wiederaufbau
GOVERNMENT OF KARNATAKA
i<
■0
i
i
i
I
t
J
-
t --
1/
Projektvertraq
f
vom
- 01■ ?r
i
i
zwischen der
t
r
kreditanstalt fur wiederaufbau
i
und der
5
REGIERUNG VON KARNATAKA
i
|
j
I
I
uber
DM 23.000.000,-
tt-
- Gesundheit (Sekundarkrankenhauser) Karnataka, Phase I -
r
'A1UUEN'9500944\2VERTRAg\ST1LO61O.DOC
//
-2Projektvertraq
L
i ■
zwischen der
■J
KREDITANSTALT FUR WIEDERAUFBAU, Frankfurt am Main,
("KfW")
und der
REGIERUNG VON KARNATAKA
vertreten durch ihren Gouvemeur
sowie durch das
Health and Family Welfare Department
("Projekitrager”)
■
P
J &
r
|Die
sich
hat
KfW
durch
Vertrag
vom
•CFinanzierungsvertrag”) verpflichtet, Indien ("EmpfSnger") einen Finanzierungsbeitrag bis zur
|Hbhe von
1
DM 23.000.000,—
fell- -■
Ju gewcihren.
T'Uf der Grundlage dieses Finanzierungsvertrages schlieBen der Projekttrager und die KfW
f en nachstehenden Projektvertrag:
.
'
--
s
-
&
- ............
:--------- ---
-
------
-------- - ~ ------
■
-3-
Artikel 1
!g!
,pndunqszweck
I
Die vom Empfanger in voller Hbhe als ZuschuB an den ProjekttrSger weitergeleiteten
Finanzierungsmittel werden ausschlieBlich fur die Finanzierung der Kosten fur
1.1
Rehabilitierung, Erweiterung und Ausbau von Sekundarkrankenhausem in der
Gulbarga Division sowie deren Erstausstattung mit Medikamenten, Ge- und
Verbrauchsgutem und Fahrzeugen; Bau und Einrichtung von 4Werkstatten fur
Wartungszwecke; Bau von Personaiwohnungen und Abfallentsorgungsanlagen sowie
Consultantleistungen
("Projekt"),
und
zwar
vorrangig
zur
Bezahlung
der
Devisenkosten, gewahrt. Retroaktive Finanzierung wird ab Dezember 1995 wirksam
i
sein.
I
I
Der Projekttrager und die KfW bestimmen durch besondere Vereinbarung die
Einzelheiten des Projekts sowie die Lieferungen und Leistungen, die aus dem
i
Finanzierungsbeitrag finanziert werden sollen.
I
Steuem und sonstige bffentliche Abgaben, die der Projekttrager zu tragen hat, sowie
i
2
Einfuhrzdlle werden aus dem Finanzierungsbeitrag nicht finanziert.
r
i
Vi
J ■
ri •
11
5^
-4-
/
Artikel 2
jjszahlunq
Die KfW zahlt den Finanzierungsbeitrag uber die indische Regierung entsprechend
!.1
dem Projektfortschntt auf Abruf des Projekttragers arr den Projekttrager aus. Der
Projekttrager
die
KfW
regeln
durch
besondere
Vereinbarvng
das
Auszahlungsverfahren, insbesondere den Nachweis fur die vereinbarungsgemSBe
Verwendung der abgerufenen Betrage.
i
Die KfW kann Auszahlungen nach dem 30. Dezember2002 ablehnen.
12
1
♦
' S1
und
-
gr >.' ■ ■
fe-•
A‘i'
J .' < •
■
■
I'-' ':" ■ '
I
■' '
-5-
Artikel 3
•
Vertraqliche ErklSrunqen und Vertretunq
3.1
Der Secretary Health and Family Welfare Department des ProjekttrSgers und die von
diesem
I
gegenuber
der
KfW
benannten
und
durch
von
ihm
beglaubigte
Unterschnftsproben legitimierten Personen vertreten den Projekttrager bei der
Durchfuhrung dieses Vertrages. Die Vertretungsbefugnisse erlbschen erst, wenn ihr
f
ausdruckhcher Widerruf durch den jeweils zustandigen Vertreter der KfW zugegangen
ist.
i
3.2
I
Anderungen Oder Erganzungen dieses Vertrages sowie andere Erklarungen und
Mitteilungen,
die
aufgrund
dieses
Vertrages
zwischen
den
Vertragspartnem
abgegeben werden, bedurfen der Schnftform. Erklarungen und Mitteilungen sind
zugegangen,
sobaid
sie
bei
der nachstehenden
Oder einer anderen
dem
Vertragspartner mitgeteilten Anschrift des betreffenden Vertragspartners eingegangen
sind:
i
Fur die KfW:
Fur den Projekttrager:
O’
r.- ■ "■
Kreditanstalt fur Wiederaufbau
Postfach 11 11 41
60046 Frankfurt am Main
Bundesrepublik Deutschland
Telefax: (069) 74 31-29 44
Telex: 4 15 25 60 kwd
Government of Karnataka
Health and Family Welfare Department
III Stage (First Floor) Multlstoreyed Buildings
Dr. B.R. Ambedkar Road
Bangalore 560 001
India
Telefax: 0091-80-2252499
-6-
Artikel 4
,as Projekt
I'1
Der Projekttrager
f !a)
wird
das
Projekt unter Beachtung ordnungsgemaEer finanzieller und
technischer Grundsatze sowie in wesentlicher Ubereinstimmung mit der
zwischen ihm und der KfW abgestimmten Projektkonzeption vorbereiten,
durchfuhren, betreiben und unterhalten;
i
b)
beauftragt unabhangige, qualifizierte europaische beratende Ingenieure, die
mit lokalen Consultants zusammenarbeiten, ihn bei der Vorbereitung und
Bauuberwachung
des
Projekts
zu
unterstutzen,
und
ubertragt
die
Durchfuhrung des Projekts qualifizierten lokalen Bauuntemehmen;
I
c)
vergibt die Auftrdge fur die aus dem Finanzierungsbeitrag zu finanzierenden
Consultingleistungen
unmittelbar und
die
Finanzierungsbeitrag zu finanzierenden
Auftrdge fur die
aus dem
Lieferungen und alle anderen
Leistungen teils nach vorangegangener dffentlicher Ausschreibung, die auf
Untemehmen mit Sitz in Indien begrenzt werden kann, Oder teils nach
vorangegangener intemationaler dffentlicher Ausschreibung;
d)
t
wird Bucher und Unterlagen fuhren Oder fuhren lassen, aus denen alle
Kosten fur Lieferungen und Leistungen fur das Projekt und die mit diesem
Finanzierungsbeitrag finanzierten Lieferungen und Leistungen eindeutig
ersichtlich sind;
e)
wird den Beauftragten der KfW jederzeit die Einsicht in diese Bucher und in
alle
ubrigen
fur
die
Durchfuhrung
und
den
Betrieb
des
Projekts
maBgebenden Unterlagen sowie die Besichtigung des Projekts und aller mit
ihm in Zusammenhang stehenden Anlagen ermdglichen und
0
I
wird alle von der KfW ertoetenen Auskunfte und Berichte uber das Projekt
und seine weitere Entwicklung geben.
I
Der Projekttrager
und die KfW regeln durch besondere Vereinbarung die Einzelheiten
IC-2U Artikel 4.1.
Kt ,
p*
•’ '
r.'
-7 -
Artikel 5
K 5;-
A/erschiedenes
i'
15.1
Sollte eine Bestimmung dieses Vertrages unwirksam sein, so bleiben die ubrigen
Bestimmungen hiervon unberuhrt. Fur eine etwa hierdurch entstehende Lucke soil
dann eine dem Zweck dieses Vertrages entsprechende Regelung gelten.
5.2
Der Projekttrager kann Anspruche aus
diesem Vertrag
nicht
abtreten
Oder
verpfanden.
-
«•5.3
Dieser Vertrag unterliegt dem in der Bundesrepublik Deutschland geltenden Recht.
Erfullungsort ist Frankfurt am Main. In Zweifelsfallen ist fur die Auslegung dieses
Vertrages der deutsche Wortlaut maflgebend.
Die durch diesen Vertrag begrundeten Rechtsbeziehungen zwischen der KfW und
dem Projekttrager enden mit dem Ablauf der Lebensdauer des Projekts, spatestens
jedoch 15 Jahre nach Unterzeichnung dieses Vertrages.
i
5.5
Dieser Projektvertrag tritt fur den Betrag von DM 3,0 Mio erst ist Kraft, wenn das
diesem Betrag zugrundeliegende Regierungsabkommen in Kraft getreten ist.
-8-
■
;
In vier Urschriften, je zwei in deutscher und englischer Sprache.
Bangalore,
Frankfurt am Main,
den
den
f G • 01 ■ 9 7
KREDITANSTALT FUR WIEDERAUFBAU
/p
r*'."
/ i "-Z-y '
-■
h''£» •
1
r.-
■?<>-... • •
B-
SK.r~i^. '------- -. -
’yl i-<
t^r “ "\'££~' _-
----X\
■
. oi ■ 97
REGIERUNG VON KARNATAKA
I
C-^OV -72__
NOTE
Sub: Signing of agreements between Government of India
State Government and die KTvV on the secondary
hospital development project tn Gulbarga Division.
The agreements referred to above have signed art er discussion tn the chambers
of Shri Subash Kuntia. Director, Department of Economic Affairs. The following
documents were signed:
1. Financial agreement between the Government of India and KfW.
2. The project agreement between Government of Karnataka and KfW.
3. Supplementary agreement laying down the procedures for implementation
of 'die project between Kamatal— Government and KTA ,
4. Ail Agreed tAinulcs of the discussion indicating dial Uiurv could be some
changes in the supplementary agreement to taciiitate the implementation of
the project on the lines of the World Rank Project.
(GAUTAM BASU)
Secretary to Government
Health & Family Welfare Department
>
•
■?_-
yA'..
--- - ---------
,
•
"■■ ■■
...-i
:
•
:
•
•
'
'’3'
OF
REPRESENTATIVES
BETWEEN
DISCUSSION
THE
OF
MINUTES
AGREED
GOVERNMENT
OF
KARNATAKA
AND
REPRESENTATIVES OF KFW, GERMANY FOLLOWING SIGNING
THE
OF
AGREEMENT
IMPLEMENTATION
SECONDARY
KARNATAKA
OF
THE
PHASE
FOR
UPGRADING
OF
FACILITIES
IN
OF
PROJECT
CARE
HEALTH
LEVEL
PROJECT
AGREEMENT
SEPARATE
AND
THE
AGREEMENT,
FINANCING
I ON 16-1-1997 AT 10.30 AM
IN DEA,
DELHI
Having
expressed
the
contracting
Agreements,
satisfaction
parties
implementation of the project.
the
operation
of
some
clauses
agree
over
the
execution
of
the
that
in
the
course
of
the
some practical problems may arise rendering
in
the
agreement
difficult
and
that
such
problems can be solved by mutual discussion between the representatives of
Government of Karnataka and KfW,
taking due note of the procedures beina
followed under the World Bank assisted Karnataka Health Systems Project.
KREDITANSTALT FUR WIEDERAUFBAU
K
IJheidt
GOVERNMENT OF KARNATAKA
GAUTAM BASU,
Date: 16-1-1997
.rJv__
SECRETARY
HEALTH
WELFARE,
KARNATAKA.
&
FAMILY
x
y
Pago 1
Supplementary Conditions of Kreditanstalt fiir Wiederaufbau (KfW)
r Payments under the Disposition Fund Procedure (’’Supplementary Conditions”)
The following conditions are applicable to payments under the agreed Disposition Fund
Procedure:
1.
After prior agreement with KfW the Project-Executing Agency will arrange for a
Special Account to be opened (Special Account) with a renowned bank (bank in
charge of the account), which will be kept in its own name or in the name of a third
party authorized by the Authorized Party and, specifically, to handle
i
a)
expenditures in foreign exchange:
with a commercial bank in Germany or in another country from which the
majority of procurements is to be made.
b)
expenditures in local currency:
with a commercial bank/central bank in the country of the Authorized Party.
As far as possible, this account is to be kept as a foreign currency account in
the country of the Authorized Party in order to avoid losses from currency
devaluation and to allow retransfer at all times; in appropriate cases
expenditures in foreign currency can also be effected from this account.
I
6
2
The Special
Special Account
Account must
must be
be kept
kept exclusively
exclusively for
tor payment
payment transactions under the
Disposition Fund on a credit basis. KfW has the right to obtain information on this
account at all times.
s
Unless expressly agreed otherwise. KfW will make an initial deposit at the request of
the Authorized Party up to the agreed amount, generally for an amount of the planned
excenditures for three months as soon as
a)
it has been notified of the name and place of the bank in charge of the
special account and of the account holder, as well as of the account number
and designation (project/measure, nature of account, e.g. trust account) of
f
the Special Account;
b)
it has received a Confirmation of the Bank in charge of the Account in the
form required by KfW (see Annex 2/1);
c)
d)
it has received a Transfer Instruction of the party authonzed to draw on the
account, in the form indicated in Annex 2/2;
all remaining contractual prerequisites are fulfilled:
- the Project Management Team is fully staffed and in place,
- Government orders have been issued providing authority to the Project
Executing Agency to manage essential operational activities including civil
works construction and maintenance activities,
- the Project-Executing Agency has provided KfW an implementation
schedule for the various project measures in the Gulbarga Division including
the number of posts to be sanctioned and filled up each year dunng the
project period.
3.
Payments may be made only for the agreed purpose and only for measures
approved by KfW in writing (for instance, on the basis of concluded supply and serv
ice contracts, cost and time schedules for the implementation of force-account work,
procurement lists agreed with KfW, etc.).
J WS10\SMIC\SMICO145.DOC
-1
I
'age 2 of the "Supplementary Conditions"
Annex 2
Page 2
import duties and in the caTe o“£ frrmmt
5.
nC^ contribution as well as
orX|eXdrnceao7UoOehnadtoS,e' ,ha Pr0'ec,-&e““"9 Agency shall keep ell
through the Disposition Fund ilnTT corr®spondln9 t0 the disbursements made
^:s,0^yDK^e=e0'
=
6.
7
; 2.-=.... 5-
3.
If the amount available in the Disposition Fund r------■ ■ ■ are
not
needed
in full, contrary to plan
SyXe;da“7Xe TSw “•
Agency
arrangemen, has Seen Sed
'red UnlMS
any7 funds n0
not' reqU
required
unless a
The Project-Executing Agency will ensure
that all agreed evidence of expenditures
is compietely at KfW’s disposal within
twelve months after conclusion of the
measures/completion of the project or after disbursement in full of the funds intended
for the Disposition Fund.
Any amounts that c•
cannot‘ be
adequately proven to have been expended for the
agreed purpose will be refunded
- J to KfA/ immediately by the Project-Executing
Agency.
9.
n\z cr^5rlit stiII in tr~11nto
x• • ■
.
contribution to suspend disbu/sem^nd^r “nX
is entitled to recall
Jf the "Supplementary Conditions”
10.
11.
Annex 2
Page 3
KfW has the right at any time
a)
to reduce the volume of the Disposition Fund and
b)
to demand the refund of amounts that have not been adequately proven to
have been properly used.
All repayments are to be made to the account of KfW with the Landeszentralbank
Frankfurt/Main, No. 500 204 00 in favour of the relevant account of the
Loan/Financing Agreement.
Annex 2/1: Specimen for "Confirmation of Bank in charge of the Account" according to item
2.b.
A. jx 2/2‘ Specimen for "Transfer Instruction" according to item 2.c.
Annex 2/3: Specimen for "Request for Replenishment and submission of evidence of use of
funds"
!
.Annex No. 2/1 to the ’’Supplementary Conditions” of KfW
Annex 2
Page 4
Confirmation of the Bank in charge of the account
To Kreditanstalt fur Wiederaufbau
Palmengartenstrasse 5-9
60325 Frankfurt am Main
German Financial Cooperation
Financing Agreement of KfW dated
No.:
Designation of Project:
95 66 944
Upgrading Secondary Level Hospitals in the
Gulbarga Division
Special Account No. /
The Department of Health and Family Welfare (DHFW)/Govemment of Karnataka has
requested us by letter dated
to open a special account to be maintained
exclusively on a credit basis for payments to be made from funds of German Financial
Cooperation.
We therefore have opened a special account no
for payments from the
above Financial Contnbution in the name of DHPA/ with the separate designation "Special
Account Upgrading Secondary Level Hospitals in the Gulbarga Division".
A/e have taken notice that the above account will be filled and replenished exclusively with
purpose-tied funds from the above Loan/Financial Contribution and we herewith waive the
assertion of our nght to offset and retention as well as our right of lien in respect of these
balances to which we are entitled under our general bank conditions or to which we may be
entitled for any other reasons. We will inform you without delay of any attachments on the part
of third parties in the above Special Account.
i he party/ies/persons authonzed to draw on the account is/are
(Secretary DHP/V or his/her nominee together with the consultant)
We shall not modify the authority to draw on the above account unless and until we have
received the consent of KfW.
We are permitted by the Account Holder to draw on the Account to inform you at any time of
the account and the payment transactions effected via the account. The Account Holder to
Draw on the Account has informed us that it has issued to you an instruction to transfer the
balances on the above account to your account No. 500 204 00 with the Landeszentralbank
Frankfurt/Main.
This confirmation applies equally to any sub-accounts.
Date
Signature of Bank in charge of the account
-2-
Annex 2
Page 5
Annex No. 212 to the ’’Supplementary Conditions”
Transfer Instruction
to
(bank in charge of the account)
German Financial Cooperation
Financing Agreement of KfW dated
No.:
Designation of Project:
Special Account No. / Designation:
95 66
Upgrading Secondary Level Hospitals in the
Gulbarga Division
/Upgrading
Secondary
Level
Hospitals in the Gulbarga Division
Dear Sir/Madam:
We herewith instruct you irrevocably to transfer the balances existing on the above account
;
and on any related sub-accounts to the
account> of Kreditanstalt fur Wiederaufbau.
Frankfurt/Main, No. 500 204 00 with the Landeszentralbank Frankfurt/Main in favour of the
aoove Loan/Ftnanc.ai Contribution account whenever this Transfer Instruction is presented to
you by Kreditanstalt fur Wieceraufbau.
Date
Signature of account holder/party authonzed to
draw
Confirmation of signature by Bank in charge
of the account
This Transfer Instruction
The Transfer instruct™ is then to be (orvrarded. e.tner directly or v.a the ^nk .n charge of ^e 3^ to WW toseUwr
-Confirmation-. KfW will inform the account holder/authonzed party In the event it intends to make use of this Transfer Instruction and
state the reasons for this.
Annex 2
Page 6
-3-
Annex No. 2/3 to the ’’Supplementary Conditions" of KfW
Date
Re:
(Partyauthorized to request replenishment)
To Kreditanstalt fur Wiederaufbau
Abt. RS b3
Palmengartenstrasse 5-9
60325 Frankfurt am Main
German Financial Cooperation
Financing Agreement of KfW dated
No.:
Designation of Project:
Special Account No. / Designation:
95 66 944
Upgrading Secondary Level Hospitals in the
Gulbarga Division
/Upgrading
Secondary
Level
Hospitals in the Gulbarga Division
Bank in charge of the account:
Request for replenishment and submission of evidence of use of funds under the
Disposition Fund Procedure
Dear Sirs:
in accordance with the agreed Disposition Fund Procedure we enclose documentary evidence
on the use of funds in simplified form substantiating the use of DM................................. (in the
case of excenses in local or third currency, amounts are listed in the relevant currencies and
their equivalents in DM at prevailing exchange rates). This evidence is composed of.
1.3 Status of account pursuant to Annex I
2.3 Cumulated statement of expenditures for supplies/services provided on the basis of the
jget agreed with KPA/ for this purpose, specimen: Annex II.
3.3
3.S Statement
Statement of
of expenditures
expenditures made
made in the current accounting period for goods
supplied/services rendered for each specific measure/contract, specimen. Annex III.
A/e confirm that the expenditures were made and accounted for in conformity with the
provisions on the Disposition Fund Procedure and were not financed from any other sources.
Phe original documentary evidence is kept at
,s available for
nspection by yourselves at any time.
A/e request replenishment of the Disposition Fund Special Account Upgrading Secondary
_evel Hospitals in the Gulbarga Division No
with ....
name and place of bank in charge of the account) in the amount, of DM
(or foreign currency equivalent).
Signature of party authorized to request replenishment
\nnexes:
Specimen forms
\nnex I: Status of account
Annex II: Cumulated statement
I
Annex III: Statement of Individual Items
I
-4 -
specimen
Annex 2
Page 7
Annex I to the Request for replenishment No
dated
Status of account for the accounting period
accounting period
to be made up also for any sub-accounts)
to
DEM or other currency
Balance or eccounl a, beginning ol acMunllng oenoa
• Arnows reeeleea (nrougb K(w a„ording ,o
Payments effected (sum of column 4, Annex 2)
+ Credit interest
Bank fees
Date
Signature
Authorized Party
Specimen Annex II to the Request for replen.shment No
dated
(cumulated statement)
Loan/Financmg Agreement
No.
1
Designation of Project
2
Current No./type
naivicual
~easures
Amount agreed
with KfvV
Date
Accounting period
from............. t0
3
4
5
6
Expenditures in
preceding
accounting
periods
Expenditures in
current
accounting
period
Total
expenditures
Still to be
disbursed
(column 2 minus
column 5)
Signature
Authorized Party
Specimen Annex III to the Request for replenishment No
^aan/Financing Agreement
dated
dated.
Designation ot Pro'e^ "**
Designation of Project
measure)
from
1
Current No.
2
Name and
address of
contractor
3
Date of contract
4
5
Description of
Invoiced amount,
commodity/
curre-ncy
service
6
7
Exchange rate
Date/type
amountpaid
Add sums of columns 5*7
Date
Signature
to
Authorized Party
Project Governing Board
State Level
Steering ^ommittee
I------------Central Level
Additional Director
(Project Director
Wbdd Bank Project)
T
Project Administrator
----- -------Z
Central Level
Director Health Services
Proj. Management
Consultation Service
Additional Director
(Project Director for German
Financial Cooperation)
Gulbarga Division
|
J. Director Hospitals +
Dy, Director Training
Dy. Director Hospitals South
Dy. Director Hospitals North
Dy. Director MIS
J. Director Equipment
Chief Accounts Officer
Administration Officer
District Surgeon
JaUuen95669441bfe.pporgan.pre
Project Team
District Surgeon
DHO
Executive Engineer
Draftsman
Project Account
Clerks
I_____________
Divisional Level
District Health Committe
Chief Executive Officer (of ■
Zilla Panchayat)
District Surgeon
District Health Officer (DHO)
Engineer (PWD)
---- --------
District Surgeon
"
Equipment
- Management of Waste
- Training of Technical Staff
- Monitoring Referral System
- Quality Assurance
- Surveillance of
Communicable Diseases
OistnctHealth & F.W Officer
- Supervision of Taluka
medical Officers' Activities
- Coordination of Primary Health
Care Activities
- Surveilance of Communicable
Diseases
- Monitoring Referral System
QJ Z3
(Q 3
CD CD
. X
Gi
Annex 3
Page 2
PROJECT MANAGEMENT AND ORGANISATION
Project Governing Board (PGB):
Members:
Chief Secretary to the Government (Chairman)
Additional Chief Secretary, Finance
Secretary to the Government, Department of Planning
Secretary to the Government, Department of Public Works (PWD)
Secretary to the Government, Department of Health and Family Welfare
(DOHFW), Project Coordinator
Additional Secretary, Karnataka Health System Development Project,
Project Administrator
Director of Department of Health and Family Welfare
Representative of the Government of India from the Ministry of Health
and Family Welfare
Responsibilities:
The PGB will meet twice a year.
Empowered to make major policy decisions and develop broad policy
outlines of the project
Approve the annual budget
Authorise major project revisions
Ratify decisions made by the Steering Committee
Formulate rules and regulations
Delegates powers to the Steering Committee
Undertake an annual review of project implementation and monitor
overall project progress
Steering Committee
Members:
Secretary to Government, DOHFW (Chairman and Project Co-ordinator)
Secretary II to Government, Finance
Additional Secretary, DOHFW
Director, Department of Medical Education
Director, Department of DOHF/V
Joint Director, Hospitals
Additional Director, Strategic Management Cell, Department of Health
Chief Engineer, Design and Engineering Wing, DOHFW
Chief Architect, Design and Engineering Wing, DOHFW
Chief Accounts Officer, Department of Health
Additional Director of the Gulbarga Division
Consultant for the Gulbarga Division
Responsibilities:
- The Steering Committee will meet every two months
- Nodal body for project implementation
- Supervise and monitor project implementation
- Undertake planning activities
- Facilitate project management activities
Secretary DOHFW/ Project Co-ordinator
Responsibilities:
• Co-ordination of the different activities of the two projects
Annex 3
Page 3
Project Administrator
Responsibilities:
- Supports the Project Coordinator with the organisation of the
implementation of the different activities of the two projects;
- Approves project expenses in co-ordination with the consultant to be
realised in the Guibarga Division, which exceeds the ceilings defined by
the PGB and therefore cannot be approved by the Project Director.
Add. Director Project, Guibarga Division:
Responsibilities:
- Supported by the project team and the consultant
- Reports directly to the Project Administrator
- In-charge of the day-to-day management
- Coordination of the technical assistance for the Guibarga Division
- Approves project expenses in co-ordination with the consultant up to a
ceiling still to be defined by the PGB
Project Team Guibarga Division
Members:
District Surgeon of each District (in-charge of hospitals with 100 beds and
more)
District Health Officers of each Distnct (in-charge of hospitals up to 50
beds)
Executive Engineer
Civil Engineer, if necessary
Equipment Engineer, if necessary
Electrical Engineer, if necessary
Draftsman, if necessary
Project Account
Clerks
Public Works Department (only supervision)
Responsibilities:
- Reports directly to the project director
- Supervising and monitoring all the facilities to be renovated, extended
and equipped
District Health Committee
Members:
Chief Executive Officer, Zilla Parishad
District Surgeon
District Health Officer
Superintending Engineer, PWD
V
Anneal
Page 4
Responsibilities:
. Facilitate the functioning of the referral system
. Collection and redistribution of the user charges
- Maintenance of equipment
- Waste management
- Training of technical staff
- Quality assurance
Project Management Consulting Services
Responsibilities:
COPoTnnaSs°lhe technical assistance with the Project Co-ordinator.
Project
j°p’"sesrJ| coo^dinaton with the project
SBeU 5 arSe“ S" Z- Pining.
Annex 4
Page 1
I
officer In charge:
our ref.:
extension:
Date:
L/a
Ms. Jungling
Jun
3187
17.05.1396
German Financial Cooperation with
DM 23 million financial contribution for Upgrading Secondary Level
Hospitals in the Gulbarga Division
No.:
Separate Agreement dated
pertaining to the Financing Agreement dated
Pursuant to Section 3.4 of the above-mentioned Separate Agreement, the contract for
shall be awarded cn the basis of competitive bidding to independent, qualified
consultants domiciled in the European Union. With reference to the negotiations on the
above agreements we are gladly, willing to assist you in selecting and contracting the
consultants and during the performance of the consulting services. For this purpose we
herewith conclude with you an
AGENCY CONTRACT
with the following provisions:
1.
We shall ensure that the terms of reference to be presented by you for the
services to be rendered by the consultants are supplemented, if necessary, or
drawn up in the event that you consider yourselves not in a position to work out
the terms of reference.
2.
We shall carry out the procedure provided for in the Separate Agreement for
the selection of the consultants on your behalf and submit the following
proposals to you for approval:
definitive terms of reference for the consulting services including a draft
consulting contract (KfW Standard Consulting Contract)
a short list of qualified bidders
a substantiated proposal for award of contract
the draft consulting contract negotiated with the consultants.
3.
KfW has already got your approval on item 1 and 2. We shall inform you
without delay about the outcome of the competitive bidding.
4
You hereby authorize us to conclude the consulting contract on your behalf.
After concluding the contract we shall furnish you with one original of this
contract.
c.
After we have concluded the contract with the consultants and have sent you
one original, the further execution and supervision of the contract shall rest with
you. We shall continue to advise and assist you in this within the limits of our
possibilities.
6.
You hereby authorize us to make down and interim payments from the financial
contribution to the consultants in accordance with the agreed disbursement
procedure and the provisions of the consulting contract. This authorization shall
be deemed a request for disbursement from the financial contribution. We shall
disburse the final payment upon your explicit request for disbursement
Annex 4
Page 3
-3-
7.
We shall not be liable for negligence on the part of the consultants and their
agents in performing their assignment.
8.
We shall carry out the measures specified in items 1 to 6 free of charge.
9.
Amendments of, and additions to, this agreement shall be in writing. Article 5.2
of the Financing Agreement dated
shall apply to this Agency Contract
accordingly.
Kindly give your consent to the foregoing agreement by signing the enclosed copies in
a legally binding manner and sending them back to us.
Yours faithfully,
KREDITANSTALT FUR WIEDERAUFBAU
Read and agreed:
Annex 6
Page 1
Memo for Progress Reports
The reports on the progress of the project to be submitted quarterly by the project
executing agency shall include at least the following points:
1.
List of Project Measures
(in accordance with the programme measures listed under Section 1.1 of the
Separate Agreement)
Detailed description of the activities undertaken and progress made in the period
under review; any changes in planning, reasons for this.
2.
Assignment of the Consulting Engineers
Award of contract; kind of services rendered and activities of personnel assigned
to the programme site.
Award of Contracts for Goods and Services
Bidding procedure; deadlines; results and evaluation of bids; award of contract.
4.
Goods and Services Provided
(broken down according to the list of programme measures stated under item 1
above)
5.
Supplies:
Kind and quantity, delivery dates, guarantees;
acceptance at factory; acceptance at programme site.
Transport;
Kind and volume; duration; insurances; storage at
construction site.
Construction:
Kind and scope of work; equipment; labour input;
acceptance of work.
Adherence to Time Schedule
Comparison of targets with actual values; reasons for changes in time schedule;
description of effects on the progress of the programme.
itfiir’ T"
*
-----------------
otate of Accounts and Disbursements
for the goods and services stated in the list specified under item 1 above.
7.
Adherence to Cost and Financing Schedule
Comparison of targets with actual values; proposed financing of cost increases, if
any.
8.
Financial Situation of the Project-Executing Agency
Development of annual health budget of Kamataka, in particular with respect to
the programme area.
State of Fulfilment of Conditions
It is recommended to use graphs to demonstrate the stages of deliveries and
services and the development of costs (bar graphs or network plans). The
prcgress reports are to be sent to KfW within four weeks after the end of the
period under review.
Wend Bank Tecnmca! Assistance -Activities
Description of activities undertaken and progress mace in the pericd uncer
review.
Annex 7
Page 1
Terms of Reference
Country:
1.
India
Project; Service Health Programme Karnataka
Background
facilities including the^onsSo^ofTso^^
medium secondary healthcare
-as -
other divisions oflhe State of Kamalak^ThTwid B^kf
Wi" bS imp,emented in 3,1
especially in the field of strenqthenina the
d
< Project covers additional services
of clinical, technical and management skills of hosortafstaff ^lthcare ^en/lces and upgrading
the Gulbarga division).
P 3 sta covenn9 the whole state (including
imclementation The civil and enninOO
construction drawings baseaIon^IxistmT
onstruction as well as in the overall project
°d T be based On Previously prepared
by local architects. The supply for the proiect nc-Tidebeing adaPted to local conditions
medical supplies.
P J Ct includes vehlcles' medica' equipment and other
2.
Scope of Services
2.1
Overall Project Management
fudgeT5”" °' °’'era" pr°iect lmPte™"“°n in respect ot time schedule and project
-
•
Xae’o^uX’XpS
Kama“a
respaa <*
collected fees wlthln°thehospllal’1"19 syslen’ and of ,f,e Suldellnes for the utilisation of
Ajsessment of Indicators which have been agreed upon with the government of Karnataka
•
•
Number of outpatients treated;
Hospital bed occupancy rate;
Average length of stay per inpatient
Number of hospital deliveries;
Number of surgeries adequately performed;
J:\L3A1\GASS\9566944\31DFCONS\TOR.DOC
•
•
•
•
1
2.2
Annex 7
Page 2
Number of laboratory tests;
Number of X-rays;
Availability of medical drugs (% of norms);
each hospital included in the project measures, manages an adequate budget including
a maintenance component of a minimum of 3.5% of the equipment costs and of 1.5 %
of the physical infrastructure (at current prices).
Assistance in Project Planning
Construction and Engineering Works:
Review of the design and engineering drawings prepared by local architects and engineers
as well as assistance in the final design of each health facility (including staff houses and
workshops) to be upgraded or built.
Obtaining all necessary approvals necessary for the implementation of the project.
Supply of medical equipment:
Preparation of the final list of procurement including all supply categories (vehicles, medical
equipment and other medical supplies) for the project period of three years.
Determination of quantities delivered to each of the districts per year.
Preparation of specifications for the medical equipment and medical consumables.
Cost estimations for each supply category and elaboration of budget schedule.
Elaboration of procurement procedures and logistic framework for each of the supply
items.
2.3
a)
Project Implementation
Methods of Tendering
The methods of tendering will be based on the procurement guidance of KfW for local
competitive bidding which includes the following steps:
Notification (prequalification)
Issue of bidding documents (terms of bidding, terms of contract, quantity and quality of
supply)
Submission of bids
Public opening of bids
Evaluation and selection of lowest evaluated bid based on qualification criteria
Contract award
Contract performance
b)
Assistance Services
Construction and Engineering Works:
Review of work drawings/details and relevant documents necessary for the bidding
document.
Review of the specifications for all buildings and engineering works, external works and
landscaping.
Review of all tender documents (condition for bidding and terms of contract).
To submit the first tender package, which should serve as a model document to be
followed by the project authorities, to KfW for approval.
Evaluation of the local companies/firms participating in the prequalification and short listing
of the firms to be invited for tender.
Evaluation of tender by assessment of bidder, bidder track record and tender price analysis
Preparation of contract documents.
D
Annex 7
nroposals for the award of contracts.
Page 3
GoKlndtoT’S^
C°nCept accordinS t0 the agreements reached between
Supply of equipment
' XZXir* and daW"On Q' biddi"3 Procedures in accordance with
■ ^“^x«^xsrcia,aspecteMonitoring of Project Implementation
2.4
Construction and Engineering Works
■
Supply of equipment
Monitonng of execution of contracts including provisional and final acceptance.
2.5
Verification of Payments
"0 Pr°f' 'mP,erTler|tation (nonsuiting, design.
’
P J
2-6
.account and the request for replenishment of the project account.
Assistance by the District Health Committee
~
:
■
C°™*e which w» be
Certification of all tender evaluation
sss s
szxcron and —
Certification of all payment released to contractors ’
contribution of the Government of Karnataka
progress of components of the world bank project within the Gulbarga division.
3.
Execution of Project Management
Oivision rtm°he HeadQuarteHnt?'a»>SUra p,ejmJhanentpr-sence 'n bie project in the Gulbarga
Gq W "7- .
Minutes of Meeting
i
i
XnnexureI
German Financial Co-operation with India
Project:
Upgrading Secondary Level Health Care Facilities in the Gulbarga Division,
State of Karnataka, India, Phase I
The representatives of the Governments of India and Karnataka, consisting of Ms. Shailaja
Chandra, Additional Secretary, Health, Government of India (Gol), Mr. B.K. Bhattachaiya.
Additional Chief Secretary and Principal Finance Secretary, Government of Karnataka (GoK)
and Mr. Gautam Basu, Health Secretary, GoK visited Frankfurt from February 5 to 7, 1996, to
discuss the final details for the preparation of the above mentioned project.
The KfW-team consisting of Mr. Heidt, Ms. Jungling and Ms. Witt would like to express their
sincere gratitude to the representatives of the Governments of India and Karnataka for the
fruitful discussions and the excellent co-operation
Reference is made to:
The project proposal for German Financial Cooperation with India of the Department of
Health and Family Welfare, Government of Karnataka. May 1994.
The Final Project Proposal of the Department of Health and Family Welfare. Government of
Karnataka: Upgrading Secondary Level Health Care Facilities in the State of Karnataka
India, July 1995.
The minutes of meetings of June 13, 1995 and of October 21, 1995.
State Health Systems Development Project II, India, Staff Appraisal Report, January 23.
1996, World Bank.
The minutes of meeting summarise the main findings and records the understanding reached
with the Ministry of Health. Gol, Finance Department and Department of Health and Family
Welfare (DHFW), GoK. They are subject to the approval of the management of KfW, the
German Government, the Government of India and the Government of Karnataka
1. Project Rationale
The GoK has substantiated the availability of adequate primary health care services for
justifying a specific project on secondary level health care services as follows:
Since the last decade, priority has been given to the primary health care level The preventive
care has been carried out to a satisfactory extent. For instance, the Pulse Polio Programme
reached almost 100 % coverage rate in the Gulbarga Division in 1995 Furthermore, special
programmes are implemented in this area in order to reduce the regional imbalances.
a
2
Recruitment procedures have started in the Gulbarga Division and in Bijapur District to fill up
400 additional posts of Auxiliary Nurse Midwives rANM) in the newly created Sub Centres.
There are still some vacancies with regard to paramedical staff. All posts for medical doctors at
the Primary Health Centres have been filled. Up to 1995, 1.200 doctors have been contracted
by DHFW in the State.
In the Health Sector Policy Development Programme of Karnataka (see Annex 1) it is
envisaged that the problem of mismatching of medical staff will be solved in due course and
that doctors, especially lady doctors will be recruited on contract basis for special health check
up camps for women. These services of private lady doctors will be enlisted whenever
necessary.
With regard to sustainability, the GoK has developed a scheme for decentralisation of
administrative and financial authority from the DHFW to divisions and districts. Certain para
medical staff for public health care activities can be recruited at district level. Revenues from
user-charges will be redistributed directly to the health facilities via the District Health
Committee.
2. Project Approach
The KfW will ask the German Government to provide a grant (to be passed on to GoK also as
grant) of up to DM 23 millions in order to implement the first phase of the above mentioned
project. The project will support the GoK in further improving the health status of the rural
population in the Gulbarga Division and will form an integral part of the Karnataka Health
Systems Development Project funded to a large extent by the World Bank (WB). The financial
contribution by KfW will mainly cover the rehabilitation and the up-grading of 26 rural
secondary level health facilities in the Gulbarga Division. The WB will fund similar projects in
the rest of the State of Karnataka and will piovide technical assistance for the whole State.
This approach enables to strengthen the organisational structure of preventive and curative
aspects of health care by integrating primary health care services with first referra* hospitals.
Additionally the GoK through the WB assistance envisages to increase access to primary care
services among Scheduled Castes and Scheduled Tribes (SC/ST) population and women in
the Gulbarga Division.
3. Project Aim
The overall project aim is to improve the health status of the rural population in the Gulbarga
Division, especially women and children, by reducing infant mortality and the mortality rate of
mothers and children The project aim is the improvement of quality and efficiency of the
secondary level health care facilities in the socio economically backward project area
By the second year after completion of the tQ''hnical assistance provided through the World
Bank, the project aim will be measured by the following indicators:
Number of outpatients treated;
Hospital bed occupancy rate
Average length of stay per inpatient;
Number of hospital deliveries:
Number of surgeries adeouately performed
Number of laboratory tests:
3
Number of X-rays;
Availability of medical drugs (% of norms);
each hospital included in the project measures, manages an adequate budget including a
maintenance component of a minimum of 3.5% of ttie equipment costs and of 2 5 % of the
physical infrastructure (at current prices).
The baselines and targets of the indicators have to be defined for each type of hospital latest
one year after beginning of the project and have to be provided prior to the first annual review.
4. Project measures and costs
The project compromises the following measures, at the estimated costs so far calculated:
Costs
GoK
(D
(2)
Rehabilitation of Secondary
Level Health Institutions
11,7
a) Construction__________
7,0
b) Medical Equipment,
4.3
Medicines____________
c) Vehicles______________
0,4
Rehabilitation of two
District Hospitals_________
1,1
Maintenance Facilities
1,3
Waste Disposal FaciIities
0,9
Management-lnformationSystem and Surveillance
0,2
SC/ST/Wonien____________
0,8
Salaries__________________
1,8
a) Hospital Staff__________
1,6
b) Maintenance, Waste
0,2
Disposal______________
Project Management_______
4,2
a) Consultant Services_____
1,5
b) Fees for design________
0,5
c) PMC_________________
2,2
Price and Physical
Contingencies____________
6,7
Price Contingencies________
3,7
Physical Contingencies
3,0
TOTAL________________
* Including DM 50.000 for salaries.
Financial
Contribution
(3)
% of costs (1) to
total project costs
(4)
10,2
7,0
2,8
41%
24%
153/o
0,4
13'0
1,1
0,4
0,8
4%
5%
3%
1,5
1,5
0,9
0,1*
0,2
0,8
1,8
1,6
0,2
0,4
0,4
28,7
1%
3%
6%
5%
1%
3,8
1,5
0,5
1,8
14%
5%
2%
7%
6,7
3,7
3,0
23%
13%
10%
23,0
100%
The general administration costs of the DHFW of Karnataka, the DHOs and administration of
the health institutions in the Project area will not be financed from the Financial Contribution.
The Financial Contribution covers the following components:
rehabilitation and adequate equipment for 7 secondary level health care facilities:
rehabilitation, up-grading and adequate equipment for 19 secondary level health care
facilities, a total of 627 additional beds;
4
construction of 190 housing units for medical personnel;
construction of waste disposal facilities for each of the considered hospitals;
initial basic provision of medical goods;
construction and equipment for four equipment maintenance facilities, including four
vehicles:
21 emergency vehicles;
renovation and equipment for the two district hospitals Bidar and Bellary which cannot be
postponed to the second phase;
consulting services to support the Project Director and his team for the implementation of
above mentioned measures
5. Budget Allocations for the Health Sector and Incremental Costs (Sustainability)
GoK agreed upon, that the share of non-plan and plan budgetary allocations to the health
sector relative tc the overall plan and non-plan budget of the state is, at least, maintained each
year at the Fiscal Year 1994 level; shares of 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; reduce the existing regional imbalances in favour of the underdeveloped
districts and tribal areas (including all districts in the Gulbarga Division); sufficient resources for
drugs, essentia! supplies and maintenance of equipment and buildings are allocated at first
referral hospitals in accordance with the agreed norms (see also Annex 1, Para. 1, 2 and 3).
Incremental recurrent costs after project completion including contingencies are expected to be
about Rs 100 million in the Gulbarga Division. The GoK commits itself to take over all the
recurrent costs arising from improvement of standards according to Government norms for
existing as well as additional beds.
Although the budgetary targets are necessary
necessary and
and achievable,
achievable, they
they are
are still
still not
not sufficient.
sufficient.
Taking into account the growth of population, further effort is required which cannot be covered
by the Government alone. GoK ensures, that user-charges are implemented more rigorously. In
order to improve the existing system, KfW will fund a study aimed at analysing the existing cost
sharing systems and proposing improvements on an operationalised level as soon as possible
(WB has been formed by GoK). This cm
may be completely financed out of the Study and
Expert fund K*.c recommends the involvement of an international consultant coming, for
instance, frcm me London School of Tropical Medicine and Hygiene which has been working
for years in the ^search of cost sharing systems all over the World. The GoK shall implement,
on the basis of the findings of this study, an operational cost sharing system.
6. Project Organisation and Implementation
A European consultant shall support the Government of Karnataka (GoK) in the
implementat'or of the project Instead of direct hiring of this consulting firm by the GoK, it is
agreed upon, t^at the consultant shall be selected by KfW on behalf of GOK, on the basis of
an Agency Correct The consultant shall review the previously prepared technical documents
and assist in the final design of the hospitals, the final lists of procurements, preparation of
tender documems for construction, evaluation of bids, proposals for the award of coiitrects
drafting contrac-s. commissioning of deliveries and supervision of construction and
implementator He she will be permanently based in the State of Karnataka and may sub
contract specifo services with local firms. Furthermore the consultant shall assist the Project
Director in mairtaming the coordination of the technical assistance provided by the World Bank
in the Gulbarga Division. The preliminary ToRs for the consultants are attached in Annex 2.
r
5
KfW will submit to GoK the detailed draft ToRs for comments and approval The KfW will start
with the pre-qualification and short-listing of consultants in February 1996
The organisation of the project is specified in Annex 3 The consultant shaH be a member of
the Steering Committee. GoK will delegate authority required for day-to-day managment to the
Project Director within the first six months after the beginning of the project The Project
Director will than be able to authorize project expenses up to an amount st'il tc oe defined for
different activities, in coordination with the consultant. Project costs exceeding these limits shall
be countersigned by the project administrator and the consultant. The GoK shall pay the
salaries of the project team.
The proposals for preliminary and final design (incl. tender documents etcj of the hospitals
shall be drawn by local architects and engineers, directly hired by the GoK Before tendering,
they will be reviewed by the European consultant. The construction work shall be supervised
by local architects and engineers sub-contra^ed by the European consultant. The contractors
shall be selected through competitive bidding for lots of at least DM 300.00C - The first tender
package will require to be previously reviewed and approved by KfW and should serve as a
model document to be followed by the project authorities with the ccncurrance of the
consultant.
The procurement of goods shall be carried out in accordance with the WB regulations as
mentioned in the Staff Appraisal Report of January 23, 1996.
7. Maintenance Centres and Waste Disposal Units
The maintenance centres and the waste disposal units will be established according to the
agreements reached between GoK and WB (see Annexes 4 and 5).
8. Retroactive Financing
As the project shall form an integral part of the Karnataka Health Systems Development
Project, the project measures envisaged for the secondary level health care facilities in the
Gulbarga Division shall start at the same time. Therefore, KfW agrees on retroactive financing
of such project costs occuring after December 1995 provided these cost have been incurred
based on the agreed final design (see Para. 5). Retroactive financing will be acceptable for
planning/designs and urgently needed repairs up to an individual amount of DM 50.000 and
should not exceed a total of DM 500.000 provided the works are executed in accordance with
the prescribed procedures of the State Government. With beginning of the project the
consultant shall approve these expenditures made by GoK prior to refunding
9. Disbursement Procedures of Funds
The Financial Contribution shall be transferred to the Government of India (Gol) who will pass
on the funds to the Ministry of Health and Family Welfare, Karnataka, without any delay. If
delays occur it will be the responsibility of the GoK to demand a quick transfer of funds from
Gol. Advanced disbursement will be made under the Disposition Fund Procedure For this
purpose a special account will be opened in the name of the Department of Health and Family
Welfare. GoK. GoK would request an initial deposit into this account up to an amount covering
the average fund requirements for three months. KfW would reimburse the respective amount
6
on the bes s of the presentation of evidence of the use of funds, together with the submission
of request for replenishment.
10. Pre-Requisites for disbursement
1. The sc eve mentioned project management team has to be staffed before the beginning of
the p'c.ect.
2. Gove^ment orders have been issued providing authority to the DHFW to manage essential
opera: onal activities including civil works construction and maintenance activities.
3. GoK s~a!J provide KfW an implementation schedule for the various project measures
indue '-g the number of posts to be sanctioned and filled up each year during the project
pence
11. Agreements Reached
1. GoK screed upon that the share of non-plan and plan budgetary allocations to the health
sectc' 'eiative to the overall plan and non-plan budget of the state is, at least, maintained
each .ear at the Fiscal Year 1994 level (see also Annex 1, Para. 1);
2. Shares of the primary and secondary levels in the total resources (plan and noh-plan)
alloce’.ed for the health sector would be increased each year until the year 2002 (see also
Anne* " Para. 2);
3. Redi ze the existing regional imbalances in favour of the underdeveloped districts (including
all dist^cts in the Gulbarga Division) and tribal areas (see also Annex 1. Para. 3);
4. Suffic e-t resources for drugs, essential supplies and maintenance of equipment and
build-gs are allocated at first referral hospitals in accordance with the agreed norms.
5. The
shall delegate to the Project Director adequate power to decide on project
expenses with the approval of the consultant up to an amount determined latest half year
after
Droject has been sanctioned.
6. GoK
orovide KfW in cooperation with the consultant an annual work plan setting forth
the respective activities under the project to be carried out during the prevailing fiscal year
incluz
the budgetary allocations to be made available for such purposes.
7. The ^-7' shall submit to KfW for its review and approval the procurement plans with regard
to the Gulbarga Division.
8. For p.<ooses of enhancing the quality of health care services under the Project GoK shall:
(i) me ~:ain the key headquarters p rsonnel appointed for purposes of implementing the
Projez: di) appoint and thereafter maintain key additional personnel with adequate
qual’’ :=:‘on and experience; (iii) adopt, no later than six months after completion of the
phys z= mprovements in any hospital under the Project, and thereafter implement staffing
and tez-nical norms acceptable to the KfW
7
9. A minimum of 3.5 % of the equipment costs per year and 2.5 % of costs for the physical
infrastructure shall be provided as a maintenance budget.
12. Project Phase II
A second project phase will include the rehabilitation and equipment of the remaining
secondary hospitals. This phase shall be appraised by KfW during the second year of the first
phase (approx. May 1997) and implementation should start approx, in the beginning of .1993. It
should be completed within three years. The type of the Financial Assistance (grant or soft
loan) to be made to the GoK by the German Government shall be determined after the
appraisal.
Frankfurt, February 7, 1996
-- ^'<!3----------------- -
Mr. B.K. Bhattacharyef
Additional Chief Secretary
Principal Secretary, Finance Department
Government of Karnataka
M’ Heidt
Vice President
South Asia and Central Asia
KfW
L
Mr. Gautam Basu
Secretary to Government of Karnataka
Health and Family Welfare Department
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/curative 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, Dharwad
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 tlic 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 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 state Government recognizes
the need for focusing attention on
the primary and secondary' levels
of health care and also to step up
allocations for these levels. A
major portion of the increased
allocation wall go to the primary
and secondary levels.__________
Through both project as well as
non-project interventions, a policy
of positive discrimination in favor
of the underdeveloped districts
and tribal areas witliin advanced
districts will be followed to reduce
the existing imbalance. This
differential policy is ahcady under
implementation. Additional
resources are 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,
especially for populations in the
Quality and access will be
improved by: (i) upgrading and
expanding physical capacity; (ii)
upgrading clinical effectiveness
HEALTH SECTOR DEVELOPMENT PROGRAM
Carnataka (continued)
Issue
Effect
Proposed Change or Action
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
wall 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 and Family Welfare. Tliis
health spending pnorities
will,
either independently or
presently do not take into full
consideration the size and scope of 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 healtli manpower 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
cost-effective means for achieving
the best use of limited resources;
and (v) undertake periodic review
of the healtli manpower supply
situation and training needs in the
state. A study of the scope and
prospects of enlisting private
sector support for promotion of
health care at primary and
secondary levels will be
undertaken.
least developed areas of the state,
particularly women, scheduled
castes and scheduled tribes.
Strategic planning
j
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
6.
Workforce.
Effect
Proposed Change or Action
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 does not fit current
needs. There arc many vacancies
due to poor and cumbersome
recruitment procedures, and
unimaginative personnel policies.
No ban on recruitment will be
imposed with regard to rcciuiting
medical, paramedical and
technical staff. In a short period
the problem of mismatching in
medical staff will be solved. 'I lie
practice of deputing staff 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.
The distribution of medical
specialists is not commensurate
with the need (e.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.
Services offered 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
participation of NGOs in the area
of primary and first referral health
care. In remote tribal and
backward districts, NGOs will be
encouraged to operate some
government facilities so ns to
ensure the outtcach of health
services to the disadvantagcd
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.
10. Prevention and conttol of
major communicable diseases.
The existing surveillance system
is very weak, especially at the
secondary' level and in urban
areas.
11. Contracting sen-ices.
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.
13. Consolidation versus
expansion of institutions.
1 he state Government has been
rapidly expanding tlie number ot
Proposed Change or Action
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 major portion of revenues
raised by the 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 costeffcctivcncss and quality of
existing contracted scr vices.
Furthermore, the Government will
consider new proposals for
contracting-out health services,
especially support services such as
laundry, cleaning, manufacturing
I.V. fluids, etc.________________
'flic state Government will make
adequate provision in the health
budget for drugs and other
medical supplies, and for
maintenance of equipment and
buildings._____________________
Further expansion of beds and
hospitals will be sli ictly need-
HEALTH SECTOR DEVELOPMENT PROGRAM
Karnataka (continued)
Issue
14. Poverty alleviation.
Effect
Proposed ( Ii.iiiju* or A< lion
subccntcrs, 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.
based, and will be undertaken only
after ensuring that existing
facilities arc properly maintained
and utilized.
The investment made in this
project, especially through special
programs for tlic disadvantaged
section (e.g., SC/ST and women)
will aim at augmenting the
product!vity/caming potential
through better health status.
'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
welfare in Punjab is 5.31% of the
state revenue budget and 0.88% of
NDP in 1993/94. These health
expenditures are inadequate to
provide essential primary health
care together with a package of
curative services.
2.
Allocate most of tlie
incremental funds for the
health sector to primary’ and
secondary levels of care.
Recognizing the link between the
provision of basic health services
and poverty alleviation, the state
Government will ensure that in
each fiscal year during
implementation of the project, tlic
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.
3.
Primary and secondary levels of
health care have not been
receiving tlie requisite allocation
of funds. Tliis has resulted in a
shortage of drugs, machmcry
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.___________
Safeguard the operations and
The existing secondary' level
maintenance component of the hospitals function poorly because
health budget.
of inadequate allocation of funds
.for operational and maintenance
purposes (30%-35%). 65-70% of
the current budget goes to the
salary component.
Taking into account the budgetary
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.
Avtt' tx el
OUTLINE SCOPE OP SERVICES FOR THE PROJECT MANAGEMENT CONSUL I AH r
1.
background
supervision of procurement and construction as well
------ .. -.I as in the overall project implementation.
2.
SCOPE OF SERVICES '
2.1
Assistance in Project Planning
Review of detailed design of each hospital project to be upgraded.
proS Of eqUiPment a"d
SUPply liSt Whlch ™" ba
'or OKh of the hospital
^aloation of the overall project report In respect of project schedule and ptojacl budget.
2.2
Assistance in the Tender Process
Assistance in the elaboration of bidding document
and tender evaluation for all tender
categories.
Assistance in the evaluation of tender.
✓
Verification of tender evaluation.
• .
2.3
. J
Monitoring of Project Implementation
in respec,.°f ’*."** °f *"
Supervision of overall project implementation in
2.4
respect of time schedule and project budget.
Venfication of Payments
Verification of all project payments related to the project implementation (consultino d°sion
construction, engineering services, equipment, initial supply and vehicles) All payments for
SSS?" eXO!ed"""R 2 5 "*■"
to off 100.000) shaN be^vellfied^by £
Verification of the project account and the request of the replenishment of the project account
2.5
Overall Project Supervision
Participation in essential project management meetings held by the DHFW
Participation in the project appraisal missions of tlie World Bank.
J:\L3Ai\wirrtr.iuRDoioG.noc .
<
Elaboration of quarterly project report which shall reflect the overall project progress inlcurfing
the following topics. (Budget utilisation, contribution of the Government of Karnataka staff
sanctioning, cost sharing activities, progress of components of the world bank project within
the Gulbarga division.)
3.
EXECUTION OF PROJECT MANAGEMENT
The project management consultant shall provide a permanent establishment at the project
office of the Government at the Gulbarga Division and regular monitor the project sites.
4.
SELECTION OF THE PROJECT MANAGEMENT CONSULTANT
The project management consultant will be jointly selected by KfW and the Government of
Karnataka. The final terms of reference will be based on the above scope of services (item 2)
J-
i
(
I ,
MANAGEMEN I AND MAINTENANCE SYST EMS FOR EQUIFMEN F AND
BIULDLNGS FOR FIRST REFERRAL FACILl ILES
I. Management and Maintenance of Equipment
Karnataka
The amhoriries tr<ronsiblc for Government health services m Karnataka State
recognise that the quality of these services has come to depend increasingly not onlv on
the availability of appropriate medical and nursing skills, but also on the efficacy and
reliability.of the medical equipment provided. In spite of its high and rising cost, medical
technology is widely mismanaged in health care. In the State, there is a severe shottaee of
“suitablv trniiwd. expermnr’'d technical pcrsoiiii 'l in the healthcare technical service':
Frequently thir. de:uth 'd ’-cimical taff, coupled with the lack nf kiumlmii’e and
inexperience in practical matters of the medical and technical staff employed, contributes
directly to the breakdown and reduction in the operating life of expensive and essential
equipment. The mam problems encountered arise from:
•
improper equipment-selection and procurement policies resulting in the
introduction of inappropriate or inferior quality equipment:
•
inadequacies in maintenance and repair arrangements: and
•
insufficient training of equipment users.
The State is pcisu^ded that proper
ent of equipment involves fiftly
ensuring that the funds allocated for purchase, installation and maintenance ate spent to
the best advantage; and secondly, establishing and supervising the various services
required for the effective, safe and efficicnt.use of
r”’pment over a reasonable life
time. To meet these objectives equipment management will be accorded high priority.
Through the Health System Project the State proposes to establish a good
equipment management and maintenance system that will result in:
•
reduction of numbers and frequency of breakdowns:
•
prolonged life of the equipment;
•
improved quality of health care delivery services: and
assured safety of users and patients.
The existini! Health Equipment Repair and Maintenance Unit in the Directorate is
inadequate when compared to the vast range of equipment spread all over the State. There
are only nine persons under the Health Equipment Officer. There is only one X-ray
technician, two semi-skilled artisans and one X-ray darkroom assistant. The remaininc five
are either administrative cadre or Group D staff. The follov.mg paragraphs describe the
objectives and organisation of the equipment management and maintenance setup, the
traininn requirements of medical, paramedical and technical staff, and requirement of
funds for establishing an efficient and better management of equipment maintenance
system.
The objectives of the revamped system will be:
1.
To provide e'rp'ut technical servicesand advice on the purchase of equipment,
spare*:, service contracts etc.;
Annex
t .
2.
To procure, install, commission, maintain and service biomedical and other hospital
equipment for patient diagnosis, monitoring, therapy and care;
3.
To maintain and service heating, ventilation, air conditioning (HVAC) systems,
power systems etc.;
4.
To carry out minor maintenance works related to buildings, electrical
fixtures;
5.
To organise training programmes for biomedical technicians and users;
6.
To modify existing equipment if necessary (with appropriate safeguards:, in
response to operational and/or clinical needs; and ,
7.
To maintain records for administration and management purposes.
sanitary
Professional management of the system will ensure that there is no procurement of
obsolete systems which may prove to be ineffective and uneconomical, involvin'! huge
operational costs. Other shoncomings such as inadequate radiation protection, uneven load
distribution, noise and vibration level of equipment, lack of temperature and humidity
controlled environment, electrical leakage, explosion hazards due to gases etc. will also be
' avoided.
It is also proposed that proper maintenance of reponing and records system will be
designed and installed. Records would contain the status of the equipment, inspections
undenaken, repair works carried out and costs incuucd. Safety inspection tours will be
regularly undenaken.
Organisation
The Equipment Management Unit at HQ-lcvel will be under the Additional
Directors (Health Systems) and will be headed by a Joint Director (Equipment) who will
have functional autonomy and a specifically allocated budget for procurement and
maintenance. The Unit will be responsible for maintaining the equipment in all the
Government hospitals in the State. It will be organised as a three-tier system with Head
Quaners and Central Workshops at Bangalore; Hospital Engineering Units and Mobile
Engineering Units at each district hospital. The Mobile Engineering Unit will be under the
control of the Distnct Hospital Engineering Unit and will be responsible for maintaining
the equipment in all the hospitals in the district. The District Hospital Unit will report to
the District Surgeon for administrative purposes. For planning and technical Guidance, the
District Hospital Engineering Unit will be supervised by the Dy. Director (Health
Equipment).
The Dy. Director (Training) will organize training programmes for medical,
paramedical and technical staff. The training will cover not only use of but simrie
maintenance procedures such as replacement of fuses, replacement of caskets, tcopinc up
with oil in hydraulic equipment etc. One Dy. Director (Equipment) will look after the
equipment needs of hospitals under the jurisdiction of the Director of Medical Education
and the other Dy. Director (Equipment) will look after the equipment needs of hospitals
under the Director. Health &. FW Services. The Dy. Director (Transpon) will be
responsible for planning for procurement, of vehicles and select private caraces :n each
Taluka to repair all the vehicles of the depanment in that Taluka.
> '•
Annex
The districts have been classified into four categories (A-D) on the basis of the
number and size of hospitals. Sangalore Urban and Rural Distncts are treated as one and
fall into Category A. Looking at the large number of big hospitals. Bangalore requires
three Distnct Hospital Engineering Units. Three. Districts. Chitradurga, Dharwad and
Mysore fall under Cateaorv S. and each of these distncts needs two Distnct Hospital
Engineering Units. The District Hospital Engineering Units in these districts will be placed
in different large Hospitals, eight Districts fall under Category C and seven under
Category' D. Table I (attached) gives the details of the hospitals to be maintained by the
Unit in each district; and Tables 2 & 3 (also attached) give details of the proposed
facilities and staffing of the different sections/workshops.
The annual wage bill at the end of the project period is estimated at Rs. 23.50
million and over the project period at Rs. 82.25 million. The capital cost of setting up the
maintenance facility is estimated at Rs. 23.56 million for civil works, Rs. 53.48 million for
machinery and equipment and Rs. 8.75 million for vehicles.
Procedures for maintenance and repair
At an early stage of setting up of the Eiriirment Management and Maintenance
Unit, an inventory will be taken of all medical emn.pment and instrumentation throughout
the system. The list thus obtained will becom / basis to determine the requirements for
services. A format for the inventory records and lor the maintenance and repair of
equipment will be also prepared.
The each maintenance and repair.workshop will maintain a card for each item of
equipment or instrument. It will contain the complete history of the item from the date of
purchase up to its ultimate disposal. The total purchase cost, records of maintenance and
repair operations with cost, and the estimation of the probable life expectancy will be
noted in the card.
\
The equipment record card will form the key reference for all the service functions.
The maintenance and repair staff will be given guidelines for procedures. The standard
guidelines will include the method of recording the work undertaken, and the materials to
be used and explain the basic principle of selections, inspections, preventive maintenance
and repairs. A Standards Guide will be supplemented by Procedure Manuals. These
manuals should suggest the required frequency of preventive maintenance procedures,
calibration instructions, trouble shooting methods .md repair procedures.
Requisition forms for repair services will be made available to all hospitals. At the
time of failure or apparent damage, a preliminary infection will be earned out by the
in-house technical staff and rf they are unable to carry' out the repairs, the next level Unit
may be informed which will then take up the work. The engineering Unit will decide
whether the repair will be attempted ’on site’, in its maintenance faculty, or by an outside
agency. In the latter instance, the engineering depanment will be responsible for issuing
instructions for repairs and transport procedures. A ’work order form will be prepared and
directed to the appropriate staff. On the completion of the repair, the details of the services
rendered will be transferred from the work order form to the equipment record card.
Training of maintenance peisonnel
The Slate has still to articulate its policy on whar levels of maintenance and repair will be
undertaken by in-house technical staff. This will dictate the type of technical training that
Annex
'
-
’
•
•
•
will have to be given and influence the decision on which arrangements and/or
organisations and institutions are best suited to provide this. The policy will should also
make clear which technologies are to be maintained by contractors.
Training in use cf equipment
As described above, the Department of Health and Family Welfare proposes to set
up a full-fledged equipment maintenance wing at the Directorate level as well as at district
levels. Maintenar.ee of sophisticated equipment will be contracted out to the manufacturer
of the equipment or his authorised service centre. All other equipments will be maintained
by in-house mairienance wing. However, it is essential for the actual users to be fully
acquainted with :.:e use and operation of the equipments so that they are not damaged due
to mishandling. Tney should also be aware of simple maintenance checks, replacement of
fuse etc. to ensure minimum down time. It is planned to include such training wherever
feasible, into the clinical training programme. For other equipments, training will be
impaned at the nearest Taluk or District hospital where such equipment is available. An
indicative list of the training required by various cadres is given in Table 4 (attached)
Annex
Table 4: Training in Use of Equipment
Doctor
I.:---- ;----------------
1)
Docton ci Nurses
Nurses <i Operating Iheatir
/Assistants
| Audiometer
jcardiac monitor
lEndoscope (fibreopuc)
Defibrillator (with recorder)
(Operating microscope
Phototherapy unit
(Cryosurgery (basic)
Radiant heater (4 kw)
|Cryosurgery (deluxe)
Shon-wave electro-physio unit
OT ceiling lamps
Ventilator (adult)
Emergencv resuscitation kit
Focussing lights. OT. mobile
Boyles Apparatus with Flutec
Sigmoidoscope (rigid adult)
Suction machine (high vacuum. (
MTP)
Operating table (hydraulic)
Autoclave (electrical)
[apyles Apparatus without Flutec Acute Medical Care
equipment
I Pulse Oximeter
Autoclave HP (horizontal £•_
vertical)
Shadowless lamp. QT (mobile)
Suction aoparatus (electrical)
Oxygen cylinder
Suction apparatus (foot operated'
Opthalmoscope
•Nitrons cxide cylinder
Vacuum extractor
Slit lamp (with table)
Gas regulators & flow meters
Instrument Sterilizer
Retinoscope
Atnbu bag
Perimeter
Laryngoscope.(adult & child)
Pulse air tonometer
BP machine
Dental unit
Oxygen masks (with regulators)
Autoscope
Universal bone drill
Eiecto-surgery machine
Electric cautery set (gynaec)
Automist (OT fumigator)
Weighing scale (adult)
Weighing scale (infant)
Infra-red lamp
Emergency lamp
Fire extinguishers
1
1
1
*<♦
ty
MAINTENANCE ARRANGEMENTS
First-line maintenance by in-house
technical staff
Minor attention by in-house staff
(other work contracted-out locally )
500mA X-ray system
300mA X-ray system
100mA X-ray system
I Chest stand.’X-ray
I 60mA mobile X-ray system
Dental X-ray system
Ultrasonic scanner, linear
U/sonic scanner, linear sector
Defibrillator (with recorder) •
Endoscope, fibre-optic
Operating microscope
Ventilator, adult
Emergency resuscitation kit
Acute Medical Care system
; Dental Chair
■ Aerotor (turbine & compressor)
Ultrasonic dental scaler
Dental lab. : bath, motor etc
i Operating table, hydraulic
pH meter
: Glucometer
Blood-gas analyser
• Generators (various)
Incinerators
; Hot water systems (solar)
|i Gas regulators & flowmeters
Sewing machine
Tables (vanousi
Beds (various)
Foot steps
Beside screen
Stools (various:
Saline stano
Wheel chair
Emergency/recovery trolley
Stretcher on trolley
Oxygen cylinder stand/trolley
Height measuring stand
Cots (various)
Beside locker
Trolleys (various)
Cabinets (vanousi
Traction system
Chairs (various)
Racks (various)
Steel cupboard
Wooden bench
__
i
!
i
i
i
_______
_!
Fully contracted out ser/ices
Anaes. m/c (with FloTec)
Anaes. m/c (without FloTec)
Pulse Oximeter
Oxygen cylinder
Nitrous oxide cylinder
Ambulance
Hearse
Pick-up
!
Typewriter
Photocopier
Roneo m/c
lnterr-:;)3
Fax machine
Telephones
Fire extinguishers
I
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LT~y
LLrilCiTlL^ room
V/ELDING
bench
CD
library
UJ
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CD
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it- J -
drill
11
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zledtronic
mechanical
TOOL board
r"------ 7
copvir/c
'MACHINE I o
Workbench
!
WORK SHOP
'3
I <0
Fi
I
PI
VISE
i 1
1
CARPENTER’S
workbench
^^RPENTER'S
r°OI. B()A/m
entry
VEHICLE
access
I
T'r P,CAL LAYOUT
for
vehicle
o
o
access
rv
s WORKSHOP
1:6O MTS.
0
3 MF I F H<;
!
I !
X
PROJECT ORGANISATION
Project Governing Board
State Level
Steering:Committees |
Healthsecretary
I
Project Coordinator |
>1
i
/pVoy A<k<n«o‘* ikroAoV
_______ I
I
Central Level
Additional Director
(Project Director
World Bank Project)
J.Director Hospitals +
Dy. Director Training
Dy. Director Hospitals South
Dy. Director Hospitals North
Dy. Director MIS
J. Director Equipment
Chief Accounts Officer
Administration Officer
|
Distnct Surgeon
i
cf
Central Level
Director Health
Sen/ices
Proj; Management
Consultant Service
KfW
Additional Director
(Project Director for
German Financial
‘Cooperation)
i Gulbarga Division
Divisional Level
Project Team:
Distnct Surgeon
DHO
Awicteet
Civil Engineer
Equipment Engineer
Elecu, Engineer*
Draftsman *
Project Account
Clerks
.
District Health Team:
Chief Executive Officer (of Zilla
Panchayat)
D.Surgeon
->DHO
Block- HOs ect.
District Surgeon
I
Heaa of
I
District Health
Ollicer
Hospital
—
I
Head or
Head of
Hospital
Hospital
J___
I
Biock Health
Officer
Slock Hea.tn
Officer
*
I
/iiniex
PROJECTMANAGEMENT AND ORGANISATION
Project Government Board (RGB):
Members:
Responsibilities:
Chief Secretary to the Government (Chairman)
Additional Chief Secretary, Finance
Secretary to the Government, Department of Planning
Secretary to the Government, Department of Public Works (PWD)
Secretary to the Government, Department of Health and Family Welfare
(Project Coordinator)
Additional Secretary, Karnataka Health System Development Project
(Project Administrator)
Director of Department of Health and Family Welfare
Representative of the Government of India from the Ministry of Health)
and Family Welfare
Additional Director of the Gulbarga Division
- The RGB will meet twice a year.
- Empowered to make major policy decisions and develop broad policy
outlines of the project
- Approve the annual budget
- Authorise major project revisions
- Ratify decisions made by the Steering Committee
- Formulate rules and regulations
- Delegates powers to the Bering Committee
- Undertake an annual review of project implementation and monitor
overall project progress
Steering Committee
Members:
Secretary to Government, DHFW (Chairman and Project Co-ordinator)
Secretary II to Government, Finance
Additional Secretary, DHFW
Director, Department of Medical Education
Director, Department of DHFW
Joint Director, Hospitals
Additional Director, Strategic Management Cell, Department of Health
Chief Engineer, De^gn and Engineering Wing, DHFW
Chief Architect, Design and Engineering Wing, DHFW
Chief Accounts Officer, Department of Health
Consultant for the Gulbarga Division
Responsibilities:
- 1 he Steering Committee will meet every two months
- Nodal body for project implementation
- Supervise and monitor project implementation
- Undertake planning activities
- Facilitate project management activities
Secretary DHFW / Project Co-ordinator
Responsibilities:
J \L3A1V,*4TTV/’JRlw)10’ I -,C
- Co-ordination of the different activities of the two projects
9
I*
Project Administrator
^esponsibi/ities:
,he 0r9a™«>»0'> of the
Implemenlauon
to
’
»» PGB aoc ^eta-e rannot
app'o^X
Add. Director Project, Gulbarga Dl,ision:
Responsibilities:
- SXXs,,e, consu"M
- imcharge
,he dayqo.dX-.aXent
ceiling still to be defined by the pgb
00 W'fh the C0nsu,t3nt up to a
Project Team Gulbarga Division
Members:
more)
9e°n
ea<i’ <,'slncl ('o-oParge of hospitals win, 100 beds a|ld
X) * Heal"’ °,fcere
strict (in.ct,a„,e df hospi,a|s up
Executive Engineer
Civil Engineer, if necessary
Equipment Engineer, if necessary
Electrical Engineer, if necessary
Draftsman, if necessary
Project Account
Clerks
Public Works Department (only supervision)
Responsibilities:
- Reports directly to the project director
anS equSer
a" ,he
to be renovated, extended
District Health Committee
Members:
S?nrFQeCUt,Ve OffiCer' 21,3 Par'Shad
District Surgeon
District Health Officer
Superintending Engineer
Responsibilities:
- Maintenance of equipment
- Waste management
- Training of technical staff
- Quality assurance
charges
t
5i
w
C
'J
J
Project Management Consulting Services
Responsibilities:
- Supports the project director and the project team;
- Assist in the final design of the facilities and supervision of
implementation;
- Co-ordinates with the Project Co-ordinator, Project Administrator and
Project Director the technical assistance;
- Approves project expenses in coordination with the project co-ordinator
or project director depending on the amount;
- Sub-contracts local architects and engineers for detailed planning.
G^ov
Secretary to the
Government of Karnataka
Department of Health and Family Welfare
Bangalore / India
officer In charge:
our ref.:
extension:
Date:
Ms. Jungling
Jun
3187
16- Of - 9-7
L lll/a German Financial Cooperation with India
Financial Contribution of DM 23 million for Upgrading Secondary Level Health
Care Facilities in Karnataka, Phase INo.: 95 66 944
Dear Sirs,
¥-
i
With the Rinsincwg Agreement dated
——— entered into between India
("Recipient") and Kreditanstalt fur Wiederaufbau ("KfW"), the parties to said Agreement
aim to improve the quality and efficiency of the secondary level health services in the
Gulbarga Division through Upgrading of Secondary Level Health Care Facilities . The
funds shall be used primarily for the rehabilitation and extension of Secondary Level
Hospitals in the Gulbarga Division, for the construction of staff housing units and waste
disposal units, for drugs, consumables, medical equipment, vehicles and for the
construction and equipment of four maintenance units. The overall project aim is to
improve the health status of the rural population in the Gulbarga Division, especially
women and children, by reducing infant mortality and the mortality rate of mothers and
children.
ecr
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u'e remaining divisions or me oiaie or ixarnaiaxa ano win prcvioe iecnmcji assistance
for the whole State.
«
In accordance with the Rneeetng Agreement the following shall be determined by
separate agreement:
Pursuant to Article 1.2:
the details of the Project as well as the goods and services to be financed from
the financial contribution;
Pursuant to Article 2.1:
the disbursement procedure, in particular the evidence proving that the disbursed
financial contribution amounts are used for the stipulated purpose;
Pursuant to Article 4.2:
the details pertaining to Article 4.1 (Project Implementation)
\Ne propose that the following be agreed upon:
1.
Details of the Project and Specification of the Goods and Services
1.1
According to the documentation at KfW's disposal and the negotiations held
between KfW and the Project Executing Agency, the Project comprises the
following measures at the estimated costs so far used as basis:
3
Upgrading Secondary Health Care Facilities in Karnataka, Phase I
Measures
Total
Local
Foreign
Financial
Costs
Costs
Exchange
Contribution
Rs.
Rs.
Costs
Rs.
DM.
(Million)
(Million)
Rs.(Million)
(Million)
(Million)
277.20
233.2
44.00
244.20
11,1
a) Construction
154,00
154.00
154.00
7,0
b) Medical Equipment,
114.40
70.40
81.40
3,7
Rehabilitation of
Secondary Level Health
Institutions____________
44.00
Medicines__________
c) Vehicles
8.80
8.80
0.4
24.20
8.80
24.20
24.20
1,1
Maintenance Facilities
33,00
33.00
13.20
0,6
Waste Disposal Facilities
19.80
19.80
17.60
0,8
Management4nformation-
4.40
4.40
17.60
17.60
96.80
63.80
88,00
4,0
33.00
1.5
Rehabilitation of two
District Hospitals
System and Surveillance
s SC/ST/Women__________
if
; Project Management
a) Consultant Services
33.00
b) Fees for design
13.20
13.20
13.20
0,6
j c) PMC____________
50.60
50.60
41.80
1,9
j Price and Physical
118.80
118.80
118.80
5,4
i
------------------------- ——-------------- —
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—------------------------
.
-------------------- —
33.00
| Contingencies__________
Price Contingencies______
I Physical Contingencies
52.80
52.80
52.80
2,4
66.00
66.00
66.00
3,0
TOTAL
591.80
514.80
506.00
23,0
*)
77.00
conversion at an exchange rate of 1 DM 3 22Rs
Should any major changes emerge in the measures stated in the above list of
project measures or in the cost estimates, KfW shall be informed without delay.
Execution of such measures may commence only on the basis of revised
planning and upon KfWs prior consent.
o .. :~r-z. •
z
4
The list of the goods and services to be financed from the financial contribution
shall be prepared on the basis of the contracts concluded for such goods and
services. New contracts shall be summarised in quarterly summary statements
of contracts (Statement of Contracts) concluded according to standard form in
Annex 1. Evidence of the compliance of all contracts with the Financing
Agreement, this Separate Agreement and the agreed Standard Form of
Contracts shall be checked and certified by the Consultant (see section 3.5).
KfW reserves the right to have ail original contracts submitted for inspection at
any time.
For Programme measures to be executed on force account a schedule of the
force-account measures, broken down by main cost categories ("Schedule of
Force-Account Measures") shall be prepared. Costs incurred for general
administration in connection with force account work must not be included in
this Schedule of Force-Account Measures. After review of the Statement of
Contracts and the Schedule of Force-Account Measures, KfW shall transmit to
the Project-Executing Agency numbered letters stating the amounts it has
reserved for financing from the Financial Contribution and shall send it the "List
of Goods and Services", supplemented from case to case.
1.3
When concluding contracts for goods and services to be financed from the
financial contribution, the Project Executing Agency shall observe the following
principles:
a)
The payment conditions of the contract must be in line with commercial
practice.
b)
To safeguard the advance payments and the due performance of the
contracts, the contracts shall provide for the appropriate advance
payment guarantees and performance bonds to be given by banks or
insurance
companies.
Said
guarantees
and
bonds
shall
be
denominated in a freely convertible currency if and to the extent that
foreign exchange costs are to be financed.
c)
As no import duties may be financed from the financial contribution
pursuant to Article 1.3 of the Financing Agreement, such import duties,
if part of the contract value, shall be stated separately in the contracts
for the goods and services and in the invoices.
d)
It shall be ensured that the goods to be financed from the financial
contribution are insured adequately and to the customary extent
5
against risks occurring during transport and project implementation
so that their replacement or restitution is possible. Said insurances
shall be concluded in a freely convertible currency to the extent
that foreign exchange costs accruing to the Project Executing
Agency are to be financed.
e)
If payments due under the contracts for goods and services are to be
made from the financial contribution, said contracts shall include a
provision stipulating that any reimbursements, guarantee or similar
claimable payments and any insurance payments shall be made for
account
of
the
Project
No. 500 204 00 with the
Executing
Agency
Landeszentralbank,
to
KfWs
account
Frankfurt am Main
(BLZ 500 204 00), with KfW crediting such payments to the account of
the Recipient. If such payments are made in local currency they shall
be remitted to a special account of the Project Executing Agency in
Indian Rupees, which may be drawn on only with the consent of KfW.
Such funds may be re-utilized in accord with KfW for the execution of
the project.
2.
Disbursement Procedure
The disbursement procedure shall be governed by the "Guidelines for the
Disbursement of Funds of Financial Cooperation and Comparable Programmes
by KfW', which form an integral part of this Agreement and by the following
special provisions:
The payments for the Consultant shall be effected in conformity with Para 6 of
the Agency Contract enclosed as Annex 4.
For the measures specified in Section 1.1 of this Separate Agreement
(Purpose) disbursement will be made under the Disposition Fund Procedure up
to the amount of
DM 23.0 million
reduced by the costs for the consultant (p. 3, Project Management, Consultant
Services) and other foreign exchange costs.
These funds are intended for the financing of local costs. For this purpose a
6
special account (Special Account) will be opened in the name of the
Department of Health and Family Welfare, Govtemment of
("Authorized Party").
Details are contained in item 1
Karnataka
of the enclosed
Supplementary Conditions of KfW for Payments under the Disposition Fund
Procedure. The "Supplementary Conditions" form an integral part of this
Separate Agreement and are accepted upon signing thereof.
The Project-Executing-Agency hereby requests an initial deposit of
DM 500.000.00.
as soon as the prerequisites for disbursement as defined in section 2 of the
attached "Supplementary Conditions" are fulfilled.
The presentation of evidence of the use of funds, together with the submission
of requests for replenishment (see specimen form in Annex 2 "Supplementary
Conditions”),
shall
be
effected
by
the
Project-Executing-Agency after
expenditures of at least DM 300,000.00 can be evidenced, but not later than
three months after the preceding payment. If this deadline cannot be met. KfW
will be informed immediately of the state of affairs (see item 8 "Supplementary
Conditions").
In order to ensure a synchronized beginning with the World Bank financed
project component, retroactive financing of project costs occunng on and after
December 1995 shall be allowed, provided these cost have been incurred
based on the agreed final design. Retroactive financing will be acceptable for
planning/design and urgently needed repairs up to an individual amount of DM
50,000.00 per contract and should not exceed a total of DM 500,000.00
provided the works are executed in accordance with the prescribed procedures
of the State Government. The consultant shall approve these expenditures
made by the Project Executing Agency prior to refunding.
3.
Project Implementation
3.1
The Department of Health and Family Welfare, Government of Karnataka
(Project Executing Agency) is responsible for the implementation of the Project
and shall delegate to the Project Director the authority required for day-to-day
management within the first six months after signing of this agreement The
Project Director shall then be able to decide on project expenses with the
approval of the consultant (see 3.4) upto an amount still to be determined.
Project costs exceeding these limits must be countersigned by both the project
7
administrator based in Bangalore and the consultant. The Project Executing
Agency shall pay the salaries of the project team. For details of the overall
project organisation, see Annex 3.
3.2
The timetable and the cost and financing schedule including staffing (posts
sanctioned and filled) required for the proper technical and financial
implementation of the Project shall be prepared by the Project Executing
Agency prior to the beginning of the Project and submitted to KfW for approval.
Such schedule is to show, by deadlines and amounts, the intended
chronological interrelation of the individual project measures and the resulting
financial requirements. Additionally, the Project Executing Agency shall, not
later than by the end of each calendar year, provide KfW in conjunction with the
consultant, an annual work plan setting forth the respective construction
activities and procurements under the project to be carried out during the next
following fiscal year including the budgetary allocations to be made available
for such purposes. The form of these schedules shall be agreed with KfW.
3.3
For purposes of enhancing the quality of health care services under this
Project, the Project-Executing Agency shall: (i) maintain the key headquarters
personnel appointed for purposes of implementing the Project; (ii) appoint and
thereafter maintain key additional personnel with adequate qualification and
experience; (iii) adopt, no later than six months after completion of the physical
improvements in any hospital under the Project, and thereafter implement,
staffing and technical norms acceptable to the KfW;
3.4
In order to support the Project-Exectuing Agency in the preparation,
implementation and monitoring of the projectt, an European consultant to be
shall be designated. The consultant
financed from the financial
I---------- contribution
-
shall work together with local consultant firms.
KfW will assist the Project-Executing Agency in selecting and contracting the
consultants on the basis of the Agency Contract, enclosed as Annex 4.
3.5
The tasks of the consultant shall be to review the previously prepared technical
documents and assist in the final design of the hospitals, the final lists of
procurements,
preparation
of
tender
documents
for
construction
and
procurements, evaluation of bids, proposals for the award of contracts, drafting
contracts, commissioning of deliveries and supervision of construction and
implementation. He shall be permanently based in the State of Karnataka and
may sub-contract specific services with local firms. Furthermore the consultant
8
shall assist the Project Director in the coordination of the technical assistance
provided by the World Bank in the Gulbarga Division. The consultant shall be a
member of the Steering Committee. The agreed Terms of Reference for
consultants are attached as Annex 7.
The Projecy Executing Agency shall engage local architects, engineers and
medical experts to prepare standard designs for hospitals as well as set
standards for equipments and consumables. These standards will be reviewed
by the consultant and shall be approved by KfW. The final design of
construction measures shall be based on the existing standard design but shall
allow, if required, for modifications in order to adapt the design to local
conditions and requirements. The construction services shall be locally
tendered and awarded by the Project Executing Agency in cooperation with the
consultant.
Prior to the first tender invitation the Project Executing Agency together with the
consultant shall prepare a set of Standard Tender Documents for construction
services and for equipment procurement. These Standard Tender Documents
shall be submitted to KfW for approval and shall be used for all tenders within
the Programme. The Project Executing Agency together with the consultant
shall likewise prepare a set of Standard Contracts for construction services and
for equipment procurement. These Standard Contracts shall be submitted to
KfW for approval and shall be used for all contracts within the Programme.
3.6
The procurement of goods shall be carried out through the central procurement
unit established for the implementation of the Karnataka Health Systems
Development Project II which shall function according to procurement
regulations of the World Bank.
3.7
-
The final lists of procurments for each hospital shall be based on the existing
standard lists but shall allow, if required, for modifications in order to adapt the
lists to local conditions and requirements. The contracts for goods shall be
awarded in cooperation with the consultants by way of competitive bidding in
India for lots not exceeding DM 300.000,-. For lots above this threshold , an
international bidding shall be required.
3.8
The remaining details concerning the awarding procedure and contractual
provisions are explained in the "Guidelines of KfW for procurement in the field
of Financial Cooperation".
9
3.9
"Additional Supplementary Conditions".
3.9.1
The share of non-plan and plan budgetary allocations to the health sector
relative to the overall plan and non-plan budget of the state shall be maintained
by the Government of Karnataka (GoK) each year at the Fiscal Year 1994
level;
3.9.2.
Shares of the primary and secondary levels in the total resources (plan and
non-plan) allocated for the health sector shall be increased by the GoK each
year until the year 2002;
3.9.3.
The existing regional imbalances of budget allocations of the underdeveloped
districts (including all districts in the Gulbarga Division) and tribal areas shall
be reduced by the GoK;
3.9.4.
Sufficient resources for drugs,
essential
supplies and
maintenance of
equipment and buildings shall be allocated at first referral hospitals in
accordance with the agreed norms;
3.9.6.
A minimum of 3.5 % of the equipment costs per year and 2.5 % of costs for the
physical infrastructure shall be provided as a maintenance budget.
3.10
The Project Executing Agency shall report to KfW quarterly on the progress of
the Project. Until further notice, the Project-Executing Agency shall report to
KfW quarterly on the progress of the Programme. Prior to submission of the
first report , the Project Execution Agency together with the consultant shall
prepare a reporting form, which shall cover the points stated in the list attached
hereto (Annex 8) and submit it for approval to KfW. The first such report shall
be prepared as of March 31, 1997. The reports shall be countersigned by the
consultant and submitted to the KfW not later than 6 weeks after the end of
each reporting period.
After completion of the Programme, the Project-Executing Agency shall report
on its further development. KfW shall in due course inform the ProjectExecuting Agency separately about the details, particularly the period, to be
reported on.
3.11
The Projecy Executing Agency shall send KfW all such documents as are
10
necessary for KfW to give the aforementioned comments and approvals earl
enough to allow reasonable time for examination.
3.12
If sign boards relating to the Project are set up they will read as follows:
"A Development Project of Government of Karnataka, co-financed by th
Federal Republic of Germany through Kreditanstalt fur Wiederaufbau."
Following notification by the German Embassy, the Project Executing Agenc
shall ensure that the project seal will be placed on the project sign board.
I
4.
Miscellaneous Provisions
The above provisions may be amended or modified at any time by mutua:
consent if this should appear useful for the implementation of the Project or the
execution of the Financing Agreement. In all other respects, the provisions of
I
I
Articles 5.2 and 7 of the Financing Agreement shall apply to this Agreement
accordingly.
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Director uf necdth ex, Faniiiy Welfare Serv;' es,
Juiy 25th 2001.
I
1
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Vac.Prev.Dise
\/ACGiNE PREVENTABLE DISEASES
The Vaccine Preveritable diseases covered by DIP are
1. Diphtheria
2. Whooping cough
3. Tetanus
4. Tuberculosis
5. Polio
6. Measles
Evaluation of routine immunization by the Department of Family Welfare
Government of India (1997-98), shows that the level of fully immunized cbJldrcn for the
6-vaccine preventable diseases range from 60-80% in Karnataka.
The recent 1998-99 NITIS survey, RCF1 household surveys and Multi Indicator
cluster surveys show, that measles immunization coverage of children aged 12-23 months
was only 67% in the state and was as low as 32.5% in Gulbarga, 44% in Raicliur 57.2°6
in Bidar, and 69.3% in Bellary. The Pulse Polio Immunization Programme since 1995 lias
icduceu the iiicidcnce of Polio Cases to eight(o)at the end of 2000. lhe Campaign
approach in some places has lowered impiemeniation of other programmes including
routine immunization for other diseases. Large number of vacancies, particularly ANMs
in northern districts have a negative impact on MCH programme,
specially
immunization.
Karnataka has the lowest coverage among the cluster of four southern contiguous
states in respect of. BCG (84.8%), DPT-3 and OPV (75.2%), Measles (67.3%).
Immunization with all antigens is 60?/n. though immunization cards are available only for
41.2% of cliildren.
Antenatal women receiving 2 doses of 1.1. in Karnataka is /4.9?b (NMiS-2)
thougli. State Programme of Action Plan lor the Child (1994) targeted 10096 Coverage.
PRIMARY OBJECTIVE:
To improve the Routine Immunization Covei age to 100% and there by reduce 'die
incidence of Vaccine Preventable Diseases. (VPDs) by 2007.
SECONDARY OBJECTIVES:
fo identify gaps in tlie Routine Immunization programme and to take necessary
measures to improve routine Immunization Coverage.
Special focus to be on Taluks and Districts which have recorded poor coverage.
The following are the Districts identified for strengthening immunization coverage.
1. Gulbarga
2. Raichur
3. Koppal
4. Bellary
5. Bijanur
6. Dinar
7. Bagalkot
8. Chamaraja Nagar
FOCUSSED INTERVENTIONS:
OFFirFRi0N °F THE EXIST,’NG POSITION —
BY
DV a
1 M
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A nodal officer should be appointed in each of the Districts whose responsibility
will be to implement (he proposed interventions of this project. His fet job will be to
assess and evaluate the existing levels of immunization coverage and to identify (he
icasuns ilwic of Tills should serve as a base line fur fuither activities.
The nodal officer will be tlie manager totally responsible for implementing all the
project mderventions and lie will have control over all oilier functionaries. The number
and qualification of the District nodal officer is given in tlie guidelines.
At the Taluka level an existing Departmental officer preferably the Tah.ka health
officer will be tlie nodal person for implementation of tlie programme. He will work
under the directions of tlie District nodal officer & will be the taluka manager for
strengtliening routine immunization. A special incentive of Honorarium is proposed
subjected io satisfactory perfonnancc.
Vac.Prev.Dise
2
1. INVOLVEMENT
OF
PANCHAYATH
FHNCTIONARIFS
INTENSIVELY, ACTIVELY AT EVERY STAGE.
VERY
Sensitise the Panchayat members regarding routine immunization. Involve them
in getting all children in their area immunized with primary immunization & Booster
Doses.
I hey will be actively involved in implementation of mass immunization
campaigns. They can lunction clTcctivcly in co-ordination with the local AWW & ANM.
The Panchayat functionaries will be introduced to take the responsibility Tot organizing
routine immunization camps by providing place and other facilities required for the
programme.
2. ORIEiNTATTOiNb'TRAINLNG OF ALL ANM’s, AWW, LIT Vs MALE HEALTH
™®™S.d;^“'luNrrY I1EALTH GU1I,ES ano ivuncuayath
-*■ '-•'i iv- x rvzr iz-xxvxxoi_f •
At the beginning of the project a one-day training programme for al! health
Functionaries, AWWs & CHGs both female and male will be given about tits objectives
of the project, the interventions and the operational details. This will be conducted ai the
raiuKa/rnC revel by the nodai officer of districi/taiuka. The panchayat functionaries of
Zilla Panchayat, taluk Panchayat & Grama Panchayat will also be trained on ail aspects
with emphasis on community participation. This training will be made compulsory for
elected representatives.
lhe training process will be repeated for re-orientation every quarter.
3. PLANNING OF "MOTHER CHILD PROTECTION SESSIONS "TO COVER
backlog.
ivioincr Vziiiid protection Sessions vviii bo organized ai the PIIC level io cover
backlog every quarter.
This backlog for the quarter will be identified by the Medical Ofiiccr of Health of
the PHC by scrutinizing documents like registers, of Anganwadi centers and sub-cenircs,
and immunization cards.
Vac.Prev.Dise
3
The Grama Panchayalh will also be encouraged to keen a record of children to be
immunized and update the same at frequent intervals. This record will also be used for
identifying (lie backlog. While identifying backlog special attention is pi oposed
•
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given to the socially under privileged sciticnicnts and to nomadic and homeless.
F.fTorts will be made to identify the under privileged and nomadic tribes for belter
coverage.
4. DEVELOPMENT OP DELAYED IMMUNIZATION PROTOCOL 10
IDENTIFY LAPSES.
Thorough search will be undertaken to identify zero dose children bv the
ANM^Anganawadi workers,Pancliayat functionary and corrective measures taken.
6. STRICT DEALING OF LAPSES IN IMMUNIZATION PROTOCOLS.
7. ADEQUATE SUPPLY OF VACCINE AND OTHER LOGISTICS.
Logistics
a. Ensure adequate supply of Vaccmes/Syringes/Nccdics.
b. Strengthening cold chain by identifying and appointing reputed agencies for
annual inamieiiance coniiacts.
8. THOROUGH INVESTIGATION1 OF OCCURENCE OF ANY VACCINE
PREVENTABLE DISEASES.
9. INVOLVEMENT OF PRIVATE PRACTIONERS OF NURSING HOMES
DURING MASS CAMPAIGN ON HONORARIUM BASIS.
10. MAKE
SHIFT
ARRANGEMENTS
Oir
FI El J)
STAFF
FROM
n.Tip rnunnT totivt/'n TYTL'T'll IC'-I'd
1 '11L± Vrl 11J V/ VJAVAl ’S kJ lyjLO A JLVAV-, 1 o.
RECOMMENDED GOSDELSNES
In order to achieve near 100% coverage of routine immunization the following
gUiueliiiCS aiC iu be followed.
Annointing a Nodal Professional, preferably a postgraduate in ComtnunitY
Medicine to the following eight districts. The Officers are to be placed as follows.
Vac. Prev. Disc
A
Bijanur & Bagalkote District
Raicliui- & Koppal
Gulbarga (8 Taluks only)
Bidar + Gulbarga (adjacent 2 Taluks)
Bcllary
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Cliamarajanagar
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1'oilowing measures will be taken
immunization activities.
up on priority to Ibrtily die ongoing
1 • Filling up of all vacant pos Is of ANMs and Sfaff Nurses.
2. ANMs to work only in the field alKl no denotation.
3. ANMs to compulsorily reside at HO.
4. ANM to be pro„(M , 1K)
5- ANM .o be providcii a Mper for ass. iing
6. tare reeetee ANM P„sls bl„p „ an,„gc,Ilc,ll5
conccnied aulhorifa n,"d taw'thei^Jot,"1”1’ “‘£"“
8. insuring continuous supply of registers and formats.
9. Provide a <qualified Statistical Assistant at taluk level for data maintenance,
monitoring and analysis.
Vac.Prev.Dise
5
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NATIONAL FAMILY HEALTH SURVEY, 1998-99 (NFHS-2)
£1
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KARNATAKA
3
PRELIMINARY
REPORT
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Institute for Social and Economic Change, Bangalore
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and
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International Institute for Population Sciences, Mumbai
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April 2000
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I. BACKGROUND
3
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A.
INTRODUCTION
India’s first National Family Health Survey (NFHS-1) was conducted in 1992-93. The
Ministry of Health and Family Welfare (MOHFW) subsequently designated the
International Institute for Population Sciences, Mumbai, as the nodal agency to initiate a
second survey (NFHS-2), which was conducted in 1998-99. An important objective of
NFHS-2 is to provide state-level and national-level information on fertility, family
planning, infant and child mortality, maternal and child health, and nutrition of women
and children, and to examine this information in the context of related socioeconomic and
cultural factors. This information is intended to assist policymakers and programme
administrators in planning and implementing strategies for improving population, health
and nutrition programmes.
The NFHS-2 sample covers more than 99 percent of India's population living in 26
states. It does not cover, however, the union territories. NFHS-2 is a household survey
with an overall target sample size of approximately 90,000 ever-married women in the
age group 15-49.
NFHS-2 has been conducted with financial support from the United States Agency
for International Development (USAID) and UNICEF and technical assistance from ORC
Macro, Calverton, Maryland, USA, and the East-West Center, Honolulu, Hawaii, USA.
Thirteen field organizations were selected to collect the data. Some of the field
organizations are private sector organizations, and some are Population Research Centres
established by the Government of India in various states. Each field organization had
responsibility for collecting the data in one or more states. The Institute for Social and
Economic Change in Bangalore was selected as the field organization for NFHS-2 in
Karnataka.
An important purpose of this preliminary report is to make the basic findings of
NFHS-2 in Karnataka available to decision makers as soon as possible, in order to
maximize the usefulness of the findings. A more comprehensive final survey report for
Karnataka will be published later.
1
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II. SURVEY DESIGN AND IMPLEMENTATION
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A.
SAMPLE DESIGN
I
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The sample for the Karnataka state survey consisted of 4,273 successfully interviewed
households and 4,374 ever-married women age 15 —49. The sample selection and
implementation procedures were designed to ensure that the survey provides statistically
valid estimates for population parameters and their sampling variances.
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Reporting domains
The sample was designed to provide estimates for the state as a whole and for urban and
rural areas of the state. The sample sizes are not large enough to provide district-level
estimates.
y-
Design
M
Within each domain, the sample was selected in two stages: the-selection of primary
sampling units (PSUs)—villages or census enumeration areas—with probability
proportional to population size (PPS) at the first stage, followed by the selection of
households within each sample area at the second stage, so as to achieve a self-weighting
sample of households (i.e., so as to give every household in the domain the same chance
of being included in the survey).
I
Selection of sample areas
i
In rural areas, the 1991 Census list of villages served as the sampling frame. The list of
villages was stratified on the basis of a hierarchy of variables:
i
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•
by region, which is a grouping of districts according to their location and physical
characteristics
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within a region, by categories of village size and percentage of scheduled caste and
scheduled tribe population in the village1
I
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within each stratum, by level of female literacy in the village (obtained from the 1991
Census Village Directory)
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'Scheduled castes and scheduled tnbes arc groups that are officially recognized by the Government of India as
underprivileged.
i
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From the list so arranged, the villages were selected systematically with
probability proportional to the 1991 Census population of the village. Small villages were
linked together to form PSUs of at least 50 households. Also, sample villages with more
than 350 households were segmented and two segments per village were selected using
the PPS method.
■n
Ji
-i
The procedure was similar in urban areas. The 1991 Census list of wards was
arranged according to districts, and within districts, by level of female literacy, and then a
sample of wards was selected systematically with population proportional to size. Next,
one census enumeration block, consisting of approximately 150-200 households, was
selected from each selected ward using the PPS method.
Selection of households
.11
A mapping and household listing operation carried out in each sample area provided the
necessary frame for selecting households at the second sampling stage. The work was
carried out by 10 teams, each comprising one lister and one mapper, and the operation
was supervised by five field supervisors and two field executives. The teams were trained
from 16-24 January 1999 in Bangalore. The houselisting operation was carried out from
28 January to 31 May 1999.
The households to be interviewed were selected with equal probability from the
household list for an area, using a systematic sampling procedure. The interval applied for
the selection was determined so as to obtain a self-weighting sample of households. The
average number of households to be selected in each selected village was 35. To avoid
extreme variations in the workload, however, minimum and maximum limits of 15 and
60, respectively, were put on the number of households that could be selected from any
area.
I
'M
B.
QUESTIONNAIRES
Hl
Three types of questionnaires were used in NFHS-2: the Household Questionnaire, the
Woman’s Questionnaire and the Village Questionnaire. The overall content and format of
the questionnaires was determined in a series of workshops held at UPS in Mumbai in
1997 and 1998. The workshops were attended by representatives of a wide range of
organizations in the population and health fields, as well as experts working on gender
issues.
The questionnaires used for NFHS-2 in Karnataka were bilingual, comprising
questions in Kannada and English. The Household Questionnaire was used to list all usual
residents of each sample household plus visitors who slept in the household the night
’-i
3
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!
before the interview. Basic information collected on each listed person includes age, sex,
marital status, relationship to the head of the household, education and occupation.
Information was also collected on the prevalence of certain diseases, namely asthma,
tuberculosis, malaria, and jaundice, and on certain risk behaviours, namely chewing paan
masala or tobacco, drinking alcohol, and smoking. Further, information was collected on
the usual place where household members go for treatment when they get sick, main
source of drinking water, type of toilet facility, source of lighting, type of cooking fuel
used, religion of the head of the household, caste/tribe of the head of the household,
ownership of a house, ownership of agricultural land, ownership of livestock and
ownership of selected items. In addition, a small sample of cooking salt used by the
household was tested to see if it was fortified with iodine. The Household Questionnaire
also asked about deaths occurring to household members in the two years before the
survey. Basic information on the age, sex, and marital status of household members and
visitors was used to identify eligible respondents for the Woman’s Questionnaire.
The Woman’s Questionnaire was used to collect information from eligible women,
defined as all ever-married women in the age group 15-^19, including not only usual
residents of the household but also visitors who slept in the household the night before the
household interview. The questionnaire covered the following topics:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Background characteristics
Marriage
Reproductive history
Knowledge and use of contraception
Antenatal, natal and postnatal care
Quality of care
Pregnancy
Feeding practices for children
Immunization and the health of children
Reproductive health
Fertility preferences
Status of women
Husband’s background and woman's work
Acquired immune deficiency syndrome (AIDS)
F'
II
Ip
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If
LIT.
In addition, the health investigator on each survey team measured the height and weight
of each respondent and each of her children bom since January 1996. The height and
weight information is useful for assessing levels of nutrition prevailing in the population.
The health investigators also took blood samples in order to assess the haemoglobin level
of the respondent and each of her children bom since January 1996. This information is
useful for assessing prevalence rates of anaemia among women and children.
4
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DSF
i'S-
i
Haemoglobin
Haemoglobin levels
levels were assessed in the field at the end of the interview using the
portable HemoCue System, which provides test results iji less than one minute. Severely
anaemic persons received immediate referral to local medical authorities for treatment.
<3
C.
'■’3
“3
L
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E
5
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;-3
TRAINING AND FIELDWORK
Training of field staff for the main survey was conducted in Bangalore. The training was
conducted by officials of the Population Research Centre at the Institute for Social and
Economic Change, who were themselves trained in a Training of Trainers Workshop
conducted earlier by UPS. The training in Bangalore consisted of classroom training,
general lectures, and demonstration and practice interviews, as well as actual field
practice and additional training for field editors and supervisors. Health investigators
attached to interviewing teams for height and weight measurements and anaemia testing
were given additional specialized training in a centralized training programme conducted
by UPS in collaboration with the All India Institute of Medical Sciences (AIIMS), New
Delhi. The training included not only classroom training but also extensive field practice
in schools, anganwadis, and communities.
The main fieldwork for NFHS-2 in Karnataka was carried out by four interviewing
teams, each of which consisted of one field supervisor, one female field editor, four
female interviewers, and one health investigator. The fieldwork was carried out between
21 February 1999 and 31 July 1999. Monitoring and supervision of the data collection
operations were carried out by the coordinators and senior staff of the Population
Research Centre at the Institute for Social and Economic Change. UPS also appointed one
research officer who was assigned to help with the monitoring throughout the training and
fieldwork period, in order to ensure that correct survey procedures were being followed
and the quality of the data was being maintained. From time to time, project coordinators,
senior research officers and other faculty members from UPS, as well as staff members
from ORC Macro and the East-West Center, also visited the field sites to monitor the data
collection operation. The work of the health investigators was monitored separately by
medical health coordinators appointed by UPS. The data were quickly entered into
microcomputers and field-check tables were produced to enable timely checks for certain
commonly occurring errors in eliciting information and filling out questionnaires.
Information from the field-check tables was fed back to the interviewing teams and their
supervisors in the field so that they could improve their performance if needed.
D.
DATA PROCESSING
All completed questionnaires for NFHS-2 in Karnataka were sent to the office of the
Institute for Social and Economic Change in Bangalore for data processing. This
processing consisted of office editing, coding, data entry and machine editing. The data
5
I
p^1
I
were processed using five microcomputers in conjunction with the data entry and editing
software known as the Integrated System for Survey Analysis (ISSA). Data entry was
done by four data entry operators under the supervision of senior staff at the Population
Research Centre at the Institute for Social and Economic Change who were trained at a
data processing workshop in Mumbai. Data entry and editing operations were completed
by October 1999. The tables for the preliminary report were produced at UPS, Mumbai.
E.
■-
SAMPLE IMPLEMENTATION
Basic features of the sample are summarized in Table 1. A total of 133 PSUs were
selected, of which 41 were urban and 92 were rural. A total of 4,273 households and
4,374 eligible women were interviewed. The average number of women interviewed per
PSU was 37 in urban areas, 31 in rural areas and 33 overall.
Table 1 also shows response rates for the household interview and the woman’s
interview, as well as the overall nonresponse for the survey. Nonresponse can occur at the
stage of the household interview, and subsequently, at the stage of the woman’s
interview. The last row of the table shows the overall effect of nonresponse at the two
stages. The survey succeeded in achieving a fairly high overall response rate of 92 per
cent. The overall response rate is lower (90 per cent) in urban areas than in rural areas (93
per cent).
Table 1 Sample results
Number of Primary Sampling Units and sample results for households and ever-married women age 15-49, Karnataka, 1999
Result
Urban
Rural
Total
41
92
133
Number of households interviewed
1,552
2,721
4,273
Number of eligible women interviewed
1.504
2.870
4.374
Average number of interviewed women per PSU
36.7
31.2
32.9
Household response rate
96.0
97.8
97.1
Individual response rate
93.5
95.3
94.7
Overall response rate
89.7
93.2
91.9
Number of Primary Sampling Units (PSU)
Note: Eligible women are defined as ever-mamed women age 15-49 who stayed in the household the night before the
interview. This table is based on the unweighted sample.
6
■g-ITJS**-’
|
3-
III. RESULTS
3
3
A.
HOUSEHOLD CHARACTERISTICS
3
3
3
3
3
3
'3
"3
A sociodemographic profile of the household sample covered in NFHS-2 in Karnataka is
presented in this section. Table 2 shows the distribution of the usual-resident household
population based on the weighted sample by selected characteristics, namely age, sex,
marital status, female education and male education. There are 22,554 persons in the
weighted sample2.
The age distribution of the household population shows that the child population
(0-14 years) is proportionately larger in rural areas (34 percent) than in urban areas (29
percent). This is as expected, because of higher fertility in rural areas than in urban areas.
The overall sex ratio for Karnataka is 983 females per 1000 males. The sex ratio is 996 in
rural areas and 960 in urban areas. A lower sex ratio in urban than in rural areas may
result from the disproportionate migration of males to urban areas.
3
:^3
-3
-3
-’3
‘■3
-3
-3
■'3
The data on marital status show that among women age 15 years or older, 66
percent are currently married, 15 percent are widowed, 2 percent are divorced, separated,
or deserted and 18 percent have never been married. A negligible percentage of women
are married but have not had gauna performed (less than 1 percent). The percentage of
never married women is lower in rural areas than in urban areas, as expected, since rural
women tend to marry at a younger age than urban women.
The data on educational levels of the population age six and above show that the
proportion of females who arc illiterate (45 percent) substantially exceeds the proportion
of males who are illiterate (26 percent). For both males and females, literacy levels arc
substantially higher in urban areas than in rural areas. The proportion of females who
have completed at least high school is more than three times as high in urban areas (30
percent) as in rural areas (8 percent).
,z:3
-3
*
3
3
3
■ The sample is designed so (hat the weighted total sample size is the same for households and women as the unweighted
total sample size. This equality does not generally hold, however, for subgroups of the population.
3
: J
7
•
*
Table 2 Background characteristics of the household copula lion
Percent distribution of the usual-resident household population in the survey by background characteristics.
Karnataka. 1999
Background characteristic
Urban
Rural
Total
Total population
8.4
9.7
10.8
11.1
10.5
9.2
■7.5
7.3
5.5
5.4
3.7
3.3
2.8
4.8
7.832
10.0
11.8
12.2
10.9
8.9
8.0
6.4
6.5
5.1
4.7
3.6
3.0
3.5
5.5
14.723
9.4
11.0
11.8
11.0
9.5
8.4
6.8
6.8
5.2
4.9
3.7
3.1
3.2
5.2
22.554
Sex
Male
Female
Total population
51.0
49.0
7.832
50.1
49.9
14.723
50.4
49.6
22.554
960
996
983
Marital status of women age 15+
Currently married
Married, gauna not performed
Separated
Deserted
Divorced
Widowed
Never married
All women age 15*
63.7
0.2
08
0.1
0.3
13.5
21.3
2.731
66.5
0.3
1.3
0.6
0.2
15.9
15.3
4.842
65.5
0.2
1.1
0.5
0.2
15.0
17.5
7.573
Female education*
Illiterate
Literate. < primary school complete
Primary school complete
Middle school complete
High school complete
Higher secondary complete and above
All females age 6+
25.9
14 3
19.2
10.9
14.8
14.9
3.439
54.7
15.8
15.1
6.1
5.7
2.6
6.442
44.6
15.2
16.6
7.8
8.8
6.9
9.881
Male education1
Illiterate
Literate. < primary school complete
Primary school complete
Middle school complete
High school complete
Higher secondary complete and above
All males age 6*
12.1
14.6
18.6
12.6
18 5
23.5
3.573
33.6
19.1
20.3
9.8
9.5
7.6
6,456
25.9
17.5
19.7
10.8
12.8
13.3
10.029
Age
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Sex ratio (females per 1,000 males)
Note: This table and all subsequent tables are based on the weighted sample.
’ In this report, “primary school complete’ means 5-7 completed years of education, “middle school complete”
means 8-9 completed years of education, “high school complete' means 10-11 completed years of
education, and “higher secondary complete and above- means 12 or more completed years of education.
8
f•
B.
I
CHARACTERISTICS OF RESPONDENTS
Table 3 shows the distribution of respondents (ever-married women age 15-49 years who
stayed in the household the night before the interview) by selected background
characteristics. The age distribution of respondents shows that 47 percent of respondents
in Karnataka are below age 30 and 22 percent are above age 39. Out of 4,374 women
interviewed, 92 percent are currently married, 6 percent are widowed, and 3 percent are
divorced, separated, or deserted.
I
Table 3 Background characteristics of respondents
Percent distribution of ever-married women age 15-49 by background characteristics, Karnataka. 1999
Background charactenstic
I
Urban
Rural
Total
Number
of women
6.1
9.8
17.8
19.7
16.5
14.4
12.2
9.6
427
777
863
721
631
534
419
91.8
1.8
0.7
0.2
5.5
4,015
80
29
7
242
726
1,296
254
2,097
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
15.6
20.5
18.0
15.4
13.3
11.0
11.7
18.9
19.3
15.7
13.9
11.6
8.8
Marital status
Currently mamed
Separated
Deserted
Divorced
Widowed
93.1
1.6
0.2
0.3
4.8
91.1
1.9
0.9
0.1
5.9
Employment status
Workihg in family farm/business
Employed by someone else
Self-employed
Not worked in last 12 months
Missing
5.4
17.4
7.8
69.4
0.1
22.6
16.6
36.2
4.8
36.5
0.0
29.6
Education
Illiterate
Literate. < primary school complete
Primary school complete
Middle school complete
High school complete
Higher secondary complete and above
31.7
3.7
17.3
9.5
19.2
18.6
67.7
4.8
12.7
5.0
6.6
3.1
55.2
14.3
6.6
11.0
8.5
2.414
192
626
289
482
371
Number of women
1.523
2.851
4,374
4,374
5.8
47.9
0.0
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Table 3 also shows that more than half (52 percent) of ever-married women in
Karnataka are doing work other than their own housework. Among all women, 17 percent
work either on a family farm or in a family business, 30 percent are employed by
someone else, and 6 percent are self-employed. The proportion working is much higher in
rural areas (63 percent) than in urban areas (31 percent); Jiowever, the proportion of
employed women working for someone else is the same (57 percent) in both urban and
rural areas.
? ■
9
J
is
areas and only 10 percent in rural areas.
c.
I
!
WOMEN’S AUTONOMY
NFHS-2 also provides information on selected indicators of women’s autonomy and
s a s. he indicators in Table 4 pertain to women’s participation in household decision
making freedom of movement and access to money. Only 8 percent of respondents are
not involved in any household decisionmaking at all. Regarding participation in particular
types of decisions, 88 percent are involved in decisions about cooking, 49 percent in
decisions about their own health care, 47 percent in decisions about purchases of
jewellery and other major items, and 45 percent in decisions about going to stay with
parents or siblings. Regarding freedom of movement, 43 percent of respondents do not
need permission to go to the market, and 34 percent do not need permission to visit
relatives
-J or friends. Sixty-seven percent of the respondents are allowed to have at least
some money that they can spend as they wish.
I
f
Table 4 also shows differences in women’s autonomy by background
characteristics. In general, autonomy as measured by women’s participation in
decisionmaking, freedom of movement and access to money, increases with age. A higher
percentage of urban women than rural women are involved in all types of
decisionmaking. Urban women, also have substantially greater freedom of movement and
greater access to money compared to rural women. According to employment status, it is
only women who are self-employed who consistently have greater autonomy than women
m other employment categories. With the exception of participation in decisions about
cooking, participation in all other types of decisions tends to increase with education.
Also educated women have greater freedom of movement and access to money than less
educated women. Sikh women are more likely than Hindu or Muslim women to
participate in each of the different decisions, to have freedom of movement and access tb
money. Participation in any decision making does not vary much by castc/tribc status;
however, women belonging to the scheduled tribes are less likely than other women to
have access to money, and scheduled caste women are less likely than other women to
participate in most decisions and have lower freedom of movement.
I
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Table 4 Women's autonomy
Percentage ot ever-married women involved in bousehotd ^.onma^ percentage of women with freedom of movement and
■t.
percentage of women with access to money by background charactensbcs. Karnataka.
■
1
5
3
9
a
a
a
3
3
3
3
3
3
3
3
2
3
3
Background characteristic
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Residence
Urban
Rural
Employment status
Working in family
farm/business
Employed by someone
else
Self-employed
Not worked in last 12
months
Percent
age not
involved in
any
decision
making
Percentage who
do not need
permission to:
Percentage involved in
decisionmaking about
2
Cook
ing
Own
health
care
Pur
chase of
jewellery,
etc.
Staying
with
parents/
siblings
Go to
the
market
Visit
friends/
relatives
Percent
age with
access to
money
Number
of
women
20.7
13.6
7.9
5.4
4.4
1.9
3.8
70.5
81.4
88.8
92.6
93.7
96.0
93.7
35.1
38.9
46.5
52.5
57.1
594
58.2
35.4
36.4
44.5
48.6
55.9
57.7
56.8
35.3
35.2
42.3
45.2
52.0
52.5
52.5
26.1
34.4
41.0
45.1
48.6
54.8
53.5
21.4
28.3
32.7
32.7
39.6
46.6
41.6
46.6
62.3
67.1
68.7
72.0
75.8
74.4
427
777
863
721
631
534
419
6.9
8.8
89.1
88.1
55.5
45.9
54.4
43.5
50.7
41.1
52.9
37.7
41.2
30.7
79.5
60.3
1.523
2.851
86.5
49.0
46.8
43.0
39.4
33.8
60.4
726
10.3
6.1
4.3
90.7
91.3
49.3
59.0
48.4
56.3
45.8
57.1
41.3
54.3
33.7
44.6
63.4
80.4
1,296
254
87.3
48.1
45.6
42.6
43.9
33.7
69.9
2.097
9.1
Education
Illiterate
Lit.. < middle school
complete
Middle school complete
High school complete
and above
89.3
45.7
44.0
40.9
38.6
31.3
59.9
2.414
8.0
6.8
11.1
89.5
84.5
52.3
52.1
48.6
50.3
45.7
47.1
41.7
45.9
32.4
32.7
68.3
72.9
818
289
8.9
86.1
55.4
54.3
52.4
55.7
45.3
83.7
853
Religion
Hindu
Muslim
Sikh
Other
8.1
9.2
4.8
(6.0)
88.4
87.3
91.3
(91.1)
49.7
42.3
60.3
(68.9)
47.2
44.5
57.9
(62.9)
44 4
40.9
59.2
(56.9)''
44.6
26.7
56.7
(57.6)
35.4
23.1
43.4
(54.7)
66.9
62.0
86.5
(83.2)
3.741
492
105
35
Caste/tribe
Scheduled caste
Scheduled tribe
Other backward class
Other'
Missing
8.4
7.1
7.4
8.8
(18.2)
88.9
88.6
89.2
87.6
(75.8)
43.4
46.6
52.9
48.4
(38.6)
43.2
43.9
49.8
46.9
(40.5)
39.5
42.7
47.2
44.2
(34.4)
38.7
46.2
45.1
42.1
(38.4)
32.3
35.4
35.0
34.4
(34.4)
64.4
53.8
67.9
69.7
(54.7)
704
252
1.809
1,559
49
43.0
34.3
67.0
4.374
5
Total
3
employment status, who is not shown separately.
Note: Total includes 1 woman with missing information on
'Wom7ndwho2^no't't>ek>nSttodaCscf>eduled caste, a scheduled tnbe. or an other backward dass
8.1
83.4
49.3
47.3
44.5
I
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3
3
3
3
11
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D.
1
FERTILITY AND REPRODUCTIVE PREFERENCES
Fertility levels have been estimated from the birth history data collected for each eligible
oman in the survey. The fertility estimates pertain to the three-year period immediately
mmristi6 ,SUtn'eypVhlch’ in Kamataka, corresponds roughly to the period from 1996
in Table 5 and Figure 1.
tOta^
8
I
i
I
rates (TFR) are shown
4
wom
h
u eStlrnate Of the TFR for the state as a whoIe is 2.13 children per
exnerie’
°f Ch'ldren that WOuld be bom t0 a woman if s^e
expenenced current age-specific fertility rates (for the three-year penod before the
'I16
hCr reProductive years> ag« 15-49. The NFHS-2 estimate
TFR is lower than the Sample Registration System (SRS) estimate of 2 5 children
schedule o/fe^lT^
eStimateS for the years 1996 and 1997. Under the age
estlmated from NFHS-2 in Karnataka, a rural woman would have, on
erage, 0.36 children more in her childbearing years than an urban woman.
II
EI
I
I
I1'
able 5 also shows how fertility changed between NFHS-1 and NFHS-2. Over the
year period benveen the two surreys, fertility has declined in Karnataka from 2.85
"nowT F
■0f92 ;° 2-13 In 1996~98- AH age groups in both urban and rural areas
□now declines in fertility, except the age groups 40-44 in urban areas and 45-49 in rural
below
|°
g
Nf;HS-2, fertility in urban areas (TFR=1.89) in Karnataka is now
replaceXueTe?'
’
k1"’1'17 *" H areas (TFR=2-25) has yet to reach
r.
Table 5 Current fertility
Age-specific and total fertility rates (TFR) for the
three-year period preceding the survey. NFHS-1 and NFHS-2. Karnataka
V'
Age-speafic fertility rates
Urban
15-19
20-24
25-29
A
Rural
I:
Total
NFHS-1
1990-92
NFHS-2
1996-98
NFHS-1
1990-92
NFHS-2
1996-98
NFHS-1
1990-92
NFHS-2
1996-98
0.094
0.169
0.127
0.057
0.020
0.069
0.160
0.091
0.042
0.010
0.005
0.147
0.226
0.138
0.069
0.026
0.009
0.002
0.135
0.180
0.089
0.033
0.129
0.206
0.112
0.172
30-34
35-39
40-44
45-49
0.002
0.009
TFR 15-49
2.38
1.89
TFR 15-44
2.34
1.89
0.009
0.002
0.002
0.134
0.064
0.024
0.006
0.005
0.003
0.001
3.08
2.25
2.85
2.13
3.07
2.24
2.83
2.12
0.090
0.037
0.009
f:
Ii
r
lt
T
12
J
T
i S
5F:Sr
3
"3
3
The age pattern of fertility reveals a peak in the age group 20-24 years. This is true
for both urban and rural areas. Fertility shows a sharp decline beyond the age of 25 years.
The age-specific fertility rates are higher in rural areas than urban areas for the younger
age groups (below 25 years), but lower in rural areas than urban areas for most of the
older age groups. The contribution to fertility by older women (particularly by women
age 35 years or older) is marginal in both urban areas and rural areas. Specifically the
proportion of total fertility due to fertility at ages 35 and older is 4 percent in urban areas
and 3 percent in rural areas.
“3
3
’3
c
3
3
3
3
3 '
3
<D
150 -
E
o
£
o
o
o_
100 -
O
Q.
W
x:
.•E
CD
50 -
0 4
15-19
“
'
20-24
-
-------------------- ------------------- 4
30-34
25-29
3
3
3
3
5
3
Z
3
45-49
Urban ~*~Rural|
Note: Rates are for the three years
preceding the survey
NFHS-2, Karnataka. 1999
Future fertility preferences of currently married women, by the number of living
children that a woman has, are shown in ~
Table 6 and ~
Figure 2. Overall, 15 percent of
women do not want
any
more
children,
and
.
,
1 an additional 58 percent cannot have another
child because either the wife or the husband has been sterilized or the woman says she
cannot get pregnant. Only 26 percent of all women say they would like to have another
child, and of those who do want another child 46 percent want to wait at least two years
before the birth of the next child. The results also show that the desire to stop
childbearing increases rapidly with the number of living children. Only 9 percent of
women with no living children do not want any (more) children or cannot have children
13
3
40-44
Age
3
■)
35-39
. I
s
I
because of a sterilization
livino TmtlOn Or for Other reasons- This figure rises 1
women with two f ’
o children and 96 percent for women with fourto 84 percent for
children. A small number of wome:
or more living
havi
(more) children is up to God. --■n (0.3 percent) say that the decision about
— , ing any
!
------------------ —-—
Wmen by d“lre
cnlldren.KXUta°a.7999fren“Y
^'Wren. according to number of Wing
1
Number of living children
Desire for children
None
One
Two
Three
Four or
more
Total
Want another
Within 2 years
After 2 years
Undecided when
57.6
27.3
3.7
25.3
33.9
1.5
6.1
8.3
1.1
1.8
2.8
0.7
Undecided
1.6
1.1
0.5
2.1
12.8
11.7
1.2
2.6
0.7
0.3
0.2
0.7
1.0
0.2
0.1
0.2
0.8
3.2
0.3
23.3
19.7
9.7
15.1
15.3
0.5
8.6
60.4
80.1
71.0
52.2
43
9.7
5.4
Up to God
Want no more
Sterilized
Declared infecund
4.9
3.5
Missing
0.1
Total percent
Number of women
100.0
100.0
100.0
100.0
100.0
100.0
428
662
1.137
880
907
4.015
“Less than 0.05 percent
J
I
I
j
14
-S'?-
:s >
1 I'
::
I
£ 3
Figure 2
£ 1
Fertility Preferences Among Currently
Married Women Age 15-49
Other
7%
t
Er- 5
Want another within
2 years
F
13%
Want another after
2 years
12%
Sterilized
52%
?’r 5
Want another,
undecided when
1%
\|
Want no more
15%
'•■'5
NFHS-2, Karnataka, 1999
E.
I
FAMILY PLANNING
via . J]
L.
u
In NFHS-2, women were ;asked about their knowledge of specific contraceptive methods
and whether they had ever
-r used each of the methods they knew about. In addition, they
were asked
whether
they
•
nr
’ were currently using a method, and, if yes, which method thev
caTth™8' Om,C2. We? alS0 asked about their source of contraceptives and the kind of
re they received from health and family planning workers.
Knowledge of family planning
IZZ'E? “rr"
thal methoT1^ ab°Ut
NFHS'2 "'°mi,n'S
»=re asked
aWare’ She W3S asked if she had ever uscd
3 W°man
Table 7 and Figure 3 contain information on currently married women’s awareness
and use of specific methods. Knowledge of at least one modem method of family
planning (either spontaneously or after probing) is almost universal in urban areas as well
as in rural areas.
15
I
Table 7 Knowlgrinp
—■—
;
ever use and current
. ever use and current use of family
Percentage
who know
method
Contraceptive method
99.7
Modern method
Pill
IUD
Condom
Female sterilization
Male sterilization
1.418
Traditional method
Rhythm/safe period
Withdrawal
Other method'
Number of women
3.4
3.1
0.3
0.2
0.1
1.418
99.2
99.1
61.1
68.0
37.8
98.7
71.0
. 33.9
33.7
3.3
Other method1
Modern method
Pill
IUD
Condom
Female sterilization
Male sterilization
6.4
5.6 s
1.4
1.418
RURAL
Any method
Any method
56.4
1.0
5.0
2.4
47.1
0.9
1.1
Number of women
59.9
62.3
5.4
14.5
5.4
47.1
1.1
. 56.6
55.8
17.7
Other method’
Number of women
65.4
99.7
83.3
86.0
75.3
99.4
86.7
Traditional method
Rhythm/safe period
Withdrawal
Traditional method
Rhythm/safe period
Withdrawal
Percentage
currently
using method
URBAN
Any method
Modern method
Pill
IUD
Condom
Female sterilization
Male stenlization
Percentage
who ever used
method
59.0
57.4
58.1
1.9
4.3
0.9
53.9
0.5
56.6
0.4
1.5
0.3
53.9
0.5
2.1
1.9
0.4
1.1
2.597
0.7
0.6
0.1
0.4
0.1
2.597
2.597
TOTAL
99 4
61.3
58.3
99.3
69.0
74 4
51.1
99.0
76.5
59.6
3.1
7.9
2.5
51.5
0.7
56.5
0.6
2.8
1.0
51.5
0.7
. 41.9
41.5
8.4
3.7
3.2
0.7
1.1
0.3
i
r
1.7
1.5
0.2
0.1
4.015
4.015
4.015
'“Other method’, v.—.,,, U1
which in the questionnaire was a write-in (not pre-coded) category, may be"
either modem or traditional.
r
i
I
16
IJi
Figure 3
Knowledge and Use of Family Planning Methods Among
Currently Married Women Age 15-49
sE 100
100
99
o
$
I 80
CO
S
5
59
60
57
o 40
e'-
F1’
o
§ 20
Q.
0
X
Urban_______________________________ Rurai
[ aKnowledge
DEveruse
£
F
F
DCurrent use |
NFHS-2, Karnataka, 1999
_______ —_ _______
Women are most familiar with female sterilization (99 percent), followed by male
sterilization (77 percent), the IUD (74 percent), the pill (69 percent) and then the condom
(51 percent). Each of these methods is known by at least 75 percent of women in urban
areas and 61 percent of women in rural areas, except for the condom, which is known by
only 38 percent of women in rural areas. At least one traditional method of contraception
is known by 42 percent of women overall, 57 percent of women in urban areas and 34
percent of women in rural areas. The rhythm/safe period method is better known than
withdrawal.
-L_
Dll -1
E
L
Ever use of family planning
rat.J
IEI__ J
Among currently married women age 15-49 in Karnataka, 61 percent have ever used a
contraceptive method: 60 percent have used a modem method and 4 percent have used a
traditional method. Among modem methods, female sterilization is the most popular (52
percent), followed by the IUD (8 percent). The pill and the condom have each been used
by 3 percent of currently married women. Male sterilization is the least popular (1
percent). Among traditional methods, 3 percent of respondents have used the rhythm/safe
period method, and 1 percent have used withdrawal. Ever-use of modem methods is 62
percent in urban areas and 58 percent in rural areas.
17
•
1
Current use of family planning
Regarding current use of contraception, Table 7 and Figure 3 show that 58 percent of
cu^ently married women age 15-49 are usin8
thXroTNFHS6^^
use a modem method, and 2 percent use a tradmonal method. At the time of N
.
percent of currently mamed women were using some method of contracept on 48
percent were using a modem method and 2 percent were using a traditional method. A
comparison of NFHS-1 and NFHS-2 data shows that the use of modem method
L;
(
increased by 19 percent during the 6 years between the two surveys.
In Karnataka, as in almost all other Indian states, female sterilization is the most
popular contraceptive method and is used by 52 percent of cumn^ ™f
next most popular method, the IUD, by contrast, is being used by only 3 percent ot
women Male sterilization, oral contraceptives and condoms are eac eing
y
™ than 1 percent of women. Among traditional methods the rhythm/safe penod
method is being used by 2 percent of women and withdrawal by less than 1 percent.
There are some urban-rural differences in current contraceptive use.
prevalence is only slightly higher in urban areas (60
^ndtSelJo,
though still low is substantially higher in urban areas (8 percent) than in
rural areas p perjnt). Traditional-method use is also higher in urban areas than tn ftral
areas.
P
I
II
I
Differences in rates of current contraceptive use for population subgroups arc
shown in Table 8. The overall rate of use (any method) iincreases steadily by age of
percent) and declines thereafter.
XT™"eth^^(=WS
the single ntost popular
method at all ages. Women who had completed at least high school were much.more
Uk ly to be using each of the modern spacing methods or a trad,.tonal method than
women in any other educational category, although, overall they were less My
b'
women in any other educational category
using any conception than women
£
IX
differentials in current use are found by number ot
contraception, increases steadily
g
children to 82
^ear sSom leliance on
percent for women with three living children, th
primarily
temporary methods among women with one or no hvmg child (who may be pn
y
interested^ in spac.ng children) to female sterili^.on "mo»g women w.th two
living children (who are likely to have achieved the.r destred family size).
18
i
.7
A
■ II
rRI
ii
lil
.si—'-f—rsi_ '!n_ nn__.w
—.hl—.Hi—
iii
ni
Lil
LiJ
LU
LU
LU
LU
LU
LU
LU
LU
LU
L»J
JU
Al
LU
LU
Al
L»J
A)
LU
Al
Al
LU
LU
JIJ
11J
111 ;(//
Table 8 Current use of family planning methods by background characteristics
Percent distribution of currently married women by contraceptive method currently used, according to background characteristics. Karnataka, 1999
Any
meth
od
Mod
ern
meth
od
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
5.6
36 6
66.3
77.5
76 9
72.1
63 6
Residence
Urban
Rural
Male
steri
lization
Tradi
tional
method
Rhythm/
safe
period
06
1.9
3.7
0.5
0.7
1.9
1.7
3.4
3.1
0.3
0.2
0.5
1.8
1.5
32
2.7
0.3
0.2
0.1
0.1
0.2
02
0.4
Other
meth
od ’
Not
using
any
method
Total
percent
Number
of
women
94.4
63.4
33.7
22.5
23.1
27.9
36.4
100.0
100.0
100.0
100.0
100 0
100.0
100.0
414
744
811
669
564
455
357
Pill
IUD
Con
dom
5.1
35 9
64 2
75.8
73 3
69.1
63 3
0.5
0.7
0.5
1.2
0.6
0.3
1.5
3.7
4 2
37
25
0.7
03
0.3
1.0
1.3
1.4
1 6
07
06
2.8
30 6
58 1
69 5
68 1
65 8
58 4
59 9
57.4
564
566
1.0
0.4
50
1 5
2.4
03
47.1
53 9
0.9
0.5
3.4
0.7
3.1
0.6
0.3
0.1
0.1
0.1
40.1
42.6
100.0
100.0
1.418
2,597
58.7
58.1
0.2
0.2
0.1
56.7
0.8
0.5
0.4
0.1
0.1
41.3
100.0
2,154
62.1
61.9
51.3
0.7
0.4
2.0
40
0.4
0.8
58.3
46.2
0.4
51.7
0.3
0.4
0.3
0.4
37.9
48.3
100.0
100.0
756
279
56.0
49.4
1.5
9.7
4.1
336
0.6
6.5
6.0
0.5
44.e
100.0
827
Number of living children
None
1
2
3
4+
3.1
24 0
69.0
82.1
72.9
2.1
196
67.0
81.6
71.8
0.7
0.9
0.5
0.3
0.6
0.2
78
4 4
0.8
0.1
0.7
2.3
0.1
0.7
0.7
1.2
1.0
4.4
2.0
0.5
0.8
0.7
3 7
1.9
0.5
0.8
0.2
0.8
0.1
100.0
0.3
96.9
76.0
31.0
17.9
27.1
100.0
100.0
1.6
0.4
0.2
0.5
8.4
59 7
794
698
100.0
100.0
428
662
1.137
880
907
Total 15-49
58.3
56 5
0.6
2.8
1.0
51.5
0.7
1.7
1.5
0.2
0.1
41.7
100.0
4.015
Total 15-44
57.8
55.9
0.6
3.0
1.1
50 8
0.4
1.8
1.6
0.2
0.1
42.2
100.0
3,658
Background characteristic
VO
Female
steri
lization
Education
Illiterate
Lit., < middle school
complete
Middle school complete
High school complete and
above
0.1
- Less than 0 05 percent
’ Other method', which in the questionnaire was a write-in (not pre-coded) category, may be either modem or traditional.
With
drawal
0.2
02
Source of methods
In NFHS-2, women who reported current use of a modem method of contraception at the
time of the survey were asked where they had obtained the method the last time. Results
are presented in Table 9.
Table 9 Source of modem contraceptive methods
Percent distribution of current users of modem contraceptive methods by source of method, according to specific
method, Karnataka. 1999
Contraceptive method
Source of method
IUD
Public medical sector
NGO/Trust hospital/dinic
Private medical sector
Shop
Don’t know3
50.2
Total percent
Condom
Female
sterilization
Male
sterilization
All modern
methods'
URBAN
Number of users
(9.3)
49.8
(-)
(48.7)
(36.1)
(5-9)
77.1
1.2
21.7
100.0
100.0
100.0
100.0
100.0
71
34
668
13
800
70.7
1.0
25.8
2.2
0.2
RURAL
Public medical sector
NGO/Trust hospital/dinic
Private medical sector
Shop
Don't know3
(40.0)
Total percent
100.0
100.0
100.0
100.0
100.0
40
8
1.400
13
1.470
53.7
(12-4)
89.1
0.6
10.3
(80.7)
(-)
(-)
85.3
0.5
13.1
0.9
0.1
Number of users
(60.0)
94 9
0.3
4.8
(-)
93.3
0.3
6.1
0.2
0.1
(-)
(-)
TOTAL
Public medical sector
NGO/Trust hospital/dinic
Private medical sector
Shop
Don’t know3
46.3
Total percent
100.0
100.0
100.0
100.0
100.0
Number of users
111
42
2.068
26
2.270
(-)
(46.7)
(34.0)
(7.0)
(-)
(19.3)
Note: NGO denotes a nongovernmental organization.
() Based on 25-49 unweighted cases
* Percentage not shown, based on fewer than 25 unweighted cases
- Less than 0.05 percent
'In this table, “all modem methods'* refer to the four modem methods indicated, plus the pill which is not shown
separately due to small number of cases.
2For pill and condom, includes women who say their husband or a friend or other relative obtained the method, but
they do not know the original source of supply.
20
L
I. 5
LFor Kanaka, overall, rhe majority of couples (85 percent) obta.n tteir .method
from a public-sector source. Private-sector medical institutions provide methods to
another 13 percent of users, and 1 percent of users obtain their supply from a shop and
other sources.
£5
$ 3
Substantial differentials in the source of methods are found between urbarI and
rural areas Although the public sector is the major spurcc in both urban and rural areas
93F percerh of Zl users obtain their method from a public sector source compared with
71 percent of users in urban areas. Notably, however, the private medical sector is almost
as important a source for IUDs as the public sector, in both urban and rural areas. Also
the majority of users of the condom obtain their supply from the private medical
£ 3
(47 percent) or shops (34 percent).
F> 5
Quality of family planning services
F- 3
5
One of the most important factors influencing family planning use is the quality of family
olanning services which has been receiving increasing emphasis in the govemmen
reproductive and child health care efforts. Table 10 shows, by urban-rural residence, he
peZnCof current users of contraception who were told about other methods y th
person who motivated them to use their current method. The table also shows.1he
nercentage of cunent users who were told about side effects or other problems by a heal th
or family planning worker at the time of accepting the method, and the percentage w
received follow-up services from any source after accepting the me o .
^3
I
Table 10 Quality Qf family planning services
told about other methods, who were told
5-1 3
about side effects or other problems and who
5‘-"l
Residence
I- 3
Percentage
who were toM
about other
methods by
motivator’
Percentage who
were told about
side effects or
other problems
with current
method2
Number
of
users’
12.2
5.1
342
828
38.5
35.9
81.4
82.5
800
1.470
^-2
1.170
36.8
82.1
2.270
Total
F* s
?! B
P =
F 5
£=
Number
of
users
Urban
Rural
’Excludes women who were self motivated.
time of accepting the current method
2By a health and family planning worker at the
5
Percentage
who received
follow up after
acceptance of
current
method
21
Among all current users, 7 percent were told about other methods by their
motivator. The proportion of urban women told about other methods by their motivator is
twice as high (12 percent) in urban areas as in rural areas (5 percent). Thirty-seven
percent of women were told about side effects or other problems associated with their
current method by a health or family planning worker at the time of accepting their
method, and 82 percent received follow-up services after accepting the method. These
percentages vary little by urban-rural residence.
F.
QUALITY OF CARE
Table 11 shows additional quality-of-care indicators that pertain to the last home visit by
a health practitioner or to the last visit by the respondent to a health facility during the 12
months preceding the survey, specified by source of services received (public or
private/NGO3) and by type of visit (home visit or visit to a health facility). In this table,
the visit could be for any health-related reason or for family planning or for both.
Regarding home visits, 10 percent were for family planning only, 81 percent were for
health only, and 6 percent were for both family planning and health. Eighty-nine percent
of respondents said that the health worker spent enough time with them and 79 percent
said that the worker talked to them nicely.
Regarding visits to a health facility, 99 percent were for health only, 1 percent
were for both health and family planning and less than 1 percent were for family planning
only. Almost all respondents actually received the sendee for which they went (99
percent). The median waiting before receiving service is 29 minutes and is about the same
at both public sector and private/NGO sector facilities. In all other respects, however, the
private/NGO sector facilities are rated better than public sector facilities. The proportion
of respondents reporting that the health practitioner spoke nicely to them is higher in the
private/NGO sector (80 percent) than in the public sector (68 percent). The proportion
reporting that their need for privacy was respected is also higher in the private/NGO
sector (92 percent) than in the public sector (83 percent). Finally, the proportion that rate
the facility as very clean is considerably higher in the private/NGO sector (77 percent)
than in the public sector (59 percent).
J An NGO is a nongovernmental organization.
22
i
I
1
L '
£‘2
E =
| Table 11 Quality of care
Quality-of-care indicators for last home visit/visit to a health facility within the last 12 months by
| public/pnvate source of service and by type of visit. Karnataka. 1999
£ 5
Source of most recent service received
p =;
Quality indicator
Fj-3
Percentage who received different
services
Family planning only
Health only
Both
Only other services received
9.6
81.0
5.7
3.7
9.5
81.0
5.8
3.6
Percentage who said worker spent
enough time with her
88.8
88.8
Percentage who said worker talked
to her
Nicely
Somewhat nicely
Not nicely
78.9
20.4
0.7
79.1
20.2
0.7
Number receiving home visit
744
Public sector
Private sector/NGO
Total
HOME VISIT
K
7
751
Both
0.7
98.1
1.1
0.3
99.3
0.4
0.4
98.9
0.7
Percentage who
received service they went for
98 9
99.5
99.2
Median waiting time (minutes)
29.7
29.2
29.4
Percentage who said the staff spent
enough time with her
92.2
96.8
95.1
Percentage who said staff talked to
her
Nicely
Somewhat nicely
Not nicely
Missing
68.0
30.3
1.7
80.3
19.1
0.5
0.1
75.8
23.2
0.9
Percentage who said
staff respected her need for pHvacy'
83.1
92.3
89.0
Percentage who rated facility as
Very clean
Somewhat clean
Not clean
Missing
58.9
38.5
2.5
0.1
76.8
22.5
0.7
0.1
70.2
28.4
1.3
0.1
Number visiting a health facility
1,119
1,909
3.028
VISIT TO A HEALTH FACILITY
Percentage who went for different
services
Family planning only
Health only
4a
F-'3
5-3
5^3
5-3
5-3
5;’3
5<3
Notes: NGO denotes a nongovemmenlal ofganoabon. Cases where the source of service was neither
public sector nor private sector/NGO are excluded from the table.
•Percentage not shown, based on fewer than 25 unweighted cases
'Based on women who said they needed privacy
5 ;“3
5-3
5 3
S 3
S' 2
I
23
G.
MATERNAL CARE
Safe motherhood and child survival constitute one of the most important programmes run
b "mment of India. Proper care dunng
"hKX zZon^
is crucial for the good health of both the mother and the child. In NFHS-2, respond
who gave birth to at least one child dunng the three years preceding the'
two
asked a series of questions about maternal care and sendees received for each of the t' o
most recent btrths'dunng that penod. Results from these questions are shown in Tables 12
and 13.
Table 12 shows that, by and largo, women in Karnataka
ante nata! care setvt^om“iTiX^ ^“XdimeSns during
prZnSctes hading to live births in the last three years. Sev=n«i^^c~
women received antenatal check-ups outside the home, or
pe
.
• j d t(
women visited doctors, while for another 11 percent of pregnancies they visited othe
heahh praclitioners. For 5 percent of pregnancies, women received a check-up only at
home.
Analysis of lhe data by current age of mother shows that the level of utilization of
keeping with this finding, the level of utilization
parities than among women of higher parities.
Analysis by place of residence shows that antenatal services are utilized more by
urban women than by rural women. Simi
y:
ducaled WOmen. Education is also
received antenatal care from a doctor increases from 54 percent
percent for women who have completed at least high school.
Another important aspect of-emal^ =ces is the —mtent
of institutional delivenes and conduc ing, deh
J
Qf
whem = bmlt
most recent births that occurred during the three years preceding
assisted at the delivery.
24
1
survey
I
I
■
•
■
Table 12 Antenatal carp
ys
Percentage of births whose mothers received various types of antenatal services among births in the three years preceding the
survey by background characteristics. Karnataka. 1999
Background
characteristic
Received
2 or
more
doses of
tetanus
toxoid
Received
iron and
folic add
tablets or
syrup
Received
iron and
folic add
tablets or
syrup for
3 or
more
months
Mother’s current age
15-19
20-34
35-49
69.4
76.6
(67.6)
73.6
79.4
(70.3)
68.5
76.0
(67.5)
Residence
Urban
Rural
85 1
70.3
83.4
75.6
62.4
£■ 3
F; §
I
F g
F’ 3
5’ 3
5
i
F: 3
f--
1
■
Ji
F- 3
F" 3
Received
antenatal
check-up
only
through
home
visit
Received antenatal check-up
outside home from1
Doctor
Other health
professional
Other
person
4.2
5.0
(2.6)
64.6
72.0
(62.3)
14.1
10.5
(10.6)
0.1
80.5
71.4
1.2
6.4
86.7
62.9
6.5
13.3
67.7
63.4
8.0
53.7
15.1
Number
of
births
(-)
254
989
37
0.1
398
882
Mother's education
Illiterate
Lit., < middle school
complete
Middle school complete
High school complete and
above
83.9
81.8
86.7
86.4
83.3
79.8
2.4
83.2
82.0
9.8
10.7
94.7
92.6
90.8
1.0
95.1
3.2
287
Birth order
1
2-3
4-5
6*
86.5
71.8
64 6
48.4
83.0
78.0
72.7
57.3
80.1
72.5
72.7
52.7
0.9
5.5
11.6
8.7
82.0
69.8
51.4
42.5
10.3
10.5
15.5
11.8
1.5
462
580
172
67
Total
74 9
78.0
74.2
4.8
70.3
11.2
0.1
1,280
672
0.5
211
110
Note: Table indudes only the two most recent births in the three years preceding the survey.
() Based on 25-49 unweighted cases
- Less than 0.05 percent
’Includes all women who received an antenatal check-up outside the home, even if they also received a check-up at home from a
health worker. If more than one source was mentioned, only the provider with the highest qualification is considered.
F- 3
5- 3
Ft L
J •< 3
5- I 3
Table 13 shows that 51 percent of deliveries occurred in institutions such as
government-operated district, tehsil (or taluk), town or municipal hospitals, primary
health centres, private hospitals and private nursing homes. The majority of institutional
deliveries (54 percent) were conducted in government-operated facilities, where 55
percent were attended by doctors and 45 percent by paramedical staff. By contrast, 87
percent of deliveries in private institutions were attended by doctors.
S' 3
5 3
F? 3
Noninstitutional deliveries constituted 48 percent of all deliveries. Only 17 percent
of the noninstitutional deliveries were attended by a doctor or other health professional.
The large majority (83 percent) were attended by other persons, including traditional birth
attendants, relatives or friends.
'El 3
5
25
3: I
I
background eharacLsfa
Of respondent "vX f t
urban women .han ru al
id am„
” ‘"t""'0"3 " m°re P™1™
women. Deliver, in ;„sti°S etttTa T t™'"
deliveries of women age 15-19 .oX t, " I?8'.°f
44 percent of
delivenes of women age 35J9 hot™ iZ
»i-b 57 percent of
order. Seventy percent of first births were d 1
7 ’ dC 'VeneS faI1 sharP1y
birth
percent of births at order 6 or higher.
lnst,tutI0ns compared with 21
Table 13 Assistance at delivery
"— -------- -----------------
"
I
I.
survey by place of delivery, type of ass.stance
Delivered in institution
Public
Background
characteristic
Mother's current age
15-19
I 20-34
35-49
I
Residence
Urban
Rural
Mother's education
Illiterate
Lit.. < middle school
complete
Middle school complete
I High school complete
[
and above
Birth order
1
2-3
4-5
6*
Total
Doctor
15.8
15.2
(13.6)
22.0
12.3
Not delivered in institution
Doctor
Other
Doctor
Other
health
profes
sional
13.7
12.2
(10.8)
10.2
22.4
(30.0)
4.3
2.8
(2.6)
3.1
1.5
8.9
5.9
(-)
16.6
10.6
36.4
13.0
3.8
2.8
Other
Private
TBA'
Other
Don't
know/
missing
(-)
15.6
15.1
(10.4)
28.1
24.1
(29.8)
0.4
0.7
(2.7)
100.0
100.0
100.0
254
989
37
1.3
2.0
6.3
6.3
5.3
19.5
8.3
32.5
1.0
100.0
100.0
398
882
Total
percent
Number
of
births
12.3
11.2
6.7
2.1
1.9
6.8
21.4
36.5
19.1
19.1
1.0
16.2
20.7
100.0
20.7
26.7
672
4.7
1.9
1.0
5.2
5.4
14.1
9.2
18.4
16.2
18.2
0.5
0.9
9.5
100.0
100.0
49.0
211
110
4.9
2.7
6.2
3.2
6.3
100.0
287
5.8
6.7
6.8
4.5
8.9
15.6
24.9
28.0
13.3
29.9
36.0
35.1
0.4
0.9
0.6
1.5
100.0
100.0
100.0
100.0
462
580
172
67
15.1
25.0
0.7
100.0
1.280
22.1
13.1
6.4
10.2
14.5
11.9
10.5
8.8
28.4
17.9
11.2
7.5
4.5
2.3
2.9
1.6
15.3
12.5
20.2
3.1
Note: Table includes c...'
z eM
„ m0St re“"‘
°^.
^BaSe.? On 25^9 unweighted cases
- Less than 0.05 percent
'TBA is a traditional
traditional birth
birth attendant.
2.1
1.7
0.6
2.8
1.8
6.3
in tbefbree years preceding the survey.
*.
I
I
I
26
f.
iJ;
J:S’
C 1
H.
IMMUNIZATION OF CHILDREN
The Expanded Programme on Immunization (EPI) was initiated in India in 1978.
Consistent with guidelines issued by the World Health Organisation (WHO), this
programme has the objective of immunizing children against six preventable killer
diseases, tuberculosis, polio, diphtheria, pertussis (whooping cough), tetanus, and
measles. One dose of BCG vaccine for tuberculosis, one dose of measles vaccine, three
doses of DPT vaccine, and three doses of polio drops should be given by the time a child
is 12 months old. Booster doses of DPT and polio vaccines may be given after 12 months
of age.
In order to step up the pace of immunization, the Government of India initiated a
special programme called the Universal Immunization Programme (UIP) in 1985-86.
This scheme has been introduced in every district of the country, and the target is to
achieve 100 percent immunization coverage. Pulse Polio Immunization Campaigns
(PPIC) began in December 1995 as part of a major national effort to eliminate polio.
UM
’i’
.1'
K
i’
K
k
I
■
I5
I3
I
I
■
An immunization card is issued for each child who is brought for immunization.
This card indicates the particulars of each type of vaccination (number of doses and date
of each dose) received by a child. Caregivers are instructed to bring the card with them
for updating each time a child is vaccinated. Sometimes they forget to bring the card,
however, in which case the card may not include all the vaccinations received.
In NFHS-2, respondents were asked whether they had an immunization card for
each child under 3 years of age. If the card was available, the interviewer was instructed
to copy the dates of each vaccination onto the questionnaire. Women were then asked
about any vaccinations received by the child that were not listed on the card. If a child
never received an immunization card, or if the mother was unable to show the card, the
purpose of the various vaccinations was explained to the mother, and she was asked if the
child received those vaccinations.
Table 14 and Figure 4 present findings on vaccinations received by respondents’
children age 12-23 months, an age by which children should have received all
vaccinations scheduled for infancy (i.e., for the firsts 12 months of life). Out of 426
children age 12-23 months, mothers showed an immunization card for 41 percent of
children. Based on information recorded on the card or reported by the mother, 60 percent
of children are fully vaccinated, and 8 percent have not received any of the vaccinations.
These results show that the immunization status of children in Karnataka is nowhere near
100 percent, and there is a long way to go to achieve universal immunization coverage of
young children.
■
■
1
27
Table 14 Vaccinations by background characteristics
Percentage of children age 12-23 months with immunizabon cards seen by the interviewer, and the percentage who have received each vaccine (according to the
immunization card or mother s report), by background characteristics. Karnataka, 1999
Percent
age with
a card
BCG
PolioO
DPT1
DPT2
DPT3
Polio 1
Polio2
Polio3
Measles
ah'
None
Number
of
children
Sex of child
Male
Female
398
42.7
84 8
84 8
28 4
24.3
85.3
88.7
82 9
86 8
76.1
74 4
91.3
92 5
88.5
896
79 3
77.2
69.3
65.2
62.8
57.1
8.3
7.0
217
209
Residence
Urban
Rural
52.8
36.2
87.4
83.7
387
21.2
91.4
85.1
898
82.7
78.1
74.0
93 7
91.1
91.4
88.0
81.2
77.0
69.4
66.4
59.0
60.4
5.5
8.6
128
298
Background characteristic
Percentage of children age 12-23 months who received
Mother's education
Illiterate
Lit., < middle school
complete
Middle school complete
High school complete
and above
27.6
74.9
14.2
78.1
75 8
64.0
86.8
82.7
67.1
54.9
46.6
12.3
218
44.7
(564)
97.4
(91.7)
355
(30.3)
97.4
(94 4)
96.1
(91 6)
84 2
(86.0)
98.7
(94.4)
97.4
(91.6)
90.7
(86.0)
71.2
76.3
(77.7) . (72.2)
1.3
(5.6)
76
36
63.5
94 8
45.6
96.0
93.7
89.6
97.0
95.9
90.8
84.4
77.0
3.0
96
41.2
84.8
26.4
87.0
84 8
75.2
91.9
89.0
78.3
67.3
60.0
7.7
426
Total
Adjusted total from NFHS-1,
1992-1993
34.4
81.7
.5.5
80.6
76.6
70.7
82.1
77.7
71.4
54.9
52.2
15.2
t-j
co
last line of the table, the table is based on NFHS-2. The last line of the table shows comparable results from NFHS-1.
Note: Except for the
( ) Based on 25-49 unweighted cases
those who received BCG. measles, and three doses each of DPT and polio vaccines (excluding PolioO).
’Children who are fully vaccinated, i.e.
546
I
■
‘
STS
Figure 4
Sns
Percentage of Children age 12-23 Months
Ei 5
Who Have Received All Vaccinations
-5
SEX OF CHILD
E? 5
------ 1 63
Male
]57
EV 3
Female
residence
]59
Urban
K
360
Rural
MOTHER’S EDUCATION
]’
]47
Illiterate
*i t
:i t
]71
Literate. <
Complete
□ 72
Middle School Complete
------ 177
High School Complete or More
0
10
20
40
30
50
60
70
80
90
Percent
NFHS-2. Karnataka, 1999
:.i’
K
H-ita shdws that immunization coverage of
Analysis of .he
who received DPT vaccmations ^““..^ccinations decreases from 92 percent for
Etoto“a te a^’oun, of droppmE
h
h
uk
13
K
■
II■
before completing these two senes of vaccinations.
The differentials between popuiati^ 5™?^^xpected directions. An
f childrcn in urban areas compared with
ortion of mothers showing
whom the mother showed an
’
immunization card was shown for 53 perce
^nnXXd^SiHren nses sharply with mother’s education but does not
differ substantially by sex of
of child.
child.
29
I
Vaccination coverage, however, varies little by urban-rural residence but does vary
sharply by mother’s education. Only 47 percent of children of illiterate mothers are fully
vaccinated compared with 77 percent of children of mothers with who have completed at
least high school. Boys are slightly more likely than girls to be fully vaccinated.
1
Table 14 also shows how vaccination rates and the proportion of children for
whom the mother showed an immunization card changed between NFHS-1 and NFHS-2.
The proportion of mothers who showed an immunization card increased from 34 percent
to 41 percent over the six years between the two surveys. During this period the
percentage fully immunized increased from 52 percent to 60 percent. The coverage of
three doses of Polio increased slightly from 71 percent to 78 percent, however, the
coverage of PolioO increased fourfold, from 6 percent in 1992-93 to 26 percent in 1999.
The percentage who did not receive any of the vaccinations declined from 15 percent in
NFHS-1 to 8 percent in NFHS-2.
!
i
!
i
I
i
I.
CHILDHOOD DIARRHOEA
Diarrhoea is a major killer of children under five years of age in India. In order to control
diarrhoea, more than a decade ago the government launched an Oral Rchydration Therapy
(ORT) Programme as one of its priority activities for child survival. Under this
programme, an effort has been made to increase the awareness of women and the
community at large about the dangers of dehydration from diarrhoea and how to treat the
dehydration. The government makes Oral Rchydration Salt (ORS) packets widely
available to deal with cases of acute dehydration.
In order to assess the current situation regarding the prevalence of diarrhoea and
the use of oral rehydration therapy, all respondents were asked a series of questions about
diarrhoea among children under three years of age and the treatment received. Table 15
shows that 14 percent of children under age three suffered from diarrhoea during the two
weeks before the survey. It should be noted, however, that there are major seasonal
variations in the prevalence of diarrhoea, so that current prevalence cannot be assumed to
reflect the situation throughout the year.
The findings on prevalence of diarrhoea by age of child show that the percentage
who suffered from diarrhoea in the past two weeks is highest among children age 6-11
months (18 percent). The prevalence of diarrhoea does not vary much by sex of the child
or urban-rural residence. Children of mothers who have only completed middle school are
more likely than children of mothers in any other educational category to have suffered
from diarrhoea.
30
L
yjsrar-
*1^
Ks ■
^5
l£=
Table 15 Prevalence of diantioea and use of oral rehydrabon therapy (ORT)
Among children under three years of age. the percentage reported by the mother to have had dianhoea in the past two
weeks, and the percentage of those with diarrhoea in the past two weeks who were given ORS packets or other ORT,
by background characteristics. Karnataka.1999
Background characteristic
j:
I
j:
i"
:3
1_
" 3
h
I.-,
I.
!:a
-
a
h
! 5
Percentage
of children
who had
diarrhoea in
past 2
weeks
Percentage of children with diarrhoea
who were given:
Number
of
children
ORS
packets
Other ORT
Any ORT
Number of
children
with
diarrhoea
Age of child
< 6 months
6-11 months
12-23 months
24-35 months
12.4
18.1
15.4
10.4
197
219
426
376
(29.8)
45.6
(37.9)
(40.5)
52.7
(53.9)
(52.8)
66.5
(69.0)
24
40
66
39
Sex of child
Male
Female
13.5
14.2
627
590
34.0
34.2
43.6
47.5
53.0
62.9
85
84
12.5
14.5
382
836
(38.1)
32.5
(46.6)
45.2
(61.5)
56.5
48
121
Mother's education
Illiterate
Lit., < middle school complete
Middle school complete
High school complete and above
13.8
14.0
16.7
12.9
628
202
107
280
29.5
(28.7)
34.6
(50.3)
51.6
(50.3)
(43.9^
(63.3)
(71.6)
87
28
18
36
Total
13.9
1.218
34.1
45.6
57.9
169
Residence
Urban
Rural
Note: Table includes only surviving chikjfen from among the two most recent births in the three years preceding the
survey.
() Based on 25-49 unweighted cases
•Percentage not shown, based on fewer than 25 unweighted cases
Among children who suffered from diarrhoea during the two weeks preceding the
survey, 58 percent received any ORT in at least one of the following forms: a solution
made from ORS packets, gruel, increased fluid intake or a homemade solution of sugar
salt and water. Thirty-four percent of children with diarrhoea received a solution made
from ORS packets. Because the number of children who had diarrhoea during the two
weeks before the survey is quite small, it is difficult to interpret differences in the use of
ORT for children in different subgroups. It appears, however, that girls are more likely
than boys to be treated with any ORT when sick with dianhoea. Further, urban children
are more likely to receive ORT than rural children. Similarly, the likelihood of receiving
any ORT is also much higher for children of mothers who have completed at least high
school than for other children.
31
• I
I
J.
INFANT AND CHILD MORTALITY
The level of infant and child mortality is a basic indicator of the quality of life in a
society. Although the questionnaire and interviewing procedures used in NFHS-2 were
designed to collect complete and accurate mortality data, the reporting of date of birth and
age at death of deceased children can be taxing for mothers, who may not remember the
dates accurately. Indeed, some mothers may be reluctant to report childhood deaths at all.
Accordingly, the data on childhood mortality should be viewed with caution until a more
thorough analysis is conducted.
Table 16 and Figure 5 present several mortality rates for three five-year time
periods: 0-4, 5-9, and 10-14 years before the survey. The following rates arc presented:
•
•
•
•
•
Neonatal mortality—the probability of dying within the first month of life;
Post-neonatal mortality—the difference between infant mortality and neonatal
mortality;
Infant mortality—the probability of dying between birth and exact age one
year;
Child mortality—the probability of dying between the first and fifth birthdays;
Under-five mortality—the probability of dying between birth and the fifth
birthday.
Table 16 Infant an<j child mortality
Infant and child mortality rates for three five-year periods preceding the survey. Karnataka. 1999
Years preceding
survey
Neonatal
mortality
(NN)
0-4
5-9
10-14
37.1
50.8
42.5
Post-neonatal
mortality
(PNN)
(iQo)
Child mortality
Gq.)
70.1
51.518-9
71.725.3
40^4
Infant mortality
14.4
21.0
27.7
Under-five
mortality
GQo)
69.4
95.2
107.7
Note: The first 5-year period before the survey does not indude the month of interview. Post-neonatal mortality
is computed as the difference between infant and neonatal mortality. Rates are specified on a per-thousand
basis. See text for definition of rates.
The infant mortality rate for Karnataka for the five-year period immediately
preceding the survey is estimated to have been 52 per 1000 live births. This means that 5
out of every 100 children bom in Karnataka did not survive until their first birthday.
Child mortality for this period was 19 per 1000, and the undcr-fivc mortality rate was 69
per 1000. Thus, approximately one in 14 children died before completing 5 years of age.
• * in
* most of the mortality
‘ ' rates.
There has been a decline over the three five year periods
Declines in neonatal mortality and infant mortality have, however, not been steady. Both
rates increased a little between the farthest two periods and then declined sharply bet ween
the two most recent periods.
32
k
I
Figure 5
Jr £
Infant and Child Mortality by Time Period
80
[>
72
70
i/
70
60
:L3
52
o
8
50
40
J11
1-,
I.
Q
CX
40
O)
30
25
Q
20 -
ra
19
f
10
i5
0
Infant mortality
Child mortality
■ 10-14 years ago Q&-9 years ago
u
p
Note: Rates are for 5-year periods
preceding the survey
years ago|
NFHS-2, Karnataka, 1999
h
1;
h
The NFHS-2 infant mortality estimates for Karnataka are slightly lower than
recent estimates for the Sample Registration System (SRS) of the Office of the Registrar
General. The average of the SRS estimates for the years 1995-98 is 56, which is slightly
higher than the NFHS-2 estimate of 52 per 1,000 for the five-year period before the
survey (approximately 1994-98).
■ »J
K.
k
I-
ANAEMIA AMONG WOMEN AND CHILDREN
Anaemia is a condition that results when the level of haemoglobin in the blood is too low.
Haemoglobin in the red blood cells transports oxygen from the lungs to other tissues and
organs in the body, so that these tissues and organs can perform their functions. A
deficiency of haemoglobin means a deficiency of the body’s ability to deliver oxygen to
those tissues and organs. Anaemia usually results from a nutritional deficiency of iron,
folate, vitamin B12 and some other nutrients. This type of anaemia is commonly referred
to as iron-deficiency anaemia.
33
1
J - •
I_
I
■»
Anaemia has detrimental effects on the health of women and children and may
become an underlying cause of maternal death, antenatal loss, and perinatal loss.
Anaemia among children can be associated with impaired cognitive performance, motor
development, coordination, language development and scholastic achievement, as well as
increased morbidity from infectious diseases. Early detection of anaemia can help to
prevent complications of pregnancy and deliver}' as well as problems with child
development. Measurement of the prevalence of anaemia can provide important
information for development of health inten'entions. such as iron fortification, to prevent
anaemia among women and children.
*
Because anaemia is such a serious health problem in India, NFHS-2 undertook
direct measurement of haemoglobin levels of all ever-married women and their children
under three years of age. This measurement was done in the field using the HemoCue
.. s^ste71,
system’ a single drop of blood from a finger prick (or heel prick in the case
ol infants below six months of age) is drawn into a cuvette, which is then inserted into a
portable, battery-operated instrument. In less than one minute, the haemoglobin
concentration is indicated on a digital read-out. Results are shown in Tables 17 and 18.
These tables distinguish four levels of anaemia:
no anaemia—haemoglobin concentration of 11.0 grams/dccilitre (g/dl) or higher for
children or pregnant women and 12.0 g/dl or higher for nonpregnant women
• mild anaemia—10.0-10.9 g/dl for children or pregnant women and 10.0-11.9 g/dl for
nonpregnant women
• moderate anaemia—7.0-9.9 g/dl
• severe anaemia—less than 7.0 g/dl
•
Appropriate adjustments in these
l'
cutoff points have been made for persons living at
altitudes above 1,000 metres and’ women who smoke, since both of these groups require
more haemoglobin in their blood.
Results for women are shown in Table 17 and Figure 6. Overall, 58 percent of
women have no anaemia, 27 percent are mildly anaemic, 14 percent are moderately
anaemic, and 2 percent are severely anaemic. The prevalence of anaemia is relatively
high among younger women age 15-24 (47 percent), rural women (46 percent), illiterate
women (48 percent), women of‘other* religions (51 percent), scheduled caste women (47
percent), scheduled tribe women (46 percent), and women working in a family farm or
family business or employed by someone else (47 percent). The prevalence of anaemia is
relatively low among women who have completed at least high school (32 percent), urban
women (36 percent), and Christian women (37 percent). Pregnant women are only
slightly more likely than nonpregnant women to be anaemic at all, but are twice as likely
as nonpregnant women to be moderately anaemic.
34
I
ft
I
Table 17 Anaemia among women
Percent distribution of women by degree of iron^efidency anaemia, according to background cbaracterist.cs. Karnataka. 1999
Percentage of women with:
3
Severe
anaemia
Total
Percent
Percentage
with any
anaemia
Number
of
women
No
anaemia
Mild
anaemia
Moderate
anaemia
52.6
59.8
59.3
29.3
25.4
25.8
16.4
12.5
12.2
1.7
2.4
2.7
100.0
100.0
100.0
47.4
40.2
40.7
1,141
1,503
1.476
26.0
23.1
30.1
24.3
27.3
17.2
15.9
10.9
13.7
12.9
1.4
2.5
2.5
1.9
3.0
100.0
3
4+
55.4
58.5
56.6
60.1
56.8
100.0
100.0
100.0
100.0
44.6
41.5
43.4
39.9
43.2
442
669
1,170
908
930
Residence
Urban
Rural
64.2
54.0
24.6
27.7
9.8
15.4
1.3
2.9
100.0
100.0
35.8
46.0
1,439
2,681
Education
Illiterate
Lit.. < middle school complete
Middle school complete
High school complete and above
52.5
59.4
62.4
68.3
28.7
26.8
21.7
22.1
15.5
11.5
15.5
9.1
3.3
2.3
0.4
0.5
100.0
47.5
40.6
37.6
31.7
2,255
778
281
806
Religion
Hindu
Muslim
Christian
Other
57.4
58.6
63.3
(48.7)
26.4
27.0
30.6
(35.4)
13.8
12.4
6.2
(12.6)
2.4
2.0
100.0
(3.3)
42.6
41.4
36.7
(51.3)
3,539
450
99
31
Caste/tribe
Scheduled caste
Scheduled tribe
Other backward class
Other’
Missing
53.4
54.1
58.1
59.7
(50.0)
26.0
27.2
26.8
26.3
(35.0)
18.3
16.5
12.7
11.7
(12.9)
2.4
2.2
2.4
2.2
(2.1)
100.0
46.6
45.9
41.9
40.3
(50.0)
674
231
1,717
1,453
46
52.7
52.6
57.0
62.3
28.0
29.7
25.9
24.4
15.2
15.4
14.7
11.6
4.1
2.3
2.4
1.8
100.0
47.3
47.4
43.0
37.7
679
1,203
243
1,995
51.5
54.6
20.7
30.3
24.9
12.5
2.8
2.5
100.0
48.5
45.4
277
100.0
56.8
26.3
12.7
2.3
100.0
41.2
3,129
57.6
26.6
13.5
2.3
100.0
42.4
4,120
Background characteristic
3
5
9
3
3
3
3
3
-j
3
Xi
3
3
3
3
3
■3
3
3
Age
15-24
25-34
35-49
Number of living children
0
1
2
Employment status
Working in family farm/business
Employed by someone else
Self-employed
Not worked in last 12 months
Pregnancy/breastfeeding status
Pregnant
Breastfeeding (nonpregnant)
Nonpregnant/nonbreastfeeding
Total
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
714
adjusted for altitude and smoking when calculating the severity of anaemia. Total includes 1 woman
Note: Haemoglobin levels are l_,------- ------with missing information on employment status, who is not shown separetely.
3
73
() Based on 25-49 unweighted cases
’Women who do not belong to a scheduled caste, a scheduled tribe, or an other backward class.
-3
35
I
0
-I
■I
=•
Figure 6
Anaemia Among Women and Children
£
70
60 -
Percent
58
50
J
40
40 -
34
27
30 ■
19
20 -
14
10 -
7
v.*-* 1" X.
-
2
I
0
Not anaemic
Mildly anaemic
Women age 15-49
i
Moderately anaemic
Severely anaemic
Children under 3 years
NFHS-2, Karnataka, 1999
Results for children arc shown in Table 18 and Figure 6. Overall, 34 percent of
children have no anaemia, 19 percent are mildly anaemic, 40 percent are moderately
anaemic, and 7 percent are severely anaemic. A much higher proportion of children (66
percent) than women (42 percent) were found to be anaemic. Children of 12—23 months
have the highest prevalence of anaemia (78 percent), perhaps due to the initiation of
x'. weaning at this age, coupled with poor nutritional supplementation. Rural children are
^ore likely than urban children to be anaemic. Also, male children are slightly more
' than female children to be anaemic, as are Muslim children compared with Hindu
Anaemia is, however, even higher among children of birth order 6 and above
W
children of illiterate mothers (73 percent), scheduled caste children (73
PCK
'■ken whose mothers are severely anaemic (81 percent). Anaemia rates
famiy
’’dren of mothers who have completed at least high school. Notably,
relativ
* of the children (54 percent) even in this group, are anaemic,
women
-lationship between anaemia status of mothers and their
slightly n
■'nsequences of poor maternal health on the children, as
as nonpreg.
id their children.
36
I
IB
s
I
*
Table ig Anaemia gmonq children
de9ree °f iron’<Jefiaency anaemia, according to background
ye3rS °f
dTaracteristtnl)UKOn ^t^'^lTogH^
Percentage of children with:
2
)
No
anaemia
Mild
anaemia
Moderate
anaemia
Severe
anaemia
Total
percent
Percentage
with any
anaemia
Number
of
children
Age of child
< 12 months
12-23 months
24-35 months
43.8
21.9
37.8
20.8
20.2
16.4
33.7
48.7
36.8
1.7
9.2
9.0
100.0
100.0
100.0
56.2
78.1
62.2
345
356
308
Residence
Urban
Rural
37.6
32.6
19.8
18.9
38.0
41.1
4.6
7.5
100.0
100.0
62.4
67.4
326
685
Sex of child
Male
Female
31.8
36.7
17.0
21.5
43.0
37.0
8.2
4.8
100.0
100.0
68.2
63.3
516
496
Birth order
1
2-3
4-5
6*
40.8
31.2
31.0
(22.3)
16.0
21.5
21.4
(13.4)
38.5
39.7
39.8
(57.8)
4.7
7.6
7.8
(6.5)
100.0
100.0
100.0
100.0
59.2
68.8
69.0
(77.7)
357
469
141
45
26.6
19.2
44.3
9.8
100.0
73.4
503
Background characteristic
I
J
I
i
i
f
Mother's education
Illiterate
Literate. < middle school
complete
Middle school complete
High school complete
and above
38.5
36.8
20.5
16.8
37.1
42.0
3.9
4.4
100.0
100.0
61.5
63.2
177
90
45.7
19.1
32.7
2.5
100.0
54.3
242
Religion
Hindu
Muslim
34.5
30.9
19.6
18.6
40.3
38.1
5.6
12.4
100.0
100.0
65.5
69.1
820
167
Caste/tribe
Scheduled caste
Scheduled tribe
Other backward class
Other1
26.8
34.7
37.5
35.5
20.8
19.8
18.1
18.5
44 4
37.6
41.6
37.0
8.0
8.0
2.8
9.0
100.0
100.0
100.0
100.0
73.2
65.3
62.5
64.5
198
61
357
384
Mother's anaemia status
Not anaemic
Mildly anaemic
Moderately anaemic
Severely anaemic
39.1
31.0
25.1
(19.1)
20.9
17.3
16.1
(23.3)
35.3
44.0
49.7
(42.5)
4.8
7.8
(15.1)
100.0
100.0
100.0
100.0
60.9
69.0
74.9
(80.9)
538
310
138
26
Total
34.2
19.2
40.1
6.6
100.0
65.8
1,012
9.2
Haemo9lobin levels are adjusted for altitude when calculating the severity of anaemia among children. Total includes 20
____ a-..
a . . ■■
Children who are “Christian’, A4 children belonging
to “other*
religions and.......
11 chiklren with missing information on the
caste/tribe. who are not shown separately.
() Based on 25-49 unweighted cases
’Children who do not belong to a scheduled caste, a scheduled tribe, or an other backward dass
rfl I In ron buhn nro
37
11
Please confirm your consent to the above Agreement by signing in a legally binding
form and returning the enclosed copies.
We enclose a copy of the present letter with the request to forward it to Government of
India and in due course also to the consultants.
Yours faithfully,
KREDltANSTALT FUR Wl
RAUFBAU
r
Enclosures
1.
2.
3.
4.
5.
6.
7.
8.
Standard form for Statement of Contracts
Supplementary Conditions (for payments under the disposition fund procedure)
Organizational structure of the project
Agency Contract
Guidelines of Kreditanstalt fur Wiederaufbau for procurement in the field of
Financial Cooperation
Memo for Progress Reports
Terms of Reference for the Consultant
Guidelines for the Disbursement of Funds of Financial Cooperation and
Comparable Programmes by KfW
Read and agreed:
Frankfurt am Main,
this
day of^, 19AT
KREDITANSTALT FUR WIEDERAUFBAU
this'^day of^,
GOVERNMENT OF KARNATAKA
<S|ov
b/"
V
I •
I
'Draft Aide Memoire
in nnih r ,
KfW review mission
(on lhe
of June 1999 in Delhi; and from lhe iZ to (Z 15'” of June 1999 |n Bangalore)
on, the Proiect "Upqra^jg_£_econd.ary_Lev_el_HeaIth_Care FaciIities in
Lhe Gulbarqq
.Division, Slole of Karilalaka, Phase P
Gerhard Redecker (Senio? Con^truc^n Advilorl)rivilsiterd(|P d^6? Manager) and Mr.
Project "Upgrading Secondary Level Health Cam fS^'3 . ° reV'eW th'S on9oing
• ■
State of Karnataka, Phase I" (the Project) Durinn in ■ S.ln( h.6 ^u,bar9a Division,
discussions with Messrs. Tawhid Nawaz and Dr9 nLrr|Vo' I
Kl'/V'miss|on had
Southern General Hospital NHS Trust) in Delhi Ihp H
Drr H C
' Family Welfare,
Mai adev-nna
L
'
Df' er 'World Bank and
H°™urable Minister for Health &
-Government, Heallh' a Family Welfare Department) Dr VTh'3 (Secretar>' lo
.dmmislrator a E/o Addl. Secretary to Govern men and Ihe ®Ubraman)'a (Project
Kama aka Heallh Systems Development Proied Team n
members of the
as well as with representatives of the fS, I A Government of Karnataka
would like lo express their sincere graUtudZ he renT'fofTi,"' The KIW -mission
especially to Dr. Subramanya for' thJ k nd hospi nUtv mp56
SS °f lhe Go,< and
the excellent co-operation. The draft Aide Mo n
Ve'Y °pen discusslon and
and conclusions of the KfW-misslon whlcl/m o < sH"’l'larlsQS 'ho main findings
management of KIW and the GoSnZtaw?" '° 11,8 appiovai °(
Consulling Services
j
During the course of discussions the mission sIaIpH ihoi r
considerable delay has already occurred in the
' 3 nUmber of reasons/a
time schedule'of the Project With thP "?r‘hefplannin9 Process, affecting the overall
arehUects during .he pas| mon^hhe 0Zu° anZa°s n®
?Pa^
he elaboration of functional layouts and pS naX .enga9edJp activities related
c°vered by (he Terms of Reference 'f ?,arX‘%eS,9r,Is- 1 hes® activities ,
are
~ consequence, the assigned person-monfhX consX Co”sull,n9 Contract. As
a
inexc ess of the tune schedule and work programme THp Sfrvices have been utilised •?
. gener^con'dusions'^ere"reached St'‘enl °f Ul? T°R
Zuired" The'ToSn^
■ .
*1
.
•
has lo^peeded ^conSde^
aspects mentionedbelow^073' °f P'anS and tenders shall be limited to (he
Development PrS^^
Karnataka Health Systems
........... ■
■
- saw:s,“•
i'nproved substantial^
;
C A
•/
"X -
,
I
.
f"’d O"d reporting by the Consultant has to be '
f
f
' \
/ \
(z \ '
1
•i
of above considerations, the following principles for an amendment to
/fig Lonlract nave been agreed upon,*
Hospital Planner,.-Mr. Stojanovic, has been replaced by Mr. Fitz
./consultant for on-site construction’supervlslon’shalkbei-required.
^ne Consultant shall attend to all pending planning issues and monitor the
/implementation of civil works.
■
For on-site quality audit, the Project-Executing Agency (PEA), should contract an
independent construction audit firm by way of the competitive bidding process
•V
Bslablisheiin lhe KHSDP-Ihe cosl sha"ba
The input of the local partner of the Consulting Consortium'
Messrs. STEM shall-- be substantially scaled down.
I
ut
by
the
W°rk®,d
Consultan^shodly50
ivolvemenl in lhe planning and implementation process are established be°ow
^elirr'-ary Designs / Civil Works
its pre-checked
ere given and approval in principle coiiirnunicaled to Hip PFA n ic
ie Preliminary Designs to KfW for additional concurrence.
,
i
r V—
VerSI°n °f
inal.Desiqn and Tender Documents / Civil Woiks
he final designs and. tender documents shall be elaborated bv iHp innoi
- •-
conXz^
“z sis ^.Snzzzzhz 'i,e
c^-on™’
□nsu .nt, either during a slay of the Consultant in lndiPeC
.docUment.ali°n to the
leU^A shall fonvard the sets of documpntc r -h a',or.ln.kls office in Germany,
rectly to the Consultant. After review the Cnnc.-i 61 i'e> ",dlvldual|y or in batches)
statement of conformity together with a coov of ihT
forv/ard lo PEA and KfW
nly broken down by bills not kerns or sub item
I SUmmarised
cost estimate
sobmlsslon .
-I- Consonant
XZ^Zh
inventory of all documents contained in ;
"not
« -or no.o.econ
■
BoQ
bmission of tender documents is required.
I
' '-V
2
z<
'
‘
^nderin
/ CM W’orks
,
- Ihe PeZ wW makeb|h^renCd°'r1Sauc;ian'on lha Final
evaluation repo,t s|la|| ®'1"er ^vertlsemenl. The
■ Consonant A coiX
by ",e PSA
!
■
a certification of (lie r '°n ,eport and
actual tender evaluation orn^ SC On' The dire
ct Involvement o he e
130,1 sha"
lhe request of the PFa APn°CeSS Wl■■■“ d
Jepend on his
• 0 Consultant In tho
Sthe PEA •a'coov'of
ter?;Tthe ,"°?bjac."on by KIW-and-sIgrtHg odnhaS Wel1 as
-OPT Cl .banned contact
sha„ be
^arded to Kfw
^^MgXObfer^CIvli Works
h
4
•.T
I
lba BOQ.during
•respective^ amountHwilhout■additioHfrc! (any slPy,e:vafiation noU^e
yency.,n (he overall cosh
«*
LZl£^-HeeaiLy^^
u.-<- >
Works r-
^OBtractoJrXnende^00^
sss? tV
k-
Varia(ior’ '
■
•
-irecUy
ACC0Unl" USSd
used by (he
b/ lo«l
ih
this subject prior to k
,nlerverie-if. ;
Proceed immediat^ ? payment out■./
of
ce of any detailed
cleared by the Projec °Ad 1,318 lhe resPeclive ’i - .ion Fund.
on
------should now
He?!
5
P
ay,I1
enls
Agreement Alter fin^lislnn h"?,1?10' u"der “'o
' le""s established J, are only (0 b0
IH ‘he Separate
Prepare a list of
to KfW. The’
carry out random checks
beeri rnade for proiprt
le Consultant • '
Project purposes r
works
- ■ to theh:CXsOnn
fhXd'
s~LF- 'hatshall
he only
shall
....
-J and appropriate ■
Pessary ,orhlscerlinca|ion
n
ess
of
(he
■Sauipmefjt
tlocur^nent
Iri line , ■
equipment
lhe |„
l^llSDh, (jig pp.
report for concurrence L the r d 0,abo'ale
‘ ‘he-respective tenl' lender lhe
evaluation
H
report Shall be OTA
Consul(ant end no-objectlon bj Kn« s^luaUon
for s odsequent evaluation.P epared b/ the
C^Hant whiqh
e
The
,
Bangalore, i|le i5n>
i
i
•I
i
of June 1 99g
ve as a model
a
C-) ov
'Draft Aide Memoire
KfW review mission
(on the 12,h of June 1999 in Delhi; and from the 14lh to the l5’h of June 1999 in Bangalore)
on the Project "Upgrading Secondary Level Health Care Facilities in the Gulbarqa
Division, Stale of Karnataka, Phase I"
■
I
A KfW-mission consisting of Ms. Regina Schneider (Project Manager) and Mr.
Gerhard Redecker (Senior Construction Advisor) visited India to review the ongoing
Project "Upgrading Secondary Level Health Care Facilities in the Gulbarga Division,
State of Karnataka, Phase I” (the Project). During their visit the KfW-mission had
discussions with Messrs. Tawhid Nawaz and Dr. David Porter (World Bank and
Southern General Hospital NHS Trust) in Delhi, the Honourable Minister for Health &
Family Welfare, Dp H.C. Mahadevappa, Messrs. A. Sengupta (Secretary to
•Government, Health & Family Welfare Department), Dr. S. Subramanya (Project
Administrator & E/o Addl. Secretary to Government) and the other members of the
Karnataka Health Systems Development Project-Team, Government of Karnataka,
as well as with representatives of the Consultant Consortium. The KfW-mission
would like to express their sincere gratitude to the representatives of the GoK and
especially to Dr. Subramanya for the kind hospitality, the very open discussion and
the excellent co-operation. The draft Aide Memoire summarises the main findings
and conclusions of the KfW-mission, which are subject to the approval of the
management of KfW and the Government of Karnataka."
k
Consulting Services
During the course of discussions the mission stated that, for a number of reasons, a
considerable delay has already occurred in the planning process, affecting the overall
time schedule of the Project. With the aim of supporting the capacity of the local
architects, during the past months, the Consultant was engaged in activities related
to the elaboration of-'functional layouts and preliminary designs. These activities are
not covered by the Terms of Reference of the Consulting Contract. As a
consequence, the assigned person-months for consulting services have been utilised
in excess of the time schedule and work programme. Therefore, a re-programming of
the consulting services and adjustment of the ToR are required. The following
general conclusions were reached:
The planning work by the local architects as well as clearance by the Consultant
has to be. speeded up considerably.
Involvement of KfW for approval of plans and tenders shall be limited to the
aspects mentioned below.
In line with the procedures of the World Bank-funded Karnataka Health Systems
Development Project (KHSDP), quality audit / control of the construction shall be
done by an independent construction audit firm which is specialised for that task.
The Consultant shall be required to react in a more flexible manner to the needs
of the project in order not to delay implementation.
The quality of overall project monitoring and reporting by the Consultant has to be
improved substantially.
.................
rj
.
A
■ £ .
■/'
\
X.\Lc.
1-
a
•
/te basis of above considerations, the following principles for an amendment to
'Consulting Contract have been agreed upon:
The Hospital Planner, Mr. Stojanovic, has been replaced by Mr. Fitz.
- ' No consultant tor on-slle construction supervision shall be required.
- The Consultant shall attend to all pending planning issues and monitor the
implementation of civil works.
For on-site quality audit, the Project-Executing Agency (PEA), should contract an
independent construction audit firm by way of the competitive bidding process ,
according to the procedures established in the KHSOP.^The cost shall be included
in the Consulting Contract.
- The input of the local partner of the Consulting Consortium, Messrs. STEM, shall- - •
be substantially scaled down.
A detailed proposal on the time schedule, ToR and work schedule shall be worked
out by the Consultant shortly. The general guidelines for the Consultant’s
involvement in the planning and implementation process are established below:
^-eliminary Designs / Civil Works
KfW has recently been presented with 3 batches of planning documents pre-checked
by the Consultant, 2 of them (10 hospitals) have already been reviewed. Comments
were given and approval in principle communicated to the PEA. It is understood that
the local architects / engineers will incorporate these comments, as far as relevant
and possible, into the final design. There is no need to submit a revised version of
the Preliminary Designs to KfW for additional concurrence.
Final Design and Tender Documents / Civil Works
The final designs and tender documents shall be elaborated by the local architects.
The technical specifications to be followed are those established for the KHSDP.
The Consultant shall review these designs and documents and check on the
incorporation of his /.KfW’s comments made on the Preliminary Designs. This
revision shall take place upon presentation of the respective documentation to the
Consultant, either during a stay of the Consultant in India, or in his office in Germany.
. .,e PEA shall forward, the sets of documents (either individually or in batches)
directly to the Consultant. After review, the Consultant shall forward to PEA and KfW
a statement of conformity together with a copy of the summarised final cost estimate
(only broken down by bills, not items or sub-items). Any comments which may still be
required on the final designs, shall be cleared on the spot together with the Building
Scrutiny Committee, or be counterchecked by the Consultant during site visits, ex
post. The submission of final design documents for each hospital to KfW is not
required.
Complementary to the bid documents already cleared by KfW earlier, the Consultant
shall provide KfW with an inventory of all documents contained in a full set of tender
documents, submitting any standard document or attachment not yet received by
KfW for no-objection (typical technical specifications, typical set of BoQ etc.). Once
KfW has stated it’s no-objeclion to the sample set of documents, no further ■ ’
submission of tender documents is required.
■
2
■
nderinq and Awarding of Cbntracts / Civil Works
Once the Certificate of Conformity has been issued by. the Consultant on the Final
‘Design and Tender Documentation, the PEA will make the tender advertisement. The
tenders shall be analysed and an evaluation report shall be prepared by the PEA,
together or in co-ordination with the Consultant. A copy of the evaluation report and
the proposal for contract award, together with a certification of the Consultant, shall
be forwarded to KfWfor no-objection. The direct involvement of the Consultant in the
actual tender evaluation process will depend on his availability in India as well as bn
the request of the PEA. After the no-objection by KfW and signing of the contract by
the PEA a copy of the signed contract shall be forwarded to KfW for information.
4
Variation Orders / Civil Works
r
It is understood that rehabilitation works require some adjustments to the BoQ during
implementation. The PEA is entitled to directly negotiate with the contractors variation
'orders of up to 15% of-, the contract amount (any single variation not to exceed 5% of
the contract amount) without additional clearance by tire Consultant or KfW. The
respective amount of'15% shall be considered as contingency in the overall cost
A
estimate of each hospital.
Urgent Repair Work / Hospitals
J-'
It was clarified that Urgent Repair Works; can be either carried out by local
contractors after tendering,, or by labour contracts directly handled by the PEA or the
local hospital administration. The term “Force-Account" used by the Consultant
should be dropped. ,
The Consultant shall not intervene’in the clearance of any detailed expenditure on
this subject prior to its payment out of the Disposition Fund. The PEA should now
proceed immediately to initiate the respective works. All payments are only to be
cleared by the Project Administrator under the terms established in the Separate
Agreement. After finalising the Urgent Repair works, the PEA will prepare a list of
expenditure for the request for replenishment to KfW. The Consultant shall only
certify that all expenditure has been made for project purposes. For that, he shall
carry out random checks on the utilisation of the funds and appropriateness of the
works to the extent he sees necessary for his certification.
Equipment Procurement
In line with the procedures applied in the KHSDP, the PEA shall tender the
equipment procurement per item‘and elaborate the respective tender evaluation
report for concurrence by the Consultant and no-objection by KfW. The first
evaluation report shall be prepared by the Consultant whiqh shall serve as a model
for subsequent evaluation.
;
'
Bangalore, the 15th of June 1999
‘i
■
>
3
NR.037
S.4/5
G-| o-v-
KfW
/ E L E FA X
-
telefax
-
telefax
I
Telefax number: 0091 - 80 - 220 4154/ 225 2499 office In c|larae:
Government of Karnataka
Attnl^fnlForTli,y Welfa*'e Department
hi qS®n.guPta> Secretary to Government
DrSR R AmblS00?/ Maltistoreyed Building,
ur. b,r. Ambedkar Veedhi
Bangalore-560 001, India
.
our ret:
extension:
email:
date:
Ms. Schneider
Sohn
2856 '
rBgina.schneider@kfw,de
September 10, 1999
numbor of pages
(Incl. this pago)
2
Lilia-
German Financial Cooperation with India
Upgrading Secondary Level Health Care
Facilities In the Gulbarga Division,
oiate of Karnataka, Phase I
Subject:
Our meeting with the project team on the 4lh
of September 1999 |n Bangalore
Dear Mr. Sengupta,
"""s’0"
^ore from'the Sn the I^ZneT
wore very concerned Zu the elan
year'
d
V,Sit t0
y°U may "'Ca" dl,ri"8 "’a1 ,imG
- -...
project is now on the right track In thfe
all members of the pro act earn and
’
3
’’°Uld
'0
T
their dedication and hard work b ov 7
implementation period as much as possible™"16
10
181 we l8arn6d that the
°Ur sincwe
Pra|eCt OdmWslratw Dr- Subramanya tor
PreV,°''S
,0 ShOrlS" lhe
1. Based on the agreement reached during
our last visit the consultant contract has already been
amended accordingly. The services
which are provided by the consultant under the
amendment are valued,bp all parties concerned
J and seem to be - apart from some minor
misunderstandings - useful and contributive to the project goal.
J:\l 3Al\SCIIN\956G944^lRr:RlCH\vlsll999.doc
kafoitanstalt
FUR WIEDERAUFBAU
Palrnengartenstraflo 5-9
60355 Frankfurt am Main
Poatfacli 11 1>
I elofon: (0G9) 74 31-0
Tolofax (069) 74 31 29 44
S.W.I.F.T,: KFWJDEFF
Internet: http:ZAvww.lrfw.dfl
IH .UJ,
-2t0 c,lec^ t,1e subslanlial Increase of ,he conslruction f - .
costs the project team together
2.
X tZx x?'a; ndertook 'ed,ou3 “01 *"»
°7w ,o w -
estimates are rather promising. According Z
can be met out of the project funds.
estimates for all hospital
concern that the project
“a"T'*0'’ T''' ‘h8
new cost
11
e55®™31 construction cost
3. Ih view „f the past
witWn ,his
'' and toward
-' aotMles from the efectlon-based st’ J
tender
Z
d
’ Th ’ tender for the first
construction can be floated in SpntPmh
September, conetruobon might atady commence In
December.
banking you vi
ary much for your good cooperation and understanding.
Yours sincerely,
kreditanstalt fur wiederaufbau
<;„n
Pischke
co..'
1.
2.
.
Schneider
Affairs, New Dem wooi^Telefax numbe?r0MiFiniDeParlment Economic
KfW-Office, via e-mail
lber’ 0091-11-3014048 / 3017511
1
I
i
!
!
<S| W " 2-
CREDIT NUMBER 2S33 IN
Project Agreement
(Second State Health Systems Development Project)
between
INTERNATIONAL DEVELOPMENT ASSOCIATION
and
STATE OF KARNATAKA
STATE OF PUNJAB
STATE OF WEST BENGAL
and
PUNJAB HEALTH SYSTEMS CORPORATION
1
j
}
Dated
i'S
, 1996
CREDIT NUMBER 2833 LN
PROJECT AGREEMENT
AGREEMENT, dated
, 1996, between
INTERNATIONAL DEVELOPMENT ASSOCIATION (the Association) and THE
STATE OF KARNATAKA, THE STATE OF PUNJAB, THE STATE OF WEST
BENGAL, acting by their respective Governors (the Project States) and PUNJAB
HEALTHSYSTEMS CORPORATION (PHSC).
WHEREAS (A) the Association has received a letter dated February 13, 1996.
February 15, 1996 and February 8, 1996 from the State of Karnataka, the State of Punjab
and the State of West Bengal respectively (collectively the Project States), each such
letter describing a program of objectives, policies and actions to improve the primary'
and first referral levels of health care (hereinafter referred to as the Karnataka Health
Sector Development Program, the Punjab Health Sector Development Program and me
West Bengal Health Sector Development Program, respectively) and declaring the
respective Project State’s commitment to carry out its Health Sector Development
Program;
WHEREAS (B) by the Development Credit Agreement of even date herewith
between India, acting by its President (the Borrower) and the Association, me
Association has agreed to make available to the Borrower an amount in various
currencies equivalent to two hundred thirty five million five hundred thousand Special
Drawing Rights (SDR 235,500,000), on the terms and conditions set forth in me
Development Credit Agreement, but only on condition that the Project States and PHSC
agree to undertake such obligations toward the Association as are set forth in mis
Agreement;
WHEREAS the Project States and PHSC, in consideration of the Association s
entering into the Development Credit Agreement with the Borrower, have agreed to
undertake the obligations set forth in this Agreement,
NOW THEREFORE the parties hereto hereby agree as follows: ■
ARTICLE I
Definitions
Section 1.01. Unless the context otherwise requires, the several terms defined m
the Development Credit Agreement, the Preamble to this Agreement and in the General
Conditions (as so defined) have the respective meanings therein set forth.
-2-
ARTICLE D
Execution of the Project
Objectives of the P
I 5
PHSC deClare their com-™ent to the
objectives of the Project as set forth m Schedule 2 to the Development Credit
Agreement and, to this end, shall carry out the Project with due diligence ^d efficiency
and m conformity with appropriate administrative, financial and health practices and
s a provide, or cause to be provided, promptly as needed, the funds, facilities services
and other resources required for the Project.
’ services
(b)
Without limitation upon the provisions of paragraph (a) of this Section
and except as the Association and the Project States and PHSC shall otherwise am-ee the
LT ,T „
PHSC/“
”>
Project
accordance
b
Implementation Program set forth in Schedule 2 to this Agreement.
the OrZXe
°f itS
C°ntributi0n in accorda"ce with the provisions of
Section 2.02. Except as 1the Association shall otherwise agree, procurement of
the goods, works and consultants'' sendees required for the Project and to be financed out
of the proceeds of the Credit shall
... be governed by the provisions of Schedule 1 to this
Agreement.
Secuon 2 03. (a) The Project States and PHSC shall carry out the obligations set
forth m Secnons 9.0j 9.04, 9.05, 9.06. 9.07 and 9.08 of the General Condition; (relating
o insurance, use of goods and services, plans and schedules, records and reports'
the ProjeTf06
aCqUISItI°n’ resPectively)in resPect of the Project Agreement and’
r the
• purposes of Section 9.07 of the General Conditions, and without
For
limitation thereto, the Project States and PHSC shall:
(b)
(i)
prepare, on the basis of guidelines acceptable to the Association
and furnish to the Association not later than six (6) months after
the Closing Date or such later date as may be agreed for this
purpose, between the Association and the Project States and
PHSC, a plan designed to ensure the sustainabilitv of the
Project;
-3-
(ii)
afford the Association a reasonable opportunity to exchange
views with the Project States and PHSC on said plan; aiic.
(iii)
thereafter, carry out said plan with due diligence and e.._cienc\
and in accordance with appropriate practices, tak—into
account the Association's comments thereon.
Section 2.04. (a) The Project States and PHSC shall, at the request ?f the
Association, exchange views with the Association with regard to the progress of the
Project, the performance of its obligations under this and other matters relating .0 the
purposes of the Credit.
(b)
The Project States and PHSC shall promptly inform the Associ^on of
any condition which interferes or threatens to interfere with the progress of the Project
the accomplishment of the purposes of the Credit or the performance by each oi _em of
its respective obligations under this Agreement.
ARTICLE m
Financial Covenants
Section 3.01. (a) The Project States and PHSC shall each maintain records and
accounts adequate to reflect in accordance with sound accounting practices their
operations, resources and expenditures in respect of activities related to their respective
parts of the Project, of the departments or agencies responsible for carrying cut the
Project or any part thereof.
(b)
The Project States and PHSG shall:
(i)
(H)
(iii)
have records and accounts referred to in paragraph (a of this
Section for each fiscal year audited, in accordar ; with
appropriate auditing principles consistently appi—cl by
independent auditors acceptable to the Association;
furnish to the Association as soon as available, but in 2_> case
not later than nine months after the end of each such :• ear: (A)
certified copies of its financial statements for such year as so
audited; and (B) the report of such audit by said auar_Drs. of
such scope and in such detail as the Association
have
reasonably requested: and
furnish to the Association such other information cczceming
said records, accounts and financial statements as we_ as the
-4-
audit thereof, as the Association shall from time to time
reasonably request.
ARTICLE rV
Effective Date; Termination;
Cancellation and Suspension
Section 4.01. This Agreement shall come into force and effect on the date upon
which the Development Credit Agreement becomes effective.
Section 4.02. (a) This Agreement and all obligations of the Association and of
the Project States and PHSC thereunder shall terminate on the earlier of the following
two dates:
(i)
the date on which the Development Credit Agreement shall
terminate in accordance with its terms; or
(ii)
the date twenty years after the date of this Agreement.
(b)
If the Development Credit Agreement terminates in accordance with its
terms before the date specified in paragraph (a) (ii) of this Section, the Association shall
promptly notify the Project States and PHSC of this event.
Section 4.03. All the provisions of this Agreement shall continue in full force
and effect notwithstanding any cancellation or suspension under the General Conditions.
ARTICLE V
Miscellaneous Provisions
' I or permitted to be given or made
Section 5.01. Any notice or request required
under this Agreement and any agreement between the parties contemplated by this
Agreement shall be in writing.
Such noticei or request shall be deemed to have been duly
......
« given or made
i----- when
--------it shall be delivered by hand or by mail, telegram, cable, telex or
’ 1 or permitted to be given or made at such
radiogram to the part}' to which it is required
'
~
I
or
at
such other address as such party shall have
party's address hereinafter specified
designated by notice to the part}' giving such notice or making such request. The
addresses so specified are:'
-5-
For the Association:
International Development Association
1818 H Street, N.W.
Washington, D.C. 20433
United States of America
Cable address:
Telex:
INDEVAS
Washington, D.C.
197688 (TRT),
248423 (RCA),
64145 (WUI) or
82987 (FTCC)
For the State of Karnataka:
Chief Secretary to the
Government of Karnataka
Bangalore, India
For the State of Punjab:
Secretary to the
Government of Punjab
Department of Health
Chandigarh, India
For the State of West Bengal:
Chief Secretary to the
Government of West Bengal
Calcutta, India
For Punjab Health Systems Corporation:
Managing Director
Punjab Health Systems Corporation
Chandigarh, India
Section 5.02. Any action required or permitted to be taken, and any cocument
required or permitted to be executed, under this Agreement on behalf of ±e Project
States or PHSC, may be taken or executed by the Chief Secretary in the case of
Komataka and West Bengal, or the Secretary, Department of Health in the case of
-6-
Punjab or the Managing Director in the case of PHSC or such other person or persons as
the respective Chief Secretary, the Secretary, Department of Health, or the Manaains
Director shall designate in writing, and the Project States and PHSC shall ftimish to the
Association sufficient evidence of the authority and the authenticated specimen sisnature
of each such person.
Section 5.03. This Agreement may be executed in several counterpans, each of
which shall be an original, and all collectively but one instrument.
IN WITNESS WHEREOF, the parties hereto, acting through their duly
authorized representatives, have caused this Agreement to be sisned in their respective
names in the District of Columbia. United States of America, as of the day and year first
above written.
INTERNATIONAL DEVELOPMENT ASSOCIATION
By
/s/
Regional Vice President
South Asia
STATE OF KARNATAKA
STATE OF PUNJAB
STATE OF WEST BENGAL
PUNJAB HEALTH SYSTEMS CORPORATION
ft 1
By A/
VAllUQl
Authorized Representative
-7-
SCHEDULE1
Procurement and Consultants' Services
Section I:
Procurement of Goods and Works
Part A:
General
Goods and works shall be procured in accordance with the provisions of
Section I of the “Guidelines for Procurement under IBRD Loans and IDA Credits*'
published by the Bank in January 1995 (the Guidelines) and the following provisions of
this Section, as applicable.
International Competitive Bidding
Part B:
1.
Except as otherwise provided in Part C of this Section, goods shall be procured
under contracts awarded in accordance with the provisions of Section II of the
Guidelines and Paragraph 5 of Appendix 1 thereto.
2.
The following provisions shall apply to goods to be procured under contracts
awarded in accordance with the provisions of paragraph 1 of this Part B.
(a)
Grouping of contracts
To the extent practicable, contracts for goods shall be grouped in bid packages
estimated to cost $200,000 equivalent or more each.
(b)
Preference for domestically manufactured goods
The provisions of paragraphs 2.54 and 2.55 of the Guidelines and Appendix 2
thereto shall apply to goods manufactured in the territory of the Borrower.
Part C:
Other Procurement Procedures
1.
Except as provided in paragraphs 2 and 3 hereof, civil works may be procured
under contracts awarded on the basis of national competitive bidding procedures in
accordance with the provisions of paragraphs 3.3 and 3.4 of the Guidelines.
2.
Civil works estimated to cost the equivalent of $45,000 or less per contract, up
to an aggregate amount not to exceed the equivalent of $18,000,000, may be procured:
(i) under lump sum, fixed price contracts awarded on the basis of quotations chained
from three qualified domestic contractors in response to a written invitation. The
invitation shall include a detailed description of the works, including basic
-8-
experience and resources to successfully complete the contract; or (ii) through direct
contracting m accordance with the provisions of paragraph 3.7 of the Guidelines and in
accordance with procedures acceptable to the Association: or (iii) with the Association’s
prior agreement, under force account procedures in accordance with the provisions of
paragraph o.S of the Guidelines, provided, however, that civil works procured under such
procedures shall not in the aggregate exceed $10,000,000.
Except as provided in paragraph 4 hereof, equipment estimated to cost less than
the equivalent of 3200 000 per contract, up to an aggregate amount not to exceed the
equivalent of 312,700,000. may be procured under contracts awarded on the basis of
national competitive bidding procedures, in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines.
4.
Equipment estimated to cost the equivalent of S50.000 or less per contract, up to
an aggregate amount not to exceed the equivalent of: (i) 54,200,000, may be procured
under
■ , ,contracts awarded on the basis of international shopping procedures in accordance
with the provisions of paragraphs 3.5 and 3.6 of the Guidelines; and (ii) S12 700 000
may be procured under contracts awarded on the basis of national shopping procedures
m accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
Vehicles estimated to cost not more than the equivalent of 3300,000 in the
aggregate may be procured under contracts awarded on the basis of national shopping
procedures in accordance with the provisions of paragraphs 3.5 and 3 6 of the
Guidelines.
Except as provided in paragraph 7 hereof, medical laboratory supplies estimated
to cost less than the equivalent of 3200.000 per contract, up to an aggregate amount not
to exceed the equivalent of: (i) 32,700,000. may be procured under contracts awarded on
the basis of national competitive bidding procedures in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines, and (ii) 3400.000 mav be procured under
• contracts awarded on the basis of international shopping procedures in accordance with
the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
Medical laboratory supplies estimated to cost less than the equivalent of S50.000
per contract, up to an aggregate amount not to exceed the equivalent of S2,300,000 mav
e procured under contracts awarded on the basis of national shopping procedures in
accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
8.
Except as provided in jparagraphs
J 9 and 10 hereof, medicines, furniture.
Management Information System/Information,, Education and Communication
-9!
(MIS/IEC) materials and supplies shall be procured under contracts awarded on the basis
of national competitive bidding procedures in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines.
s
Medicines estimated to cost less than the equivalent of $50,000 per contract, up
9.
to an aggregate amount not to exceed the equivalent of $1,500,000 may be procured
under contracts awarded on the basis of international shopping procedures in accordance
with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
10.
Medicines, furniture, MIS/IEC materials and other supplies estimated to cost
less than the equivalent of $50,000 per contract, up to an aggregate amount not to exceed
the equivalent of $3,700,000, $2,800,000, $1,700,000 and $11,100,000 respectively, may
be procured under contracts awarded on the basis of national shopping procedures in
accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
11.
Except as provided in paragraph 12 hereof, maintenance of buildings and
vehicles and equipment may be carried out under contracts awarded on the basis of
national shopping procedures in accordance with the provisions of paragraphs 3.5 and
3.6 of the Guidelines.
12.
Maintenance of buildings, and vehicles and equipment which meet the
requirements of paragraphs 3.7 and 3.8 of the Guidelines and costing in the aggregate
less than the equivalent of $3,100,000 in the case of buildings and $7,000,000 in the case
of vehicles and equipment, may be carried out either: (i) through direct contracting; or
(ii) force account, in accordance with the provisions of said paragraphs 3.7 and 3.8
respectively, of the Guidelines, and in accordance with procedures satisfactory to the
Association.
Part D:
1.
Review by the Association of Procurement Decisions
Procurement Planning
Prior to the issuance of any invitations to prequalify for bidding or to bid for
contracts, the proposed procurement plan for the Project shall be furnished to the
Association 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 Association, and with the provisions of said paragraph 1.
I
- 10-
2.
Prior Review
With respect to each contract for goods or civil works estimated to cost more
than the equivalent of S200,000 or $300,000 respectively, the procedures set forth in
paragraphs 2 and 3 of Appendix 1 to the Guidelines shall apply.
2
Post Review
With respect to each contract not governed by paragraph 2 of this Part, the
procedures set forth in paragraph 4 of Appendix 1 to the Guidelines shall apply.
Section II:
Empioyment of Consultants
1.
Consultants’ services shall be procured under contracts awarded in accordance
with the provisions of the "Guidelines for the Use of Consultants by World Bank
Borrowers and by the World Bank as Executing Agency" published by the Bank in
August 1981 (the Consultant Guidelines). For complex, time-based assignments, such
contracts shall be based on the standard form of contract for consultants' sendees issued
by the Bank, with such modifications thereto as shall have been agreed by the
Association. Where no relevant standard contract documents have been issued by the
Bank, other standard forms acceptable to the Bank shall be used.
Notwithstanding the provisions of paragraph 1 of this Section, the provisions of
2.
the Consultant Guidelines requiring prior Association review or approval of budgets,
short lists, selection procedures, letters of invitation, proposals, evaluation reports and
contracts, shall not apply to: (a) contracts for the employment of consulting firms
estimated to cost less than $100,000 equivalent each; or (b) contracts for the employment
of individuals estimated to cost less than $50,000 equivalent each. However, said
exceptions to prior Association review shall not apply to: (a) the terms of reference for
such contracts; (b) single-source selection of consulting firms; (c) assignments of a
critical nature, as reasonably determined by the Association; (d) amendments to
contracts for the employment of consulting firms raising the contract value to $100,000
equivalent or above; or (e) amendments to contracts for the employment of individual
consultants raising the contract value to $50,000 equivalent or above.
r
- ii SCHEDULE 2
Implementation Program
1.
Each Project State shall:
(a)
ensure that within the allocations for the health sector in each Fiscal
Year during the implementation of the Project the share of resources for Primary and
Secondary Levels of Health Services shall be increased in each such Fiscal Year until
FY 02; and
(b)
allocate in each Fiscal Year during the implementation of the Project
adequate resources for drugs, essential supplies, and maintenance of equipment and
buildings at facilities providing First Referral Level Health Services in accordance with
norms agreed to with the Association.
2.
Each Project State shall maintain its Strategic Planning Cell with adequate staff,
resources and terms of reference acceptable to the Association.
3.
Each Project State and PHSC shall levy user-charges in district and subdivisional hospitals jn accordance with a program and time schedule acceptable to the
Association, such program to focus, inter alia, on: (a) permitting the revenues collected
from user-charges to be retained at the hospital level; (b) implementing user charges in a
phased manner after improvements in the quality of basic services and infrastructure
development have been completed; (c) developing and applying criteria for exempting
the poor from user charges; and (d) strengthening appropriate management and
collection arrangements for maintaining existing user charges, including the
establishment and maintenance of District Health Committees in Karnataka and West
Bengal for collecting such charges.
4.
Punjab and PHSC shall, as the case may be, take all such measures as may be
necessary or required: (i) to enable PHSC to carry out its part of the Project; and (ii) to
ensure that PHSC undertakes health care activities at the secondary level in accordance
with service delivery norms acceptable to the Association, and in carrying out other
heath care activities shall ensure that its ability to perform its obligations under this
Agreement as determined, inter alia, from a review of the progress achieved in
implementing the annual work plans and in meeting the development and performance
indicators referred to in paragraph 9 hereof is not adversely affected.
5.
For purposes of enhancing the quality of health care services under the Project,
each Project State and PHSC shall: (i) maintain the key headquarters personnel
appointed for purposes of implementing the Project; (ii) appoint and thereafter maintain
key additional personnel with adequate qualification and experience in accordance with a
- 12schedule of appointment agreed with the Association; (iii) adopt, no later than six 4
months after completion of the physical improvements in any hospital under the Project,
and thereafter implement, staffing and technical norms acceptable to the Association:
and (iv) provide on an annual basis adequate funds, satisfactory to the Association, for
the maintenance of previously existing equipment in health care facilities supported
under the Project.
4
For purposes of carrying out Part B.3 of the Project as set forth in Schedule 2 to
6.
Development
Credit Agreement, each Project State and PHSC shall, no later than
the_____ r—
December 31, 1996: (i) issue appropriate directives to hospitals to strengthen the
management of the referral mechanism between the Primary, Secondary, and Tertiary
LevefHealth Services; (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.
Karnataka and West Bengal shall maintain the District Health Committees with
7.
such staff, resources, powers, functions and responsibilities so as to enable them to
facilitate, 'inter alia, the functioning of the referral mechanism, the collection and
distribution of user charges, maintenance of equipment, waste management, training of
technical staff, quality assurance, surveillance of communicable diseases and the
monitoring and supervision of their respective activities to be carried out under the
Project.
J
8.
Each Project State shall take all such measures as may be necessary or required
in ordf to provide, and thereafter maintain, authority to DOHFW in the case of
Karnataka and West Bengal and to PHSC in the case of Punjab for managing the
activities to be carried out by them under the Project, including construction and
maintenance activities.
9.
Each Project State and PHSC shall:
by April 30 of each year during the implementation of the Project
(a)
beginning with April 30, 1997:
(i)
provide to the Association an annual work plan, acceptable to
the Association, setting forth the respective activities under the
Project to be carried out during the prevailing Fiscal Year
including the budgetary' allocations to be made available for
such purpose, as well as the performance benchmarks and
development objectives to be achieved and drawn from the
overall framework agreed to be achieved under the Project
including, inter alia, hospital activity indicators, hospital
- 13efficiency indicators, and quality, access and effectiveness
indicators to be measured in accordance with methodology
satisfactory to the Association; and
(ii)
review with the ' Association the progress achieved in
implementing the Project under the annual work plan for the
previous Fiscal Year and the interim plan referred to in sub
paragraph (c) below of this paragraph (9) with special reference
to the achievement of the performance benchmarks and
development objectives incorporated therein;
(b)
implement each annual work plan in a manner satisfactory to the
Association, with the goal, inter alia, of meeting the performance benchmarks and the
development objectives set forth therein; and
implement the Project until the formulation of the first annual work plan
(c)
in accordance with an interim plan agreed with the Association.
10.
Each Project State shall ensure that: (i) its respective incremental budgetary
allocations under the Project for the Primary’, and First Referral Level Health Services
for each Fiscal Year during the implementation of the Project shall be fully additional to
the allocations made in FY 95; and (ii) the budgetary’ allocations for the annual work
plans and the interim plan referred to in paragraph 9 hereof are made available on a
timely basis sufficient to meet the resource requirements under such plans.
11.
Karnataka and West Bengal shall implement the Project in tribal areas (as
designated by'eacEsuch Project State) and West Bengal shall implement the Project in
the Sunderbans Area in accordance with the principles, objectives and policies of the
Tribal and Backyvard Area Development Strategy with emphasis on: (a) strengthening
linkages between Primary, and Secondary Level Health Services; (b) providing an
incentive package to doctors and other medical staff to work in the tribal areas of
Karnataka and in the Sunderbans Area of West Bengal: (c) increasing the appropriate
utilization of the medical system by the Scheduled Tribe population; (d) reducing the
cost to Scheduled Tribes of utilizing such system in Karnataka; and (6) increasing the
number of beds at sub-divisional and community hospitals.
12.
PHSC shall cany’ out Part A.2 (ix) of the Project in accordance with procedures
and arrangements satisfactory to the Association.
13.
The Project States and PHSC shall, with the participation of the Borrower and
the Association: (a) jointly carry out by June 30, 1999 a mid-term review of the Project,
includins on management aspects and financial sustainability, under terms of reference
- 14-
■ -) the Association; and (b) earn'
satisfactory to
satisfactory
to the Association.
a manner l—
out the recommendations of such review in
J1
INTERNATIONAL DEVELOPMENT ASSOCIATION
CERTIFICATE
I hereby certify that rhe foregoing is a true copy
of the original in the archives of the International
Development Association.
i
FOR SECRETARY
G'| OA" □- .
■ 7/^
INDIA
PROPOSED STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
(KARNATAKA)
INTERNATIONAL DEVELOPMENT ASSOCIATION
AIDE-MEMOIRE (MARCH 1995)
1.
An International Development Association (IDA) team consisting of Messrs./Mmes.
T. Nawaz (mission leader), P. Sudharto, E. Dib, S. Rao-Seshadri, K. B. Banerjee and
D. Porter visited Karnataka between February 23 and March 2, 1995 to review the preparation
of the proposed State Health Systems Development Project II. The mission would like to
express its gratitude to the Chief Minister of Karnataka, Mr. H.D. Deve Gowda and the
Health Minister of Karnataka, Mr. H.C. Mahadevappa, for meeting the team to discuss the
overall objectives and the concept of the project. The mission also met with
Mr. S.B. Muddappa, Chief Secretary, Mr. C. Noronha, Additional Chief Secretary and
Mr. B.K. Bhattacharya, Additional Chief Secretary and Principal Secretary, Finance
Department, Government of Karnataka. The mission would like to thank Mr. Gautam Basu,
Secretary Health and Family Welfare Department, Government of Karnataka, and his
colleagues for their cooperation and hospitality. A wrap-up meeting was held with Mr. Basu
and his staff, as well as officials from the Finance Department, on March 2, 1995 in
Bangalore.
2.
This aide-memoire records the overall progress made in the preparation of the
proposed project and summarizes the main findings and recommendations of the mission and
the understandings reached with the Government of Karnataka.
PROJECT OBJECTIVES AND COMPONENTS
3.
Objectives: The Government and the Bank reaffirmed that the main objectives of the
project would be to:yi) improve efficiency in the allocation of health resources through policy
and institutional development; and (ii) improve the performance of the health care system
through improvements in the quality, effectiveness and coverage of health care services at the
first referral level and selective coverage at the primary level.^The achievement of these
objectives would contribute to improving the health status of the people of Karnataka,
especially the poor and the underserved, by reducing mortality, morbidity and disability.
4.
Components: It was agreed that the project would have the following major areas of
investment: (i) Management Development and Institutional Strengthening including
(a) improving the institutional framework for policy development; (b) strengthening the
management and implementation capacity of institutions including structures, procedures,
management information systems, culture of service delivery, resources and training;
(c) developing surveillance capacity for the major communicable diseases; and (ii) Improving
Service Quahty, Access and Effectiveness by: (a) extending/renovating community, area and
district hospitals; (b) upgrading their clinical effectiveness; (c) improving the referral
mechanism and strengthening linkages with the primary and tertiary health care levels.
1
i
’ ©
POLICY FRAMEWORK
5.
The mission notes with satisfaction that the dialogue on key sectoral policy issues has
progressed considerably. The Chief Minister and the Health Minister reaffirmed their strong
support for improving the quality of services and for deploying adequate resources to
achieving these goals. Senior officials of the Government of Karnataka informed the mission
that the Government is committed to a policy package of health sector reforms reflecting key
sectoral development issuesJpr the primary and secondary levels of health care. These
include the need to: (i) set up a Strategic Planning Cell under the Health Secretary’ to
undertake analyses of health sector issues; (ii)'formulate an effective surveillance system for
the major communicable diseases; (iii) contract out selected services, especially supporting
services; (iv) review the policy framework for private provision of health care services;
(v) increase the overall size of the health budget; (vi) redress the imbalance in public
expenditures between- the different tiers of health care system; (vii) safeguard the operations
and maintenance component of the health budget to ensure adequate supplies of drugs and
essential medical materials and maintenance of equipment and infrastructure; and
(viii) implement service improvements and user charges.
6.
User Charges.lt was agreed that introduction of user fees for certain services such as
paying beds, charges for diagnostics and drugs, and registration fee for in-patients was
essential to achieve financial sustainability. Measures, however, would need to be developed
for exempting the poor. It was agreed that user fees would be used specifically for non-salary
recurrent cost purposes. The Department of Health also proposes that a high proportion of
funds collected through user charges would be retained at the point of collection. This was
discussed with the Finance Secretary who responded positively to this suggestion. It was also
agreed that the Government of Karnataka would have prepared a draft Letter of Health Sector
Policy confirming its commitment to instituting action on the above sectoral policy issues by
the project appraisal mission.
7.
Linkages with other health sector projects. The mission is pleased to note that the
proposed project would complement and consolidate investments made by on-going
Population, Health and Nutrition projects in Karnataka by providing policy and
implementation coordination with other health and family welfare projects. 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 VIII, Population IX and CSSM projects. The
proposed project would also fill some of the input gaps in primary health care in tribal areas
(excluding family welfare, which is already being addressed in Population IX). Discussions
were held with consultants to KfW on the scope of the proposed project to upgrade primary
and secondary health care facilities in five districts in Northern Karnataka. It was agreed with
the Government that World Bank project inputs in those districts would be complementary
and avoid duplication.
2
i
PROJECT PREPARATION PROGRESS AND RECOMMENDATIONS
8.
Good progress has been achieved in project preparation activities since the last
mission. What is now required is final consolidation and updating of past efforts to reflect
understandings reached during this mission. In order to expedite further project development,
it was agreed that a multi-disciplinary Project Coordination Team would be set up. A
designated Coordinator would be appointed, and would be assisted on a full-time basis by a
Technical Officer from the Directorate of the level of a Joint/Additional Director, who would
consolidate individual project development activities. Given the size of the project and the
policy issues involved, it was proposed that an IAS officer with direct access to the Secretary,
Health and Family Welfare would be nominated to act as Project Coordinator. In addition, the
Project Coordination Team would need to be strengthened to include additional personnel
experienced in clinical training and referral, equipment management, and physical works.
9.
With regard to project scope, it was noted that the government has already revised the
original proposal to reflect a more realistic approach. This would take into full consideration
staffing constraints and financial viability. The selection of facilities would take into
consideration specific criteria, including poverty, gender concerns and specific needs of
scheduled castes and scheduled tribes. In order to select facilities for upgradation, it is agreed
that the mapping exercise underway would be completed and facilities in tribal areas would
be flagged.
10Workshop. The project preparation workshop held in Bangalore on February 28 to
March 1 provided a useful participatory mechanism for defining the roles and functions of the
vanous types of health facilities and referral hospitals by involving key people in project
preparation and design. In addition to being attended by key people in the medical profession
in Karnataka, the workshop was attended by senior health officials from West Bengal, Punjab
and the Center. The workshop: (i) reviewed, defined and recommended the range of clinical,
technical, administrative and domestic services that ought to be provided at the various levels
of hospitals up to the district level; (ii) clarified the range of services available at primary
health centers and tertiary hospitals and thereby provide the critical links in the referral
mechanism; (iii) recommended the norms for physical assets, equipment, instruments,
furnishings, materials etc. that would be needed to provide services of adequate quality, based
on the proposed range of services reviewed; (iv) reviewed the key management and
administrative issues at the three types of referral hospitals; and (v) reviewed the policy
framework and key issues in the primary and first referral levels of health care. The findings
of the workshop will be issued by the Department of Health within the next few weeks and it
was agreed that the findings would be used for further project development.
11.
Project Administration and Management. The project proposal provides the
administrative and management structure under which the proposed project would be
implemented. However, the implications for project administration and financing mechanisms
resulting from the devolution of responsibility to local bodies heed to be further clarified.
3
I
7 A:
12.
Site Survey and Preparation of Physical Works. It was agreed that the Government
would undertake an extensive survey of all health facilities at the secondary level. This would
include: list of all existing health facilities, detailed survey of each facility, cadastral plans of
the facilities, ’as built' drawings of existing buildings, schedules of accommodation, and
physical survey of buildings requiring renovations only. It would need to be ensured that
required land will be available to allow for extensions at upgraded facilities. Details are
provided in Annex 5. The mission has agreed to arrange grant funds to conduct site surveys
as well as inventory of equipment at existing facilities (see below).
13.
Inventory of Equipment. A start has been made in gathering information from each
facility that will receive inputs under the proposed project concerning the nature and state of
its current inventory. Suitable proformas have been designed to simplify data collection and
standardize recording, and the local consultants contracted to undertake pilot surveys at two
facilities made use of these when visiting sites and interviewing staff. If necessary, the
proforma should now be revised taking account of the norms determined at the Workshop.
The project preparation team of the Government, and specifically the officer responsible for
equipment issues, should verify the data collected by the survey consultants by spot checks at
a reasonable number of facilities. Furthermore it should analyze the returns to establish what
new equipment, or necessary maintenance or repair work, at each facility needs to be
procured and funded to bring the inventories up to the accepted nonns. The work will require
access to a computer system with data-base and spreadsheet software.
14.
Equipment Maintenance. The current capacity to deliver appropriate maintenance and
repair services within the public health services is minimal. No efficient or cost-effective
services can be expected to develop without a significant in-house capability to deal with the
entire range of equipment management issues from specification, through procurement,
installation, commissioning, training of users, maintenance and repair services, finally to
obsolescence and planning a new cycle. The separate but related issue of how maintenance
and repair is best conducted, by in-house teams or contractors, needs to be considered at an
early stage and recruitment of appropriate key personnel to be groomed for the combined
roles of technical manager, service specialist and trainer must be initiated as soon as possible.
15.
Workforce. It was agreed that the proposed levels of staffing for medical and nursing
cadres would be reviewed. In addition, strategies will be developed to improve the
recruitment, deployment and retention of staff where difficulties of posting and retaining staff
are being experienced.
16.
Referral System. The mission met with officials in charge of service delivery and
discussed the existing referral system and its deficiencies. To improve the referral mechanism
and strengthen linkages with primary' health care it was agreed that administrative directives
would need to be issued and communications between different levels of the health care
system would need to be improved. In collaboration with health officials, the mission has
identified necessary steps and activities to be taken during the preparation of the project.
Annex 3 provides details.
4
I
12.
Clinical skill training. The mission has reviewed the training needs document. It was
noted that clinical training needs would neeiito be linked to service norms at each level as
defined by the workshop. Based on this, the Government would draw up a clinical skill
training plan. Annex 4 describes the necessary steps. The mission recommends that the
responsible officials visit Andhra Pradesh and review their preparatory work in clinical skill
training.
18Plan fPI.I?eveloping Surveillance Capacity for Major Communicable Diseases. It was
agreed at the Workshop that the Government would draft a development plan for a state-wide
system for communicable disease surveillance. This would be made available to the next
mission for consideration as part of the project proposal.
19.
Detailed^Project Costing. In revising the project proposal, it was agreed that a number
of detailed cost tables would be prepared reflecting cost by individual components and
sub-components of the proposed project. A model cost table was discussed and some samples
were left with the Department.
20Dn.i.g List and Formulary. The mission noted the need to develop an essential drug list
and formulary, such as the one in Andhra Pradesh, with suitable modifications to reflect the
epidemiological profile in Karnataka. This was discussed at the Workshop and
recommendations were made for immediate action.
21Plan for,Disposal of Medical Waste. It was agreed that a plan for the disposal of
medical waste would be prepared in order to mitigate the potential risks related to service
delivery. This plan would recommend specific actions that would be incorporated into project
design.
22.
Tribal Plan. It was agreed that a Tribal Plan integral to specified project components
would be developed based on the findings of the Beneficiary/Social Assessment Study
discussed below and other available information.
23.
Beneficiary/Social Assessment and Private Sector Studies. A Beneficiary/Social
Assessment proposal has been discussed with the Government, and a final proposal will be
made available to the mission shortly; terms of reference are attached as Annex 1. A study of
the private sector has also been discussed with the Government, and a final proposal will be
made available to the mission shortly; terms of reference are attached as Annex 2. The
mission agreed to arrange grant funds for conducting both of these studies.
24.
Performance Indicators. It was agreed that a discussion on performance indicators
would be initiated, and a preliminary list of indicators would be discussed with the next
mission.
5
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'.Z
25.
Assessment of Fiscal Capacity. A draft terms of reference for an assessment of the
state's fiscal performance was discussed with the Additional Chief Secretary and Principal
Secretary, Finance. The Government objected to commissioning consultants for carrying out
such a study. However, the government agreed to provide data to support its position that
sufficient resources are available for sustaining its fiscal position.
26.
Next Steps. The IDA project preparation team will return to Karnataka towards the
end of May or early June. Depending on the progress made and early delivery of the revised
project proposal, it will be decided whether further preparation work prior to preappraisal is
necessary.
March 2, 1995
6
13°)
ANNEX 1
BENEFICIARY SOCIAL ASSESSMENT
Terms of Reference
Objectives. I he main purpose of undertaking a Beneficiary/Social Assessment of the proposed
project would be to provide an understanding of the who the potential project beneficiaries
would be, where they are located and their socio-economic status. To bring better care within
easy access to needy populations, particularly the scheduled castes, tribes and populations
residing in remote and far-flung areas, it is also necessary to understand the health seeking
behavior and attitudes of these disadvantaged groups. Opinions of these key stakeholders,
particularly their felt needs, motivational factors, behaviors, lifestyles, work patterns, access to
resources, power equations within groups and with other groups should be better understood
for planning and designing the proposed project on need based issues. The Beneficiary Social
Assessment would provide the basis for policy guidance to (a) ensure that tribal populations
benefit from the proposed project and (b) avoid or mitigate potentially adverse effects on tribal
populations. The proposed project would seek to include appropriate components or
mechanisms to ensure that the social and economic benefits recieved by such groups are in
harmony with their Cultural practices.
Components of the Proposed Study. It is, therefore, proposed that a study be undertaken to
understand these crucial issues with the following objectives:
1. Describe the social services currently being offered by the government in tribal areas and
for women i.e. programs in nutrition, education, family welfare and health;
2. Undertake a Social Context Analysis i.e. identify and select areas that are geographically,
socially and culturally distinctive within the state, diffentiating also between urban and rural
areas. Present some basic demographic data with regard to scheduled caste and scheduled tribe
populations’;
3. Undertake an Institutional Analysis to understand the supply factors that adversely influence
health care utilization i.e. a description and analysis of the roles and linkages (if any) between
the traditional and allopathic systems of medicine in the different areas. The analysis should
include groupd that have a direct and indirect interest in the outcome of the project, e.g.
traditional and allopathic medical communities, local leaders and elites, community
organizations etc.;
4. Determine the Health Needs of the community through: (i) Demand analysis i.e. analysis of
service utilisation of government services within both traditional and non-traditional health
systems and (ii) Supply Analysis i.e. an analysis of the of the current distribution of health care
facilities for needy populations, particularly tribals living in far-flung areas;
’ Basic demographic data would include such infonnation as number of tribes, their population, distribution of tribal
population in the state, socio-economic status, birth and death rates, sex ratio, literacy rates, mode of
subsistence, economic activity etc.
i
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5. Assess the perceptions and attitudes related to the Health Seeking Behavior of disadvantaged
populations, particularly women and tribal populations, by investigating factors affecting
physical, social and economic access to health facilities2; and
6. Estimate the Private Costs of seeking treatment, including both monetary and non-monetary
costs.
2 Measures of Physical Access include distance to be traveled, arrangements made when traveling, availability of
transport, travel time, waiting time at destination, availability of appropriate services, drugs and supplies at
facility, convenience of working hours etc. Measures of Social Access include local beliefs and practices,
particularly with regard to maternal and child health, diseases of adults and children which are prevalent and
for which medical care is sought, availability and recourse to a tribal doctor, attitude of health facility staff
towards tribal peoples etc. Economic Access variables include treatment costs, comparative cost of seeing the
tribal doctor, transportation costs, costs of lost wages, socio-economic status of patients etc.
I
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ANNE.X2
REVIEW OF PRIVATE HEALTH SECTOR
Terms of Reference
The role of the private sector in delivering quality health care continues to be underdeveloped
inspite of substantial private investment. Recent research shows that private sector services are
of very varied quality and are provided by a wide range of qualified, less-than-qualified and
unqualified practitioners. Lack of regulations and effective legal remedies contributes to
inappropriate practices. Private contractual services, specially support services, remain under
utilized. There is a need to create an environment in which the private sector can provide costeffective services, specially some prevetive and promotive care services.
Objectives. The main objective in conducting a review of the role of the private health sector
in health care provision is to assess the quality of services provided by private care
practitioners and to evaluate regulations relating to service quality. The review would also try
to shed light on possibilities for expanding the scope of private sector involvement, particularly
in the voluntary sector.
Components of the Proposed Study. The review should provide the following data,
description, and/or analysis:
1. Describe the scope of the private sector, including the size of the sector, the services
offered, geographical and social spread of the sector, what fees, monetary and non-monetary,
are charged by profit and not-for-profit private sector organizations for the specific services
provided;
2. Describe the health sector NGOs operating in the state - which are the important ones?
where do they operate? what activities do they specialize in?
3. Define the coverage of the groups via alternative medical systems (e.g. ayurvedic), the
acceptance of alternative medical systems among social groups (especially the poor, tribal
communities and women) and estimated cost of such treatment;
4. Assess the quality at private sector institutions relative to public sector at each level
according to performance indicators3; summarize the lessons the public sector could learn from
the private sector in terms of improving all aspects relating to the quality of health services and
user fees;
5. Assess to what extent it would be feasible for the government to contract out secondary care
to the private sector for specific diagnostic, therapeutic or support services? Analysis of this
should be based on economic as well as social and institutional considerations;
6. Analyze and assess to what extent the state health secretariat/directorate regulates, accredits
and monitors private and ayurvedic services;
3 See AP I leal th SAR Annex 18.
I
Provide a brief analysisof the consumer protection act as it relates'to the health sector
currently under government review;
8. Assess the future demand for health care services by studying the utilization pattern of both
public as well as private health care institutions; and
9. Suggest ways in which public sectoral planning could be improved: what is the future of the
private sector in the respective states and how would this affect public sector institutions; how
could monitoring, regulation and accreditation of private sector health facilities be undertaken.
I
/3S'
ANNEX 3 : STRENGTHENING THE REFERRAL SYSTEM.
1. At present the referral system in the state is not functioning effectively. Some of the
reasons are: patients are directly proceeding to hospitals for minor illness which overload the
hospitals, patients perceive the lower level facilities as providing lower quality services, and
lack of organizational and management links between PHCs and hospitals at various levels.
2. An effective referral system which minimizes by-passing of lower levels of health
facilities has the following characteristics: i) patients should first receive care at the lower
facilities where appropriate initial treatment can be given and a decision made about the need
for referral to next level; ii) there should be a designated focal point for the reception of
referrals at the first referral hospital; iii) the referred patient should be seen promptly by
someone at a superior level of expertise, this will establish trust of the referring and the
referral institutions. Patients may be referred from one level to the next for: clinical
examination or special examination, consultation or expert advice, intervention and inpatient
care.
3. The proposed project will aim to improve the current referral condition. The following
points are necessary steps that were discussed with the health officials during the mission:
1) Assess the cunent referral system and pattern, including transportation used to carry
critical patients in an emergency from one level of health care to the next.
2) Review the grouping or linkages between different tiers of the system e.g. which
PHCs (’feeders') refer to a particular CHC/GH, which CHCs/GHs to a particular Taluka
hospital, and then to District hospital.
3) Develop procedures or administrative directives to facilitate the referral system which
include the following:
referral protocols for providers that specify the 'what”, "when” and "how";
guidelines for the higher level facilities on how to provide technical support to the
lower level facilities (eg. regular meetings, outreach or visiting by specialists);
■ preparation of forms for sending with referred patients;
identification of a ’unit' in the receiving facilities for accommodating referred patients;
consideration of direct access to diagnostic facilities for referred patients to avoid
queuing again;
■ preparation of forms to feedback information on patients to referring facilities.
4) Determine the transportation and communication needs for improving the referral
system. This includes need for vehicles for transporting patients in an emergency and
telephones tor communicating in advance the condition of such referrals. Regarding
vehicles, consideration should be given to the types of vehicles, where to place these (at
PHCs, CH'Cs, or Taluka hospitals), whether to procure, lease or hire, suitability for use in
urban or rural conditions, and the number of the vehicles. Special attention should be
given to the needs of areas with disadvantaged groups or tribal communities. Charging of
user fess for the use of such vehicles will be considered.
I
5) Consider practical mechanisms on how to operationalize the referral system. Are
referral committees like those to be established in AP necessary for monitoring the
implementation of the referral system or is some other mechanism more effective in
Karnataka ? (See AP-SAR Annex-11).
6) Investigate methods for disseminating information regarding referral system (IEC).
Who are the target groups, what communications media and channels to be used?
7) Propose an incentive system for the patients and providers who follow the procedures
such as reducing waiting times for those patients carrying referral slips and levying
reduced user fees.
8) Show how the proposed project will link with other WB-assisted projects such as
IPP-9, IPP-8 and CSSM in referral matters, to avoid duplication.
9) Develop a plan of action for project preparation and an implementation plan for the
project duration, with detailed description by year with regard to referral activities.
10) Cost the activities to be undertaken separately during project preparation and
implementation.
4. The working group responsible for developing the referral protocols could use the
following questions as an agenda for discussion.
1)
What conditions should be referred?
For further
clinical
examination/
investigation
For
consultation or
expert advice
For
intervention
(e.g: surgical,
radio-therapy)
For inpatient
care
’Cs facilities to CHCs,
’1 diukas. District
Hospitals and tertiary
hospitals
CHCs to Taluka
Hospitals, District
Hospitals and tertiary
hospitals
Taluka to District
Hospitals and tertiary
hospitals
District Hospitals to
tertiary hospitals
2
I
2)
Action to be considered prior to referring:
■ What to do before sending the patient ? (e.g. critical patients needing
stabilization, required examinations, etc. )
■ What essential information should accompany the patient, e.g. standardised
referral forms, clinical examination results, other results such as lab test or
radiology examination. The information should be sufficient to ensure continuity
in patient care, but not burdensome to the staff.
■ What are the transport arrangements for critical patients.
3) Counselling and information for the patient prior to the referral. This could include:
purpose of referral, how the referral will benefit the patient, where and when to go, what
is likely to happen at the referral hospital, what will be the cost to the patient, what
precautions need to be taken or preparations made before referring a patient..
3
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F
ANNEX 4 : STRENGTHENING CLINICAL SKILLS
1. The effectiveness of the referral system depends on the quality of services provided at
various levels in the system. In order to improve the quality of the clinical services, the state
should establish a system of regular in-service training for all categories of staff who provide
clinical and diagnostic services. Clinical training will be aimed at upgrading clinical
knowledge and practical skills, and to enable staff to provide good quality care within the
service norms defined by the workshop.
2.
The following steps are suggested by the mission:
1)
Conduct a rapid training need assessment [TNA] to identify clinical training needs of
physicians and nurses in the facilities. This should cover all types of facilities from
CHCs to district hospitals.
2)
Identify training priorities, using the TNA result.
3)
Draft training specifications: where the training should be conducted, who should
provide the training, what methodology, duration, stipend, accommodation
arrangements, etc.
4)
Prepare course curriculum for each cadre.
5)
Prepare modules for each type of training (e.g. surgery, ob-gyn, anethesia, pediatrics),
using available materials, WHO references, AP modules, etc.
6)
Conduct training of the trainers.
7)
Conduct coordination with other training programs from other projects [CSSM, IPP-9]
in terms of course curricula, resources, modules. Explore possibilities of using trainers
or co-trainers from these projects.
8)
Develop training activity plans to be implemented during the project preparation and
throughout the project life, with details by year. How many staff will be trained.
Taking into consideration the material support for the training courses, define which
activities will be implemented during project preparation and which activities during
project implementation.
9)
Develop evaluation methods for training activities.
10) Draft proposals on appropriate use of technical assistance or consultancy to prepare
TNA, course design, curricula, training modules and TOTs.
H) Cost the activities to be undertaken separately during project preparation and
implementation.
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IMPLEMENTATION SET UP
the proposed Project. The outcome of the discussions described below was also reviewed and
discussed with the Department of Health.
PREPARATION OF DESIGNS & DRAWINGS
13. The PWD Design Department, headed by the Chief Architect, will be responsible for the
preparation of designs and drawings to be undertaken by architects and architectural firms.
The Design Department will be reinforced by two senior architects experienced in hospital
design. These two consultants will interact with the architectural firms and the users, and will
monitor
™°
n °r ®and
nd review
rev,ew the designs, drawin
drawings, construction details and technical specifications
structural, plumbing and electro -mechanical designs and drawings will be reviewed by
engineers deputed from PWD. These engineers will be under the administration of the
Design Department.
SUPERVISION OF CONSTRUCTION SITES
14. To ensure good quality supervision, the supervision of each hospital site will be
contracted with the architectural firm that prepares the designs and drawings. The monitoring
of supervision will be done by the Des.gn Department's two senior architects and the
engineers deputed from PWD. The Ch.ef Architect will certify works and bills submitted for
payment.
PROCUREMENT OF WORKS
♦V’ Procyement of C,V11 works ls the responsibility of the PWD. This Department handles
e advertisement for bids, issuance of bid documents, receipt and evaluation of bids, and the
prepara ion of bid evaluation report including the recommendations of the Tender Board
ommi ee. Contracts for construction will be signed by the Department of Health and
payments effected by the same.
BIDDING DOCUMENTS
16. The bidding documents for the procurement of civil works will comprise tlie following:
,
(
—-------- ”
U1V AVllVWlllg,
a)
rawings. J^veJln8 architectural and working drawings; construction details,
structural, plumbing and electro-mechanical drawings
b) Specifications
c) Bill of Quantities
d) General and Special Conditions
e) Instructions to Contractors
0 Bid and Performance Bonds
g) Contract Form
2
!
1^
a .
V
17. Standard bid documents for local competitive bidding (LCB) for the procurement of civil
works already approved by the state of Karnataka and the World Bank, will be used without
any a era ions or mo i ications. If and when a paragraph is not relevant (for example, a
sma vo ume jo ), i s ou be brought to the attention of the Bank for review and comment
prior to the use of the document for bidding.
18. Standard bid documents for international competitive bidding (ICB) and LCB for the
procurement of goods, already approved by the State and the Bank, will be used under the
proposed project.
COSTING OF CIVIL WORKS
19j (L°StMSliniKteSJfOr re"ovation/rePairs should be prepared during the survey of facilities
and should be based on tthe
1-----scope of works of each facility along with related specifications
and bill of quantities.
2 . When using a unit cost to estimate the cost of new construction, the unit cost should be
based on the average costs of gross area for different types of construction (laboratories,
operation theatres kitchen, toilets and others) and should be inclusive of all works. However,
costs of site development works may be calculated separately. Final cost estimates will be
calculated on the bas1S of the established bill of quantities and ongoing rates for new
construction. Also, costs of topographical site surveys and soil tests and analysis should be
accounted for.
21. Estimates should be based on base line costs only. Note that physical and price
contingencies should not be added in the cost; they will be computed and added by the Bank.
MAINTENANCE OF BUILDINGS
22. The mission visited a number of hospitals and noted the lack of appropriate and adequate
maintenance. Buildings are becoming dilapidated quickly, seepage of water though roofs, and
broken fittings and fixtures needing repair remain unattended for months. This is resulting in
loss oi valuable assets.
23. The present set-up for building maintenance is ineffective. Buildings are not adequately
maintained; they are left to deteriorate before tenders are called for repair. Appropriate
maintenance set-up with adequate yearly budget is needed. The Department of Health may
need to hire local consultants to evaluate the extent of damage resulting from poor
maintenance and due to inadequate budgeting for appropriate maintenance. Such consultants
should be asked to recommend practical and efficient maintenance anangements.
3
I
‘ I
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
KARNATAKA
SUPERVISION REVIEW
May 2000
AIDE-MEMOIRE
s
1.
An International Development Association team consisting of Messrs./Mmes. T Nawaz
(Team Leader), D. Peters, S. Chowdhury, P. Kudesia, G.N.V. Ramana, M. Voss, H. FI. Pyne, D.
Porter, and C. Giles, reviewed implementation of the Second State Health Systems Project (Cr.
2833-IN) in Karnataka between May 10- 15, 2000. The mission met with Mr. M. Reddy,
Health Minister and Mr. B. K. Bhattacharya, Chief Secretary, Government of Karnataka and
discussed the overall progress of the project. The mission also met with Mr. A. Sengupta,
Secretary, Health and Family Welfare, Government of Karnataka; Mr. S. Kaul, Commissioner,
Health and Family Welfare, Mr. A. Risbud, Project Administrator, Karnataka Health Systems
Development Project (KHSDP) and senior staff of KHSDP. The mission jointly reviewed this
project along with the IPP VIII, IPP EK and Reproductive and Child Health Projects (RCH) and
discussed issues related to the integration of the various programs. Separate aide-memoires have
been discussed for these projects. Discussions were also held with the Task Force on Health and
Family Welfare, Government of Karnataka, and the Bank team was joined by P. Heywood, Team
Leader, Disease Control and Nutrition cluster of projects. Future analytical and lending work
was also discussed with the government. The mission wishes to thank the officials for their
cooperation and hospitality.
2.
Project implementation progress is recorded in : (i) the Background Papers for Review of
the Project, May 2000 prepared by KHSDP; (ii) the Interim Report of the Task Force on Health
and Family Welfare - Karnataka, Towards Equity with Quality in Health, April 2000; (iii) the
Summary of The Health, Nutrition and Population Initiative for Karnataka — towards equity and
quality with focus on primary health care, Office of the Commissioner, Health and Family
Welfare Services, May 2000; and (iv) the Report on Financial Progress, KHSDP, May 2000.
The aide-memoire summarizes the main findings and recommendations of the mission.
3.
Project Development Objectives (DO). Progress toward achievement of the
development objectives of the project is satisfactory and implementation of agreed health sector
policy measures is on track. DOI: Policy Indicators. Budgetary allocation. The expenditures for
the health sector increased from Rs. 535 crores in FY96-97 to Rs. 819 crores in FY98-99.
Budgetary allocations for the health sector have been enhanced to Rs. 1023 crores in FY 99-00
and Rs. 1113 crores in FY 00-01. The share of resources to the primary and secondary' levels, as
well as resources for non-salary recurrent costs (drugs and supplies, etc.), have also increased
substantially since the beginning of the project. Cost Recovery, District Health Committees
(DHCs) are collecting user charges for a range of services including fees for room rents.
I
laboratory and diagnostic services, selected surgery and medicines. User charges arc being
collected at all district hospitals. All revenues collected are being retained by the DI ICs for
deployment among hospitals in the district for non-salary recurrent expenditures. To date, about
Rs. 1.8 crores has been collected and activities such as ambulance maintenance, repair of water
and sanitary connections, purchase of supplies have been financed. Those below the poverty
line, established through the JRY program, and entitled to a Green Card, arc exempt from paying
user charges. Contracting out. Contracting out of non-clinical services has been established in 24
hospitals and is being extended to another 41 re-commissioned hospitals. Contracting out of
clinical services is being explored through the participation of NGOs. Overall, the project has
made important impacts on the policies of the government in the health sector beyond the first
referral level - in the areas of better management practices, drug procurement policy,
performance monitoring and service norms at the primary and tertiary levels.
V4-'.
PO2.. Access.and Effectiveness Indicators. There has been a significant improvement in
the following areas, increased availability of drugs and supplies at the facility level; meeting
equipment norms and timely repair of equipment in upgraded facilities; increased referrals to
higher level institutions; and increased access to basic health services for SC/ST and women.
Quality assurance mechanisms at upgraded facilities are being established. These improvements
are leading to increased credibility of services provided and are beginning to show greater patient
satisfaction.
DO3. Activity Indicators. As part of the M&E mechanism, hospital activity indicators
such as out-patient attendance, in-patient admissions and discharges, bed turnover rate, bed
occupancy, average length of stay, and utilization of diagnostics and equipment are being
collected. This information is being used to assess hospital perfonnance and is being fed back to
the respective institutions for follow-up action. Utilization of services at upgraded facilities is
increasing substantially.
6.
Overview. Since the last mission in November 1999 implementation of the project has
been satisfactory. A new Project Administrator was appointed in mid-March 2000. Since the
systems that were put in place earlier were well established, the transition in project management
h25 keen relatively smooth. Some areas have consolidated implementation while a few appear to
have suffered due to the transition in project management arrangements. As had been
recommended in the last mission, the focus of the project is now clearly shifting towards the
software issues. The civil works component of the project is more or less on schedule for the
civil works originally planned under the project, and project expenditures and disbursements are
close to the target estimated in the SAR To date, work has been completed at 90 hospitals and
these are now in the process of being re-commissioned. Work is ongoing in another 101
facilities. The additional civil works start-up has been slow, and these activities now need
increased attention to complete within the project period. Procurement and quality testing of
equipment, equipment maintenance, management and clinical training procrams, referral,
collection of activity indicators, and outreach programs to scheduled caste^ scheduled tribe and
v>omen are progressing well. The project has begun to establish links with the primary-' care
network and is playing an important role in stimulating better practices in some specific areas in
the management of the health sector, beyond this project. As had been recommended m the mid
term review (MTR), the project will now have to pay increased attention to the following areas:
3
the overall staffing of medical and para-medical personnel according to norms al re
commissioned facilities and the gap in skill-mix in the health sector overall: acknowlcdgemcm of
the importance of the attitude ot providers in improving service quality and patient satisfaction;
quality assurance, HMIS, and IEC activities. The next mission planned for October 2000, will
be one year after completion of the MTR. The mission expects the project management to report
on the status of implementation of recommendations made by the MTR.
7.
To date, Rs. 292 crores have been spent under the project, and disbursements in
Karnataka under SHS II are about US $ 50 million. These figures are close to the SAR target,
but with the extensive work program still remaining in the next two years, expenditures and
disbursements need to be enhanced beyond the level of FY00. The procurement plan for FY01
has been reviewed and modified based on discussions during the mission. There are no
outstanding audit issues. The financial management arrangements continue to function
satisfactorily. The Government of Karnataka has budgeted about Rs. 130 crores for FY01, but
the mission was advised that expenditures during the year could be enhanced to meet project
activities.
8.
Management. Project management continues to give priority to strengthening the
coordination mechanisms among SHS II, IPP VIII, IPP IX, RCH and the KfW projects, and to
strengthening its linkage with the Directorate of Health. It is also working closely with the newly
established Task Force on Health and Family Welfare; this is one of the three Task Forces
established by the Chief Minister, reflecting the commitment of the GOK to the health sector. Its
Terms of Reference covers improvements in public health, stabilization of the population,
improvements in management and administration of the Department of Health and Family
Welfare, changes in the education system covering both clinical and public health, and
monitoring the initial stages of implementation. Improved communication across the sector and
the better use of resources have been two tangible results from early collaboration between the
Task Force and the project management. As the Project Director is the Convenor of the Task
Force, continued collaboration on improvements in health care delivery is expected. 1 he
Commissioner for Health and Family Welfare has also recently been appointed to oversee the
activities of the Directorate of Health, as well as to coordinate the activities under IPP VIII, IPP
DC, RCH, KfW and SHS II. He will play an important role in coordinating the Health
Department in the areas that have sector wide implications, such as Health Manacement
Information Systems and disease surveillance.
9.
M ork force issues. Recruitment. Project management will continue to oversee the
recruitment of Bio-medical Engineers and Microbiologists which has been delayed due to
administrative requirements. In the meantime, arrangements will be made to employ 5 qualified
bio-engineers immediately on a contract basis. Clinical Mismatch It is proposed to adopt a
system-wide approach to ensuring the placement of specialists to meet the overall needs of the
services, including agreed service norms in project hospitals. This approach is designed to elicit a
higher degree of cooperation and satisfaction of clinicians in their postings, and to lead to a more
sustainable outcome. It is anticipated that over two rounds significant progress will be made to
addressing the mismatch. It was agreed that the mismatch of doctors in secondary hospitals
would be reduced from xx% to yv% by October 3 1,2000. Addressing this mismatch
I
4
satisfactorily will be a key element for the long-term success and sustainability of the health
sector.
10.
Strategic Planning Cell (SPC). The Terms of Reference have been finalized and no
objection given by the Bank for the study on options and cost effectiveness of final disposal of
waste. Selection of the external agency to undertake the study will now proceed. In addition, the
study on Manpower Planning in the Department of Health and Family Welfare is progressing
and a final report will be available by October 31,2000. Documentation of the experience to date
with the contracting out of non-clinical services in 30 KHSDP hospitals will now commence
and be completed by October 31, 2000. In addition, a study on public/private mix will be
commissioned. This study will be in two parts examining both medical institutions and private
practitioners. Regarding medical institutions, the focus will be on their regulation, the overall
number and need, and the content, quality and relevance of training. The examination of private
practitioners will focus on an assessment of services provided, and on the development of a
regulatory framework and of ongoing performance measures. The Commissioner, Health and
Family Welfare will play an important role in the coordination of analytical and operational
research work in the health sector through the SPC, and through coordination of the Task Force.
11.
Civil Works Component. Progress to date on civil works continues to be very good. Of
the remaining 14 works of the original plan, six have been grounded and four are in the process
of finalizing bid evaluations since the last mission. The minor works, such as the district
surveillance laboratories are all proceeding well. 90 hospitals have been completed to date. The
additional works agreed at mid-term — 25 hospitals in Gulbarga Division which were transferred
from the phase II of the KfW program, 4 Bangalore and 1 Mysore hospitals are proceeding
relatively slowly. They will require additional technical manpower and other necessary support
to implement the works within the time-frame. It was noted once again that the civil works
component of the 4 Bangalore and 1 Mysore hospitals would consist of minimal civil works
input, and the service norms for equipment and manpower would be brought to the level of
district hospitals to enable them to function as referral hospitals. Implementation plans have
been reviewed and individual hospital designs will now be prepared and reviewed. All civil
works under the project will need to commence by December 31,2000 in order to be completed
and re-commissioned before the project closing date of March 31, 2002. The mission noted that
it will not be advisable to start any new construction of hospitals after December 31, 2000.
12.
Procurement of Goods (equipment, furniture, vehicles, drugs, medical laboratory
and other supplies, MIS and IEC materials). The procurement plan for the final two years of
the project (FY00-02) has been finalized. Of the proposed expenditure on equipment (RsJ 8.3
crores), over 50% require completion of civil works before installation can commence.
Therefore, deliveries of these are scheduled for the last 6 months of FY 01. This will entail a
major effort by KJ-ISDP in inspecting facilities and checking equipment deliveries, and then
participating in the commissioning and hand-over processes. Plans need to be drawn up to ensure
that there will be adequate managerial input to this work and technical supervision of the
contractors and suppliers involved. No breakdown is given of the types of physiotherapy
equipment it is proposed to procure for district hospitals' quantification and technical
specifications are needed.
I
5
13.
Equipment Maintenance and Repairs,..,Good progress continues to be made in the
development and expansion of the planned network of maintenance workshops. Civil works are
completed for 10 district workshops, and a further 8 schemes are in progress. Building estimates
arc under preparation for 2 more, and in the one remaining district (Chamarajanagar), a suitable
site has still to be found. There should be no problem in completing all of these small-scale
works well before the end of fYOl. More critical than workshops is the issue of availability of
skilled manpower, particularly bio-engineers to lead and manage these activities. The interim
solution of hiring five bio-engineers on contract for two years is clearly not a long term answer.
It will be necessary to recruit bio-engincers to the official posts established under the project well
before project completion to ensure that they acquire appropriate skills and experience from the
STEM consultants who have played the leading role in the development of the maintenance
system. The benchmark for October 31, 2000 is to extend the computerization of the equipment
asset and maintenance database to three districts, one each in the revenue divisions of Mysore,
Gulbarga and Dharwad-Hubli.
14.
Surveillance. The benchmarks agreed for disease surveillance have been partially met.
Civil works at district surveillance laboratories are progressing, with completion of nine
facilities. The report of functioning of the district level co-ordination committees has not been
done in a manner that would provide any feedback. The benchmarks agreed are : (i) to hold a
workshop for officials at state, district, taluka and lower levels to establish workable procedures
for strengthening the surveillance system for the state by June 30, 2000 and (ii) based on the
recommendations of the above workshop, standardize reporting formats and develop the required
software and initiate pilot implementation in 2 districts by October 31,2000.
ifVvi-i
15.
Training. The different training programs for doctors and paramedicals under the
project continue to be implemented as planned, and the benchmarks agreed for March 31, 2000
have been partially met. Training in some new areas are needed, based on feedback received
from the hospitals and staff. In response to this, the project will develop training modules and
curriculum for X-ray technicians and staff nurses in burn management. These training activities
will commence shortly. The external evaluation of the impact of training on the performance of
the trainees needs to be completed as a priority. Training during the remaining project period
should focus on meeting the overall objectives of the project, with emphasis on improved health
outcomes at the facility level. The benchmarks agreed are as follows: (i) finalize the draft report
on external evaluation of clinical training by September 30, 2000; (ii) finalize appointment of
external agency for the evaluation of administrative training by September 30, 2000; (iii) initiate
training for X-ray technicians at KHSDP hospitals by August 31,2000; and (iv) initiate training
of staff nurses working at KHSDP hospitals in management of bums patients by September 30
2000.
~
16.
Referral. Efforts continue to be made towards achieving the previous benchmark of
increasing the referral linkages between RCH, IPP IX and other health programs. The referral
system under the project dealing with referral cards and registers being used at re-commissioned
hospitals, is in place. An analysis of the referral decisions is, however, not being done. Such
analysis would pro\ ide useful feedback to the management of the functioning of the system and
quality of services being provided. Project management would need to continue to focus on
expanding the referral system to the entire districts without wailing for all hospitals to be
upgraded. The benchmark agreed for October 3 1.2000 is to undertake a clinical review of
I
6
referral decisions over a three month period in Tumkur, the pilot district, and one other district
where re-commissioning is at an early stare
.
6^
17.
Health Care XA astc Management. Studies on waste generation have been conducted in
six hospitals. These give very useful information on the nature and quantity of different items in
the waste stream at typical facilities. The results are generally in line with other findings in
public sector hospitals in India. Data of this type will be useful to the consultants engaged to
appraise final disposal options, and the project team should continue these studies in a selection
of hospitals so that the final data is fully representative. The short-term and medium-term
measures have been introduced in 50 hospitals and procurement is in hand to obtain materials for
the remaining facilities. Manuals have been developed for 30 hospitals that are in the process of
being re-commissioned and staff have received the first round of training in waste segregation,
handling and disposal procedures. The mission discussed with the project team the need to raise
awareness of hospital staff about the potential hazards of needle-stick, sharps and other injuries
that could compromise their health through careless practices. There is a need to document the
scale of this problem, to introduce procedures for logging injuries, recording actions taken to
treat and counsel staff involved and, where relevant, to initiate appropriate measures to minimize
the risk of further incidents. In addition to the initiation by the Strategic Planning Cell of the final
disposal options appraisal study, the agreed benchmark for October 31,2000 is to implement
short-term and medium-term measures at all 65 re-commissioned hospitals.
18.
Improving Access to Health Services for Schedule Castes and Schedule Tribes
■ (SC/ST). Implementation of the Yellow Card Scheme, an intervention aimed at improving
access to health services among SC/ST populations, is progressing satisfactorily. The
benchmark set in November 1999 to develop the terms of reference for an evaluation of the
Scheme by an external agency has been met. Furthermore, a recommendation of the MTR to
expand the Scheme throughout the entire state has been undertaken. To date, about 20,000 health
check up camps, with an average of about 135 attendants per camp, have been conducted in all
twenty seven districts. Of the total target population of 8.9 million, about 2.7 million (30.6%)
SCs and STs have received medical screening at these camps. Seventy percent of the check-ups
needed treatment, of which 3% were referred to a higher level health facility.
19.
In addition to the rapid assessment of the pilot in 1996, in January 1999 and March 2000
project management reviewed the performance of the districts in conducting health check up
camps. These reviews highlighted key problem areas and made recommendations for improving
the Yellow Card Scheme, (i) improve flow of funds and supply of drues and reagents from the
District to PHCs; (n) ensure full staffing at health check up camps; (iii) strengthen capacity of
staff to conduct and manage outreach activities; (iv) involve communitv based organizations and
local village panchayat leaders; (v) broaden the scope of the camps to include health education
activities; and (vi) develop a outreach strategy to improve access and facilitate follow up
services. The mission commends the efforts of PMC in monitoring the implementation of the
Scheme, and urges the PMC to act promptly on the recommendations made by these reviews.
Furthermore, continued improvement in access to services bv women is essential The
benchmark agreed for October 31,2000 is to review an interim status of the external evaluation
of the impact of the Yellow Card Scheme by October 31, 2000.
I
7
20.
Information, Education and Communication (IEC). Benchmarks identified in
November 1999 called for a mechanism to coordinate IEC activities of’1 fam.'1”
welfare programs and for selection of a professional agency to develop IEC materials. These
benchmarks have not been met thus far. However, coordination between these programs is
expected to proceed, given a commitment expressed by the new Commissioner of Health and
Family Welfare and the Project Administrator of KHSDP. In addition, attended an IEC
workshop in Mumbai in March 2000 to explore options for involving a professional agency to
develop IEC materials. To date, the majority of the IEC activities undertaken by PMC staff has
been facility-based. The activities have focused on providing information to hospital staff on
issues such as referral, waste management, and proper use of equipment and maintenance. The
mission recommends that PMC hire a consultant (communication specialist) to assist ongoing
facility-level EEC activities, and to facilitate in the formulation of a community-oriented IEC
strategy that includes an implementation plan for the remainder of the project. The agreed
benchmark is to contract a consultant to assist ongoing IEC activities and to develop a
community-oriented strategy by October 31,2000.
21.
Management Information System (MIS) and Performance Indicators. The data now
being entered regularly into KHSDP's hospital MIS database has not yet been subjected to
independent verification. While some progress has been made with the development of database
management and analysis software with technical help from consultants, a common
understanding needs to be reached of the definitions of several important indicators. Analysis of
hospita^ management indicators needs to be improved. Solutions to these issues can be expedited
by seeking technical assistance from one of the other State Health project teams that has
successfully dealt with these matters. The quality of future management decisions on health care
delivery and use of resources is dependent on accurate data. A two-stage process can be used to
achieve this. Firstly, the project team should test the accuracy of the data it is receiving and take
appropriate actions to improve the data quality. The second stage is to engage consultants to
validate the database assembled over recent years and to develop with the project team the
analytical framework for the management reporting system. The benchmarks agreed arc: (i) to
undertake an in-house verification of the HMIS data and provide a report on the analysis of this
data by October 31,2000; and (ii) based on the existing data, independently validate the HMIS
system in place by March 31, 2001.
22.
Quality Assurance. The initial approach to quality' assurance adopted by Karnataka
included a focus on facilities, administration and management, and infrastructure support
services. In line with this approach, two rounds of performance review had been conducted
involving 21 hospitals. The more recent quality performance review consisted of a team of
specialists evaluating 20 project hospitals on performance indicators in the following service
areas: maternity, sterilization, laboratory; pharmacy; and casualty. Initial results of this
performance review have been tabled, and provide a basis for ongoing performance review.
23.
Discussion centered on the need to adopt a comprehensive approach to quality assurance.
I his would include a focus on facilities (including infrastructure support) and administration and
management and also a focus on data reliability, medical records (medical audit), clinical
practice, including the development of a core set of clinica. indicators, patient satisfaction and
staff education. As part of this approach, and as a means
providing an ongoinu mechanism for
i
8
clinicians to assess clinical performance, consideration would be given to the introduction of
Quality Circles. In this way Quality Assurance mechanisms would be adopted across all project
hospitals, and in the medium to longer term applied across the board at a state level as an
important mechanism for sustaining the improvements in health care delivery. In the short term,
the current set of clinical indicators should be monitored. A core set of indicators will now need
to be decided upon, and these indicators should be tested and refined over time. The benchmarks
agreed are to: (i) develop a TOR for a patient satisfaction survey by an external agency in a
sample of re-commissioned hospitals by June 30, 2000; (ii) finalize the above report by March
31,2001; and (iii) provide an analysis of the ongoing quality assurance work and decide on a
limited number of core indicators to monitor service quality by October 31, 2000.
24.
Compliance with Covenants. All covenants are in compliance in the Karnataka
component of the project.
i
9
KARNATAKA HEALTH SYSTEMS DEVELOPMENT PROJEC T
Benchmarks
Management
Recruitment
Strategic
Planning Cell
Contracting
out Nonclinical
services
Civil Works
Surveillance
Continue to strengthen coordination mechanisms among
SHS II, EPP VUI, IPP IX, KfW and RCH Projects
Continuous
Reduce mismatch of doctors in secondary hospitals
according to norms—from
to ...%
October 3 1, 2000
Publish C & R Rules for the recruitment of Bio-medical
Engineers and Microbiologists
October 31,2000
Recruit 5 Biomedical engineers on contract
August 31, 2000
Finalize the agency and initiate study on Options and Cost
Effectiveness of final disposal of waste
September 30, 2000
Update action taken on Karnataka Government Health
Policy Matrix
Continuous
Prepare a draft report on man power planning, in the
Department of Health &. Family Welfare
October 31,2000
Finalize Issues and Options paper on Public-Private mix
addressing the issues highlighted in the Policy Matrix and
any other issues that have emerged since
October 31,2000
Report on the experience with contracting out of nonclinical services at 30 KHSDP Hospitals_____________
Contract out non-clinical services in 65 re- commissioned
hospitals (cumulative total)
October 31, 2000
Commence works at 195 (cumulative total) hospitals
October 31. 2000
Ground all works including additional works agreed
during MTR
December 31,2000
Complete civil works at 115 hospitals and initiate the
process of re-commissioning in all completed hospitals
Hold workshop for officials at state, district, taluka and
lower levels to establish workable procedures for
strengthening the surveillance system for the state
October 31, 2000
Based on the recommendations of the above workshop,
standardize reporting formats and develop the required
software and initiate pilot implementation in 2 districts
October 31, 2000
June 30, 2000
October 31, 2000
i
10
Training
F'na!IZC lhe drnn rcPOH on external evaluation of clinical
training
September 30. 2000
Finalize external agency for the evaluation of
administrative training
September 30, 2000
Initiate training for X-Ray technicians at KHSDP hospitals
Medical Waste
Management
Equipment
Procurement
and
Maintenance
Referral
S(yST/Gender
Issues
IEC
Quality
Assurance
Initiate training of staff nurses working at KHSDP hospitals
in management of burns patients_________________
Implement short-term and medium-term measures at all 65
re-commissaoned hospiuls
Extend computerization of equipment asset and
maintenance daubase to 3 districts, one each in the revenue
divisions of Mysore, Gulbarga and Dharwad-Hubli
Undertake a clinical review of referral decisions over a 3
month period m one pilot district and one other district
where re-commisionning is at an early stage
Review interim sUtus of external evaluation of the impact
of yellow card scheme
September 30, 2000
October 31,2000
September 30, 2000
October 31, 2000
October 31,2000
Undertake an external review of the institutional-based IEC
program
March 31,2001
Finalize strategy for community - based IEC for project
activities
October 31,2000
Develop a TOR for a patient satisfaction survey by an
external agency in a sample of re-commissioned hospitals
June 30, 2000
Finalize above report
MIS
August 31, 2000
Provide an analysis of the ongoing quality assurance work
and decide on a limited number ofcorc indicators to
mom tor service quality
Undertake an in-house verification of the HMIS data and
provide a report on the analysis of this data
Based on the existing data independently verify the HMIS
system in place
March 31, 2001
October 31,2000
October 31,2000
March 31, 2001
i
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II (Cr 2833-IN)
AI Dl .-MEMO IRE .CM ARCH I ‘)<)7)
An Internalional Development Association team consisting of Messrs /Mmes T Nauaz (miss.on
leader). D Porter, S. Rao-Seshadri, P. Sudharto. S. Chakravarty and R Willey vis.ted Karnataka
between March K-ll, 1997 to review implementation progress of the Stale Health Ssslcms
Development Project II (Cr. 2833-IN) in Karnataka. The nuss.on met with Mr B Eswarappa
Secretary l-l.-alth and Family Welfare Department; Mr. B. R. Prabhakar Chief Secretary
Government of Karnataka; Mr. B P Bhattacharya, Finance Commissioner; Dr S Subramanva
Project Adm mstrator and ex-officio Additional Secretary ; and senior staff of the project The
mission wishes to thank the officials for their cooperation and gracious hospitality A wrap up
meeting will be held with Mrs. Shailaja Chandra, Additional Secrctarv Union MOHFW and Mr
R.S. Shanin Director DEA.
Project implementation progress is recorded in the various documents prepared bv the Karnataka
Health Systems Development Project. The aide-memoire summarizes the main findings and
recommendations of rife mission.
General Overview. The project was approved on March 21, 1996, signed on April 18 and became
effective on June 27, 1996. There have been changes in key personnel, including a new Health
Secretary anc a Project Administrator. However, the transition has been smooth the project has
-progressed will and is on the right track. In particular, (he civil works component, equipment
procurement and some software aspects have progressed ver.- satisfactorily. There is a core team
now in place, and die activities and plans with regard to training, referral disease surveillance
SC/ST compc nent and equipment mail tcnancc arc progressing well. There is still much to be done
to get the project firmly grounded, particularly with regard to the recruitment of some kev
personnel, doming the activities of the Strategic Planning Cell and clinical waste management.
The Govemrnmt Order for the opening of the P.O. account in the name of the Project Director am!
the District Surgeon in each district is expected to be issued shortly, and will facilitate the flow of
funds. Expenditures till March 31, 1997 are expected to be about Rs. 140 million (about US$4 0
million), of wiich retroactive financing comprises about Rs. 112 million (about US$4 2 million)
These are sonewhat below the SAR projections, although disbursements arc in line with what has
been projcctcc in the SAR. Benchmarks tor activities to be undertaken in the coming months arc
provided in the Attachment.
Q
Health Sector Development Program. Budgetary Allocations for the Health Sector The
budgetary alk cations for the health sector were substantially enhanced between FY95-96 and
FY96-97. Widtm the health sector, the share of resources allocated to the primary and secondan
levels have also been substantially increased. For example, revenue expenditures'for the priman
and secondary levels were increased by 16% and 28% respectively between FY95-96 and FY9<.97; and the s tare of the primary and secondary levels in revenue expenditures has also been
increased. Eic covenant on increasing resources to the pnma.v and secondan levels is in
compliance. Cost Recovery Funds collected at the hospital level are being distributed, bv the
Distnct Heahh Committes to the hospitals based on the level of revune collection Tins is bcginniiv
to make a ditfc rence with regard to some flexibility with recurrent funds at the institution level
i
Management. The mission is pleased to note that die government remains fully committed to
implementing the project expeditiously. The new Health Secretary and the Project Administrator,
both of whom were appointed in January 1997, have consolidated the activities diat had previously
been initiated, and have provided good leadership to the project team. A core team is now in place,
which will play an important role in project implementation. To facilitate d e flow of funds, a
Government Order is expected to be issued shortly, to open personal dupe sit accounts to be
operated by the Project Administrator and District Surgeons in each district. With the progress of
SHS II implementation, the coordination of various project activities will be coisolidatcd with IPP
VIII and IX. KfW and the proposed RCH project. The Bank mission will review this during every
mission.
Recruitment. Recruitment is progressing well. The recruitment of kev staff at headquarters is a
priority, and Deputy Directors (6) for equipment, training, transport, HM1S and hospitals North
and South ’need to be hired expeditiously. In addition, six teams of equipment maintenance
personnel and 600 paramedics also need to be hired.
' it
Civil Works. To date, preliminary designs have been completed for about 50 hospitals and it is
expected that 90 preliminary designs will be complete by mid-July 1997. Final drawings have been
prepared for about 19 hospitals and it is expected that 45 final drawings will have been completed
by Julv 1997. The bid documents for 11 of these have been submitted to the Bank for clearance
and work on 13 hospitals is expected to start by the end of June. Work will corrmcnce in a total of
?() hospitals bx the end of November 1997. The first batch of works arc expected to start by end
of June 199/. In addition, award of work to architects for 160 hospitals in Pfascs I - IV is also
expected to be finalized by July 1997.
The mission reviewed the proposal for the construction or a building on the prem’ses of the ED
hospital. Bangalore, to house the state surveillance unit which needs to be urgently relocated from
Mandva to Bangalore to facilitate the coordination of project activities. The irission agreed with
the plan to proceed with the first phase of construction, which will consist of the ground floor of a
throe-storied building.
It was brought to the attention of the mission that 8 hospitals in Uttara Kanrada district and 5
hospitals in Shimoga. Hassan. Mysore and Bijapur districts had been underfunded in the state’s
implementation plan. The mission reviewed the state’s revised cost estimates for these facilities,
and siiuc the\ arc within the allocation to the civil works component of the project, it agreed with"
the government’s proposal to proceed with these works.
Medical Equipment. Bids have been received for 100 equipment packages tendered out by NCB
(99) and 1CB (1) for a total value of about Rs. Ill million. The mission gave guidance on
procurement rules and procedures, and it is now anticipated that 30% (by val ie) of the current
procurement plan, cleared by the Bank, will be completed by September 30, 1(,97. The mission
agreed that, in future, minor items could be bought through local shopping within the limits defined
in the Development Credit Agreement.
Repair and Maintenance. Existing Equipment. Based on the survey work completed in the pilot
district Bijapur, it is evident that assets of significant value can be restored to operation, reducing
the government s investment costs. The mission approved a proposa
eugege consultants to
undertake the defined scope of work necessarx to repair and refurbis! dentifieJ non-functioning
equipment The mission also approved the proposal to extend the survey to all th: 19 districts, and
I
it is expected that this work will be completed by end-Junc 1997. The engaged consultants will
then extend the repair and refurbishment program to the remaining districts, :nd complete this
work by end-December 1997
Development of Maintenance Organization and Workshop
Facilities. The mission agreed with the changes proposed for establishing maintenance services
planned under the project. The revisions will not increase investment or operation costs beyond
those originally estimated. The scheme will be phased allowing corrective measures to be taken
based on feedback on service activities and performance criteria. In Phase I (3 years) all health
facilities in 13 districts will be serviced from 4 divisional workshops, and 4 other workshops will
be established in large urban centers. For the pilot distri:. Bijapur, maintenance will be contracted
out. The mission approved the TOR for procuring this service for 3 years. It is expected that all 9
service centers will be established and operational by end-of September 1997.
Drugs and Medicine. It was clarified that the drugs and medicine budget was allocated not only
for the additional beds planned under the project, but also for enhancing the quality of services for
existing beds. Project funds should, therefore, be utilized for topping-up the government’s current
allocations for drugs and medicine for existing beds.
Management of Medical Waste. Annex 10 of the SAR had outlined a plan for the management
of medical waste. As a result of legislative action by the GOI and other developments since then,
the mission reviewed this plan. A more concictc set of actions is now proposed, within the overall
plan outlined in the SAR, distinguishing between actions to be taken within the hospital premises
and actions to be taken with regard to ultimate disposal outside hospital premists. A three phase
approach has been discussed and agreed with the government. The first phase (short term) would
focus on the immediate reduction in hazards from clinical waste by the introduction of low cost/no
cost measures such as simple segregation to remove sharps and infected waste, and secure on-site
storage to reduce scavenging. A number of specific measures were discussed with the project team
which could be introduced in the short term. The second phase (medium term) would include (i)
scale up measures, such as fuller segregation and limited on-site treatment, including needle
crushers; (ii) formation of an inter-disciplinary working group, as in West Bergal, but with the
addition of a small task force to implement agreed measures; (iii) survey of waste arising and
technological options; (iv) appraisal of options and cost-benefit analysis, where possible, for each
hospital; and (v) design and implementation of training program. The third phase (long term)
would focus on completion of options appraisal, development of appropiate management systems
from cradle, to grave, implementation of clinical waste management plans and implementation of
full training program. It was therefore agreed that the proposal to procure incinerators, whether~
on-site or regionally, will be on hold until the all the options arc sorted out in Phase III of the plan.
Strategic Planning Cell (SPC). The SPC has been staffed and it has been agrccc that much of the
work undertaken by the SPC will be contracted out. A number of activities ar: planned for the
coming months including: (i) updating of actions taken on the Karnataka Govjmment’s Health
Sector Development Program; (ii) analyzing the BOD work done by ASCI for Karnataka; (iii)
initiating a study on user charges; (iv) evaluating the effectiveness of the yellow card scheme
implemented during FY97; and (v) reviewing the implementation of District Health Committees
and Referral Committees.
Training. The mission has reviewed and agreed on a schedule of activities to implement the
training program under the project. Clinical Training. Substantial progress har been made with
regard to planning training activities for specialists and nurses. It is expected that all training
modules and the first batch of trainers will be trained by September 1997 The first batch of
training is scheduled to start in mid-March 1997. Management Training Management training
arrangements for executives, doctors and paramedics will be finalized by June 1997 and the first
batch of training is scheduled to start in mid-July 1997.
Referral. In order to facilitate the functioning of the referral system at the district level, District
Referral Committees will be set up in pilot districts by cnd-April 1997. Rcfciral guidelines will
need to be completed before piloting the system in District Chitradurga in mid-July 1997.
HMIS. Plans for the HMIS arc being finalized, and it is proposed that a TOR for contracting the
pilot scheme will be ready by mid-May 1997.
J
SC/ST Component. The project has made a good start in implementing the SC/ST component. It
is proposed to extend the pilot yellow card, which has already been started, to the rest of the state
by mid-July 1997. A mechanism needs to be developed to coordinate the gende r component with
existing family welfare programs and the proposed RCH project.
I EC. A plan needs to be developed to operationalize the IEC strategy outlined ia Annex 12 of the
SAR, coordinating activities with the family welfare program by October 1997.
Performance Indicators. The performance indicators need to be updated and the inconsistencies
in the baseline data gathered during project preparation need to be rectified. The updating of these
indicators should be continued every six months and will be an important input in measuring the
gains in hospital activitiy, efficiency and quality improvement during the project period.
Compliance with Covenants. All covenants arc in compliance with the exception of the one on
the development of referral and clinical protocols, which is in partial compliance. This is expected
to be complied with by June 1997.
I
Karnataka
_______ Issue
Management
Recruitment
Strategic Planning Cell
Civil Works
Equipment
Maintenance and
Repair
Clinical Waste
Management
Referral
Deadline
_____________________ Benchmark________________ ____
Coordination between SHS 11,1PP VIII and IX, KfW and the
proposed RCH project will be reviev cd during every mission
April 15, 1997
Open and operate a personal deposit account in the name of lhe
Project Director at the state level.
May 15, 1997
Open and operate a personal deposit account in the name of the
District Surgeon in each district.__________________________
HQ Staff:
May 15, 1997
Deputy Director, Equipment
May 15, 1997
Deputy Director, Training
May 15, 1997
Deputy Director, Hospitals (North)
May 15, 1997
Deputy Director, Hospitals (South)
August 15, 1997
Deputy Director, HM1S
September 15. 1997
Deputy Director, Transport
Other Staff:
May 15, 1997
6 teams of equipment maintenance personnel
600 paramedics_______________________________________ June 15. 1997
Update actions taken on the Karnataka Government Health Policy September 15. 1997
Matrix.
April 30. 1997
Analyze the Burden of Disease study done by ASCI and review
the cost-cffcctivcncss analysis for Karnataka.
May 15, 1997
Initiate a study on user charges.
Evaluate the effectiveness of lhe yellow card scheme implem mted May 30, 1997
during FY96-97.
October 15, 1997
Review the implementation of District Health Committees ai d
Referral Committees.___________________________________
July 15, 1997
Complete 90 preliminary designs for Bank review.
July 15, 1997
Complete final drawings and bid documents for 45 hospitals for
which preliminary designs have been cleared by the Bank.
Commence work on 30 of hospitals for which final drawings have November 30. 1997
been cleared.
Award works to architects for 160 works in Phases l-lV._______ July 15, 1997
October 31, 1997
Complete 30% of the procurement of equipment packages as per
technical specifications approved by the Bank.
Repair of existing equipment in pilot district Bijapur based on
survey done.
Complete survey of status of equipment in all districts.
Extend and complete repair program to all other districts.
Set-up and operationalize the nine planned equipment
maintenance workshops (Phase 1).________________________
Within the overall plan outlined in the SAR, the project would:
Develop a short term plan based on low cost measures to improve
clinical waste management in one pilot district and implement
(he plan.
Develop a medium term plan to identify the major constraints on,
and options for, an overall clinical waste management system.
Modify the existing long term strategy utilizing the experienzes
and results of Phases 1 and II._______________________
Set up District Referral Committees in pilot districts.
Complete referral guidelines.
Start pilot of referral system in one district (Chitradurga).
May 15? 1997
June 30. 1997
December 31, 1997
September 30. 1997
July 31, 1997
July 31. 1997
December 31. 1997
April 30. 1997
June 30, 1997
July 31. 1997
i
Training
HMIS/Surveillancc
SC/ST/Gcndcr
[EC
Clinical Training for Specialists and Nurses:
Complete all modules.
Complete training of trainers (firstbatch).
Start first batch of training.
Management Training for Officers and Nurses:
Clear TOR.
Finalize management training arrangements, for executives,
doctors and paramedics.
Start first training session,_____________
Finalize plan for HMIS.
Finalize TOR for contracting pilot scheme,
Extend pilot yellow card program to the rest of the state.
Make O&M funds available to the program.
Develop mechanism for coordinating gender component with
proposed RCH and other FW programs.__________________
Develop a plan to operationalize the strategy outlined in Annex
12 of the SAR and coordinate activities with the FW program
September 30. 1997
August .31, 1997
March 15. 1997
March 31, 1997
June 30,1997 ~
July 15, 1997
April 15, 1997
May 15, 1997
July 15, 1997
June 30, 1997
April 30, 1997
October 31,1997
I
'i—
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
MID-TERM REVIEW : OVERVIEW
(Interim Report: June 1999)
'n.
An International Development Association team consisting of Messrs./Mmes. T. Nawaz
MeXnHaterh^PeteS P’ f edDia’ G’N’V' Ramana’ P- Kakkar- D- PorteT A. Singh, C. Giles,
M Chand S. Chaimavarty and S. Rao-Seshadn initiated a mid-term review (MTR) of the Second
State Health Systems-Froject CCr. 2833-IN) between June 1 - 15, 1999. A five-day workshop
was held in New Delhi with the participation of the project teams from the three states and the
Sank team. TJermssion also visited West Bengal and Karnataka and previously, in April, had
visited Punjab For Karnataka, the mission met with Mr. A. Sengupta, Health Secretary
Government of Karnataka; Dr S. Subramanya, Project Administrator, Karnataka Health Systems
Development Project (KHSDP); and senior staff of KHSDP. For Punjab, the mission met with
^SnLChp^pMTm^lntgnDlrec^r’ PunJab Health Systems Cooperation (PHSC), and senior
stoff of the PHSC In West Bengal, the mission met with Mr. Partha De, Health Minister- Mr
M. Gupta, Chief Secretary; Mr. N. K. S. Jhala, Principal Secretary Health; and Mr. T. K. Das ’
Project Dn-ector and ex-officio Principal Secretary, Government of West Bengal and senior staff
of the project. The mission wishes to thank the officials for their cooperation.
ThlS 0VeTeL°Tthie a^e’memoire summarizes the main findings and recommendations
of the mission The MTR has been initiated. However, it cannot be completed at this time since
a number of activities need to be undertaken in each state. In Karnataka, the MTR is mostly
complete but the MTR report undertaken by the Government needs to prioritize and cost the new
proposals to be taken up during the remaining project period. In Punjab, the flow of funds from
the State Government to tire PHSC needs to be expeditiously resolved and re-costing of proposal
activi res undertaken. In West Bengal, the PMC needs to demonstrate sustained improvement
improvement in
in
acuvities as reflected m increased expenditures and disbursements over the next three months.
The PMC will also need to confirm the re-programmed implementation plan is realistic and can
be completed m the remaining project period. It was agreed that these activities will be
completed prior to a follow-up mission in late October 1999.
The State Health System Development Project II, assisted with an IDA
Credit of SDR 235.5 million, aims to assist the Governments of West Bengal, Karnataka and
. unjab.to. (i) improve efficiency m the allocation and use of health resources throuzh policy and
institutional development; and (n) improve the performance of the health care system through
improvements in the quality, effectiveness and coverage of health services at the first referral
level and selective coverage at the primary level to better serve the neediest sections of societv
The project is an mvestment loan with policy reform in the areas of resource allocation for the '
ealth sector, capacity development for sector analysis and management strengthening, enhanced
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. Project investments include: (i)
i
2
institutional strengthening for policy development and implementation capacity; (ii) improving
service quality, access and effectiveness at the first referral level; and (iii) improving access to
primary health care in remote and underdeveloped areas.
J
4
Karnataka. * Progress towarcAchievement of the project development goals is
satisfactory and the implementation of the project in Karnataka is highly satisfactorv
Implementa ion of agreed health sector development policy measures is on track. Management
arrangements and the mechanism for the flow of funds are working well. The civil works
component of the project is on schedule, and expenditures and disbursements are expected to
hieve the targets estmated by the SAR by the end of June, 1999. To date, 40 hospitals have
been commissioned, and work is underway in an additional 105 hospitals. Procurement and
quality esting of equipment equipment maintenance, management and clinical training
STh’XS11 Of ,performance indicat°rs, HMIS, and outreach programs to scheduled
hHd d be “d women
Proceeding well. Recruitment of doctors and paramedical
th
underwa.y> “d 11 is expected that specialists will shortly be posted according to norms in
the 40 commissioned hospitals, thus addressing the issue of skill mix at these facilities. The
projec has begun to establish links with the primary care network and is playing an important
ro e m s imulatmg better practices in some specific areas in the management of the health sector
eyon this project. The project will now have to pay increased attention to software issues
which acknowledge the importance of the role of clinicians and paramedics in improving service
quality and patient outcomes.
H
°
o.
Punjab. Progress towards achievement of the project development goafand
attention ^ftl^ ManagingDiX^dZp^
project when their focus should have been on resolving initial implementation issues. Project
aS?1£n relatiV£ly g°Od in the COntext of the
straits in
tmnsfeZed t^be
7“
faCiIitiCS
medical Shipment
ransferred the PHSC have been renovated, supplies have been provided, and initial clinical
i managerial traimng has been done, improving the ability to deliver better services There are
major cost over-runs projected for civil works, requiring an urgent re-planning of future
ommitments If the flow of funds problem and re-costing of the civil works can be resolved
immediately, the project should be able to be completed on time. Planning and research
capacities have been erftianced so that most health sector development policy measures are
Prog^ssmg well. The PHSC has done well to strengthen the health mmagement information
y tern, induce quality assurance processes and referral systems, and improve the user fees
,: ems. However it is unclear whether the proportion of State expenditure on health, and to
primary, and secondary levels of health care have been increasing. The MTR has so far
reconfirmed the relevance of the project objectives and activities, but the mission is unable to
omp e e the MTR until the flow of funds issue and the re-costing of proposed activities is
completed. These need to be completed by the PHSC and the Punjab Government so that he
final conclusion of the MTR can be made by the next mission in late October 1999. ‘
I
imp ementation of the project during the first two years raises questions as to whether all planned
project activities can be completed in the remaining project period. The mission believes Lt
increased disbursements over the past three months is an encouraging indication of the increased
Z'S T H
PlanS f°r the
S Pr°JeCt P£riod -d Relieves that
hey can be achieved provided the attention that has been provided to the project over the past 8
months is sustained. Management arrangements and the mechanism for the flow of funds L
working welt The myil works component of the project is now fully geared up and work is in
progress at 84 hospitals. Expenditures and disbursements are considerably below the targets
estimated by the S AR for June 1999, mainly because of the delay in the civil works component
Procurement and quality testing of equipment, equipment maintenance, management anddinmal
fraimng programs, application of performance indicators, HMIS, and outreach programs in the
Sunderbans component of the project are proceeding well. Recruitment of doctors■ and
paramedical staff is underway, and it is expected that specialists will shortly be posted according
to norms with the recruitment of 1,200 doctors. The project has begun to establish links with the°
primary care network and is playing an important role in stimulating better practices in some
specific areas m the management of the health sector, beyond this project. The devolution of the
project to the DHCs has been effected and this is expected to bear excellent long term prospects
for sustainability -- however it has had a high cost in terms of short term implementation delavs
In West Bengd, the interim MTR has so far confirmed the relevance of the project objectives '
ut it is not realistic to complete the MTR until the improved implementation is sustained durina
he next three months and it is possible to confirm that the reprogrammed implementation plan =
the"TeSL’ee meornethsai!hnSRPr>eCt
^ntl1 mOre sustained Progress can be demonstrated in
the next three months, the Bank team will postpone consideration of additional activities.
However it encourages the Government to reprogram planned activities as discussed with the
missiom In the meantime, the Government needs to suitable modify its MTR report based on
more information on implementation on the ground and make this available prior to the next
mission m late October, 1999 when it is expected to complete the MTR.
8.
r"
I.
Summary of Project Achievements at Mid-term
*
*
of Pr°ject achievements, lessons and future actions whicli
emerged from the MTR workshop.
Delivery of Inputs
Physical inputs (civil works and goods) are being delivered (after some inilial delay) and is
resu ting m better equipped, cleaner, and safer hospitals, with ambulance services and erealer
availability of drugs
Ghnical and management training has been done to improve, skills, knowledge, base attitudes
and behaviors of providers
’<1LL1LUUC5
Health messages have been displayed and disseminated
Vacancies and mismatches in health personnel have been reduced
4
Systems Development
.
.
.
•
.
•
•
•
Hospital information is being collected and used for decision-makmg
Procedures to improve public accountability are being used
Mechanisms to coordinate national and state programs have been initiated
Decentralization of health management has been strengthened in West Bengal
More transparent and fair procedures for procurement are being used and more effective
quality assurance procedures introduced
Contracting procedures have been introduced and are working well
Cost-recovery and retention has been introduced
offendsfondS meChaniSmS have been developed within state systems to handle a large flow
Waste management systems have been introduced and are being used
Equipment management and maintenance systems have become functional
Referral systems have been piloted successfully
Disease surveillance and control systems are being refined and used
Quality assurance procedures have been introduced
Measurable Outcomes
•
•
•
Small increases in outpatient and inpatient visits are being seen
Hospital efficiency is changing through increases in bed occupancy and greater use of
diagnostic testing
o
Increased outreach services to disadvantaged groups
Baseline levels of patient satisfaction are being measured
Qualitative Results
Raised awareness of health among politicians and key decision-makers
• Improving morale among public health sector staff
• Public health sector is now better able to consider issues across programs and levels of care
(e.g. disease surveillance, referral, IEC)
Government is adapting new ways of doing business introduced by project, and open to more
Public health sector is now looking beyond public sector to new partnerships with NGO and
private sector
r
• Expectations of the public and providers are rising
• Raised awareness of problems of vulnerable groups
i
5
II.
Issue
Lessons Learned
Future Actions
• Changing allocations has
• Prepare options papers on
been more difficult than
how to improve State
anticipated: overall
health allocations within
allocation to health has not
context of overall State
changed much, pressure
priorities and fiscal
for the wage bill has
constraints
-increased, but there have
• Integrate Strategic
been marginal increases to
Planning Cell into state
selected non-wage items
health policy and planning
• Investment in physical
bodies
improvements is powerful • Shift from rigid norms to
motivator in promoting
need and performance
systemic reforms
based planning
• Attitude and behavior
• Explore options to
change of policy-makers
improve use of private
and key staff within state
financing and private
health systems is vital step
provision, including.new
toward reconsidering role
provider payment
of government and private
mechanisms and
sector
organizational models
• Strengthen monitoring of
i
effects of cost-recovery
and exemptions
Management & Institutional
• Multidisciplinary7 project
• Add skills on key software
Arrangements
team essential. Up-front
areas (e.g. economics,
• Appropriate project
training in Bank
information systems,
management arrangements
procedures is needed. ■
marketing) to project
• Adequate flow of funds
• Establishment of
teams
• Strengthening state health
autonomous bodies are not • Integrate PMC activities
management systems
sufficient in easing flow of
and systems (e.g.
• Management information
funds - financial
information systems,
systems to support
commitment of state’is still
financial management)
decision-making
critical
into mainstream of health
• Management of physical
• District Health
systems
assets to ensure quality,
Committees can be
• Integrate planning and
performance and safety
effective provided they are
supervision of SHSII
engaged early and have
project with other national
substantial decision
programs
making power, including
• Extend contracting to
financial authority and
clinical services
control over postings
• Increased use of 3rd party
• Managing contracts is an
evaluation of outputs and
efficient mechanism where
outcomes and applied
Policy
• Increased allocation to
health, especially to
primary and secondary
levels and non-wage
recurrent items
• Systems for policy
analysis and strategic
planning
• Role of government in
utilizing public-private
partnerships
i
6
Issue
Lessons Learned
tested so far (non-clinical
hospital services, waste
management; minor
building maintenance
including toilets, waste
supply etc)
• “Centers of excellence”
created by project may be
-unsustainable
• Concurrent evaluation and
feedback in areas of
patient satisfaction and
hospital performance
enables managers to take
prompt corrective action
• Quality assurance requires
appropriate local standards
to be meaningful
• Economic benefits of asset
care demonstrated by
success of one-time repair
programs
• Technical inspection and
testing pf products
essential to ensure quality
and safety
Future Actions
research
~
• Develop local standards
for quality assurance
• Expand standardized
guidelines and operational
procedures (e.g. model
contracts, hospital
commissioning guidelines)
• Undertake study of costr
effectiveness of various
maintenance and repair
modalities currently'being
tried in different states and
develop criteria for
optimizing arrangements
• Develop data base on
- equipment for secondary
care including, technical
specifications, unit costs...
maintenance guidelines,
life-cycle costs for O&M.
i
r;
7
Issue
Health Service Delivery
• Functional referral system
• Disease surveillance
• Hospital waste
• Health communications
• Training
• Engaging NGOs
Lessons Learned
• Referral protocols need to
be responsive to changes
in services in public and
private sectors; proGsion
of all project inputs is not
a prerequisite to initiate
action
• Though surveillance
•systems are established,
rapid response still needs
to be strengthened
• Actions on improving
hospital cleanliness and
waste management
requires continuing
attention but can yield
positive results
• IEC strategy so far limited
only to client and provider
information, its effects on
behavior change is not yet
known
• The effectiveness of
training needs more
rigorous monitoring
• The limited partnerships
with NGOs has been
positive, but dependant on
good screening of NGO
and medium-term
commitment
Future Actions
• Expand referral systems
throughout state
• Refine surveillance system
design around control
actions, integrate with
epidemics, divisions of
DOH, and address noncommunicable diseases
• Implement long-term
waste management
strategies and continue
training & promotion
• Refocus IEC on behavior
change and monitoring of
change; integrate IEC
strategies in state across
national and state
programs
• Critically evaluate training.,
by linking training to
clinical and managerial
outcomes
• Increase involvement with
NGOs
I
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
KARNATAKA
MID-TERM REVIEW
November 1999
AIDE-MEMOIRE
1.
An International Development Association team consisting of Messrs./Mmes. T Nawaz
(Team Leader), D. Peters, S. Chowdhury, P. Kudesia. G.N.V. Ramana, S. Rao-Seshadri, M.
Voss, P. Kakkar, D. Porter, C. Giles, R. Ahner, V. Rewal, S. Chakravarty, C. Giles and'Nina
Anand conducted a mission between October 27 and November 23, 1999 to complete the mid
term review (MTR) of the Second State Health Systems Project (Cr. 2833-IN) that was initiated
in June, 1999. Part of the mission visited field sites in Karnataka, and the mission met with Mr.
B. K. Bnattacharya, Chief Secretary, Government of Karnataka; Mr. A. Sengupta, Health
Secretary, Government of Karnataka; Mr. Naik, Commissioner, Health and Family W’elfare; Dr.
S. Subramanya, Project Administrator, Karnataka Health Systems Development Project
(KHSDP), and senior staff of KHSDP. The mission wishes to thank the officials for their
cooperation and hospitality.
The purpose of the mid-term review was to take stock of the project by assessing the (a)
project objectives: (b) project design (content and institutional arrangements); (c)
implementation progress: and (d) allocation and disbursement of funds; and (e) credit and project
agreements, and restructuring these as appropnate. Project implementation progress is recorded
in the Mid term Review Report prepared by the KHSDP. and the subsequent Progress Note on
Implementation, i he aide-memoire summanzes the main findings and recommendations of the
mission.
_ Project implementation progress is recorded in various documents prepared for the MTR
by KHSDP including: Mid-Term Review Report; Health Sector Development Policy Program in
Karnataka. Status or Civil Works; Status Report on Procurement: Health Management
Information System; Training Overview; Report on the Referral System; Report on Disease
Surveillance. Report on Medical Audit (Quality Audit): Status of Financial Management System:
Analysis of Disbursement and New Proposals; Note on User Charges: Report on Private-Public
Mix; and Report on Access to Women's Health.
4.
]Background.
The State Health System Development Project 11, assisted with an IDA
Credit of
SDR
2
-- ------ --?•? million, includes the states of Karnataka. Punjab and West Bengal. In
Karnataka, me project aims to assist the government to: (i) improve efficiency in the allocation
and use Oi health resources through policy and institutional development: and (ii) improve the
-pci Iormance of the health care system through improvements in the qualitv. effect!veness and
covetage of healtn services at the first rclerral level and selective coverage at the primary level to
,
betier serve me neediest sections of socie:;
project is an investment loan addressing policv
reform ir. if e areas of resource alJocauor. for. The
the
heahh
---- --- 1 sector, capacity development for sector
issues in the■ areas of m-------i r ^-cm^nt^stmn^.jening, enhanced participation of the private and
voluntary se:mors in the delivery of heaim
who can af* -■”C to pay. Proieo* investm'-’" services, and implementation of user charges for those
. include: (:j insuiutional strengthening for policy
devtfcrmm and implementation caoacii’.
’• fii) improving service quality, access and
e;isctiveness at the first referral level: and
fiii) improving access to primary health care m reinoie
and underdeveloped areas.
5.
The Ppjyt^ass approved on March 21, 1996, signed on April 18. 1996 and became
effective oproject
’S exPec[ec close on March 31,2002. The good work done for
pmject p.^enon uanslated immediately and without delay in most project activities Earlv on
Heaiih s“re^ ““
a
:
aD<i
” id1 s- S
d
Ai-msX zz t := ™
«« "V«« ««
in hinng manage.™,.
I™ I"'0V,‘i'd g“d to>’a“s dvil
of
learn has WVVm
°f Pr°JeC'
™
establishmf- -A, n
success 01 Project implementation to date. In addition, the
oeedv oroTTf T
fu^ ™chamsm through the letter of credit system has facilitated
bs»n exernnT- fheT"^fT X commitment of the Government to this project has so far
be n exempt y. i he support provided by the Chief Secretary in his present capacity as well ^s
XXTaTXTf0" aS TnC,pf SeCreiary CUm Hnance Commissioner duTa X Xf
XiXaivS X /
implementation success to date. The early mobilization for key
Population semor.
developm^n^-oals
Xi ST; TT
3 m°del
°ther StateS and Pr0Jects in the Health, Nutrition and
C°nClLiaSS tbat Pr0=ress
achievement of the project
sau factory anc the tmpiementation of the project tn Karnataka is htshlv
1’0'*’' "T"" “ 0" i;aCi;'
Managemem
uniienvay in 60 hospitahTSurSe^aSoSfr^
f1
h°SpitalS- re-co™nissianing is
maint^aan-^ --.nnn
,
■ mk-‘“ anG Quality testing of equipment, equipment
WIS ondo-Tach nX6"
C
ri’2inin5 Pro?r2rns- appiication of performance indicato-s
t ISrT—T TZ7 ;7Cheduled
scheduled time and women are proceedina ’
sublaVlf-;V„ ,r±
d0‘:10rs“d p^edical staff and spectalists have been
‘
begun to estagsh links tv.th
stimuiatmc h—-amm in cC
netv'01k aud is playing an important role m
‘
~
111 now nave to pay increasec attention to software issues
Qua!fv n.„0V':?age Ch£ imP°rtanCG of the role of clinicians and paramedics in improving servi. »
qualm. pauen; outcomes and sanction, referral, qual.ty assumnee and EEC act.TeT
7- \ As of November 1999. savings in project
costs are approximately Rs.60 crores
(equivalent to LSS1-4 million) due io e
xchange rate depreciation and cost conscious managemem
.-practices. However, there have be cn savings in goods and services and in the categorv of
incremental staff salaries. To accomi. .‘date these, reallocations oi the proceeds of the Credit
ic
the extent o. SDR 4.71 million trom goods and services to civil works and SDR 2.26 million
horn mmemental starf salaries, and incremental operations and maintenance costs to civil works
was made d. me request o; the Government on .k4ay 17. 1999. In addition, the Bank team had
earner agieec to the use oi USS9 million equivalent from‘the unallocated category' for the
incieaseo cos. of civil works. This accounts for almost all the pro-rated unallocated Credit for
Karnataka. The mission also reviewed a number of proposed activities for the Rs.60 crores
savings. The project team has prioritized these proposals since the last mission in May|1999 and
ensured that mey are in accordance witn the overall objectives of the project. These have been
reviewed b\ me Bank team ano a number of additional activities have been agreed to in principle
which are noied in this aide-memoire. Detailed inhpl emen ration plans will now be prepared on
each additional activity and submitted to the Bank team for review prior to the next mission.
8.
Project Development Objectives (DO), progress toward achievement of the
development objectives oi the project is satisfactory'. DOI: Policy Indicators. Budgetary
dliocsiion. The budgetan' allocations for the health sector were enhanced from Rs.705 crores in
FT96-97 to Rs. 903 crores in FY98-99. In constant terms the increase is more modest but there
has been a slight increase in real resources for the health sector. Within the health sector the
allocations for primary and secondary levels increased from Rs. 450 crores to Rs. 690 crores
between rh 96-97 and FY98-99. In terms of the share of resources, allocations to the primary
and secondan levels have also increased from 85.p% to 87.3% during this period. Resources for
non-salary recurrent costs, particularly tor drugs and supplies, have been substantially increased
since the beginning oi the project. Cost Recovery. The Government Order (GO) of 1995
establishing District Health Committees (DHCs) gave them the responsibility, among olther
things, of collecting user charges tor a range of services, including fees for room rents.
laboratory and diagnostic services, selected surgery- and medicines. User charges are biing
collected ai all district hospitals. All revenues collected are retained by the DHCs and deployed
among hospitals in the district for non-salary recurrent expenditures To date, about Rs. 1.6 crores
has been collected and activities such as ambulance maintenance, repair of water and sanitary
connections, purchase of supplies have been financed. Those below the poverty line, established
through the jt\T program, and entitled to a Green Card, arc exempt from paying user cnarges.
Conuacting oul. Contracting out of non-clinical services has been established in 16 hospitals and
clearance hcs been obtained tor contracting out non clinical services in an additional 28
hospitals. Due to the acute shortage or anesthetists in government hospitals, facilities fo|r
conu.acting me services oi anesthetists have been created. Similarly, permission has been given
io MOi io contract the services oi LMOs lor conducting health check up camps for women.
New opportunities lor contracting out oi clinical services are being explored through the
participation oi NGOs. Overall, the project has made important impacts on the policies of the
goxemment in the health sector beyond the first referral level - in the areas of better
management practices, drug procurement policy performance monitoring, service norms -at the
primary and ternary levels and the surveillance of communicable diseases.
I
i-—— —1AIF1? tinq_E.rigCb\eness Indicators. There has been a significant improvement ir.
the-iOllow ing areas, increased a\,ailac',..ity of drugs' and supplies at the facility level: meeting
equipment no.ms and timely repair o: equipment in upgraded facilities: meeting staffing norms
_and enhancement of the clinical skills oi doctors, nurses and paramedics: increased referrals to
highci level institutions; and increases access to b^sic health services for SC/ST and wo|mcn.
$
Quality assurance mechanisms at 11
upgraded facilities are being established. These improvements
are leading to increased credibility of
se. /ices provided and are beginning to show greater patient
satisfaction.
X ppyZSKZeT ZX
zrs
,= - s pan oft eyi&E mechanism, hospital activity indicators such as out-patient
a enaance, in patient a missions and discharges; bed turnover rate, bed occupancy, averaee
isbein^usS'toas UU IfatlOn °f
and equipment are being collected. This information
follow on TTnn rbr-r perfon™ce and * being fed back to the respective institutions
increases as are i ar'' ' ’ 1Za?°n rateS In the “Pgraded facilities are now showing substantia]
increases as are patient satisfaction and outcomes
KarnataZXdZTheZXdon XT”' “''eloP"’:nl Pr09^». *= Government of
1 coo"iiMIi°”
State Health and PopdattoZcH
heakXj° h
Pr°“S5
“ pr0Vide the Sovemm“I
»” overall perspective of
ZnXed FX7X,On”’ ““ repOni”§ ““hamsms for health sector pobey need to be
wjrh X .
’ be grePortins on the scope, practices and opportunities for collaboration
with the private sector needs to be incorporated m the planmntt process. In addition the poZ
“1'! , At,
on user charges^at upgraded public facilities needs to be reviewed, including opportunities for'
charge^1136111
!S substantiaI SC0Pe for increasing revenue from user
wZ? ZSZSZ "gan,ZaIra"al Z'”"1'
of'the
corporate enury as io AP and Punjab. The Government of KmaZ aceZdTXreZ.hr be
XTXreZ
•I
”8 ’ Pr°j'C' S“Ch “ ■lhis ,hroush a
^0 department tn Ute
recruHTnpnt xT tTi' man^ment Prac“ces such as organizational structure, fund flows and
recruttment. Nonetheless it believed that there would be laraer benefits bv wav of linkinc the
project to the overall health sector.
“
'
miMiu-oie
•
Organizational structure, The organizational structure consists of a Project Governing
.Board beaded by the Chief-----Secretary
wi/
v<ith high level representation from all relevant
departments of the government. The PGB is fully empowered to make major policy
decisions and develop broad policy outlines for the project, approve the annual budget
authorize major project revisions if necessary, ratify decisions made by the Steering ’
ommittee, formulate rules anc regulations and undertake an annual review of protect
aciJVlues and monitoring, Tne ?GB has delegated adequate powers to the Steering
0UL Ils unczons as the nodal body for project implementation. The
.
f e Chairman o; the Steering Committee which supervises and
monitors project implementation, undertakes project activities and facilitates project
n gemen . e roject Administrator, a Secretary who heads the Project Management
P00^1 e 01 l lc imPlenien’ation of day-to-day project activities. This thrce-tier
.. .tcm as ma c n possible lor prompt decision-making and for implementing the project
expeditiously. Further, this sirucrjrc has enabled the PMC to be closely integrated with
the technical wing of the DOHFAV.
How of run ds. The mechanism established under the project to facilitate the flow of
. funds is exemplary. It has set a precedent for other states implementing a health sector
project oi this type, enabling implementation of large number of small project activities.
Cumbersome processes requiring repeated reference to Finance and other government
departments for obtaining clearances have been shortened while retaining accountability
through the establishment of a letter of credit (LOG) system.
Recruitment. Recruitment continues to be undertaken through the Public Sendees
Commission with DOHFW playing a key role. This system makes recruitment protracted,
thereby adversely affecting the project implementation schedule. In order to deal with
this issue, the government has proactively made a one-time exception in the recruitment
oi doctors and paramedics. This means that while the needs of this time-bound project
have been met, the institutional process for recruitment remains unchanged.
13.
The xMTR concludes that: i) in the area of organizational flexibility, while progress has
been slow, systems developed under the project have greater potential of replicability tb the
overall health system; ii) in the area of financial flows, it has been possible to achieve substantial
improvement over the existing practices in the rest of the health sector; hi) in the area of
recruitment, progress has been made not so much because of any inherent advantage of workinc
within government line department, but as a result of exceptions provided to the projedt.
14.
Recommendations. The MTR recommends that, in view of the progress achieved to date
and to move forward from hereon increased attention be devoted to the software components of
the project, including EC, NGO participation, training and referral, quality assurance, referral
and disease surveillance. The recommendation of the previous mission that project management
formalize procedures for recommissioning of hospitals has been drafted and a manual lias been
developed and distributed to all hospitals, laying out a detailed plan for accomplishing this. This
will be reviewed by the Bank team and continually updated by the project team.
r
lo.
orkforce Issues. With regard to the earlier recommendation on addressing the
mismatch in the skill-mix at the 40 commissioned hospitals, an assessment has now been made
and a report has been prepared. The skill mix issue at 60 commissioned hospitals has been
substantially addressed. All recruitment formalities have been completed with respect tb the
recruitment of 57o Assistant Surgeons and 115 Dental Surgeons to address the skill mismatch.
In addition, 20 Entomologists and 12 Graduate Pharmacists have been recruited. A benchmark of
March M. 2000 was agreed on to continue to address mismatch in all specialists posts accordinc
to norms in hospitals being commissioned. The driaft rules for the recruitment of Biomedical
Engineers and Microbiologists have been finalized and submitted to the government for further
processing, and will be published bv March 31. 2000
6
16.
^ecommciidaiio)!. The MTR m
chat project management continues to address
skill-mix according io agreed norms recommends
as
as hospitals are re-commissioned.
17.
SPC - “■ “P »
Director (Strategic PJanninc)'' h renn
The post of So^st has bee X
—Sic
2„d
dnd IS curremt) headed by an Additional
2nd Fami]>' Wdfare-
XY
of Economist remains vacant and effort"The P°St
number of activities have been undenaheX the X 5 d
A
newsletter; development of a databank eXaXX ’T of
effectiveness of the traimng program a studv n„
t
tnUninS
°Vera11
manaaement system in hosnitals- a
i ■'
microdlal contamination: a study on the waste
»e.»oA„2 o pTv" and f „ \X^‘]0" T YelJ°W C™ Sehm,e: ’ p"“ stud-'' - ™
comp^bo^s; and
8 Xkh SfT"
™ssi0“’S “f
noted in policy discussions and pro^SnsTn he S' ’T
°f
b“■n
recommendationsofthescudyonmcX; ”
u
ForexamPle^^ .
Executive Orders and.nassin° a CO f k cOntaminanon have ]ead t0 the government issuing
Pro™ Comae»f ** Nosoeotnia) Infecnon Control
completed b. March 51 X om
“"'"“t “ 40
h“P-als ts to be
initiation of is“d7on oX and CoX;“ "
byMarch 31’2000 i”d“d’
Public Mix Issues and Options Paper Bench'"1J\eneSS 01 fin31 disposal waste, and a Pnvaiereport on manpower planning m the DOHFW.
3°’ 200° inC1Ude "
SPC co^ZXXa^^
Ae
“ ^ed for the
SPC now has an even more important X
7 ? X aCr°SS
Pr0Srams- the
sector. Tne project should put in place kev XX’th ?
'J01™1
in-thlS
to make the SPC fully functional
°n "
°r contractU31 ^sts, in order
19.
work has commenced on 175 hospital! out'ofTXT
pr0Ceeded at an e^mplary pace:
of being commissioned. Apart from this KHSDP h
' anQ d0 dosPItals
in the Process
cover 9 more. 21 District Surveillance Units are
“P5™50 J b °Od banks and ProPOses to
workshops are being provided in all disHcts ?
instruction and equipment maintenance
a decision was taken early on bv the pX X
T’C0St
'n CIV11 WOrks'
hospitals simultaneously rather'than in X-S
M
10
C'V11 WOrks in ali
established with an Ensineer-in-Chief Xo SiX'5 P H"ned ^arber- An Engineering Wing was
addition, 46 architects “were empanelled) exTX? S
6 Divisions- In '
Owing to the large number of ci vil works already ! n
°J deSIgnS
for undertaking quality audit of the civil works The
agenCieS were en£aged
structural designs and'so.l investmat.on Xs' X X TX P^ decking of
done a commendable job in the area ofc-vi] works The
X
th£ PMC h“5
includes commencing work on remaining a °
T X benchmark of March 3E2000
inniM,o„ of .be pcoW of comra,ssioni2g
i,0Sp,“IS
/■
20.
Recommendations. The MTR concludes thkl the independent review and evaluation for
ensunng the quality of civil works has beer, verv useful and such evaluation should be continued
on a regular basis.
21.
Procurement of Goods (equipment, furniture, vehicles, drugs, medical laboratory
and other supplies, MIS and EEC materials). The procurement activities planned for 1998-99
have been completed successfully. Procurement activities planned for 1999-2000 are underway.
In respect of stand-by generators required at number of project facilities, the procurement of
these has been postponed until appropriate accommodation for these are completed as part of the
civil works program. Good quality control procedures have been established for acceptance
testing, installation and commissioning. Project management has completed planning of
procurement for the third and fourth phases of the project and the benchmark for October 31,
1999 to complete the activities planned for May-October 1999 has been met.
22.
Recommendations: KHSDP is now in a good position to develop a computer-based
inventor}7 system for the management of equipment, plant and similar assets in the facilities for
which it is responsible. This database should include comprehensive information on the type of
equipment/genenc description, manufacturer, model, senal number, dates purchased and
installed/commissioned, sendee agent, senice frequency, accessories and parts availability, and
a comprehensive senice record for major items (including operating and senice costs).
23.
Maintenance and Repairs. In-house sendee teams have now been established in all
districts of the State and are providing an accessible repair and maintenance sendee for a wide
range of equipment. The staff have also assisted in the program of installing and commissioning
new equipment. The KHSDP maintenance team has now been put in-charge of maintaining the
cold-chain and walk-in coolers of the DOHFW. Experience with maintenance of X-ray
equipment throughout the state by a third-party service agency has been ver}' positive; X-ray sets
valued at around Rs. 4 crore have been repaired and regularly serviced for a cost of around Rs.
3.3 lakh a year, i.e. (<1% of assets value). This represents excellent value for money. The
benchmarks tor October 31,1999 have been accomplished, including commencing construction
of equipment maintenance workshop buildings in the remaining 10 districts and preparing a
comprehensive report on the activities of the in-house district equipment maintenance teams
including the cost effectiveness of the sen’ices they provide. Agreed benchmarks for March 31,
2000 include completion of construction of equipment maintenance workshops in all 21 districts,
and computerize the status of equipment maintenance in four districts, one in each revenue
division.
24.
Recommendation. The maintenance arrangement should be reviewed in light of the
results of the cost-effectiveness study and the experience of other states. The benchmark.for
March 2000 is to computerize that status oi equipment maintenance in 4 districts, one in each
revenue division.
25.Training. Progress of the training component under the project is satisfactory, (a) So far
1.135 doctors have received basic clinical training in different specialties as part of this program.
. _A Training of Trainers (TOT) was arranged at JIPMER, Pondicherry, as a result of which 40
master trainers arc now available for conducting training programs. The district level training
8
)
dM°re ““ Cond“cleI' i" raedi™'' “W. OBG, pediames ,„d
anesthesia and
doctors were trained: fbj Nurses Training: There are about 1.550 Staff
ursesv,or ngm
C. caluka and district level hospitals. An additional 1 100 nurses have
conduaX^u^tra*n!n-2- A — ? needs assessment has been
d...mb J,. .,ptPpr0'leCl ‘"Xhorwes have adopted the training manual and curriculum
^nerdnu-sino
ReklTaI Hea!lh System Project. 1.762 nurses nave so far been trained
c , ." . ‘ ‘ c' Pecialist training in the areas of pediatrics, ICCU. ophthalmic nursins
teen cmic^cmd Ximpaned 10 365 nurses'
Management training has
senior MoZd Z
T>
d\CaI
(AMOs)’ NursinS Supenntendents, second
hospitals The ohiete' ■
W°rker as a team- Th,s training is complete in respect of 22
■ ‘ ■ ' , . J .1 es 01 dlIS program have been to acquaint the participants with HMJS'for
as medieZcai8 Z r
tWr aaminis'Lratlve and managerial skills. Certain issues such
at BaZaioreln S
"
'Cumcuiura- Trainmg has also been conducted
, “.
super-specialties. The benchmarks agreed for March 31 ’’OOO include-fil
XXX T 7'““°"of lab- T“h"ra”
of torXX ’
LS " .h ad™nistrgtors tra™nS and Identification of a suitable agency for conducting the
officers traininc Preparat3°n Of 3 draft re?ort on the external evaluation of clinical medical
Fs6pc) bvtendina 3^X7’
d0Ct°rS’ traininS has been evaluated by the Additional Director
iqUeStIOnn:i;e t0 £he lraineea- A more detatled evaluation of the impact of
ninH h £he.Peno“e 01 the tramees is required. Tramtna dunna the remaining pr0|ect
Z ctXTZZ66?§;thTeral] ObjeCtIVes Ofthe Pr0-iect’ -ith emphasis on Liroved
JaXXe^shoTh
?Y]eVeL DlffCrent °PtiOnS ^continuing education at th‘e
facility level should be examined, and there should now be greater focus on hands-on training.
now be^xtlndecTm^r^1 SyStSm?"der the PraJecE was piloted in Udipi District and’has
aZetXZ r
1
ga ana 1 UmkUr dlStrictS- The —nee so far has been that
■.-j
public and EEC art- Y £ rehgarQln§ the refen’al system amongst the medical personnel and the
feedtcHnSa o ICS "
intcnsified- RefeiTaJ cards
being used and
f r 15ln m°S: CaSeS’ The Pr°Ject management has felt that a referral
nn
e u - unctional until upgraded facilities have been equipped and staffed
extendX0nT’
5 ''
31 leaSt °ne mOre vear for the refe^J system to be
e “ X XT
btXXXXi
A- ‘n “
,0
m “’d‘V,‘“ h“PiUlS
“P
or«te„yd.„g the
W””S fOT 111 dlStri“ ■h'
28.
this n-b-■,|Tbe •rc‘S"!l1 £ystern need510 be expanded throughout the stale and
b. deferred ■ 11 such lme that ail facii1Iics have been up2radcdJ Th=,
a nQnlto
i . asp-cts uhere the referral system can be made more functional throu-hout the stale
■w thou requiring completion of the elril corks program. To support the expansion of the
re erral sysienr. a planned EC program for service providers and the eomnLtv is
TXXXXT ‘Pre™
TO-1 “"Y- -h PCH. fRR LX
6
C)
_9.
Health Care Waste Management. The KHSDP is currently following a three-phased
approach to the sate disposal of hospital waste in secondary hospitals. This includes a short-term
approach focusing on the immediate reduction in hazards from clinical waste with the
introduction Oi low-cost measures such as simple segregation to remove sharps and infected
waste, and secure on-site storage; a medium-term approach involving scale up measures such as
fuller segregation and limited on-site treatment such as needle crushers, formation of
interdisciplinary working groups to implement agreed measures, and appraisal of options and
cost-benefit analysis: and a long-term approach focusing on completion of options appraisal,
development or appropriate management systems and implementation of health care waste
management plans and full training programs. The passage of the Biomedical Waste
(Management and Handling) Rules (July 1998) by the Government of India and rulings by the
Supreme Court have imposed a legal requirement on every health care facility more than 50 beds
in the country to develop and implement a health care waste management strategy. The shortand medium-term waste management strategy is now' being implemented in the 60 completed
hospitals. Training workshops have been conducted for the AMOs and nurses from 26 hospitals
on the broad principles qf waste management, legal issues, and w'aste management strategies,
and EEC material has been developed and disseminated. Several lessons have been learned,
which the project authorities are attempting to address: the need for retraining and follow-up of
hospital staff w'ith regard to the importance of source segregation of waste and the significance
of color coding of bags: occupational hazard to w-aste handlers; and inadequate information
about the use oi deep burial pits and land fills. Benchmarks agreed for October 1999 have been
completed, including: extending the shon- and medium-term waste management strategy to 60
commissioned hospitals; creating a mechanism for verifying w’aste management practices;
expanding lEc activities to spread awareness and behavior change: and formulating policies for
waste reduction and re-cycling strategies, which is shortly to be issued as an Executive Order.
Benchmarks agreed for March 31, 2000 include: (j) finalize study on medical waste; (iil) extend
short-term and medium-term w'aste management to 90 hospitals: and (iii) complete status report
on how waste management system is functioning.
30.
Recommenaaiions. The mission suppons the approach taken with regard to the waste
management plan, i he challenge now is to sustain the level of achievement reached to date and
to progress further on key issues in the comprehensive management of the waste problem. The
mission recommends that the short-term and medium-term strategies be fully implemented, and
that the government continues to work towards a longer-term strategy on the basis of the studv
that is currently under preparation. It is noted, however, that the Bank is unwilling to support the
incineration Oj waste under the project until the longer-term studv on option appraisal is
•completed ana the Bank itself has developed a policy on incineration. The project can, in the
meantime, finance alternative technologies on a pilot basis, including microwave treatment,
autoclax ing ana other non-incineration system for the fnal disposal of hazardous waste.
31.
Strategy for Increasing Access for Scheduled Castes (SCI. Scheduled Tribes' (ST)
and \\ omen. Satistactory progress has been madq with respect to the implementation qf
programs aimed at increasing access for SC/ST and women. Karnataka has a large SC/ST
population accounting for about 21% of tine total population, and ;i survey concluded in 1995
jndicaied lhai die) generally sulfur higher icx'cls of monaliiy and morbidity. As a result, the
government ptoposco thecllow Curd Sunemc involving annual health check-ups for Sts and
I
’’
’ ■
■ •
•
10
S'.? }■
a-'/i
Sinee then Ae schenChas bXTxTeSt^th^T t"15
•ivv:;
activities of the DOHFW To dam
sehe™, o: ..TOra alE JX,
A
As .
3
November 1996= and
state ar>d become pan of the on-soins
“ Of T,li0” Pe°?e “Ve b“" OT“"=d
treated have been referred to hospitals for-™ .
r.““P"
ab°Ut ~6% °f thoSe
including the provision of adeo 'm- <•>T
rn''n‘" ‘de ,0S:stlcs °f conducting the camps,
scheme is being implemented m af exte'i
SUppl)es have been streamlined, and the
' have been conducted, and corrective■ m± TW
°f On’g0ing r0Unds of check'uP^
the KHSDP funded the implementation 2 “ have b<T taken based
feedback. In addition,
2 Women's
Health Check‘uP
Mysore district through the BCCHI Trust" an
NCr? Heakh
in 6 taluks in
undenaken to promote better health practice amr^
W ThlS SCheme haS
management of RTIs, STDs cervical and T
g WOmen? conducr screening and
functionaries, and conduct EEC camoaicmc
Ca?Cer' conduct Gaining programs for health
Since then, GOI has initiated a separme^scherneSr
hlgWy satisfactor>’
through six NGOs and managed by the KHSDP f U'Omen? heakh wh,ch 1S beinS implemented
-omens
ehect up
=onM^m
*“!.!’ ^J^o-Card scheme be
linked to the tribal strategy to increase awa
S ate’ U
strai:e?y for the project be
upgraded facilities in tnbal areas be staffed m acc^0"2 ^i!5
aVailabiHrv: 1I])
necessary through contractual arrangements- and (iviTtOR bf T " WW Sen'ICeS'
evaluation of the effectiveness of the Yellow cTi J °R . deVeloped for an exterTial
March 31, 2000 for conducting such an evalumirfn
?
a§CnC'V identified b-v
Vernal a^u^e^maimgem^m
(IEQ F^1]>leveI
focusing on
across the health sector and this project promde^h^
aCUVltieS need t0 be ^oadened
implemented under several pro Jams in th- e J TT' “
EC Strate^s
“<e>
have shown, for some time, recognition oMhe needJo! "7 *
Pr°JeCI authonlies
professional assistance. A workshon was h-iH ■ t 1
S[ate-W!ae strategy and have sought
need for a more compmhenXe approac w ™ IT T ?G0S and 0,6 PnVatt S“,or ™d d’e
noU. be formulaied,
""
’5 •
34.
.7
E"™*'”'1' The “T■ mcommeods tot EC activn.es piav a vital stratessie role
for the State's health system. The
of developing and implementins a strltetv -° fOntraCt 2 professionai aS£ncy WJth the purpose
to.r the remainder of the project. This strategy would
include community oriented EC. such, ass.th»
well as provrder onenied communication. suEpromotion of FRUs io disadvantaged groups, as
n as the promotion of equipment care and
maintenance. Omen the state of re-com
missioning oi the facilities under the project, the need for
renewed emphasis on EEC activities is
recommended.
Management Information S
”"d.«.
svstem
. ..indicators are being used m decision makinf \ h pr0-^c‘IS eo°d and key performance
out-patient attendance, in-patient adnnssiorC.-'m kW th,S’ hosP'lal :ictlv,1y data such as
•- and discharges, bed turnover rate, average bed
i1
occupancy, average length of stay and utilization of diagnostic services and equipment are being
routinely collected and compared with data from previous years. This information is being used
to assess hospital performance and is being fed bapk to the respective institutions for fqllow-up
actions in about 50 hospitals so tar. Initial indications are that utilization rates in the upgraded
facilities have increased. It is envisaged that all district health and family welfare facilities and
district surveillance units will be computerized by the end of FY 2000. A benchmark Jf March
31, 2000 was agreed on to institute an independent verification of the MIS system in place.
,
36.
Recomme?idauons. The mission notes that the attention now being given to hospital
performance and evaluation of patient satisfaction is the correct approach. This needs to be
extended to all facilities under the project, and routine independent evaluations of patient
satisfaction and hospital penormance need to be incorporated into the MIS system. At the same
time, the PMC needs to continue its efforts to improve the accuracy of the statistical information
from the hospitals. This would involve additional training for the medical records staff.
3 7.
Quality Assurance. There have been several workshops on this aspect of the project
along with the other states implementing state health projects with support provided by the Bank
through ARMS and Australian specialists in quality assurance. Karnataka has adopted a
broad-based approach to quality assurance with focus on hospital utilization, performance
indicators and patient satisfaction. Their view is that it will be more useful at this stage to
concentrate on these broad parameters rather than clinical and outcome indicators until most
hospitals are commissioned. A Quality Audit has been undertaken of 14 hospitals and the report
presented to the mission. It was agreed that a few critical outcome indicators be developed by |
March 31, 2000, to monitor quality in all project hospitals.
1
38.
Recommendanons. The mission agrees that the focus on quality assurance at this time
needs to be on broad-based hospital indicators and patient satisfaction. However, in thd longer
run, with the commissioning of all project hospitals, it will be important to incorporate clinical
indicators as part of the quality assurance system. It was further agreed that a few critical
outcome indicators would be chosen from within the larger protocol to monitor all project
hospitals. The mission also notes that quality assurance needs to be viewed beyond the project
hospitals and secondary level care, and that a state level policy on quality assurance will be
essential to sustain improvements in health care delivery generally. It will be important,
therefore, that the project is used as an instrument to promote and facilitate the implementation
of a state-wide policy on quality assurance. This is beyond the scope of the original project, but
given the larger benefits that are being realized out of this project, it is well worth expanding the
scope to facilitate this broader development.
39.
Project Costs and Disbursements. Costs. At appraisal, total project costs including
contingencies were estimated at Rs.5,45S million (USS 136.4 million equivalent). The mission
concludes that savings of about Rs. 60 m2.ion or USSJ4 million equi\’alent have result mainly
from the goods and services where greater procurement through 1CB resulted in lower than
anticipated costs and irom the increments, staff category due to delaved hiring of staff during the
__early stage of the project. There have beer, some increases in the costs of civil works, but far
lower than in other states. These have been accommodated by the reallocation of resources from
12
ai appraisal.
■
,- v- y .
. n=a]ore districts, including improvements to the K.R hospital in Mysore
and V>ctona, Bownng and KC General Hosp.tal in Bangalore; provision ofsome additional
q ipmen o the district hospitals under the project such as C-arm unit, ENT operating
roscope, laproscopic operating microscope, physiotherapy facilities and anesthesia“
q ’P™”n ’ uP»ra atl°n of hospitals at Gadag, Chamarajanagar, Haven, Koppal and Udupi as
Ah the adriT^ S hS£ m°n Ut-lllzatlon and hmited improvements to the existing SIHFW building
All the additions should not exceed Rs. 60 crores from project savings and an additional Rs 15
" 'f f 7, “”all<,?CBd ™‘>mI
project. The Government will now prepare detailed
Z
P
°f "’e“ aCnViMS fOr
B“k ™ pn» to the next
41.
(Compliance with Covenants. All covenants are in compliance in the Karnataka
component of the project.
K.\RNAT.<KA HEALTH SYSTEMS DEVELOPMENT PROJECT
Benchmarks proposed to be'achieved by March 31.2000
i Management
' Recruitment
Continue and strengthen coordination mechanisms amona
i SHS II. IPP \’I1. IPP LX, KfW and RCH
Continuous
■ Continue to address mismatch m ail specialists posts
i according to norms in hospitals being commissioned
March 31. 2000
> Publish C &. R Rules for the recruitment of Bio-medical
j Engineers and Microbiologists
March 31. 2000
I
I
Strategic
Planning Cell
Contracting
out Non
clinical
services
Civil Works
Surveillance
i Traming
Initiate study on Options-and Cost Effectiveness of final
disposal of waste
March 31, 2000
I Update action taken on Karnataka Government Health
i Policy Matrix
Continuous
I Prepare a draft report on man power planning, in the
I Department of Health & Family Welfare
June 30. 2000
I Private - Public Mix
I Finalize Issues and Options paper
March 31, 2000
Contract out non-clinical services in 40 commissioned
hospitals
March 31. 2000
| Commence work on remaining 14 hospitals
I
March 31. 2000
| Complete 90 hospitals and initiate the process of
| commissioning in all completed hospitals
March 31, 2000
| Complete District Surveillance laboratory buildings in all
I 19 districts.
March 31, 2000
i Provide status repon on functioning of state level and
; district level co-ordination committees
March 31.2000
; Undertake analysis of water contaminants
March 31. 2000
t Install the computers and initiate traininc on software
March 31. 2000
i Conduct in-house evaluation ot laboratory technician
training
______________
March 31.2000
________________________ J______________
■ Develop terms of reference for me evaluation of
I administrative training and iden y a suitable agency for
! conducting the evaluation
i Furnish draft report on external evaluaupn of clinical
I medical officers training
i •
' March 31. 2000
March 31.2000
i Medical Waste
Management
Equipment
Procurement
and
Maintenance
—
I Referral
*3^
Finalize short-term and medium-term studies on medical
waste
Extend waste management to 90 hospitals
Complete status report on how waste management system is
functioning
j Complete construction of equipment maintenance
, workshops in all 21 districts
March 31.2000
March 31, 2000
March 31. 2000
March 31, 2000
Computerize the status of equipment maintenance in four
districts, one in each revenue division
March31,2000
Increase referral linkages between RCH and IPP IX and
other health programs
Continuous
SC/ST/ Gender Develop terms of reference for external evaluation of
Issues
yellow card scheme and identify suitable agency for
conducting evaluation of health outcomes measures
IEC
Develop mechanism for coordinating IEC programs
between health/family welfare and nutrition sectors
Identify professional agency to facilitate development of
LEC materials
March 31, 2000
March 31, 2000
March 31,2000
Quality
Assurance
Develop a feu critical outcome indicators to monitor quality
March 31, 2000
in all project hospitals
MIS
| Institute an independent verification of the MIS system in
i place
1_
March 31, 2000
J
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
MID-TERM REVIEW : OVERXTEW
(Final Report : November 1999)
A11 friremati°nal Development Association team consisting of Messrs./Mmes. T. Nawaz
(Team
D. Peters, S. Chowdhury. P. Kudesia, G.N.V. Ramana, M. Voss, P. Kakkar, R.
Ahner,
J oner, C. Giles, M. Chand, S. Chakrav^ty, V. Rewal, R. Sahm, and S. Raolseshadn
concluded a mid-term review (MTR) of the Second State Health Svstems Project (Cr 2833-IN)
between Octooer 27 and November 20, 1999. Following visits to Karnataka, Punjab . and West
Bengal, a three -day workshop was held in New Delhi, and included the participation of the
project teams rrom the dmee states, four other stated with State Health Systems Development
lOjecis. onitviais om Nepal, and the Bank team. For Karnataka, the mission met with Mr. A.
Sengupta, JMncipal Secretary', Health; Dr. S.' Subramanya, Project Administrator and Health
rS uPmT LKaniataka Health Systems Development Project (KHSDP); and senior staff of
KHSDP For Punjab, the mission met with Mr. P.S. Badal, Chief Minister, Mr. Chabbra
Principal Secretary, Health and Family Welfare, Mr. A. Agarwal, who became Manamn"
irector, PunjCo Health Systems Cooperation (PHSC) during the mission. Mr. S.S. Channv the
PrAT
Director’ and senior staff °f the PHSC. Ln West Bengal, the mission met
with Mr. Parma De, Health Minister; Mr. M. Gupta, Chief Secretary; Mr. N. K. S. Jhala.
Principal Secretary' Health; and Mr. T. K. Das, Project Director and ex-officio Principal
ecretary,
ernment or V est Bengal and senior staff of the project. The mission washes to
thank the omcials for their cooperation.
^’n’5 C' -n ’ev>
’■he aide-memoire summanzes the main findings and recommendations
0111 ,e missi'j!‘- Die MTR that was initiated in June, 1999, required the following issues to be
resolveo berore completion of the MTR (see Aid Memoire. June 1999). In Karnataka. . Government needed to prioritize and cost the new proposals to be taken up during the remaining
project penoc. In Punjab, the flow of funds from the State Government to the PHSC needed to"
be resolveo anc a re-costing of the proposal activities undertaken to fit within the available
A02' . 1
Bengal, the PMC needed to demonstrate sustained improvement in activities as
reflecteo m increased expenditures and disbursemejits, and to confirm the re-programmed
implementauon plan is realistic and can be completed in the remaining project period. Each of
these issues nas oeen resolved to the satisfaction of the mission.
t .
The MiRsen'ed to confirm that the project objectives are anoropnate. and that de basic
aesign ana implementation arrangements will enable the project to achieve its development
o jectives. CN e.all implementation progress and progress towards development objectives is
satisfactory across the three states. No changes in ths project ailocat.ons, net of unallocated
unds, are reu’_;.ed at this time, though this may be required in the coming months, as described
below.
A kd'-'d'
2taIe Detilth System Development Project 11. assisted with an IDA
ruait o Sl i\ _.'5.o milhon, aims io assist me Governments of West Bengal. Karnataka and
._ UnJa ,10' I"
L cfiiciencyjn the allocation aijid use ofhealth resources through poliicv and
institutional development; and (n) improve the performance of the health care svstem through
„
improvements m the quality, effectiveness and coverage ofhealth sendees at the first referral
level
and
'A- selective
- A—'' - covera°e al the primary level to better sen/e the neediest sections of society.
The project is an investment loan with policy reform
in the areas of resource allocation for the
health sector, capacity development for sector
analysis and management strengthening, enhanced
participation of the private and voluntary sectors m
the delivery ofhealth services, and
implementation of user charges lor those who
can afiord to pay. Project investments include: (i)
institutional strengthening for policy development;
and implementation capacitv; (n) improving
service quality, access and effectiveness at the first referral level; and (iii) improvin'"*
t access to
primary health care m remote and underdeveloped areas.
'
'• 7
’ 'r- f Karna^ay- Progress towards achievement of the project development °oals is
san factory and the implementation of the project m Karnataka is highly satisfactory
XZn"°L thT hhealth “'elOpment P01’^
- - -ck. Management
amanoements and the mechanism for the flow of fimds are working well. The civil works
t^XftX^TV^
3nd dements have achieved the
8
■
J. . • ‘ ■ ■ 0 ate> 60 hospitals have been commissioned, and work is
undeiway m an additional Ho hospitals. Procurement and quality testing of equipment,
indicators WlS^d^’ fana§ement and clmicaI training programs, application of performance
nrcXn
o
“h P™™510 Scheduled caste’ schedu^ tribe and women are
snwial’ Xk eCrU’tment oi addlti°nal aoctors and paramedical staff is underwav and the
hosXs ThXmeenX Xnaliy P°sted ac“rd^g to norms m the 60 re-commissioned
’
ProJec as
to establish links with the primary care network and is plavin^
b“ZsZ
Z
1
Pra““S “ Some
-as in the ™„„ , kA
heabh sector, beyond ta project. He project will now have to pay increased attention to
fra are issues which acknowledge the mportance of the role of clinicians and paramedics in
EC Lt ™Z'Ce <'“a ,Iy
Pal'“' ™1“mes and satisfaction, referral, quality assurance, and
ddiviLies.
j
Punjab. T
implemen:allon process are both margmX
if the
mplememation progress
the chano ■ ' ade^aIel-v 10 the P^ject, and if project start-up had not been delayed due to
wat;
X f mana°e™ent
^e continuing debate around the PHSC. The place of the'PHSC
thXXTJ alrh^ ' °Ver T’ bUt ” diVerted th£ attenUOn of the Man<™S Director “d
on resolvino mitiai ' ei?retar}' 21 The_earb' stage of the project when their focus should have been
■ ,
~
imp ementan°n issues. Project implementation since then has been relatively
SeXl?^
th£ fl°W °f
AU facilKies
medlcal equipment
and managerial n ' i n r,
' enovale'T supplies have been provided, and initial clinical
and tnanag.enal frammg has been done, improving the abilky to deliver better sendees. But the
tight flow ot-runas. brought about because of difficulties in State finances, led to a virtual
stoppage m project activmes during the past year. In the last few months, the state has resolved
l° PHSC' 2nd HaS dOne S0 ln 3 time!v manner since then-
4kho h S''
Alt outih 80 racmues have been grounded, there had been major cost over-runs projected for
civil works basso on the initial sues that IpH m
i
c i_
H ' ■
Planning and research capacities have been en°X?
°f the/e™min§ fitments,
policy measures are proaressino well ThTpHSC 1 7
develoPmcn’
Tranr.nr
■ r
■
°
-00 rhSC has done well to strengthen the health
management informat.on system, mtroduce quality assurance processes and referral systems, and
0
improve the user fees systems. Nonetheless, a change in project management at this critical
point will make it ven' difficult tor the project to complete its activities in a timely fashion. As a
result, the Bank will carefully monitor activities and disbursements over the next six months. It is
unlikely that the pro-rata portion of the unallocated funds will be used up by Punjab in the
project period. A decision will be made whether the funds could be used by another state:
discussions on this were held with the DEA and the three states.
7.
West Bengal. Progress towards achievement of the project development goals is
satisiactory and the implementation of the project in West Bengal is now' also satisfactory.
Implementation of agreed health sector development policy is on track. The slow7
implementation of the project during the first two years leaves little room to deviate from current
plans it the project is to be completed on time. The mission believes that increased activities and
disbursements over the pa^st nine months, and particularly in the last four months, is an
encouraging indication that the project can be completed on time. It has review;ed the plans for
the remaining project period and believes that they can be achieved provided the attentiQn that
has been provided to the.project over the past year is sustained. Management arrangements and
the mechanism for the -flow7 of funds are w-'orking well. The civil works component of the project
is now7 fully geared up and w7ork is in progress at 170 facilities. Expenditures and disbursements
are considerably below- the targets estimated by the SAR, mainly because of the delay in the civil
w7orks component. This has, how-’ever, picked up sharply during the past four months.
Procurement and quality testing of equipment, equipment maintenance, management and clinical
training programs, application of performance indicators, HMIS, and outreach programs in the
Sunderbans component of the project are proceeding well. Posts for 1,200 doctors w7ere created
early, and efforts have been made to recruit them. Gaps remain in the positions of anaesthetists,
i adiologists, physicians, and technicians, which the government is trying to fill on an urgent
basis. The project has begun to establish links w'itn the primary’ care network and is playing an
important role in stimulating better practices in some specific areas in the management of the
health sector, beyond this project. The devolution of the project to the DHCs has been effected
and this is expected to bear excellent long term prospects for sustainability -- how7ever, it has had
a high cost in terms of short term implementation delavs.
Pr°jecI has disbursed nearly LSSS2 million in the last three and a half yearsL or over
25 /o oi the loan amount. Project management m Punjab and West Bengal will need to be
particularly diligent to complete the proposed acthl’ities within the project period. Disbursements
will be closely monitored during the coming months, to determine whether reallocations between
states for the unallocated and allocated.portions of the funds will be needed.
9.
Following is a summary7 of project achievements, lessons and future actions w-hich
emerged from the MTR workshop.
Summary of Project Achievements at Mid-term
Delivery ofInputs
physical inputs (Civil works and goods) are being delivered (after some initial delay), and is resultine
dn_,,yL1" e°ulpPe ■ c eane-- and saier hospitals, with ambulance services and greater availability of
skiiis'
SteX1 "»f ”"X"1' min"g h“ be“
•
h“-
■»»
Health messages have been displayed and disseminated
Vacancies
V
acancies and mismatches in health personnel have been reduced
Systems Development
Hospital information is being collected and used for dec.sion-makms
Procedures to improve public accountability are being used
moll0” h“b"“
1“dmE“
Mechanisms to coordmate national and state programs have been imtiated
Decentralization of health management has been strengthened m West Bencal
ore transparent and fair procedures for procurement are being used and more effective qualm/
assurance procedures introduced
quaiiis
Contracting procedures have been introduced and are working well
Mov. oi funds mechanisms have been developed within state systems to handle a large flow of funds
W aste management systems have been introduced and are being used
Equipment management and maintenance systems have become functional
Keierral systems have been piloted successfully
Disease surveillance and control systems are being refined and used
Quality' assurance procedures have been introduced
Measurable Outcomes
•
Increases in outpatient and inpatient visits are being seen
Sg131 efllClenCy 15 ebanging throush lnc"as« in bed occupancy and greater use of diagnostic
• ■ Increased ouffeach sendees to disadvantaged groups are ev^ent
• ■ Patient satisiaction levels are being measured
Qualitative Results
•
•
•
Raised awareness of health among politicians and key decision-makers
improved morale among public health sector sta’T
Public health sector is now better able to rnnein—
disease surveillance, referral. IEC)
aCr°SS Pr°gramS
•
Government is adapting new ways of doing business introduced by project, and open to newer.'
initiatives m tne health sector
H
Public health sector is now looking bevond nuh-- t
•,
, •
5eclor
sector to new partnerships with NGO and private
•
•
•
leVC1S ?f Care (e'g'
-Expectations of the public and providers are risir.c
Awareness of problems of vulnerable groups has been raised
/
Summary of Lessons Learned and Future Actions
i Issue
•
•
Policy
Increased allocation to
health, especially to pnmarv
and secondary' levels and
non-wage recurrent items
Systems for policy analysis
and strategic planning
Role of government in
utilizing public-private
partnerships
Management & Institutional
Arrangements
• Continuity of project
management
• Appropriate project
management arrangements
• Adequate flow of funds
• Strengthening state health
- management systems
• Management information
systems to support decision
making
• . Management of physical
assets to ensure quality*,
‘ performance and safety
$
i Lessons Learned
I Future Actions_______________
9 Changing allocations has
• Prepare options papers on
been more difficult than
how to improve State health
anticipated: overall
allocations within context of
allocation to health has
overall State priorities and
increased slightly in Punjab
fiscal constraints
and West Bengal, but more
• Integrate Strategic Planning
so m Karnataka, pressure for
Cell into state health policy
the wage bill has increased,
and planning bodies
but there have been small
• Shift from rigid norms to
increases to selected non
need and performance based I
wage items
planning
• Investment in physical
• Explore options to improve
improvements is powerful
use of private financing and
motivator in promoting
private provision,-including
systemic reforms
new provider payment
• Attitude and behavior change
mechanisms and
of policy-makers and key
organizational models
staff within state health
• Strengthen monitoring of
systems is nta] step toward
effects of cost-recovery and
reconsidering role of
exemptions
government and private
sector
• Quality' and continuity of
• State government
project management is key to
commitment can be seen by
successful implementation
its support to the project
• Multidisciplinary project
through quality management
team essential. Up-front
and retention of key
training in Bank procedures
managers.
is needed.
• Add skills on key software
• Establishment of autonomous
areas (e.g. economics,
bodies are not sufficient in
information systems.^
easing flow of funds marketing) to project teams
financial commitment of
• Integrate PMC activities and
state is still critical
systems (e.g. information
• District Heaifn Comminees
systems, financial
can be efiective provided
management) into
they are engaged early and
mainstream of health systems
have substantial decision
• Integrate planning and
making power, including
supemsion of SHSII project
financial authority and
with other national programs
control over postincs
• Extend contracting to clinical
• Managing contracts is an
services
efticient mechanism where
• Increased use of 3rd party
tested so iar ;non-clinical
evaluation of outputs and
hospital sermcek waste
outcomes and applied
management; minor building
research
maintenance mcludinc
» Develop local standards for
6
Issue
J
Lessons Learned
toilets, waste supply etc)
• “Centers of excellence”
created by project heed to be
expanded beyond the project
• Concurrent evaluation and
feedback in areas of patient
satisfaction and hospital
performance enables
managers to take prompt
corrective action
• Quality assurance requires
appropnate local standards to
be meaningful
• Economic benefits of asset
care demonstrated by success
of one-time repair programs
• Technical inspection and
testing of products essential
to ensure quality and safety'
Future Actions______________
quality assurance
• Expand standardized
guidelines and operational
procedures (e.g. model
contracts, hospital
commissioning guidelines)
• Undertake study of cost
effectiveness of various
maintenance-and repair
modalities currently being
tried in different states’and
develop cnten a for
optimizing arrangements
► Develop data base on
equipment for secondary care
including, technical
specifications, unit costs,
maintenance guidelines, life
cycle costs for O&M.
Issue__________
Health Service Deliver}’
• Functional referral system
• Disease sun'eillance
• Hospital waste
• Health communications
• Training
• Engaging NGOs
I Lessons Learned
Future Actions______
Reierral protocols need to be • Expand referral systems
responsive to changes in
throughout state
services in public and private • Refine surveillance system
sectors; provision of all
design around control
project inputs is not a
actions, integrate with
prerequisite to initiate action
epidemics divisions of DOH,
• Though surveillance systems
and address nonare established, rapid
communicable diseases; do
response still needs to be
comprehensive situation
strengthened
analysis of surveillance
® Actions on improving
system in selected states
hospital cleanliness and
• Implement long-term waste
waste management requires
management strategies and
continuing attention but can
continue training &
yield positive results
promotion
• IEC strategy sb far limited
• Refocus IEC on behavior
only to client and provider
change and monitoring of
information, its effects on
change; integrate IEC
behavior change is not yet
strategies m state across
known
national and state programs;
• The effectiveness of training
hold workshop on how to
needs more rigorous
contract and monitor IEC
monitoring; training on
agencies
specific skills used by
• Critically evaluate training
trainees has been most
by linking training to clinical
successful
and managerial outcomes;
• The limited partnerships w’ith
develop on site management
NGOs has been positive, but
development and training
dependant on good screening
programs
of NGO and medium-term
• Increase involvement with
__commitment
NGOs
i
(?l try'
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II (( i. 2833-IN)
KARNATAKA
SI PER\ ISION MISSION
AIDE-MEMOIRE (NOVEMBER 1997)
1. An International Development Association team consisting of Messrs./Mmes. T. Nawah
(mission leader). M. Voss and V. Revval \ isited Karnataka between November 15-16. 1997 to
review implementation progress of the State Health Systems Development Project II (Cr. 28331\) in Karnataka. The mission met with Mr. B. Eswarappa. Secrelan. Health and Familx
Welfare Department and Senior Staff of the Project Management Team and discussed the
contents of the Aide-Memoire. A rexiew meeting was earlier held with the Project
Administrator, Dr. S. Subramanya in Washington in late October. The mission wishes to thank
the officials for their co-operation and gracious hospitality.
2. Project implemenUU’.on progress is recorded in the various documents prepared by the State
Health Systems Development Project II in Karnataka. The Aide-Memoire summarizes the main
findings and recommendations of the mission of Karnataka.
3. General Overview: The project became effective on June 27. 1996. The last supervision
mission in March 1997 noted that the project had progressed well and was on the right track
after a smooth transition of key personnel. Since the last mission the project has moved forward
steadily and almost all the components and activities are showing very satisfactory progress. In
particular, the mechanism established for timely flow of funds is exemplary and sets a best
practice model for other social sector projects that are being implemented through state line
agencies. Most of the benchmarks agreed with the last mission have been met. The policy
program is on track: the recruitment of staff, civil works and equipment procurement arc
progressing very well. The civil works program is beginning to get firmly grounded and as a
result the project will begin to show large expenditures in the coming months. The HM1S
referral system, management and clinical training, and medical waste management activities are
all progressing satisfactorily. Total expenditures to date are about Rs. 230 million including
retroactive financing. Although this is somewhat below the SAR target. The expenditure levels
for this fiscal year are on target. The review mission agreed on a benchmark of Rs. 750 million
for project expenditure by the end of March 1998. The benchmarks for activities to be
undertaken in the coming months are provided in the attachment.
4. Health Sector Development Program: Budgetary Allocation for the Health Sector: The
budgetary allocations for the health sector were enhanced from a level of Rs. 469 crores in 199495 to Rs. 706 crores in 1996-97. The planned provision for 1997-98 continues this trend. Within
the health sector, revenue expenditures for the primary and secondary health sector have also
increased from Rs. 415 crores to Rs. 616 crores within the same period and their share in the
total health budget has also increased. The covenant on increasing resources to the primary and
secondary levels is in compliance. User Charges are being collected at 19 District hospitals. \
total of Rs. 1.5 million has been collected during the last five months, mainly from pay ing beds
and health checkup cards. Plans to enhance revenue from clinical and diagnostic ser\ ices arc
under review and the SPC is undertaking a study of user charges. Fund> collected from user
charges arc being deposited in 1)1 IC accounts and plowed back into the district hospitals where
1
.
(he funds 'verc collected. A (io\ciTincni Order has been issued on how lhese funds arc I
used b\ the concerned hospitals.
be
5. Management: The Project Management 1 nit is now almost fullv staffed and the project is being
implemented well with excellent support being prov ided by the Project Administrator and die
I Icalth Secretary. Senior staff appear to be committed to implementing the project cxpcdiliousl v
and they have now been housed of flow of funds has been resolved. Cheque drawing facililv has
been prov ided to the Project Director as well as to the Executive Engineers al the Divisional
level. In addition, the District Surgeon and Medical Officers al the hospital level have been
given permission to draw funds through a special order, l hese mechanisms established under the
project are prov ing to be exemplary in ensuring timely and adequate flow of funds and mav be
considered a best practice model for other social sector projects that arc being implemented
through state line agencies. Coordination between State Health Systems II Project and other
Population and Health projects in the stale such as IPP VIII. IPP EX. KlW projects is being
facilitated through the appointments of a State Health Systems II Project Co-ordinator to
supervise implementation of lhese projects as well. The co-ordination of specific activities will
continue to be rev dewed every mission.
6. Recruitment: The benchmarks established in the last mission for recruitment of staff have been
mostly met. Of the six Deputv Directors who were to be recruited. 4 are already in place and the
remaining 2 will be hired by December. For equipment maintenance. 40 technicians have been
recruited and have received two rounds of training in Hyderabad and Bangalore. Thcv will be
available to start work this month. In addition, the positions of 362 Doctors and 242 Group ’I)'
personnel have been tilled. It was agreed that the benchmark for March 31. 1098 would be the
recruitment of 600 nurses and 110 medical technicians as well as personnel required for the
Engineering Wing of the KFW operation in Gulbarga Division (1 Executive Engineer. 2
Assistant Executive Engineers. 8 Assistant Engineers. 1 Accountant. I Office Superintendent
and I Biomedical Engineer).
7. Civil Works: The benchmarks for civil works have been exceeded. To dale, design work has
been awarded to architects for 178 hospitals in Phases I to IV. Preliminary designs have been
completed for 117 works and these have been cleared by the Bank. Final drawings and bid
documents have been completed and cleared for 68 of these works: 52 works have been
submitted for tender and 43 tenders have been evaluated. Work has been started on 30 facilities.
The extension of the Project Office has been completed and the Project Management’^laIT are
now well established in comfortable working offices. This is helping the morale of the stalf. It
was agreed that the benchmark for May 31. 1998 would be as follows: award 198 works to
architects: complete 198 preliminary drawings: complete 100 final drawings and bid documents
and commence work on 70 hospitals for which Final drawings have been cleared.
8. Medical Equipment, Repair and Maintenance: The benchmark for completion of 30% of
procurement of equipment packages has been met. Repairs of equipment at Bijapur and
C’hitradurga district hospitals have been completed. The survev of status of equipment in all
districts has also been completed. A Central Equipment Maintenance and Training facililv has
been established in Bangalore I raining and Equipment Maintenance has been initiated and sites
for Equipment Maintenance Workshop in 9 districts have been identified. To facilitate
maintenance function. 21 veh des are being procured. It was agreed that the benchmark for the
completion of the repair program for all other districts would be December ?l. IW js .igrccd
during the last missic-n. In adciliim. it was also agreed that procurement of equipment for Phases
I
I and II hospitals would be completed and the 6 Equipment Maintenance learns would be
operationalised b\ March al. I‘MX.
9. Medical Waste Management: A three phased approach was identil’ied during the Iasi
supervision mission, fhe lirsl phase, a shnrrterm plan based on low-cost measures to improve
clinical waste management, is being put into practice at the 30 bedded Devanahalli l aluka
hospital. The mission visited this facility and was impressed with the segregation and disposal
measures that arc being introduced al this hospital. A workshop was organised through the
Karnataka Pollution Control Board and the Center for Development of Technology of Hospital
Waste Management to facilitate the development of an action plan. A short term, well thought
out plan which needs some line tuning, has been prepared and will be implemented in several
hospitals following the pilot at Devanahalli hospital. The following benchmarks were agreed
upon: a short-term as well as a medium-term pilot plan would be implemented in Devanahalli
hospital by January 31. 1998: a short and medium-term pilot plan would be extended to several
Phase I hospitals by May 31. 1998: and the long term strategy would be modified using the
experiences and results of Phases I and 11 by July 31. 1998.
10. Strategic Planning Cell: A number of activities have been initiated in recent months. The SPC
has started a quarterly newsletter in both English and Kannada, fhe first edition of which vyas
recently published. Il has also undertaken a quick review of the implementation of the District
Health and Referral Committees and an evaluation of the yellow card scheme in Mandy a
District: a study on user charges has been initiated and the SPC is following up on the actions ol
the Health Policy Matrix on a periodic basis, fhe following benchmarks were agreed upon: the
SPC’ would organize district level workshops on the health systems project in Karnataka by
December 31. 1997: complete the study on user charges by March 31. 1997: update actions
taken on the Health Policy Matrix and review the implementation of the DHCs and Referral
Committees on a continuing basis.
1 1. Contracting Sen ices: All non-clinica! services are being contracted out in Devanahalli laluka
hospital on a pilot basis and the project plans to expand this pilot to several other hospitals. A
benchmark was agreed upon that would involve contracting all non-clinical services in 5
additional hospital by March 31. 1998.
12. Training: The training program is progressing well. The benchmark for preparing all modules
have been met. Training of trainers for doctors and nurses have been completed and jhe first
batch of training has been conducted. Management training for administrators, doctors-and
paramedics and clinical training for specialists and nurses is being conducted by the SIHI'W.
The first round of management training was started in October. 1997. It was agreed that an
evaluation of training programs of doctors and nurses and for management training would be
carried out by March 31. 1998.
13. Referral: Referral guidelines have been prepared in all the major disciplines. As agreed during
the last mission. A referral system has been started in Chitradurga district on a pilot basis and a
district referral committee has been set up. However, since the hospitals have not been upgraded
in the districts, the operationalization of the referral sy stems remains limited. It is now proposed
to consolidate the referral system to those clinical conditions that arc not dependent on the
upgradalion of facilities. The agreed benchmark on the referral sy stem is to consolidate the pilot
in Chitradurga district.
I
14. IIMIS: The I IMIS plan has been finalized. The TORs for contracting the pilot scheme has been
reviewed by Bank and comments are now being incorporated. Very good work has been
undertaken in developing hospital performance indicators and the data is being fullx
computerized. These data will be continued to be updated every six months and should pro\ ide a
valuable input to the project -managers ’m monitoring effeclixeness and efficiency and in
pro\ iding input to the quality assurance program.
15.SC/ST Component: Efforts arc underway to strengthen co-ordination between the gender
component of the project with the RC1I and FW projects. Under the stale health project. NGOs
and voluntary organisations have been drawn in to implement the reproductive and child health
component of the project. However, more needs to be done in operationalizing the main cross
cutting issues between the state health project and the RCH and FW projects. The
implementation of the pilot yellow card scheme which was started earlier has now been extended
to the rest of the Slate. The scheme w ill need to be reviewed on a continuing basis.
16. IEC: The plan to operationalize the IEC strategy for hospitals has been finalized. Pilot acti\ ities
have been initiated^and are expected to be completed by May 31. 1998.
17. Compliance with Covenants: Al! Covenants are in compliance.
.1
Issue
Management
_________________________Benchmark
Continue and strengthen mechanisms between SUS II, IPP VIII and IPP
IX. KfW and RCH______________________________
Recruit personnel for I Engjpeering Division for managing KfW
operations in GulbTirga Division:
Recruitment
Strategic
Cell
Planning
Contracting
Serv ices
Civil Works
Equipment
Procurement
Maintenance
1 Executive Engineer
2 Assistant Executive Engineers
8 Assistant Engineers
I Accountant
I Office Superintendent
I Biomedical Engineer
Other Staff
600 Nurses
110 Medical Technicians
Organize district level workshop on Health Systems Project
Update actions taken on the Karnataka Government Health Policy Matrix
Complete study on user charges
Continue to review the implementation of District Health Committees
and Referral Committee
Contract out all non-clinical services in 5 hospitals
and
Waste
Clinical
Management
Referral
Training
HMIS/Surveillance
SC ST Gender
IEC
Award 198 works to architects
Complete 198 preliminary designs
Complete 100 final drawings and bid documents
Commence work on 70 hospitals for which final drawings have been
cleared
Complete procurement of equipment for Phases I and II hospitals
Operationalize 6 equipment maintenance teams
Extend and complete repair program to all other districts
Within the overall plan outlined in the S.A.R.
~ ~
Implement short term and medium term pilot plan in one hospital
Extend short and medium term pilot to Phase I hospitals
Modify the existing long term strategy utilizing the experiences and
results of Phases I and II___________
Consolidate pilot in Chitradurga district
Conduct evaluation of Clinical Training for Specialists and Nurses
Conduct evaluation of Management Training for Officers and Nurses
Complete second round of training of doctors
Complete second round of training of nurses
Continue updating performance indicators for each hospital
______
Continue review of yellow card scheme
~~
~
Complete IEC pilot activities
Deadline
Every 6 months
March 31. I99X
March 31. 1998
May 31. 1998
December 31.1997
March 31. 1998
March 31, 1998
Continuous
March 31. 1998
May 31. 1998
May 31. 1998
May 31, 1998
May 31. 1998
March 31, 1998
March 31. 1998
December 31.1997
January 31, 1998
May 31. 1998
July 31. 1998
May3l. 1998
March 31. 1998
March 31.1998
May 31, 1998
May 31, 1998
Every 6 months
Continuous
May 31. 1998
J
/
•
1
(S)W-9—
ANNt/uRf-
state health systems
INDIA
??EYEL0PMENT prO.IECT II (Cr. 2833-IN)
Karnataka
SUPERVISION MISSION
AIDE-MEMOIRE (MAY 1998)
i.
: nJ
■ “i0"al DeVe,°Pment Association team
A
(Team Leader), D. Porte/ C^Gilp? *SS°Clat'on team insisting of Messrs./Mmes. T. Nawaz
» C. Giles, S. Rao-Seshadri,
ravarty visited Kamatak
J
' S^opa'Redd>'’ Finance Commissioner; Mr. B.
Eswarappa, Health Secretary- Dr
W,.
Government of Karnataka-Dr S C.h
Development Project (KHSDpi-/ .
n
D,recIor’ Heallh aild Family Wellfare
many^ Pro-'ect Administrator, Karnataka Health Systems
office for
”sl’“ >°
m“tlnS
Eswarappa, Dr. Subramanya and s^ip,
"pa
in Bangalore.
of the J reject Management Unit on May 30, 1998
P’'
Karnataka Heallh s'^ms'DevelopT ’ 'Spre“r<,“1
",c v"ri<’,,s
Mr.
prepared by il,c
Endings and record
3.
General Overview.
The m
November 1997, which recorded n /°n nOteS
S"1Ce thc. Iast suPervision mission in
implementation has gained consider^ pr°eress w,th Pro.iecl implementation, the pace of
this juncture of implementation. -The <-• m°mentum- Progress is very satisfactory for a project at
at the facility level and the repair of fl'^k '^i' "1C^CaSe ,n the availabili'y of drugs and supplies
functioning of these institutions an i V/a u
°8
equ'.Pmen’ llas llad a P°sitive effect on the
°|their cred,bll,ty- Alniost all the benchmarks agreed
with the last mission have been met d
r: .5
elections.
Implementation of anreed^116! ■
Setback ,n tlle work Program due to the national
satisfactory; in particular, the contract/eCl°r develoPmei1t Policy measures has been
has enhanced the quality of .
’ ng.OUtofnon-clinical services al several pilot institutions
expansion. The project team is almnZTT and haS dem0llstrated the scope for significant
other software components are nrL
y
d
trai'ling’ referral’ lEC’ HMIS a"d
system of the project has been comn^T*'" a WelL Tbe flnancial management and accounting
progressing well with recard to the n
SyStem is Actioning well. The project is
civil works component of the proiect ^0CUJ'ernent oF drugs and other supplies. Progress with the
hospital works are under constructin
een excel,enl durinS the Past six months and about 80
the quality and utilization of services With
I
ICVel'
nl'S'maIch of docIors is impeding
next six months will be an importa
r
’ 1 116 conso,,dal,c?n of the civil works program, the
issues which acknowledge the im
C t0 g’VC increased Mention to this and other software
and in improving patient outcomes^ rtanCe
d,e ro*e ()f
clinicians in hospital management
Total expenditures incurred hv il
. :
for the government J:Y97-9K were *1
/C ^rC,-,ecl 10 ^’l,c ’”e
^scrore. Expenditures
agreed with the last mission - n
62 U°,e co,nP«”c(l to the benchmark of Rs. 75 crore
remarkable increase from the Rs. 2 crore incurred during the
remar-.nA
f
previous fiscal year. Disbursements locate are about Rs. 52 crore (USS 12.2 million). Due to the
failure to provide project account and SOE audit reports, the Bank has recently stopped
disbursements. The Government has assured the mission that the audit certificate will be
provided to the Bank prior to the departure of the mission from India around June 12. While both
expenditure and disbursement figures are below their SAR estimates, there are clear signs that
they will be considerably higher this fiscal year. The mission agreed on a benchmark of Rs. 40
crore for project expenditure for the first two quarters of FY98/99 (April - November 1998).
Benchmarks for activities to be undertaken in the coming months are provided in Attachment 1.
Health Sector Development Program.
4.
Budgetary Allocations for the Health Sector.
The budgetary allocations for the health sector were enhanced from Rs. 705 crore in FY96/97 to
Rs 805 crore in FY97/98 and Rs. 903 crore in FY98/99. The share of health in the overall state
budget has also increased during this period. Within the health sector, the share of resources
allocated tojhe primary and secondary levels has also increased from 85.8% to 87.3% between
FY96/97 and FY98/99, and the amounts for primary and secondary health services increased
from Rs. 450 crore to Rs. 697 crore. The covenant on increasing resources to the primary ai
secondary levels of the health system is in compliance. Cost Recovery. About Rs. 4.0 million
has been collected so far, and there appears to be significant scope for increasing collection. A
study on the willingness-to-pay user charges is being finalized, and a review of the fee structure
and the targeting for exemption for people below the poverty line will follow once the scheme
has become more firmly grounded. Contracting-out services for all non-clinical services at four
hospitals were initiated. The results are very' encouraging both, from economic and sustainability
perspectives, and in terms of quality improvements of these services. It was agreed that
contractual arrangements for all non-clinical services would be extended to 10 hospitals by
October 31, 1998.
5.
Management.
The Project Management Unit is nearly fully staffed and is providing
excellent support to the successful implementation of the project. The Project Administrator and
the Health Secretary have played a key role in facilitating project implementation. Coordination
between KHSDP and IPP VIII, 1PP IX, KfW and RCH projects is being strengthened to varying
degrees. It was agreed that a plan for developing better linkages.wilh respect to training, referral
and 1EC activities would be continued. A serious problem, however, remains with the staffing^
facilities to be upgraded under the project, particularly with regard to the mis-match of
compared to agreed norms at upgraded facilities. The problem also, exists with regard to medicar
'
technicians and they need to be recruited to make use of the new and repaired equipment. The
mission would like to emphasize that it will now be important to ensure that adequate staff with
appropriate skills is in place in the upgraded facilities so that the envisaged improvements in
service delivery take place. The government informed the mission that recruitment of required
staff was underway and that, as a start, it would fill all specialist, medical technician and nurses
posts according to norms in 20 hospitals by October 31, 1998 and gradually for other upgraded
facilities thereafter. In the meantime, the government would consider interim contractual
arrangements in those institutions where there is a need to provide clinical services, and doctor
and technician vacancies could not be filled.
6.
Flow of Funds. The mission is pleased to note that the mechanism for How of funds, put
in place prior to the last mission, is working well. This mechanism facilitated expenditures of
about Rs. 62 crore last fiscal year. Based on the plans and preparatory work undertaken for this
fiscal year, it is expected that the project’will spend about Rs. 120 crore - close to the highest
level estimated in the SAR. The Government has budgeted Rs. 80 crore lor the project for this
“)
2
J
fiscal year. During the mission the Chief
mission that additional resources would be nrnv'L
of funds was not an issue for externaHy-as^XS^
'l’C Fi"anCe Scc,'ctari' assured that
11,31
Assistant Executive EngineersTi?] OfficeSuoTr dtthd reCru itmenI of 1 Executive Engineer. 2
have been issued, considerably higher titan the Ann6"
Appo"1tment orders for 1100 nurses
nurses which
last mission. Interviews and recruitment of 110 nllrSeS
wh'dl,was benchmarked during the ""
of 110xi™
medical
recruitment will be completed by June 30 1QOR
6 i02 1technicians
lecbnic,ans i,s underway and their
New benchmarks
been set for the recruitment of 8 Assistant Enpi
encbmarks for
^or end-October
end-October 1998 have
•ngineers, 1 Accountant and filling of all sanctioned
posts of Assistant Engineers in KHSDP
_ 8.
f.)
3=v.„, „srfu, „,ivi,ks.
mcluding: (i) organizing district level
Karnataka Government Health Policy
8 d'str,cts;
updating actions taken on the
an executive summan.- will be orovided hv n .2 C0'1’plet"1S a stucb' 0,1 user charges, for which
review of the activities of District Health V C ° er 3 ’ 1998: and (,v) conducting and on-goin"
siudy »„ Microbia!
“Xb ia'" a;’d
addi,i°"- «
presented to the mission. The study has dnr,
hospitals. It was agreed that recomme^dat
underway, and preliminary findings were
le''el °f infeCti°n a’ public
be completed by October 31 JOQR in
f aCIIOns 10 be laken based on ll"s study would
(a) updating actions taken on’the Kar atat Go ""
3’' ,998 illdude:
TOR for a study on public-private mix in th^hXT1.
Tf0’ 7 Kaniataka: (c) develoP"'g a TOR
for a study on national hiehway accidents and the
In
drafi on
W
procure™^, and
(b) develoPi"2 a
P°liCy
e^p'X' ’0°rtae'T' T,, :'’"d'
have been ordered at a total cost of
177
Significant savings have been achieved nn
d
-,2
h1'
re“rd “
'’ospnals. Around 19,000 items
l0n’ V,h,cl1 ls ab°111 500/0 of llle project total,
which totaled Rs. 199 million without contin^'-"^5 C10mpared 10 tbe estimates in the SAR
delivered to project hospitals and were nhse Ee.nC'eS for lhe sanie ilell1s- Many ilems have been
b>' ll'e l11issio11 durjng visits to facilities,
Quality and value for money generally is K T
meet acceptable quality standards and the PMI .am°n8,tbe £oods inspected. A few items did not
Tighter technical specifications need to b
lake Up "lese deflciencies witb the suppliers.
Consideration must be given to nroner
,e draWn
UP
3
feW ,ypes
of equipment,
regards safety of radiological systems and 1 P anCe .’estln£ of al1 goods supplied, particularly as
provided to the in-house maintenance tea
r0'm^d,cal equipment. Instrumentation should be
' them 10 C0llduct lbese ,ests- Training of
users should be given priority. It was acreTd^)0 Tn
mortuaries and generators would be
f J equipmein- including X-ray machines, body
UUIQ Decommissioned by October 3 I, 1998.
10.
Maintenance and Repair of Eon'
established in 16 districts. Technical staff '!Prne"t:
workshop facilities, tools and test eouin
Repairs are now being undertaken for hnc T 1
well managed and fully documented
supervision mission summarizing tin-;,.
1
In;h°usc maintenance teams have been
e'Ven baS'C ,rainin? a,ld Provided with
3 Vel"cle equipped as a mobile workshop,
I^wm5 'lrOUgbouI.lbc slale ai’d all activities are being
r?'
* useful T a report is prepared for the next
during the next 6 months and its costs A ’r'Dnncc m terms of the volume of work undertaken
of one-time repair of existing euuinmAw conlrJC,or has been appointed lo inili.-iiu lhe program
n micrim repori on progress will be prepared for the
2^;
f
next mission. A plan for establishing a bio-engineering wing within the Health Department will
pla^’^lizedaVd^
°f '
10 Icad lhat
be P^Poned until the
^or^s- The progress with the civil works program has been excellent. AU 198
11 i
^°r S iaV,enn^n awarded 10 architects and preliminary designs have been completed for 191
aci ities.
ma rawings and bid documents have been completed and construction activities
lave commence in 80 hospitals. This is a very impressive-volume of work since the last
mission, ite visits to several hospitals which are at an advanced stage of upgradation revealed
tiat ie qua it\ o work was good. The PMU has been using inspection teams to visit
♦?nSwinOn SmCS °r COrrecl,nS minor design issues. The mission suggested that, in addition
the PMU could more effectively utilize the services of the consultant architects for periodic
supervision.^ uci supervision would help to further improve the quality of construction, since
tie arc itects could sort out unforeseen problems and coordinate-various activities such as^
.
masonry electrical and plumbing works. Other minor design and supervision issues have beeW
1SCUJ- •
the Rank architect and are being written up separatelv as minutes of discussion
The benchmarks agreed for October 31, 1998 are: completion of 130 final drawings and bid
documents; commencement of works at 100 hospitals for which bid documents have been
cleared; and commissioning of 10 upgraded hospitals.
12.
Procurement Plan. The procurement plan for FY98/99 was reviewed and cleared bv the
mission.
13.
Management of Health Care Waste. The mission was encouraged to see the anention
being paid to the management of health care waste at several facilities visited, particularly the
segregation o waste through color-coded bins and the adoption of simple, low cost measures
such as needle crushers. The short term action plan is being extended to all hospitals under the
project The short term and medium term pilot has been implemented in Devanahalli Taluka
n0SPQ o Th,S ShOrl 3nd medium lerm Plan
be extended to 20 Phase 1 hospitals by October
31, 1998. The longer term plan and the final disposal method will be suitably modified followin"
the completion of the waste management study currently underwav.
*
14.
]
lnd*cators- Hospital activity and efficiency information has been
collected from 120 hospitals,
-• It has been compiled district-wise and is in the process of beinc
compiled state-wise. Quality,
- > access and effectiveness indicators have not been assessed. It was
agree tiat, unti construction and other inputs have been completed, assessment of the
quahtative indicators through exit surveys and other methods would be held back, although a
start cou
e made on an action
action plan
plan for
for such
such evaluation.
evaluation. However,
However, it
it was recommended that
the Strategic Planning Cell work on establishing some base-line data to compare later results.
The World Bank would provide some models.
Il was agreed that the hospital activity data for
1997-98 would be reconciled by October 31, 1998.
15.
Surveillance.
The
government furnished a detailed plan for surveillance of
communicable diseases in the state for
review by the mission. The government indicated that
establishing the Slate Surveillance Unit at
Bangalore would be a priority, and it was agreed that
this would be completed by October 31, 1998.
I
In- addition, it was agreed that 7 district
surveillance units would be established by'October 31. 1998 and staff would be
. sent for training,
The mission highlighted the importance of communitv involvement in
the functioning of the
surveillance system as set out in the SAR.
4
2^
1
16.
Training
All the benchmarks for training have been met. Training activities for
octors. nur.es an equipment maintenance technicians have been progressing well and will
continueJn addition, training of pharmacists and laboratory technicians wilTbe started. The
mission has reviewed the training plan and targets provided in the background notes and found
these satisfactory To improve the quality of services at 35 institutions which will be operational
in January
1999, hospital
administrators would be given
intensive training in
hospital
management and project related inputs, including hospital infection control and clinical quality
assurance, b>' O^ber 31, 1998. A tentative plan for short-term overseas training courses for
staf in ie MU has been drawn up. The mission "concurs withTliis proposal. It was also agreed
that, to facilitate clinical training of doctors, equipment similar to that being provided under the
project would be made available on Joan to K. C. General Hospital, Bangalore, where the patient
load is sufficient to provide quality training.
'
hi
57
zi
Pie ’ntroduction of the referral system in Chitradurga district is awaiting the
upgradation of the hospitals. In view of this, it was agreed that the referral mechanism would he
1)
introduced in Udfpi district where upgradation in most hospitals is underway.
J
Actions to be
la -en inc u e mapping of facilities in Udipi district, provision of referral manuals and registers,
training o sta at primary and secondary health care facilities and initiating a referral system in
t e istrict y cto er 31, 1998. It was also agreed that the referral system would be included in
the agenda of DHC meetings. It was further suggested that Midnapore district in West Bencal be
V,Slm ?° StUj" 1
re erra^ sYslern ’n place there. The referral manual produced in West Bengal
could be used as a useful guide.
•
b
•18.• •
j •6 °W
^c^cme- The
The Yellow
Yellow Card
Card Scheme,
Scheme, an
an annual
annual health
health check-up
check-up scheme
scheme
initiate in August 1997 to reach the SC/ST population at the subccntcr level, has been launched
10 a
treatment.
providers.
*lrou£h one day camps at the subcenters that provide examinations and basic
ie scheme is well organized and is perceived favorably by both clients and service
A Lady Medical Officer is available at the camp-site, as well as a well-stocked
ispensary an
re erral services.
In FY97/98 486,000 people were covered under the scheme,
ic contri ution o tie medical staff and the support provided by the PMU to this scheme is
3)
commen a e. uture steps to_be addressed under the scheme could include innovative IEC
acy’v’tie.S’ suc as streel di eater, to provide health information to the patients awaiting check-ups
an
asic treatment. Next steps for the scheme include the training of two NGOs from each
Partlc,Pate ln tJie camps. A review of the implementation of the scheme at the district
i IStr.,Ct
iV^S W1
C C°n UClC
feedkack wiU be incorporated into the action plan by October 31,
IEC.
109R
d
U e.” a'L^plernent’ng action plan for IEC for target groups by October 31
1998; and (b) m.tiatmg IEC activities for referral services in Udipi district by October 31.1998.
20.
Compliance with Covenants
All covenants except the one on submission of certified
I"
KHSDP is expediting action to obtain the necessary project
account and SOE audit reports for FY96/97
audit accounts are in compliance
5
.
I
Attachment 1
Benchmarlcs
K a rna tn ITa
ISSUE
Management
Recruitment
Strategic Planning
Cell
Contracting-Out
Civil Works
—-
_____ benchmarks_____________
Continue and strengthen coordination mechanisms between
SHS II, IPP VIII and IX, KfW and RCH.
To address mismatch, fill in all specialist, X-ray technician,
laboratory technician and pharmacist posts according to norms
in 20 hospitals.
8 Assistant Engineers
1 Accountant
110 Medical Technicians
Fill-up all sanctioned posts of Assistant Engineers in KHSDP
Make recoiuinendations for action to be taken based on
findings to date of the Microbial Contamination study.
Complete study on user charges, including an executive
summary'.
Update actions taken on Karnataka Government Health Policy
Matrix.
Develop TOR for the study on public-private mix in the health
sector.
Develop TOR for a study on national highway accidents and
need for development of trauma care services in Karnataka.
Contract-out all non-clinical services in a total of 10 hospitals.
Complete 130 final drawings and bid documents.
Commence
— work
----- 1 on 100 hospitals for which final drawings
have been cleared.
Equipment
Procurement and
Maintenance
Medical Waste
Management
HM1S_______
Referrals
DEADLINE
Review ever)' 6
months
OcioberSl, 1998
Octobers], 1998
____ ft,
October 31, 1998
October 31, 1998
October 31, 1998
October 31, 1998
October 31, 1998
October 3 1, 1998
OcioberSl, 1998
October 31, 1998
Commission 10 upgraded hospitals.____________ ___
Commission all X-ray machines, body mortuaries and
October 31, 1998
generators procured for Phase 1 and II hospitals.
Initiate procurement activities for equipment as per the
October 31, 1998
procurement plan for 1998/99.
Status report on progress with the one-time repair of
equipment.
Status report on the activities of equipment maintenance teams.
Introduce the interim strategy on health care waste
management in 20 hospitals.
Reconcile the hospital activity indicators for 1997-98.
Map primary and secondary health care facilities and develop
referral chain in Udipi district.
Tram staffer primary and secondary health care facilities in
utilizing the referral system in Udipi district.
Initiate referral system in Udipi district, ensuring the
involvement of the DHC.
October 31, 1998
October 31, 1998
October 31, 1998
OcioberSl, 1998
June 30, 1998
August 31, 1998
October 31, 1998
■
•t
■ .i
ISSUE
Training
---- P---- -------- - ----------- BENCHMARKS
DEADLINE
of 35
Octobers!, 1998
per action phn"8 °f doClors' nurs« and medical technicians as
March 3 J, 1999
Surveillance
T™
H- 7 d
'CI SUrVei,lan« Units.
_ to" Sr*"
SC/ST/Gender
•"d '“toto »rr from
----------------------October 31, 1998
Octobers!, 1998
October 31, 1998
Implement action plan for Yellow Card <trT-----------------------Continuous
Octobers!, 1998
- IEC
SZXXf Xpi
Continuous
August31, 1998
&10V-
INDIA
STATE HEALTH SYSTEMS DEVELOPMENT PROJECT [I (Cr ^833-IN)
KARNATAKA
SUPERVISION MISSION
DRAFT AIDE-MEMOIRE (NOVEMBER 1998)
A,SS°C.iation team consisting of Messrs./Mmes. T. Nawaz (Team
Leader) "e) Port^r^c"
C~k L V
A
; ;rt*- R- K““- P
M- V»“. N. Anand. IMeQuad-
Cook and V. Rewal v.stted Karnataka between November 15 and November 20 1998 to review
The
T HC^h d
S?StemS DeveI°Pment Project H (Cr. 2833-IN) in Karnataka.
TTte mrsston met with Dr.H.C.Mahadevappa, Mr. B. K. Bhattacharya, Chief Secretary Dr S Subramanva,
Project Administrator, Karnataka Health Systems Development Project
^“Dramanya^
a
U iJ • .
i^eveiopmeni rroject (KHoDP), and senior staff of
Unit on November 7fSubramanya 311(1 seiuor st3ff of the Project Management
’ "8. This review was preceded by a successful major workshop brin«inu together
all ±e states implementing Health Systems Projects and other senior health officials from UPM Nadu
and the Union Ministry of Health and Family Welfare to share experiences and leammg frol'the projects.
2.
Project implementation progress is recorded in the following documents- Notes for the World
Bank Review Mission, November 19 to 20, 1998; the Financial Report and the training documents
prepared by the Karnataka Health Systems Development Project; and the KHDSpTSortZ fre
■
'
“7“' "A*
“ “* T11'
Karnataka0 OO^P?1
devel°Proent objectives of the project are being folly met in
S/9^iid^8/99 a^d yCh S~ f h
all°CatIOnS
the health SeCtOr were
u ?
u .!
Share of health in the overfol budget has increased during the same period,
and tte budget for foLT ^V1131'6,01 r^ources for
primary and secondary level has also been increased
and the budget for drugs and supphes has also been enhanced. Cost recovery from user charges is growing
and contracting out of non-clinical services has been expanded sienificantlv DO?- n rw a &
j
n
■ n
cxpaiiuca sigmncanuy. U(J2: Quality, Access and
d IndlCat.OrS-, Progesys ^ctory in the area of the availabilit^f drugs, recruitment of
1,1
fk
C lniCa*. aJld management training, mamtenance services, HMIS, quality
assurance and odier software aspects of the project. 003; Activity Indicators. It is too early to measure
sTopTof SsTtiX0^ analyS1S °f
"OntU1Ues t0 unProvc 311(1 efforts
underway to widen the
scope of this activity and its management usefulness to improve future monitoring.
4.
General Overview. Hie mission was impressed by the continued excellent progress since the last
^TXZZTav111 h
P-^ss .s noted as foghly satiEoJ
ve een achieved and ui some cases exceeded e.g. in civil works and technical
manpower recruitment. Equipment installation and one-off repair activities are slightly betod SXe
but are progressing satisfactorily and should be completed by end December 1998. Operational difficulties
have been encountered in the implementation of the Yellow Card Scheme and these^vill need to be sorted
out. Noteworthy ts the mnovative solution to the issue of manpower deficiencies whereby Cabinet
Approvfo has been obtainedAo employ staff on the basis of merit without going through the normal Public
Serv.ce Commission procedures. The project is providing a basis to address systemwide health sector
RmhZ* lSrheS
of medl^l and paramedical staff not funded by the project,
eo^n
m
PaOn
Pr°CedureS has resulted ,n 311 Wrovement and streamlimng of
n^,tPr°Tment Pr0C
T
lmportant outcomc has been greater assurance rathe
foe cXimitment of th^C 6 ™SS1°n nOt,eS
the
satisfactory implementation progress is due to
foe commitment of the Government to foe project at the highest level and the continuity of foe excellent
project management team put in place from the early days of implementation. It wouTbe import for
i
-m,d-™" f“ ■“
put in Place is working very well and has become a model for
? ad°Pted ttUS appr°aCh foil°WlnS ^cessful implementation in
da7
HPStaCt0,y
J1*
made on expenditure with the total incurred by the project to
USS16 5 m il ” Cr0,>j’‘
^Sdursement at 1116 end of October 1998 was the equivalent of
eoveLmenT^9nS OP
"h
7a USS3milIion awaiting reimbursement. Expenditures for the
government FY98-99 are about Rs_ 36 crores (end October) out of an allocation of Rs. 80 crores This
other
FfURdS' T!,ehL0C
^-7 k mer
T
brC mark of Rs- 40 crores by end November 1998 TTie project officers
anticipate that they wdl meet the spending target for the current financial vear resulting in cumulative
spending of Rs. 140-150 crores by the end of March 1999. The benchS Zee7fo“ Z£ve
acSumf for^996-97RS d’h
before the due date
P6 Pr°JeCt *S n°W compliance
*0 covenant on certified audit
637 Pr°duced audlt certification for the upcoming year, two months
A H.d^HeT Sector Deveiopment
Budm_Allocations for the Health Sector. The
rr±^Fvi7/o9°nS/pr
SeCt°r WCTS enhanCed fr0m
705 CTores in FY96/97 to Rs 805
increa “d d '
^d
fY98/99- 1116 share of health in the overall state budget has also
XX n h'S T
d t health SeCt°r’
Share °f purees allocated to the primary and
econdary levels has also mcreased from 85.8% to 87.3% between FY96/97 and FY98/99, anti the
Jot primary and secondary health services mcreased from Rs. 450 crores to Rs. 697 crores. The
covenant on increasing resources to the primary and secondary levels of the health system is in compliance
m,d the state government has provided its own funds for filling critical gaps in primary health care Cost
d^ublTfr
°Ut tRS’ II X
? collected so far in secondary hospitals. This represents more than
double ±e amount collected previously. A study on the willingness-to-pay user charge is being finalized
and a strategic approach to implementation is being developed. Contracting out.for non-climcal Services m
well underway m 10 hosp.tals and additional hosp.tals have been placed on the program for contracting
hbliX M
b110" ■Ckn,Cal
be C°n,raCted Out ” a
of 20 hospitals
SS.I i l L h h -nevanve concept paper proposing a health maintenance organization in
Devcnahalh taluka has.been prepared and presented to the mission for consideration as a pilot scheme,
e funded by pooling all the existing government allocations for both state and national
ZZ nr' f’rf
SUPPOrted m
by an NGO type operation under the project. Hie
nroviti Th
doCtorS !“ *e schenie ,W111 be voluntary and patients will be entitled to choose their
H Z T1P
X ,5e lmproved quallty of
efficiracy “ resource allocation and
fP.
.rt^Crt^ patterns' A detailed Proposal is needed to consider funding under the NGO component
oi me project.
LeJIpp*™
?»*»“»" !■“
taw-. the S«e Health
significant project resources and are tune consuming. However, it has been agreed to continue this effort
m order to realize the potential for greater effectiveness in program del.verv. The mismatch in respect of
all X-ray technician posts has been fully addressed. 80 - 85% of the mismatch of clinicians has been
addressed m the first 26 project hosp.tals. Interv.ews for the posts of laboratory technic.ans are planned
for the month of December 1998. In addition, the following categories of posts have also been fillediTTi
?CC0Untant “d;e=hmcal posts m KHSDP. .All pharmacist posts will be filled by
March 31 1999^ Draft seriesundes for the recrmtment of bio-med.cal engineers and microbtologists will
Of rh -1Z^d
1 “y J
J116 pr°Ject ls beginning to have a wider impact on other systemic problems
ot the wider health system w!th regard to recnntment policies. For example 48 of the 115 posts of dental
9
I
surgeons and 172 of the 573 assistant surgeons that
are to be appointed by March 31, 1998 relate to till
existing vacant posts in the government hospitals
Strategic Planning Cell (SPC).
Weifare. lt is ..ie.pa.cd ta P.C rsppn
be
"=*■ °f *=
avallab|e shX
report on Microbial
--
completed and a strateg.c approach to foil impiementation is being developed User chames L presStfo
bemg collected in most areas. The TOR for th^ «,,ri„
t
,
cnarges 315 presently
b^pSt^^^
^Jen^hmarks for^mpSX
SEZS?
(0 « p,ta s^ies on a^g of
procuremeni m
™ yeas has to r=vised downwords
Rs .
X
for Pre oqu.pmom procaremeni are significantly lower than the budget allocation in the SAR
result of two main factors, a smaller than estimated need for new mvestment as a result of foe successful
one-off equipment repair program and more detailed data on existme inventories- and foe sienifjS
reductions m the unit costs of foe expensive equipment purchased through ICB procedures wfoXX
for duty exemption. It is esnmated that savings of foe order of Rs. 25 croms have beSTaXed WiX^
rrns.cn noted, the agreed tohmark is to oootp.ete ptocoreutent tts per the Z S ^Ty
3i
10.
Maintenance and Repair of Equipment The one-off equ.pment repair program has proved to
31, S TS TSO 'items ofT" '
be “ *
function at a cost of Ground Rs 2 crores AIM 6 distri^
010163
^cnonmg, some m temporary premises While ^“m^
tO
e teams m the Bangalore division is encouragmg showing that in the four month perfod to October 1998
more than 330 items valued at Rs. 68 iakhs had been repaned at a total cost of aro^?% of foe v^
Mb fiJ?1 WOrk\^e?7chmark\^eed for October 31, 1998 have been achieved and exceeded
136 finfo drawings and bid documents have been completed, works have started at 107 hospitals aS P
comPleted the 61131 drawings and bid documents for a total of
170 boon tl \\r’ h
pZS'ZSs
“
"Ort “ • “ 150
“d <7 “
35
Xh 1° X
?6
PrOgreSS aChleVed t0 date m Clvil works 3116 “sure that future works are
pounded quickly a formal written request will be made by GOK through DEA for a redistribution of
m,spen budget a! ocanon amounting to Rs. 42 crores, principally from equipment costs to civil works
S to R 47
h ° T Dr10pmmt Credlt A^mMt be “led as follows: an amount
equivalent to Rs. 42 crores be transferred Bank Management that this be allowed.
13 ,
.Management of Health Care Waste. The benchmark for October 3 1, 1998 has been achieved
field visits to tfoee pilot3 facfoTes ^dreXw^
f hospitals. The mission undertook
the overall plan and the specific strategies developed for a
i
selection of taluka hospitals. Observations on the present functioning of the initial waste management
SySne?1 Ln, ° UCC a ebe instltutlons along with recommendations arc given in Annex 1 These comment
dXXs
'”8'
™“'°" ”Md
3^s So., Asm R;,». The oscXXXXraXXBX m
TOR As note’ the Sra XX™ cX
.0 te Environmental Umr anil refeied in
hospitals. A note on the propose s^ XXXX
monthly data from 110 project hospitals ^nd feedi
hospital administrators. Bus system ^1
...
TOK for
X P'" “° 10°-|’'dd“1
f»
h
receivuis 311(1
back comments on aspects of performance to foe
containing monthly data reporting proformas and m d r 3 f Td
3 1999 A booklet
issued to all hospitals in foe proj^ tXTLT
tt’
“"u T
pniIted 31,(1
medical officers by January 31 1£
t0 311 admi"ve
at all hospitals will be in^e and DisfficXX A
UnpIem“tuand mo“tor P^onnance
1999
district Quahty Assurance Committees will be established by May 31,
15.
Surveillance , An action plan for disease surveillance has been prepared with accompanvme
«
=
£““s-
xxztxxxxr*May 3 “XX
adtninisttatore'ofSS^hos^telsT^btCTco^mpfot^^Tr^nhih6^1118^
Management trai.nm8 for hosPitaI
m tine wi* the agreed plans and will be ongoing. Addition^h^^oXs”^^6^^ fo
physiotherapy and training in medico-legal matters for clinicians.
be initiated m
17
Referral A referral mechanism is being introduced in Udupi district
18.
Yellow Card Scheme. The yellow card scheme has been introduced throughout the state
o^W'V"n°PO;“°K
camps
"
Despite thts moourastng
b“"
brai
-—- - -
" 'h'
w
of
It was noted that
™
iX
™
19.
EEC. A comprehensive action plan has been drawn up in the form of
a matrix detailing target
groups, various means ot communication and tinting of the actions. Particular attention will be paid to EEC
activities in the Udupi district to facilitate introduction of the referral system.
20.
Compliance with Covenants All covenants are in compliance.
4
ZvSFSS! S
costed proposals for this puroose and
<•
, c .. .
UUJCUt wouio need to prepare
sustainability of the projeTS stafe hS X t
T
°f
To
*«
c
j t.
uu sector
F J financing,
r51310would
nealt“besystems,
it was
agreed
thatanalySZw^hZiS
an overall anah/cic nf
finances ®d
healdi
undertaken
(sinZ
to the
*e SAR). Iliese actions would highlight the scope for any project restructuring.
3 °f
€
5
i
Annex 1
Karnataka Agreed Benchmarks
Management
Recruitment
Strategic
Planning Cell
Continue and strengthen coordination mechanisms
among SHS H, IPP VUI, ipp k, KfW and RCH
projects_____________
Address mismatch, fill all specialist posts
according to norms in 40 hospitals, including
those in Udupi district
Complete the recruitment for 115 posts of Dental
Surgeons, 573 Assistant Surgeons and 12
Graduate Pharmacists
Finalize draft Rules for recruitment of Bio
medical Engineers and-Microbiologists
Fill the two vacancies of technical officers in
Strategic Planning Cell
Initiate evaluation of the clinical component and
the overall effectiveness and quality of the training
programs_____
Finalize the study on Microbial Contamination
C
Contracting out
Nou-clinical
services
Civil Works
Surveillance
Continuous
May 31, 1999
March 31, 1999
May 31, 1999
May 31, 1999
May 31, 1999
May 31, 1999
Complete the study on Waste Management in
Hospitals
May 31, 1999
Update action taken on Health Policy Matrix
May 31, 1999
Inmate pilot study on networking of Private and
December 31, 1998
Public Health Providers through financial
intermediaries in one or two talukas
Provide draft report
May 31, 1999
Contract out non-clinical services in 20
May 31, 1999
commissioned hospitals
Complete 170 final drawings and bid documents
May 31, 1999
Commence work on 150 hospitals for which final
drawings have been cleared.
May 31, 1999
Commission 35 upgraded hospitals
May 31, 1999
Equip 12 district level laboratories
May 31, 1999
Finalize the formats for reporting systems and
initiate reporting activities
May 31, 1999
Appoint Entomologists in 12 laboratories
March 31, 1999
6
i
Training
Complete training of all medical officers and
Entomologists in district laboratories
May 31, 1999
Conduct training in hospital management for 50
administrative medical officers
May 31, 1999
Initiate medico-legal training for all doctors
May 31, 1999
Initiate training in physiotherapy
January 31, 1999
Examine short and medium term waste
management options for 100 bedded hospitals
January 31, 1999
Extend the short and medium term waste
management strategy i^40 hospitals
May 31, 1999
May 31, 1999
Equipment
Procurement
Conduct initial and refresher training in 40
hospitals where Waste Management activities have
been introduced_____
Complete the procurement activities for the
equipment as per the procurement plan 1998-99
And
Maintenance
Complete one time repair of equipment
throughout the state
January 31, 1999
HMIS
Conduct training of ariministrative medical
officers in HMIS reporting formats
January 31, 1999
Develop a computerized system for processing of
HMIS data at Project Office
January 31, 1999
Continue referral activities in Udupi district and
conduct a review of the effectiveness of the
fiinctioning of the referral mechanism
Complete all the training activities under referral
system in the Udupi district
February 28, 1999.
Medical Waste
Management
Referrah
SC/ST/ Gender
Issues
EEC
Quality
Assurance
March 31, 1999
March 31, 1999
Review implementation of yellow card scheme
and incorporate feedback into action plan
January 31, 1999
Review implementation of Women's' health check
up scheme and incorporate feedback into action
plan _________
Plan and initiate EC activities for referral services
in Udupi district
March 31, 1999
March 31, 1999
Implement and monitor performance indicators for
all hospitals
May 31, 1999
Establish district Quality Assurance Committees
May 31, 1999
7
i
Annex 2 : Observations on initial waste management schemes in taluka hospitals in Karnataka
to
T,p'” pl“ m':
S.' 1^
oxtod. Ai
fep.ols
this stage, each hospital has followed the template and has introduced their own cquiomcnt needs
Gmdance given m the 1997 and subsequent 1998 manuals has not been literally transt^sei Hie master
documents clanfy waste types and specify procedures for each type.
transposed.
Visits to three hospitals (Nelamangala, Kunigal, Magadi), and discussions with both local oroiect
hospital strategies had been earned out. Color-coded bags and bins were all in use (although no contents
sZ0 w^ e^e^rS
w^Jn the b^2
'eaChate
buri31 pitS —-i
Lh ho^ital. Service
110013 (31tfa0Ugtl fCmale P011®3 WCTC not seen to be
aPr°nS’ ^°VeS
WviULUg LUC ULMJloL
1
15
white, blue and red (increasing in hazard
classification). However, m the three hospitals visited, the following deficiencies were observed^
. few bins were Placed tfiroughout the hospital, with irregular mixes of colors; for example, in wards
where most patients had baggage and food, white bins were not always present
• wastes m blue bins were destined for further hand-separation by cleaners
. although needle crushers w«e in evidence and in use, doctors and staff had little knowledge of the fate
blUC b3g Which
Othr
POtentiallTsubsequently
either be separated by cleaners or deposited in the landfill
• no bins containing wastes were available for inspection
• no storage facilities or full bags were available for inspection
■
i ** “ "• ■ ”°
‘fcp»sai
™
f«
inspection and no knowledge was offered as to the present fate of this day’s waste
■ inenriedat
bagS (,leSpite
formation that the bags would be
“for
zs.
The conclusions from this mini audit are:
• the reasons for segregation are not fully understood by management or staff
• despite presence of pits, wastes are still following origmal/altemate disposal routes
• the use of the pits is not in accordance with the original guidance
• the hospital-specific guidance lacks clarification of pit usage
• once full, there is no clear understanding of die fate of pit material
• full pits would be difficult to empty for further use
• no plans were in place for either re-use or closure of pit
• no waste survey records were being kept
Recommendations
a broader context of awareness-building and training be provided to Karnataka project staff
basic training be strengthened at hospitals, to lead to further information on project rationale and not
just process
r J
• monitoring of waste management systems take place during each inspection tour
•
rr’ touCatlOnS’ nUniberS) ,and Pit (size’ location’
c10^, final repositories) all be
reassessed before the system continues
• initiate broad-brush surveys of bag numbers - this to lead to understanding of waste types, amounts and
locations, vital for ultimate options appraisal.
8
i
I
CUHFOIOIXJJ cur x
-
.
P^MS^T(S)KV' 3--
CREDIT NUMBER 2833 IN
»,
Development Credit Agreement
(Second Stzic Health Systems Development Project)
between
INT LA
2 mi
DiTHRNATIO.NAL DE'- t.LOP.'EE?-'I ASEOCZAnOM
Dated April 18, 1996
CREDIT NUMBER *S33 IN
eevelopme^ credit ACREEM^
-
.. ns I996.b=™«nn INDIA,
INDIA, acrinsJ
acting by to ?»"=“'
—MENT. dated April lo,
nourNT
ASSOCLAU
A!—
AGREE?‘ and INTERZONAL DEVELOPMENT
CBorrower)
(the
Association).
. .
. ^ed February 13. 1996.
-f
Karnataka,
the State otP^ao
yvTmREAS (A) the
suVofT'
'
■ the project States}, ea... s
Febman’ 15. l"6
'resoectiveiy (collectively the
and actions to
Health
and the State or We5t® 21=of objectives, policies arm
referred
to
as
the
±e
1£n=r
^f^heaith com (heminan
Development Pro■
and tint —nml
±e Pumao Health Sec.o ^,-i-ew} and declaim? me
Program, resp-.t • =•■)
C;vc;c?:nent
Sector Development
to carry out its Health -----\ye£i -e-=T
State’s ccmmicner.t
__ c:;vc project ataic
pro'Ei2-*..
i
. _ , . ;r 2S to the *.e ibiiir.’ cr.d
h-vir.c satisnea itcc.t -s
v » < fR'i tbe ucrrc^c.. • r.cs • •u:r.:d
(o’ u‘
.
to this Act-------- u
Asscciaucn to ^sl5X in
out bv ±=
s~-" ar‘a.
OUl
zzri 0I
\viil be —• '.CO
•
relevant
...
Punjab
(C;..
on witr •j-.= Scrrower'j
litb. Systems • r-'
hie to the Project htam -- - “
Punjab H ;. ±= Sorro'-ver ^'il "=y.e aval
b ±e 7'cc:
— S'-.e ofr ?
' Carporation aVouan
< ACTcemenf. -.0
nr. a,
VI
-a. an me basis, inter alia, ot '±’.S
o-.ot’.
the
■'b--'
■--erms
and
cond
’
.
’
.
mns
-.Vruor:r.cn
.u^ ~.-'-o,Aer u f even date nerc'.vrm itet-.veenm
:;t to -he Zcrr
. .4 • *" »■ '.
r* th e
th- proiect A^raernrr.
■,■
u-..niLh
Svstems
a-.
r
er/, and m 'proieet States mo e .-unmo ..—mi -.
.Up
par. ano
other part:
HOW -HEMFORS ±.= ?=
01 C
:< hemo hero
aaree m felloes:
i
General Condition; Definition5
'
S““°" '•0U^'to°d“j^O"di9^
?m °f **
and Guarantee
forth below
-•■
t
J--""
/
The last sentence of Section 3.02 is deleted.
(a)
The second sentence of Section 5.01 is modified to read:
(b)
•>vr—t as the- Bank and the Borrower shall otherwise agree, no
wilWrawals shall be made: W on aceoun. of
;..e nf in'- countr-’ which is not a memoer of the Bank or to.
tc..itcr
eer,-ices sucoiied from, such territories: or (b) for
goods prooue.oow
or ^h.ss. OT ,or
.m.cn 01
ods^su " Xo or tapok >0 ±= knowUdge of d-.e Assoelo,™.
by a decision of
Unned Nodons Secsnuy Coooe:. f^.
under Chsc.er VII of ±0 Ctamr «■ <« Lnneo Nauons.
the context otner.vise requires, the several t:
Section 1.02. Unitiss
in the Preambie to this Agreement have
. General Conditions and in
following additional terms have
n-.exnin5s therein set forth and
s de
- reraec::ve
e feiio'A-r.;
meanings’.
(0)
e^izbiished in
(b)
?r=jec: S'-
“Disc-ic: Heii'.h
' uu’c: of
. rr.eons Cis
C^mrr.in
er.zoi:
-nc " cs:
i of H
meor.s
cai
in in cn .-•
w i n caiencar year:
I -..".e
c
Heald: Carr.rr/.r.ees
th and Family '■Ve::_e er a
wer.
feor oi •
LT.d er.o
:s
ro’.ec:
so. :
r • r*
*.zc Heai’.r, S'*stem.□ Lame
< e:
•jjvem.cr ci /-rnac ter r- O'.cs.
.ed Ccta^er 20. 1995 pronw
zr.d adm.m.isterinz medical car
of’esuciishing. expanding, improving
cased on the Ordinance:
includes any subsequent legislation L_
®
“?HSC’ sX
^‘rSX'u^^Xi-orocrpber..!,^
• o';. ~.c
of
1 .........
, c Cr-ic-s" means picvcnp-c an'
community health
1
c"i=r:-
~
.
-lllh &'1“- P'D lesinihcl’™'=lS““'
and dispensaries
the Association and
among
and Punjab Health
-Project Agreement" means
e of West Bengal
be amended from time to
,uka of even dateP”herewith,
n!C V aS the some ipplcmenial <□ <1>= F™)'“
State of
Corporation
hedules and agree
Systems
includes all sc:.and such term
lime. t_.
pb collec:iveiv;
em^nt:
Agree.K^aukx - ■ Bengal and Pen,
“Project States'’ means
of them individually;
CO
“ means any one c.
successor
“Project State
ano
of Punjab. or any
the Bonosver’s State
“Punjab'’ means
A—- rsX=
th
H 1006 issued by
• ; dated Feontar. _.. _e.ns the Regulations
“Reauiations
m fcr the toPe-“\?^LemLnnei policies.
of the Ordinance
to the provisions
f the Board ot ?—1 r
service
gursuar.t
dures for cperaf.cn of
and accounting
sucn manor c as prcce
^nd procedures, aucitmg
of user charges.
c-'^Gurcmcnt policies nisrs
and imoiementntion
xecnomsms
,
2-S
imcrovements
groups see1
’^"c population
refers m
(ri
“Scheduled Cas^s
Cunctituticn of Indio:
(H
.
0
Article
e1
01
a.jed Castes'’ purcuar.ttIS
<cheduiec
population croucs sc
: to tr.e |
-■ —i qi
of the Consimcticn
of Ir»d‘«a.
“Scheduled Trices'
(m i
:ec" purtu-nt to Arf.cie
cr.eouied 7
5er-’ice5 meo-.s
-a ,,v..— i ’ evei Health
Xr-7*l rkC.-”-*
„ .divisional >
“Stconcar- or
bv commumr.'mrai.
(r.)
3TC»10-.
-a ctner ser'ico
in the ?r=;e-: S“;"'
sv.c
■) 01
’•Su’.c: hospitals
in Section -■rj
»o ^n
xcor.s the account :
ciai Acc=unt"
hC r'*'"
(o)
ished
mis A?--ic planning ceil est
the strateg
, .
"Sm-iepic
kF/
and techni^1
within DOHr >
w • • **
w
“ *"
W
dical services provided by
me
s““''
_5 the strategy
the Association,
*
dated October 17,
‘pi is’
inter alia, at increasing the demand for, and improving the qualin of
edicarand hospital services for the Scheduled Tribes in each such Project State and for
ne economically disadvantaged groups in the Sunderbans Area of West Bengal; and
“West Bengal” means the Borrower's Slate of West Bengal, or any
successor thereto.
(S)
article n
The Credit
<e-'ion 2.01. The Association agrees to lend to the Borrower, on the terms ano
.. .
f ” h nr referred to in the Develooment Credit Agreement, an amount in
to two hundred thiny ftve million five hundred tod
Special Drawing Rights (SDR 235,500,000).
on 02 (a) Tne amount of the Credit may be withdrawn from the Credit
Sec::
accordance with the provisions of Schedule 1 to this Agreement^ tor
:ount in
made (or. if the Association shall so agree, to be made) m respect ot me
exzencircres
Enable co^f goods and services retired for the Project and to be finances out ot
(nc prcccccs oi the Crcoit.
(b;
Tr.t Borrower may, for the purposes of the Project, open
H ^i>^ a special deposit account in the Reserve Bank of India on term;> and c nd>
the Association. Deposits into, and payments out ot. the Sgec.ai Ac.ou..t
:• 3'l'Tm-de in accordance with the previsions or Schecuie 3 to this Agreem=..t.
i A tel • •
ww
•4Iw
March 31,2002 cr such later date as the
Sec: ;cn 2.03. Tne Closing Dale snail b ” zrcrr.ctly notin' the Borrower oi sue..
snail establish. Tne Asscciaticn snail p
•aticn
later ",*e.
The Borrower ci! ppay to the Association a ccmmmr.ent
Section L.0*1" ithdrawn from time to time at a .at. .c
tet wi.
harze on the principal amount of the Cree
r. but not to exceed the rate or cnee set by the Association as of
c. June 20 of each ye
half of one percent (1/2 of 1%) per annum.
1
(b)
TO. eommtaen,
shall 3c=^: (i) ftom
da.e si^■*£
•
- U- Am-n^ment fthe accrual date) to the respective dates on which am
T nt" ° ’ C5 OTbX Bomwer from ihc Credit Account or cancctedt and (ii) at the
“
^immediately precede the aeemal date and a. auch^er
“ X 30
Zn be applied from the next date in that year spewed m
Section 2.06 of this Agreement.
!
-5t
Tne commitment charge shall be paid: (i) at such places as te
shall reasonablv request; (ii) without restrictions of any kind impose- y or
Association
?/^e 'temtom of. the Borrower: and (iii) in the currency specified m this Agreement or
rhe purposes of Section 4.02 of the General Conditions or in such other engible carre.
or currencies as may from time to time be designated or selected pursuant o
provisions of that Section.
%-ion 05 The Borrower shall pay to the Association a sewice charge at the
nte of three-fourths of one per cent (3/4 of 1%) per annum on the princ.pal amount of
the Credit withdrawn and outstanding from time to time.
shall be payable
Section 2.06. Commitment charges and service charges
semiannually on March 15 and September 15 in each year.
c^'icn 2.07..(a) Subiect to paragraphs lb'l and (cl below, the Boirower shall
tbTormcmai amount of the Credit in semi-annuai installments payable ori eac..
March 1' and Seotember 15 commencing Septemoer la. -006 ana enoin^ = - -•
-0-. f E-h installment to and including the installment payable on Maron 1;._- 0 Sull,
Aone ord one-founh percent (1-1M%) of such principal amount, ano eacn ins_
thereafter shall be two and one-half percent (2-1/2%) of such principal amount.
Whenever (i) the Borrowers gross national product per capitx ^as
in-a bv the Association, snail" *have exce:eded S790 in consur.t 1985 dollars icr
cet
-----(jj*) the Bank snail consider the Borrower creoirwo.my for
five consecutive years :
. .
□ ar.k 'mdina. the Association may. subsequent to the review and approval thereat oy e
ending, uhe
by them of the
^ecuir'e
of the Association ar.d after duo consicerntion
:;ve Directors
Dire
~-A---men.t
of the Borrower s economy, medify tnd tem-.s or reoasm ent of installments
—meat of
ne mount cf eacn
7r/J--2r=oh (a) above by requiring the Borrower to repay r.vice t
zoroaro
ih snail have been
iuch imtaiiment not vet due until the princioai amount ot the Creo
■“h mcdiiicction to
;d if c0 reauested by the Borrower, ’-he Association may revise sucn
h instailments. the
:n iieu of some or ail of the increase in tne amounts or sucn ....
pai amount
^aVment of interest at an annual rate agreed with the Association on me pnne.
revided that, in ±e
of'the Credit withdrawn and outstanding from lime to time, p
judgment' of the Association, such
"rh revision snail not change the gr^r.t element obtained
(b)
under the above-mentioned re avment modification.
,
Cel
If at any time after a modification of terms pursuant to paragraph (b)
L, Association determines that the Borrower's economic condition has
modify the terms of repayment to conform to the schedule of installments
paragraph (a) above.
H
!
-6-
Section 2.08. The currency of the United States of America is hereby specified
/
for the purposes of Section 4.02 of die Genera! Conditions.
ARTICLE ELI
Execution of the Project
^prtion 3 01. (o') The Borrower declares its commitment to the objectives of the
qpt forth in Schedule 2 to this Aareement, and, to this end, without any
Pr0)eC • “
e
of ta other o'bliMIio„S under rhe Developmenr Credrt
( Tull ” °" X(project Surer and PHSC ro penom, In oecordance with rhe
^^^ons of the Project Agreement all the respective obligations of the Project tates
Pr°;Xi L e'n se( oA shall rake and cause .0 be taken all action, rnclucrnu the
of tads f eilirius. sendees and ocher resources, necessary or oppropnate ro
prIhl<>"the Proiect States and PHSC ro perform such obliaarions. and shall not
e or
ith
such
pencrmuncs.
"ermrt to be taken any action which would prevent or interfere with sucn penoman ..
The Borrower snail make -je proceeds oi the Credit available ro rhe
(bl
accordance with the Bonowers snndara nhandeme^
Proiec: States
□eveiocmental assistance to the Sm.es of India and. in •he cose o,Jun;a=.
that such proceeds are transferred as pan or Ptaao s prent conmoutro
accordance with the provisions of the Ordinance.
/
---------01
Section 3 02. Except as the Association snail other.vise agree, procurement
iec: and to be financed out
fne •acco’s. works and consultants' services repaired for the Prcjec
Credit shall be governed by die provisions oi Sche--.- 1
of the proceeds of the (--------Project Agreement.
that the
Section 3.0j. the BoitO’'*c. and the Association hereby^ acres General
e'eiigotions set fonh in Sections 9.0--. Q 2- Q C5. °.O6. 9.0T md 9.03 oi :es. records
Conditions (relating to insurance, use o ccds ar.d ser/iccs. piar.s and £v..c
ctiveiy) in resp^- : or the Project
n
and resorts, maintenance and land act
ition 2.03 of the
snail be carried out by the Project States and PHSC pursuant to Sc
Section 3.04. The Borrower shall participate in the carrying out of the nud^.2rm
review of the Project referred to in paragraph 12 of Schedule 2 to the Project
t ■
gre..
!
-7-
article IV
Financial Covenants
(a) For all expenditures wnh respect to v-hich
Borrower
Section 4.01.
were made on the basis of statements of expenditu ,
Credit Account
shall:
maintain or cause to be maintained in accordance: with sound
reflecting such
accounting practices, records and accoun
expenditures;
co
; orders, invoices, bills, receipts
ensure that all records (contracts
Si evidencing such enpendtaes are
and other
until at least one year arter
^^'St ^ididtavval fto|n
audit report for the nscai year in svhicn tn. i-s
the Credit Account was made: and
C>0
(iii)
(b)
enable the Association's
records.
representatives io examine sucn
The Borrower shall:
have the records and accounts reterted
'(0
F^t' t,f r,5C.|
^^3“^^opri=,ea^^s
consistently applied, by independent auoitcrs
- -
Association:
(ii’l
(HO
any case
furnish to the As-cciztion as scon as
: veer the
not later than nine months alter the ena o r-.cn
• ** •* ;d in such
reoort of such audit by said auditors, ci sue.
reasonably recuested.
d»'ail as the Association snail have
uk, n."
^dins 3 Sc==«, opinion
ion by
bv said
said sed.wrs
auditors as .0
suiemsnis ot e.-.nenoicurs submined
suemme- during
n . sucn ninvolved in
and
internal
togoiher wish *= procedures and men, I controls
„,J1K
their preparation, can be relied upon
withdrawals; and
concerning
furnish to the Association
as ,e
said records and accounts a...
reasonably request.
Association shall from time to time
F
-8-
•1^
ARTICLE V
Remedies of the /Association
Section 5.01. Pursuant to Section 6.02 (h) of the General Conditions, the
following additional events are specified:
(a)
Any Project Slate or PHSC shall have failed to perform any or its
(b)
As a result of events which have occurred after the date or the
Development Credit Agreement, an extraordinary situation shall have arisen whicn hall
make it improbable that any Project State or PHSC will be able to perform its obiig ions
under the Project Agreement.
The Ordinance shall have lapsed, or the Ordinance or the Reau:
(c)
shall have been amended, suspended, abrogated, repealed or waived so as :c
materially and adversely tne ability of PHSC to perform any of its obligations uno
ns
'_ne
Project Agreement.
The Borrower. Punjab or any other authority having jurisdiction snail
(d)
have taken any action for the dissolution or disestablishment of PHSC or :or the
suspension oi its operations.
An event snail have occurred which shail make it improbable m
•'
Sector Develccment Program or the Punjab Health : ctor
Development Program or the West Senaai Health
Sector Development Procra.. :r a
aith Set
’.cd out.
significant pan of any such Program will be carried
(e'j
Sect: on 5.02. Pursuant to Section 7.91 (d) of the General Cone
foilowing ac ait:onai events are spec: fed:
tne
the event specified in paragraph (a) of Section 5.01 ol
of this Agreement
Au
(a)
shall occur and shall continue for a period of sixty days after notice thereof snan nave
been eiven by the Association to the Borrower, and
(b)
the events specified in paragraphs (c) and (d) of Section 5.01 of this
Agreement shall occur.
r.«. ..
•v’
f
-9article VI
Effective Date; Termination
Section 6.01. The following is specified as an additional mar.er, within the
meanin- of Section 12.02 (b) of the General Conditions, to be included in the opinion or
oomions to be furnished to the Association, namely, that the Project Agreement has been
duly authorized or ratified by the Project States and PHSC respectively, and is legally
binding upon each of them in accordance with its terms.
Section 6.02. The date ninety- (90) days after the date of this Agreement is
hereby specified for the purposes of Section 12.04 of the General Conditions.
Section 6.03. The provisions of Section 5.02 of this Agreement shall cease ana
d—rmine on the date on which the Development Credit Agreement snail terminate or on
the'date rwenrv veers after the date of this Agreement, whichever snail be me earner.
ARTICLE \TI
Representatives of the Borrower; Addresses
Section 7.01. Tne Secretary, Additional Sec ■etar.', Joint Secretary, Director,
tent of Economic Affairs in tr.e
Deputy Secretary or• Under Secretary of the Deparr
eoretentative of the Borrower for
Ministry of Finance of
< the Borrower is desicr.ated as :
the purposes of Secr.ion 11.03 of the General Conditions.
Section 7.02. ine loilowin^ addresses are see
11.01 of the General Conditions:
• for the pur
For the Borrower:
The Secretary to the Government ct India
Department of Economic Affairs
Ministry of Finance
New Delhi. India
Cable address:
ECOFAIRS
blew Delhi
Telex:
953-3166175
ses of S
n
I
- 10 -
For the Association: ■
International Development Association
1818 H Street, NAV.
Washington, D.C. 20433
United States of America
Cable address:
FNDEVAS
Washiniion, D.C.
Telex:
1976S3 (TRT),
248423 (RCA),
64145 (\VUI) or S29S7(FTCC)
IN AVTINESS WHEREOF, the parties hereto. acting through their duly
authorized representatives, have caused this Agreement to be signed in their respective
imes in the District of Columbia. United States of America, as of the day and year first
;ove written.
INDIA
By/s/N. Valluri
A-
rized Representative
DiTHFDiATiONAL DE'.’ELGP.ME?-', ASSCCIATICS
By /s/; Heinz Verzin
Ac
5
Regional Vice President
South Asia
I
-11 -
SCHEDULE 1
Withdrawal of the Proceeds of the Credit
The table below sets forth tire Categories of items to be financed out of the
1.
procee ds of the Credit, the allocation of the amounts of the Credit to each Category and
the percentase of expenditures for items so to be financed in each Category:
Amount of the
Credit Allocated
(Expressed in
SDR Equivalent)
(1)
21.100.000
23.100 JOO
35.900.000
100% of foreign
expenditures.
100% cf local
cxnendirures i exfaciory cost) ar.a
80% of ;ccoi
expenditures far
other items pro
cured iocally
Equipment, vehicles,
furniture, medicines,
supplies and materials
(a) Kamatzka
(b) Punjab L PHSC
(c) West Eenzai
u)
85=0
Civil works
(a) Karnataka
(b) Punjab & PHSC
(c) West Benzal
(2)
% of
Expenditures
tn be FA.a need
29.300.000
21.000.000
-2.920.000
100%
Consultants’
services, fellowships,
studies and training
(a) Karnataka
(b) Punjab & PHSC
(c) West Bengal
5,900.000
4,300,000
6,100,000
90% until Dtcsmber
31, 1998, 75% until
December 31, 2000
and 40% thereafter
(4)
and incremental
operations and
maintenance costs
i
- 12 -
Amount of the
Credit Allocated
(Expressed in
Caugon'
(5)
SDR Equivalent)
(a) Karnataka
(b) Punjab &. PHSC
(c) West Bengal
12,100,000
' 6,700,000
7,400,000
Unallocated
13,700,000
% of
Expenditures
(0 l?e Financeii
SLR. vt> V\\\\\C’A
\
(*■)
—
21 -10
2
5-30
235.500.000
TOTAL
For the purposes of this Scnecule.
the term "forcion expenditures'’ means expenditures in the currency ot
any country other than that of the Borrower fcr goods or ser/ices supplied from tne
territory off any country other than that ot the Borrower:
i
(al
the term "local expenditures" means expenditures in the currency or the
(b)
Ecrrower or for goods or scr/iczs supplied from the territory of the Borrower.
(c)
the term “incremental salaries” means salaries in res: ec: of post: creates
Project on or after May 1. 1995. including in resnee: of contra :rjal services: and
’.e
(d)
the term “incremental opera ::ons and maintenance costs means cos^
incurred under the Project on or arcr .day I. 19?5 for the operations and maintenan^- oi
vehicles. equipment furniture, buiidmgs and or::ces.
3.
yior.vithstanding the provisions; of paroorao’n 1 above, no withdrawals shall ^e
made in respect ot payment.> made fcr expenditures prior to the date of tWs Agreement
except that wttrarawa^. in an aggregate amount not exceeding the equivalent oi
that withdrawals
SDR 6,300,000, may be made on account of payments made for expenditures betore that
date but on or after May 1, 1995.
The Association may require withdrawals from the Credit Account to be made
on the basis of statements of expenditure for expenditures for:
4.
(a)
goods and works under contracts not exceeding the equivalent of
(a)
$200,000 and 5300,000 respectively, under such terms and conditions as the Association
shall specify by notice to the Borrower,
-•j. r*.
y
y •
•' •
!
- 13 /
(b)
services under contracts not exceeding S100.000 equivalent for
employment of consulting firms and S50,000 equivalent for employment of individual
consultants; and
(c)
incremental salaries, and incremental operations and maintenance costs.
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- 14 -
SCHEDULE 2
Description of the Project
me objectives of the Project are: (i) to improve efficiency in the allocation and
use or health resources in the Project States through pol'icv and inst.tutionai
development; and (n) to improve the performance of the health care svstem in the
Project Simes through improvements in the quality, effectiveness and covemoe of health
services at the first referral level and selective coverage at the primary level so as to
improve the health status of the people, especially the poor, bv reducins morality,
morbidity and disability.
1 he Project consists of the following pans, subject to such modifications thereof
as the Borrower and the Association may agree upon ircm time to time to achieve such
bjectives:
1: \tr?.c?mer! Devein men! 2nd I
ren!ruer»n^
r.
LT.zrcving the instimticnai framework
fcr poiicv deveicomem threu'’" me
-wkwci 1 sthrr.e
’i.,,w.>» ci 3 Ctiutcgtc Planning Ceti to review end evaluate critical ic3uer ti t*',‘
C
health sector,
including private health core and insurance, burden of disease and casteffectiveness of public health interventions, medical manpower, cost recover/
mechanisms and sectoral resource allocation patterns.
c
mening management and imp:::e.T.er.-ji::on co aciry through: (1) provision
(i)
::i:ies in Karnataka and Wes: B
! i i’) rer. vaticn and expansion
:f PHSC and EC Hr ’■V in Puni:
rcvisicn of additionzi staff
EC
ci ECHF
’.V in Kam ata?, a zr.c A est Bengal: (iv i recnentm
1 itrjcrjr 0 of EC HEW in :<a
ano .Vest Bengal and the PH
:
1
2
r.nxncrr.'^ and extending the com u irtzed system cf data collect::
uon me prevision of harewar
;::;:zn::cn mrougn
■ m.vare.
consultancy suppe:
estaciishi.-.p tremed and equipped informal cn
'viii training management s’
appropriate record keeping; (viii'j introducing a rc’/iscd medical record keeping : stem
for in-patients and diagnostic services: and (ix) p:revision of support to PHSC for
promotion cf health care activities in Punjab through
—-.1 private and vofun
organizations.
01
c
n
m /-»
•
3.
Developing surveillance capacity for major communicable diseases to cover the
identtfication of cases through, inter alia, laboratory support, education of health workers
and commumty involvement, and indexing of cases or isolation of cases and treatment
- 15 -
p?rT g: inicrQvin?
Oualir^,
and Effc^uv^?,
at (Ik* First Referral
1
I.
Renovation and extension of hospitals providing Secondary or First Referral
Level Health Services and construction of staff quarters.
2.
Strengthening and improving the effectiveness of clinical and support sen-ices at
hospitals providing Secondary or First Referral Level Health Ser.'ices through, inter alia,
m establishment and application of streamlined norms and standards for technical
services, staffing, quality assurance, contracting out sendees, and monitoring
improvements in the quality of clinical care: and (ii) provision of training to strengthen
staff skills in clinical and technical areas, to improve the quality of management sen-ices
and enhance the capacity for equipment maintenance: and (iii) provision of training to
enhance management and supervision capabilities of DOHFW in Karnataka and West
Senaai
a
and PHSC in Punjab in respect of essential operational activities, including
construction and maintenance activities.
Improving the referral mechanism and strengthening linkages with the Primary
Level eaith Services and the Tertiary Level Health Services through, inter aiia. m the
hnical suppen to improve the
core at the
provision of technical
me quaiity
quality of
or care
: Primary Level Heaim
Ser.'ices and the Secondary cr First Reterrai Level Heaim Ser.'i :s; (ii) establishing and
implementing
ring referral and clinical management prctocois: (iii’) formulating and
implementin'!
rina mechanisms to provide greater access to Sec ondary Level Health Services
and Tertiary Level Health Services in a timely and effective manne r; and (iv’i
establishing and implementing an incentive system with differentiated fees fcr asers and
rrai mecnamsm.
non-users ci the
-d':
r» •
\-
rrm
icn of
oi zpr.mar/ r.ean.
:cr: providing
j
Rene vat: c n ana ex:cne;cn
ms Area ?! '.’.’es : 2en
d ear.icbiishmen: on:
• er.'ices :r. tnc Sunaeroans
• Y |» »• r» r • a
:n rhe: riverine areas
ci ::c2i:r.2 ...e-. n units :a deliver effective m
ecuibiisr.mer.t ar. oueraticn of a '.vireiess comm leaner, ivstem.
2.
Increasing access to primary health care ser/ices among Scheduled Caste arm
Scheduled Tribe population in Karnataka through, inter aiia. introduction of a system or
annual health check-ups, establishment of health check-up camps, dissemination ci
general information related to implementing the referral mechanisms referred to m
Part B (3) hereof and maintaining records of health check-ups.
The project is ex peered to be completed by September 30, 2001.
f
- 16 -
SCHEDULE 3
Special Account
1.
For the purposes of this Schedule:
(a)
the term "eligible Categories" means Categories (1), (2), (3) and (4) set
form in the table in paragraph 1 of Schedule 1 to this Agreement:
the term "eligible expenditures" means expenditures in respect of the
reasonable cost of goods and ser/iccs required for the Project and to be financed out of
the proceeds of the Credit allocated from time to time to the eligible Categories in
accordance with the provisions of Schedule 1 to this Agreement: and
(c‘:
the term "Authorized Allocation" means on amount equivalent ■0
SI".000.000 to be w,;hd:rawn from the Credit A coo unt and epositod into the Spe:
Accour.: pursuant to para graph 3 (a ) of this Schedule . previc . however, that unless
Aiscc:at:cn shall cmer.vise agree, the Autnorized Allcca: n snail be limited to an
•mount equivalent to 53.500.000 until the eggrego: : amour. : of ’a i th drawn is from the
Crecit Account plus me total amount of ail outstar ding spe o:ai commitments entered
into by the Association pursuant to Section 5.02 ,cf ch e Genera i Conditions snail be eouai
to or exceed the equivalent of SDR. 29.000.000. .
(o')
£
Payments cut cf the Sp
cures :n accordance with
:ai Account shoi’. be
orov;::cns of s acne
o
payment rm dir.
n an amount equal to or
mace exciusr. ■eiy cut of the Special Ac
r.c e :o the Borrower, revise the thr:
• 0!
exclusively
ier r or crccit) tor an
f 55.cC0.0C0
ivai
. r.2
cay trem :::
in the crcc
tou.nt me
ur
sen
3.
After the .Association has received evidence satisfactory
to it that the Special
satis
Account has been duly, opened, withdrawals of the Authorized Allocation ’and
subsequent withdrawais to replenish the Scectal Account shall be made as follows:
(a)
For withdrawals of the Authorized Allocation, the Borrower shall
furnish to the Association a request or requests for deposit into the Special Account of an
amount or amounts which do not exceed the aggregate amount of the Autnorized
Allocation. On the basis of such request or requests, the Association shall, on behalf of
the Borrower, withdraw from the Credit Account and deposit into the Special Account
such amount or amounts as the Borrower shall have requested.
t
/'
■
- 17(b)
(D
For ireplenishment of the Special Account, the Borrower shall .
furnish to the Association
i requests for deposits into the Special /
Account at such intervals as the Association shall specify-.
/
(ii)
Prior to or at the time of each
such request, the Borrower shall
furnish to die Association the documents and other evidence
required pursuant to paragraph 4 of this Schedule for the
payment or payments in
respedt of which replenishment is
requested. On the basis <or each such request, the Association
shall, on behalf of the Borrower
r. withdraw from the Credit
Account and deposit into u.e Special Account such amount as
the Borrower shall have reoiuested and as shall have been shown
by said documents and other
-• tevidence to have been paid cut of
the Special Account tor ehaibleJ expenditures.
/
1 such deposits snail be withdrawn by the Association .•-rem the C
edit Accc: : unccr
i rcsoective eimmie Coteocnec. and in the rccoeotive eouivaient arr
cunts, as s ii have
jusuheo oy saio occuments ana omer evidence.
==™v„s™l.
HULhI iS
B the
.-issoc.ation
cocuments and
mowin'* 'h-ir
cmc- -n
„ • ■ . -sucn.......
.. other evidence -i.wwing
mat sucn
oa\ment was mace
^c:us;veiy tor eugioie expenditures.
’ '
Notwithstanding the c visions of;
ii net be requires to make f mer dcoosi
•a)
it. at an;, ii :e.
•V’ccrawajs should be mace bv
acccra
w im tb.e provisions of
of S :cn 2.02 or mis Agreement:
:r.:c
h 3 of
:e Spec
r»
£‘C
Asscc: itmn snail ha\e aeicrm
e Ecrr 3’^r dyecdy from ^:he
3‘ ’‘•e ’'-■-"-rai Conditions and p
1ai
(b)
if the Borrower snail have failed :tO fumisn to the Association, within the
period of time specified in Section A01 (b) (ii) of thii
—J Agreement any of the audit
reports required to be furnished to the Association purs«_
pursuant to said Section in respect of
the audit of the records and accounts for the Special Accou
*------ mt;
z
;n[„r; (C?
if’ ^any?’7’ lhe Association sha11 have notified the Borrower of its
intention to suspend m whole or in parr the right of the Borrower to make withdrawals
from the Cred.t Account pursuant to the provisions of Section 6.02 of the Genera!
Conditions; or
I
- 18 -
,ht ,„ul
a™™. Of U,= Cradi, allocud .0 *=
once
minus the total amount of all outstanding spe-ia
Categories for the Project, ■ •' Association pursuant to Section 5.02 of the General.
commitments entered into by the
Project, shall equal die equivalent of twice the amount ot
Conditions with respect to the 1
±e Authorized Allocation.
(d)
. , .
| frnm n.e Credit Account of the remaining unwithdrawn amount
Tnereafter. wnhorawal from die Credit
. t shall fol|ow sucn
„• to Credit alloceied fo d-x eb »de
to
procedures as rhe”. afcr !j,d' ,0 to extent that the Association shall have
withdrawals shall be ma rcmainimz on deposit in the Special. Account as ot
^aed in rnxhto parents to eltob.e expendtoto.
chnll have de'enmined at anv time that am payrnc
,
(a
If the Assomat^shaOa.« eii?1bie
(a)>
outofihe_Spec:aiAc:oun4)
Scbeduie.. or (ii) was not justified by tb.e evidence
pursuant to ^XTs^er shall, promptly upon nonce from the
furmsnec to.7^, ;ddidon2l evidence as the Association may rem: :st: or iB'i
nd to the
Association. .
(cr. if the Association snail so request
deocsit into me
cf
cr th- por.ion . •.ereof net
er deposit
As£0^1Cn) an-me • j
Asscc;2t1on snail otnerv.se amee. no 7
so enmcie or
J.
b= made unul ±= Borrower has
may bs
SXffi
If the Association snail have determined at any time
--i Account will nct.be required to cover partner 7^'^^
nding in the Spec•.he Borrower snail, promptly upon notice trem .he .
c
•e exo eno re
on such outstandinz amount.
o to he Ass
e to the Association. -• C X
The
3orrc'Aer
r.ay._
uron
ic:
yjit in me Stteciai Account.
Ai:cc:at:cn ail :r any porv.on of'.l'.e !-:x: on
. u aJ, (bi and
de pursuant to para crap ns Refunds to the Association ~...
: withdrawal or
i*d)
d:t Account for subsequent “
iuie snail be credited to me
^enu inciudinz
(c.; of this Sche
with the relevant zrovisicns oi this Acree...fcr cancellation in accordance
the General Conditions.
I
(b‘)
i
!
5
Annexure II
INDIA
S TA IE HI ALTH SYSTEMS DEVELOPMENT PROJECT II
AGREED MINUTES OE NEGO TIA I JONS
«
1.
Negotiations P'r a proposed Credit of SDR 235.5 million (the Credit) for a Shite Health
Systems Development Project II (the Project)
’ bdd between the representatives of India (lb''
Borrower), the States of Karnataka. Puniab and West Bengal (the Project States), the Punjab
Health Systems Corporation (PHSC) (the h.
Pelt nation) and the International Development
Association (IDA) (the IDA Delegation) at World Bank Headquarters in Washington D C . from
January' 29 to Ecbmarv 2. 1996 The representatives of the Indian Delegation and the IDA
Delegation agreed on th? diaft Project Agreement and the draft Development Credit .Amccment
(DCA), versions dated February 2, 1996.
Actions Taken I ’ r ior t o \’cnot mt ions
2.
As a condition of Negotiations, the follow h»<» actions have been taken:
(i) a diafl letter of I leaith Sector Development Program has been furnished by each state:
(ii) relevant state Government clearances. as well as clearance from the Plannmp;
Commissi on. GOT were obtained;
(iii) Strategic Planning Cells have been set up within the DOHFW in Karnataka. Punjab
and West Bengal.
(iv) a mechanism for ensuring that the existing levels of user charges arc implemented
more rigorouslv has been approved, an agreed mechanism for exempting the poor from
user fees is in place, and District Health Committees in Karnataka and West Bengal have
been approved; established:
(v) an Ordinance has been passed by the Government of Punjab, establishing the I’HSC:
(vi) regulations relating to Board procedures, personnel policies, audits and accounts, and
user charges have been drafted and pro\ id. d by PHSC to IDA for review’;
(vii) in Karnataka, the Project Governing Board, Steering Committee and Engineering
Wing have been established, and key staff have been approved or hired:
(viii) in Punjab, key staff, including the Managing Diicctor of the PHSC. have been
appointed;
(ix) in West Bengal, key staff, including Project Director, have been hired; and
(x) in Karnataka and West Bengal. Government Orders have been issued, providing
authority to DOHI W to manage essential operational activities including civil works
construction and maintenance activities.
A
Agreed Minutes of Negotiations
2
February 2. 1996
Agreements and Understandings Reached
The following elaborates the agreements reached relating to the legal documents and other
3.
understandings.
DEVELOPMENT CREDIT AGREEMENT
4.
Article IL Section 2 0 L Credit Amount. It was agreed to increase the credit amount from
USS342.2 million equivalent to US$350.0 million equivalent. The agreed amount would be equal
to SDR 235.5 million. The additional amount of US$7.8 million equivalent would finance
medicines, and Management Information Systems (MIS) supplies and Information. Education and
Communications (IEC) materials in West Bengal (US$2.8 million equivalent) and Punjab (US$ 5.0
million equivalent).
Article II. Section 2.02: Closing Date. It was agreed that the Closing Date would be
5.
brought forward from June 30, 2002 to March 31, 2002.
6.
Article III., Section 3 01 (b) Flow' of Funds from GOI. GOI confirmed that, throughout
the life of the project, it would follow the standaid procedure for releasing about three months
anticipated project expenditures in advance to the Project States to cover expenditures under the
project, subject to periodic adjustment of the advances. Upon receipt, the Project States shall
release such funds together with their own quarterly allocations to agencies responsible for
carry ing out the project, to be used exclusively for expenditures eligible under the project. In
Punjab, upon receipt, such funds will be promptly transferred to PHSC as required for timely
project implementation.
7.
Article V, Section 5.01 (c): Remedies of the Association. After discussion it was agreed to
keep this remedy related to the Health Seri r Development Program. The Indian Delegation noted
that the Letter of Health Sector Development Program describes a program of policies and actions
and felt that the content of the Letter was not tantamount to a mutually agreed obligation on the
part of the Borrower. It was further stated that the commitment by the Project States to the Letter
of Health Sector Development Program should not therefore be a monitorable activity on which
remedies could be invoked. The IDA Delegation responded that the project was an investment
operation with substantial policy content, and this provision formed the basis for remedial action in
case an event occurs that makes it improbable that the Health Sector Development Program for
each Project State or a significant part thereof will be carried out. The IDA Delegation further
explained that the commitment of the Project States to carrying out such a program is an important
part of IDA support for the project. It was, therefore, deemed necessary to retain this covenant.
8.
Schedule 1: Withdrawal of the Proceeds of the Credit. The Indian Delegation highlighted
the fact that health is a state subject, and this project covers three states. As such, it is important
that any state be aware of how it has been perfonning.. In ease the share of projected IDA
allocations to any particular state has to be changed, it should be done through a transparent
process where each state knows what is happening to its share. Flexibility cannot be at tllC expense
of transparency. Ihis necessitates that inf mint ion regarding project implementation and
disbursement is available for each implementing state. Hence the information in Schedule 1 should
be disaggregated by Project States The IDA Delegation pointed out that this would provide a
piecemeal solution to monitoring disbursements bv GO1 and Aould reduce flexibility with regard to
categories of disbursements across states. Nonetheless, at the insistence of the Indian Delegation.
Agreed Minutes of Negotiations
3
February 2. 1QQ6
‘it was ai’iccd that Schedule I would be disaggregated b\ Project States. Il was noted dial tins
format of showing Schedule 1 by Project State would not set a precedent for other projects in the
future
i
9.
Schedule 1 Recurrent ( osf Financing 'Flic recurrent cost financing issue was discussed
in detail It was agreed not to increase the level of recurrent cost financing as well as to retain the
40% I. el of iccuiienl cost fm.incing by the Association lor the final \cai of the pioiecl I he cut
off dates for the declining levels of financing were changed from the end of the fiscal vear to the
end of the calendar \ ear.
Schedule 2: Description of the Project.
10.
Part A: Management Development and Institutional Strengthening. Under this component,
a provision has been included to support the PHSC in die promotion of health care activities in
Punjab through prix ate and voluntan’ organizations. A corresponding reference has been made in
Schedule 2: Implementation Program of the Project Agreement.
II.
Schedule 3 Special .Account. It was agreed to increase the Special Account from USS 15
million to USS 17 million equivalent.
PROJECT AGREE.MEN I
12.
Article HE Section 3.01 (b) (i): Financial Covenants. It was agreed that die Comptroller
and Auditor General of India would be the independent auditor of the project records and accounts
of the Governments of Karnataka. Punjab and West Bengal for the purposes of Section 4.01 of the
Development Credit Agreement and Section 3.01 of the Project Agreement. In addition, in Punjab,
an independent commercial auditor would audit the accounts of the Punjab Health Systems
Corporation. It was agreed that the Project States would make available to the auditors the SAR,
Project Agreement and the Development Credit Agreement. The relevant information would be
provided by the Project Management in each state to the auditors.
Schedule 1: Procurement and Consultant Services.
13.
Section 1. Part C. paras. 2 & 3: Other Procurement Procedures. IDA reviewed
procurement documents and agreed that at this time no further requirements on procurement
aspects prior to Board presentation are anticipated. It was recalled, as in all previous projects of
the last few years, that for ail contracts to be financed from the Credit under NCB procedures:
(a) no special preference will be accorded to domestic bidders when competing with
foreign bidders, or given to state owned enterprises, small scale enterprises, or enterprises
from any given state;
(b) except with the prior concurrence of the Association, there will be no negotiation of
price with bidders, even with the lowest evaluated bidder;
(c) except with the prior approval of the Association prior to bidding, the system of
rejecting bids outside a predetermined margin or “bracket” of prices will not be used; and
(d) rate contracts entered into by the Borrower's Directorate General of Supplies and
Agreed Minutes of Negotiations
4
February 2, loo6
Disposal (DGS&D) will not be acceptable as a substitute for NCB procedures. Such
contracts will be acceptable for any procurement under local shopping procedures. For
international shopping procedures, quotations should also be invited from one or more
foreign suppliers for comparisons with DGS&D rate contracts.
4
14.
Section 1, Part C; para 2 Other Procurement Procedures. It was agreed that, for "Other
Categories of Procurement”, the allotted amounts would be pro-rated between the Project States on
the basis of the respective sizes of the Credit amounts.
Schedule 2: Implementation Program.
15.
Para. 1 (a): The covenant on maintaining the share of the health sector allocation to the
overall budget was moved to the Letter of Health Sector Development Program, with some minor
modifications relevant to each state as suggested by the Indian Delegation
16.
Para. 1 (c): Details regarding norms acceptable to the Association for essential drugs and
supplies, and maintenance of equipment and buildings at first referral level hospitals are provided
in Attachments 1 and 2.
17.
Para. 2: The Association confirms that the terms of reference of the Strategic Planning
Cell, provided in the Letter of Health Sector Development Program, are acceptable.
18.
Para. 3: The parties agreed that user charges shall be levied in accordance with the
program and timetable referred to in Attachment 3.
19.
Paras. 4 and 5 (iii): Details on agreed service deliver}' norms at first referral hospitals arc
provided in Attachment 4.
20.
Para. 5 (i) and (ii): Details regarding an agreed schedule of appointment of key
headquarters personnel and other key personnel arc provided in Attachment 5.
21.
Para. 9 (a) (i): It was agreed that the performance indicators provided in Attachment 7 aic
acceptable.
22.
Para. 9 (c): The Association confirmed that the interim work plan provided in Attachment
6 is acceptable.
23.
Para. 13: Supervision and Mid-Term Review, As in other social sector projects, during
supervision, the implementation arrangements would be reviewed to ensure greater effectiveness in
achieving project objectives. To help reduce the risk to financial sustainability in each state, the
scope of an ongoing mechanism for monitoring the financial sustainability through a
comprehensive mid-term review to evaluate ownll state finances, as well as the financial situation
of the health sector, was discussed. It was agreed that at the time of the mid-term review,
additional measures to achieve fmancial sustainability of the project, if necessary', would he
discussed.
24.
Para. 11 Tribal and Backward Areas Development Strategy (Strategy). The agreed
Strategy for sen ice delivery in tribal and backward areas is provided in Attachment 9.
I
Agreed Minutes of Negotiations
a
5
February 2, 1996
25€
Disclosure of Information. The Government Delegation stated that the pre ect Staff
Appraisal Report, incoiporating the comments discussed during negotiations, does ret contain
confidential information which would restrict its release to the public, in accordance with the
Bank s current policy on Information Disclosure.
26.
Ekrthcr_Proccssing. The Punjab Health Systems Corporation has issued rcgu’a::ons with
regard to Board procedures, personnel policies, audits and accounts and sen-ice improvements
We have reviewed these notifications submitted to us and found them satifactorv. We arc still
awaiting Pl ISC's procurement procedures. PHSC has informed us that it will adopt prrourcmcnt
procedures that are consistent with Bank guidelines. Upon receipt of the regulaticr.s we will
consider that the Condition of Board Presentation has been met. Since the notification erabiishina
the Punjab Health Systems Corporation has been gazetted, the Condition of Board Presentation
that was anticipated will not be necessary. Receipt of signed Letters of Health Sector De-, elopment
Program, that were agreed upon during Negotiations, will be a condition of Board Presentation of
the project.
?!S'
Agreed Minutes of Negotiations
6
ON BEHALF OF INDIA
fcbruaiy
ON BEHAL -
1996
F IDA
s’-
Mr. Roh it Modi
Deputy Secretary
Mr. Tav/-::
Sr I cp-
Dcpailincnt of Economic Affairs
Popiila”
MinisUs of Finance
India D.i n".
A
\
i
1 z Ji -- n
!I1
•
_
Mrs. Sliailaja Chandra^-"'
Additional Secretary
Ministry of Health and Family Welfare
Government of India
Mr S\cz
Sr. Cour.5i . : _ih Asia
Legal Derir T.er.t
I
Mr Ceci: Fe'.rz
Sr. Disburse mi."i Officer
Disburscmi-*: P i-pamient
ON BEHALF OF KARNATAKA
Mr. B K. Bhattacharya
Additional Chief Secretary & Principal Secretary
Finance Department
Government of Karnataka
i
L------
Mr. Gautam Basu
Secretary
Health and Family Welfare
Government of Karnataka
i-; Division
Agreed Minutes of Negotiations
7
Fcbruaiv 2j 1996
ON BF11AI I OF Wl S I BFNGAL
f
Mr. Asok Gupta
Principal Secretary’
Finance
Government of West Bengal
................ ... ..
/
Mrs. Lina Chakrabarti
Principal Secretary
Health and Family Welfare
Government of West Bengal
ON BEHALF QF PUNJAB
Mr. G.P.S. Sahi
Principal Secretary
Health and Family Welfare and
Secretary to Chief Minister
Government of Punjab
Mr. Rajan Kashyap
Principal Secretary
Finance
Government of Punjab
ON BEHALF OF THE PUNJAB HEALTH SYSTEMS CORPORATION
fl
Mr. D.S. Bains" y
Managing Director
Punjab Health Systems Corporation
■
CONFORMED COPY
PitoSE-CX OFFICE
=
■ -f'
tF‘.
CREDIT NUMBER 2333 EN
G10X/ - T-
w
■■
Project Agreement
(Second Stale Health Systems Devclopnient Project)
benvcea
I
O FERXVIION/VL DEVELOPMENT ASSOCIATION
nod
STATE OF IL ULNATAKA
STATE OF PL7/JAB
STATE OF WEST BENGAL
and
PL'N’JAB HEALTH S'i STEMS CORPORATION
Dated April IS, 1996
f
CREDIT NUMBER 2333 IN
PROJECT /VGREEMENT
AGREEMENT, dated April 13, 1996. between INTERNATIONAL
DEVELOPMENT ASSOCIATION (the Association) and THE STATE OF
KARNATAKA. THE STATE OF PUNJAB. THE STATE OF WEST BENGAL, aenng
by their respective Governors (lite Project States) and PUNJAB HEALTH SYSTEMS
CORPORATION (PHSC).
WHEREAS (A) the Association has received a letter dated February 13. 1996.
February 15, 1996 and Fenruarv 3. 1996 irom me hiate ot Karnataka, the State ot Pumao
ano the State of West Benuai rescectiveiy icollectively the Project States), each s—.".
Icncr (’.escribing a prerrorn of object:'.es. policies and actions to improve the pnm_ .
and first referral levels -it health care iherematter referred to as the Karnataka Hez.m
Sector Dcveiooment Prccrarn. the Puniab iteaiih hector Development Program ana -.e
West Benaai Health Sector Deveicoment Program, rescecmeiyj ana declaring _.e
respective Proiect State s commitment to carry out its Health Sector ueveioomm.
Program;
WHEEXAS (Bl bv the Ceveiocment Crcait Agreement ct even date herewitn
ber.vcen Inc:x 2c::r.^ by its President (the Borrov-er) and the Association. ■_‘.e
Association his .irjcec to maxe a-.niiaole :□ the Sorrower an amount in var.zas
:n:rr.' :;\c miilicn five huncrec mousand Streets
currencies ecuivaicnt to tao nunc
Dra'Aing Rignt: SEP. 2' 5EOO.-.2O'. ?n :ne terms ana mnamcns set form :n '-.z
Ceveiocment C.euit Arre ment. f.m nr. on condition tnot me Proiect atates ana r
5
/.•..ifj’
.Xssooiat’cn .is are .et .wtrn .n
mlr.’at:
HT-’* '0 inicerm.e '.ucn
A vrrement;
’•VI IE RE. \ 2 the Rr-'i-c: ./.a:"- .mu PH-C. m consiueraticn of :ne Associa:::.-. s
into
Z.::.: Aerzen: -a,tn :-e Sender, have acreec '□
ancerzhe the colrgaticn: :et ::r.n :n •.r.is Acreement:
I
NOW THERE?'
E the carr.es hereto nereby agree as foilcv-s:
ARTICLE I
Dcfinitioos
Section 1.01. Unless the context other-vise requires, the several terms denned in
the Development Credit Agreement, the Preamble• to this Agreement and in the General
Conditions (as so denned) have the respective me;minings therein set forth.
I
■
2
article ii
Execution of the Project
Section n 01 (a) The Project States and PHSC declare their commitment to ±e
Objectives of the Project as set fonh in Schedule 2 to the Development C.-eci:
Acreement, and. to this end. shall carr.- out the Project with due diligence and erfkter.cy
and in coniormny with appropriate aaministranve. financial and health practices, ar.o
shall provide, or cause to be provides, prometiv as needed, the funds, facilities, services
and other resources required for the : reject.
(b)
Without limitation imon the provisions or paracmon (al or this bec:::r.
and exceot as the Association and the Proiect States and PHSC snail ctner.vise acree. a:
Project States ano PHSC snail rorrv out -he Project in accoroar.ee tvna
Implementation Procrzm set tortn in ocr.eouie to this Acreement.
Without limitation ucon the provision of paracraon (a) of this Section,
(c)
avaiiacie the proceeds of the Creuit received Ircm
Puniab '.nail prcmotiv maxc
Borrower to PHSC as rar: of its rmnt contribution in accoroance with the provisions ::
the Ordinance.
Section 2.02. ar.ceot as th .\Lsoc:at:cn chad v.r.envise acres, prccurerr.er.: -•
•. •—: r?2u:reu !cr :r.e Proiec: ana to re ftnancec
the zcoas. worns ana consultant:
„
-v •.•-.c •.•revisions of Scr.eaule : to
of the rtrcceecs ci the '.‘.rint •.n.iu
Agreement.
i.
Section 2.03 ..n h-.c i’r-r
forth m Sections *5 03. • ' 4 ) i'r
to insurance, use :t tooas mu
maintenance ana lana ccauisiticn. :
the Proiect.
'
(b)
Fcr
'•..res .'.nu ;’H3C .nail carr-- out the cciicatior.s :::
« ’ 07 inu C3 ‘'i the ' jcr.erai Conuiticns ireiati-z
jcs. sians uiu tcr.eouies. recorcs ana reoc._.
;n reject of the Project Acreement-.a
::urro;e: c: i;=::cn ■’07 .t ‘.h- General Ccnai-.icns. and
limitation thereto, the Project States ar.a Fb.Su snail.
(i)
I- '•
pr-are "n the basis of ttuidelines acceptable to the Associattcn
ami linnr.n to the Astncuamm not later than six (6) months a.ter
the I'hr.im' Ihite or '.mil l.urr date as may be al’,reed for ■r.u
purpose ber.veen the Association and the Project States ano
PHSC. a plan designed to ensure the sustainability o _e
Project;
-3 -
(ii)
afford the Association a reasonable opportunity to exchange
views with the Project States and PHSC on said plan: and
(iii)
thereafter, carry out said plan with due diligence and efficiency
and in accordance with appropnate practices, taking into
account the Association's comments thereon.
Section 2.04. (a) The Project States and PHSC shall, at the request of the
Association, exchange views with rhe Association with regard to the progress or the
Project, the performance of its obligations under this and oilier matters relating to the
purposes of the Credit.
2
The Project Stites and PHSC mail premotiy inform the Association of
(b)
any condition wmen interterzs or mreatens to.intcrtcre witn tr.e progress or me Project,
the accomoiishment of the purposes of the C;rc:t. cr tne pertcrmxnce oy eccn or them c:
its respective ocligations unaer this Agreement.
article hi
Financial Covenants
Section j.'JI. (.i) H-.e Protect States mu PHSC shall ezen maintain recorcs ar.
accounts aaecuate to retire: ;n .’.ccorctancz wiin :ouna accountinz practices the:
oprraticns. resources ana expenditures m respect .?! activities reiatea to their respect:*,
pans or the Protect, u trie deparrments or tcencies resocnsicle lor zarrying cut
Project cr .an’.- part thrr-ci
ib)
i .:r Pr-i'Tc: r.tjtes anil PHCC .nail.
. 11
ha\e rzccrc: ana .icccunts referrzo to :n parezraen (a) of mis
Section for eacr. fiscal ;ear auaitea. in accordance wrj:
soorccriate auciitmz pr.ncmies consistent:*.- acpiied. pv
:nceprndcnt auditors acceotacle to the Association:
(ii)
furnish to the Association as soon as available, but in any case
not later than nine monins alter the end c* each such year: (Ai
certified copies or its tinancial statements for such year as so
audited: and (B) the report of such audit by said auditors, cf
such scope and in such detail as the Association shall have
reasonably requested: and
(iii)
furnish to the Association such other information concerning
said records, accounts and financial statements as well as the
1
-4-
'O''
audit thereof as the Association shall from time to time
reasonably request.
zVRTICLE IV
Effective Date; Termination;
Cancellation and Suspension
Section 4.01. This Agreement shall come into force and effect on the date upon
Section 4.02. (a) This Agreement and all obligations ot the Association and of
the Project States and PHSC thereunder shail terminate on the earlier or the following
-two dates:
a
(H
the date on which the Deveionment Credit Agreement snail
terminate in accordance with its terms, or
(ii)
the date r.ver.rv '.ears alter ’he date of this Agreement.
If the Development Creel: Agreement terminate:: in aceercxnce with its
aracroon (a) (ii i of this Section, the Association shail
terms before the date specified in p
prem ntiv notify the Project States and PHSC ot this event.
(b)
ana e
Section -.03. All the provisions :i this .
ct nor.vithstcmdmg any czr.ceilaticn or sul
ement shail continue m mil torce
icn under ’-he '•jenerai Concitions.
article v
Miscellaneous Provisions
(
Section 5.01. Any notice or reoueet required or permtned to be ntven or made
under this Agreement and any aEreement betv-cen the parties contemplated oy this
Agreement shall be in wnting. Sued nonce or request shall be deemed to nave been duly
given or made'when it shall be delivered by hand or by matl. telegram, cade, telex or
radiogram to the pany to which it is required or permitted to be given or made at such
party's address hereinafter specified or at such other address as such party shall have
designated by notice to the parry giving such notice or making such request. The
addresses so specified are:
-5-
For the Association:
International Development Association
1818 H Street, N.W.
Washington, D.C. 20433
United States of America
Cable address:
■ V-.i’-
Telex:
INDEVAS
Washington, D.C.
1976SS (TRT),
248423 (RCA),
64145 (WTjT) or
82987 (FTCC)
For the State of Karnataka:
Chief Secretary to the
Government of Karnataka
Bangalore, India
For the State of Punjab:
Secretary to the
Government of Punnii?
Department of Health
Chandigarh. India
For the State of West Eer
Chief Secretary to the
Government of West Bengal
Calcutta. India
For Punjab Health Systems Corporation:
Managing Director
Punjab Health Systems Corporation
Chandigarh, India
Section 5.02. Any action required or permitted to be taken, and any document
[
required or permitted to be executed, under this Agreement on behalf of the Project
States or PHSC, may be taken or executed by die Chief Secretary in the case of
Karnataka and West Bengal, or the Secretary, Department of Health in -the case of
!
-6-
Punjab or the Managing Director in the case of PHSC or such other person or persons as
the respective Chief Secretary, the Secretary, Department of Health, or the Managing
Director shall designate in writing, and the Project States and PHSC shall furnish to the
Association sufficient evidence of the authority and the authenticated specimen signature
of each such person.
Section 5.03. This Agreement may be executed in several counterparts, each of
which shall be an original, and all collectively but one instrument.
IN WITNESS WHEREOF, the panics hereto, acting through, their duly
authorized representatives, have caused this Agreement to be signed in their respecuve
as of the day and year Erst
names in the E
above written.
4;
rNTEPJ^ATIONAL DEVELOPMENT ASSOCIATION
By /s/ Heinz Vercin
Actinii Rcnionai Vice President
South Asia
S i A i k OF RAF.? lA i A
STATE OF PG? GAB
STATE OF AT ST BE? ■:gal
PUNJAB HE.VLTH SY:s~ ts c Pd’CFLA ~CN
By /s/ N. Vailuri
Authorized Representative
-7-
SCHEDULE 1
Procurement and Consultants’ Services
Section I:
Procurement of Goods and Works
<
Part A:
Geneni
Goods and works shall be procured in accordance with the provisions of
Section I of the “Guidelines for Procurement under IBRD Loans and IDA Credits'’
published by the Bank in January 1995 (the Guidelines) and the following provisions of
this Section, as applicable.
Parr B:
International Corripetirive Bipdin
1.
Except as otherwise provided in Part C of this Section, goods shall be procured
under contracts awarded in accordance with the provisi ns of Section !I cf -uhe
Guidelines and Paragraph 5 of Appendix 1 thereto.
2.
The following provisions shall acpiy to 'tcocis to he procured under ccntrzcir
awarded in accordance wiih the provisions <)f parnnrmm I of this Part 13.
(a)
Gronoinr of conmcts
To the extent practicable, contra;::: tor oocu shall be ernuoed in bid oocitaoes
estimated to cost S200.000 equivalent or rncrc eacn.
l b)
Prof-
rj-toinn.
"’I•
Ti’.e provisions of parugrachs 2.5- an;
thereto shall apply to goods manufactured :n :h
Pan C:
Other P
urement Pt”
of the Guidelines and
:c r.’ o f t h e E c rro w er.
V
r»r4i j rnr
I.
Except as provided in paragraphs land 3 hereof, civil works may be procured
under contracts awarded on the basis of national competitive bidding procedures in
accordance with the provisions of paragraphs 3.3 and 3.4 of the Guidelines.
2.
Civil works estimated to cost the equivalent of $45,000 or less per contract, up
to an aggregate amount not to exceed the equivalent of $18,000,000. may be procured:
(i) under lump sum, fixed price contracts awarded on the basis of quotations obtained
from three qualified domestic contractors in response to a written invitation. The
invitation shall include a detailed description of die works, including basic
-8-
^Cifications. the required completion date, a basic form of agreement acceptable to the
Bank, and relevant drawings, where appheab'e. The award shall be made to the
contractor who offers the lowest price quotation for die required work and who has the
experience and resources to successfully complete die contract; or (n) through direct
contracting in accordance with the provisions of paragraph 3.7 of the Guidelines, and in
i accordance with procedures acceptable to the Association; or (iii) with the Association s_
■ '^Drior agreement, under force account procedures in accordance with the provisions or
It paragraph 3.3 of the Guidelines, provided, however, that civil works procured under sucn
procedures shall not in the aggregate exceed 210,000,000.
Except as provided in paragraph 4 hereof, equipment estimated to cost less than
3.
the equivalent of S200.000 per contract up to an aggregate amount not to excee- the
eauivaient of SI2.700.000, mav be procured under contracts awarded on U.e oasis oi_
national* competitive bidding procedures, in accordance widi the prov.smns or
pBKidruphs 3.3 2nd 3.4 oi the Guidelines.
44^'
f if 0.000 or less per ccnmccc up to
4 ’ ' Ecuioment estimated to cost me euuivaic
an a^^e^e amount not to exceeo the eou.va.ent of:
may be prccureo
f: ti)
(/) 04.200.000.
S
unckAcntTacta awarced on the basts of mtematmnai meopmg nr0ceouresjn ;c roanc
w,th the provisos of paragons 3.5 atm 3.o of me Gumetmes; and (it) ^..00.000,
mav be procured under contracts awaroeu on the oasts cl nattcnaHicppin^ pr
m accordance with the provisions of parattraphs 3.S and 3.0 or u.e Guidelines.
mnvaier.t of S300.000 in the
5.
Vehicles estimated to cost not mere than me
he basis of national shccpmc
atinregate may be procured under con ;c:s aw ar ecu m
oarmtrncns
3.0 arc j.6 or me
2cccrcir.cz with the provisions c
procedures in accorcance
Guidelines.
6
Ez.com as orov.cou tn purapratm
t-.ereot. meutcoi Gooratcry suppnes esm.m.^.
prion “’ he:
to cost ’ess than the e=uivaient of 3200.000
3LC0.000 per
p contract, on to an angrenate ^.cum
to exceed the equivalent of: tf) 52.700.009.
mav oe mocured under contracts awar.e- c„_
700.009. m
the basis of naticnai competitive
bidding procedures m accordance wit u - r.ovis> n
tnr. e bidding
paramaons 3.3 and
and 3.4
of
the
Guidelines,
and mi 5400.000 may be prej
3.4 of the Guideiin
contracts awarded on the basis of international sr.cppmg prcccuure. in
the, provisions of paragraphs 3.5 and 3.6 ot the Guidelines.
7.
Medical laboratory supplies estimated to cost less than th? equivalent^,000
per contract, up to .an aggregate amount not to exceed the equ.yalent of S-30°’00°
be procured under contracts awarded on the basis of national shoppn g p
accordance with the provisions of paragraphs 3.5 and 3.6 of the Guide ines.
8.
Except as provided in paragraphs 9 and 10 hereof, medicines, furniture,
and -Communication
Management Information System/lnformation, Education
I
-9 -
’ -J?
tMISAEC) materials and supplies shall be procur
S' Ptoanal eomptofive MtoS P^toto
partonphsSJ^-4^'0^'1'"'
H
9
-•-> awarded on the basis
cd under contracts
with tlie provisions of
accordance
“
.
Medicines estimated to cost less than
,o an angreato a— "« »
, „
StO 000 per contract, up
may be procured
q{. S1,500,000
. in'OTalional shopping proo=du« in acaordanee
3. - 3.d ofto Cidaitos.
Medicines, furniture.. MIS/IEC
Mlb-ltc materials
mu^..
• ■ ■ of S50.000 per contract, u
and other supplies estimated to cost
3(Trn.e23te amount not to exceed
10.
*. to =«uival«t of S;O-OlJ’F„","’oo oto SI I .'O’-000
less
S
toeoutoleMoofI S3.700.000.
SJ..0
d
0, „s j
j
be procured. under
____ contracts
• . - < «nri 3 h ei the <juic--.in^-Wuh the provisions of paragmons o..
o.
accordance —
of buildings and
12 hereof, inaintc
awarded on the basis ot
Er.cettt as provided in pamgmtm
11.
be carr.ed out unuer coniTncts ■ of parogrocns s.c and
vemcies and equipment may
-. 'M«‘ ib** ^revisions
accorcance
rnational shopping procedures in
•
.
.
i
— . .. r i r>
3.6 of the Guidelines.
equioment which meet the
md vehicles ar.u
r
Maintcnanc: of buildings,
at'id cottmq in the aggregate
3 3 of :he Uuiueiinerc'auirentems of pangrapns e., ana
:u!S and . 7 900.000 in me czsc
100.000 in the 2LC of buiU:
’nrcugn Ohect cen^ctmg^or
[ess than the equivalent ol 0-'
czrr’.eu cut e: her: ‘ i’i
ran ns
?md j.3
3f •. enxies and euuitttnent. may ce
:ne nrovi liens : :aid ;ar ••atismetory m the
-rcceuurc
ui) force account.
:n acoorcaii'
respeettveiy. of
Gtnaetme.. ana
Association.
•-»
p-
1.
\ C
n -
n-
..niir- rcr bidding or
^or
f ’
snail be furnished to the
Prior to the issuar.ee of any invmmor.s
P'an for th. ■ ■ . isions Of paragrnpn
contracts, the proposed
•n
f
.5 and works shall be
Procurement
approved by
Pronto ofjj
1 to
!,to=X"in' aectotoe-. wifh such proc.— ph.
d with the provisions of said paragraph .
the Association, anc
4
- 10 -
Prior Rcvicw
With respect to each contract for good-; oi civil wail;”. <--.tiin.'ited to cost more
than the equivalent of 5200,000 or 5300,000 respectively, the procedures set forth in
parattraphs 2 and 3 of Appendix 1 to the Guidelines shall apply.
j.
Post Revis"'
With respect to each contract not governed by paragraph 2 of this Part, the
procedures set forth in paragraph 4 of Appendix 1 to the Guidelines shall apply.
Section II:
1
Consultants’ services shall be procured under contracts awarded in accordance
with the provisions of the "Guidelines fcr the Use of Consultants by World Ban*
BonSwers and by the World Bank as Executing Aeency’ puciisneu by the Bank in
Aueust 19S1 (the Consultant Guidelines). Fcr Comdex, time-cased assignments, sucn
tontmets snail be based on die standard form of contract tor consultants' services issuea
bv the Bank, with sucn modifications thereto as shall have been agreeo. by the
Association. Where no relevant standard contract documents have been issuea oy the
Bank, other standard forms acceptable to die Bank shall be used.
2.
yionvithstandinr. the piovisiims 01 p:n:’.'.'t::i ii 1 ’1 hi. •• ten. the provisions of
.innroval of buckets,
the Consultant Guidelines requiring prior Association teview t
vniuaticn
reports and
snort lists, selection procedures, letter: of ’invitation, pronosais.
ev
c
contracts, shall not atmiv to: (a)
fa) contracts
con
fcr '.lie emnnyment: of consulting firms
:s ter the employment
estimates to cost less than si
£100.000
00.000 emnvaient
ec
eau::: ;r i b) contract:
each. However, said
:f individuals estimated to cost less than ff'UWO ecuivaient e
alien review
rcvie’A snail act .tppr- :c: (a) t!:e terms of reference tor
executions to prior Association
ciec
such contract:-, (b) singie-icurce selection
of consuii:;r.o firms: (c) assignments of a
cr.ticai nature, as reasonably determine:: ?;■ .he Association: (d) amendments to
contracts for the employment or consulting tirms raisi r” t!ie contract value to Si00.000
above" or (e) amendments to contracts fcr the emcioyment of individual
eauivaient or :—
consultants raising the contract value to 550,000 equivalent or above.
f
-11 -
SCHEDULE 2
Implementation Program
1.
Each Project State shall:
(a)
ensure that within the allocations for the health sector in each Fiscal
Year during the implementation of the Project the share of resources for Primary and
Secondary Levels of Health Services shall be increased in each such Fiscal Year until
FY 02; and
allocate in each Fiscal Year during the implementation of the Proiect
(b)
adequate resources for drugs, esseni:ai supplies, and maintenance of equipment and
buildings at facilities providing First Referral Level Health Services in accordance with
nerr^s agreed to with the Association.
- -
2.
Each Proiect State shall maintain its Sira:?-, :c Planning Ceil with adequate suii
resources and terms of reference accemaoie to tr.
:scc:ation.
j.
Each Project State and PHSC snail lew user-charges in district and subdivisional hospitals in accordance wim a program and time schedule acceptable to me
Association, such program to focus, inter alia, on: (a) permitting the revenues colle
:
from user-charges to be retainedd at the hespnai
level; (b) implementing user charges :n a
rnascc manner after improvements n T.e maiitv of basic services and mtrastru
cm c:
c: de*.'•i-.mim: md .mpiyim: iritcria tor excm
; e: c r rr. ent have been comnieteu;
peer from user cnarpes: and st ::rmm:;enmg .mprcrriote management
:e
mamte : n a exmim: user cnarr.es. inducing
:ci!
:cn arrangements tor mamtainimi
ilsnment and maintenance of tHttrid Hvmih Committees .a
;n Karnataka arm
ai for collectin'! such chorees.
Punjab and PHSC snail, as the case
:aLe muv
t.c be, take all such measures as may
0
necessary or required: (i) to enable PHSC
C to ccrr/
ca
out its part of the Project; ana (
care
ac
ensure that PHSC undertakes health
activities at the secondary levei in accnrda:
with ser/ice delivery norms acceptable to the Association, and in carrying out ether
heath care activities shall ensure that its abiiiry to perform its obligations under this
Agreement as determined, inter alia, from a review of the progress achieved in
implementing die annual work plans and in meeting the development and performance
indicators referred to in paragraph 9 hereof is not adversely affected.
o
5.
For purposes of enhancing the quality of health care services under the Project,
each Project State and PHSC shill: (i) maintain die key headquarters personnel
appointed for purposes of implementing the Project; (ii) appoint and thereafter maintain
key additional personnel with adequate qualification and experience in accordance with a
f
- 12-
schedule of appointment agreed with the Association; (iii) adopt, no later than six
months after completion of the physical improvements in any hospital under the Project
and thereafter implement, staffing and technical nouns acceptable to the Association:
and (iv) provide on an annual basis adequate funds, satistactory to die Association, for
the maintenance of previously existing equipment in health care facilities supported
under the Project.
6.
For purposes of carrying out Part B.3 of the Project as set forth in Schedule 2 to
the Development Credit Agreement, each Project State and PHSC shall, no later than
December 31, 1996: (i) issue appropriate directives to hospitals to strengthen the
management of the referral mechanism ber.vcen the Primary', Secondary', and Tertiary
Level Health Sendees: (iij 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 tor patients who use the
system.
Karnataka and West Bengal snail maintmn the District Health Committees with
sue staff, resources, powers, functions and rosponsibiiities so as to enable mem to
facilitate, inter aiia. the functioning of me reierrnl mechanisr . the collection and
distribution of user chargee, mainie nance of eq urn me nt. waste management, training of
tccnnicoi staff, quaiivy assurance, surveillance or communicable diseases and the
monitoring and suoer/ision or the: respective activities to be carried out under the
Project.
Each Projec: State shall take ail such in ear:
in ardcr to provide, and there: :r mom in. 2’J
T.ataka one West Bengal ar. to PH2’ in
jr.
activities to be carried out by
maintenance activities.
Q
9.
as mav be necessary cr repuirea
nr/ to DCHFw in tr.e ease of
ise of Punjab for marc :ng the
iecu inc:uoing consmuc on and
Each Projec: State and PHSC shaii:
(a)
bv April 30 of each year during the implementation ot the Projec.
beginning with April 30, 1997:
(i)
provide to the Association an annual work plan, acceptable to
the Association, setting forth the respective activities under the
Project to be carried out during the prevailing Fiscal Year
including the budaetary allocations to be made available for
such purpose, as well as the pertormance benchmarks and
development objectives to be achieved and drawn from the
overall framework agreed to be achieved under the Project
including, inter alia, hospital activity indicators, hospital
- 13 efficiency indicators,
and quality,
quality, access and effectiveness
indicators, and
indicator's to be
be measured
in accordance with methodology
measured in
satisfactory to the Association; and
(ii)
review with die Association the progress achieved in
implementing die Project under die annual work plan for the
previous Fiscal Year and the interim plan referred to in subparagraph (c) below of this paragraph (9) with special reference
m the achievement of the performance benchmarks and
development objectives incorporated dierein.
a manner satisfactory to the
(b-)
implement each annual work plan in
-formance benchmarks and the
Association, with the goal, inter alia, of meeting the p;
development object.ves set forth therein; and
X
implement the Project unul me 1’onnuiauon of the first annual worK plan
m accorcanc = with an interim plan agreed ■■'•itn the Association.
• iij its rerreuf.ve incremental oucaetar.
10.
Each Project State shall ensure the
jifcca'/cns ur.de/the Prciect for the Pnif.-- ’ ,I1(j pbst !<ete:mi Level Health Services
:n oi the Project snail be faily acomonai to
fcr ezeh rtseni Yem during the imciementnr.
ouduetor.’ allocations for the annual work
:ne ailucmicns made in F : 95; and ■ :i) tl.e
raurnch 9 hereof -ire made avan.-.cie on a
mana and the inter-.m plan reterrea to m p.
euirerr.ents under tucn plans.
nmeiv cams sufficient to meet the resource r:
...
...
r
bai arcac (as
:n
: rriec
:<„matm-.a and 'Vest denga: snci. mrkine
mnie:----- ____ the Frsiect m
, -t P
r.atec bv eacn such Project state!
-nd policies of the
*
arm
unueroans Arco m accorcor.ee .vr.n ...e .rt
-• _ _ ,n; (a) ..^-^-meninp
, ’
;e
r
r-*
; me Focnwarn Area Devemnmem .iramg;. ■'(b, ^.^i^
of
.mha:gee between rrimary, and ----------- ■_
.hc .--muriate
;ncenmve package to doctors, ar.u mner ...rc.-a
„._u;3ncn- (d) reducing the
Karmataka ar.a m tr.e .unue.^an,-----uf.iizauon of the medical system y
-a— Ar/taka- and (e) increasing the
cost to Scheduled Tribes of utihzmg sum system m Kmm-u..a.
number of beds at sub-divisional ana community hospitals.
12.
PHSC shall carry out Pan A.2 (lx) of the Project in accordance with procedures
and arrangements satisfactory to the Association.
The Project States and PHSC shall, with the participation of the Borrower and
review of the Project,
.he As.aeia.ion: (a) jointly carry out by Juno 30. 19•’’’
of reference
including on management aspects and financial siiat.unabi >,
13
!
- 14-
satisfactory to the Association; and (b) carry' out the recommendations of such review in
a manner satisfactory to the Association.
!•
■
!
/
IM'
)
1NDLA
STATE HEAI/III SYS TEMS DEVELOPMIu I I I’P.OJELl II
ACLREEl)AnrH nT.SAl!LNL( i’ V 1A 1,1 - ■
'
Negouaiions fo, a ,0,0^ C,^.
Svstems Development Project 11.(die Project) ''VL'tProject Slates), tlic Punjab
Bonower).
Sou <><
h.,ab and Ve^
*
'feelopn'=><
Health Svstems Corporation (PHSC) (the Indtan Delegation) and the
in Wasliington D.C., from
“X (IDA) (1 )DA Ddepuen) M Wo.ld Bank (
Indian Delegation and die ID.A
i
D2, ,QQ
uic l —
January 29 to r-February
19966. Tlic representatives ot draft
-I
Development Credit Agreement
the draft
Project Agreement and tlic
■A.‘V Dftlecmrion
_
Delegation agreed on C._
dated February 2, 1996.
(DCA), versions c
»'
Actions Taken Poor to NcgouailPI^
As a condkion of Ncgouauons. the fcllowmg acuons hnv,: been taken:
2.
(i) a draft letter of Health Sector Development Prommn hm;
been fmms’ned bv each state;
t| Tj clem mice from the Planning
(ii) relevant stmc Government clcmmicx., J.>
Commission, GDI. v.c:c obtained,
'
I
th., nonrw in Karnataka, Puniao
(iii) Strategic Planning Cells have been set up widnn die Utnit
and West Bengal;
implemented
(,V) a
for ™n5 tat
“=
...i for exempting die poor from
more ngorouslv has been approved an agreed ira-ani Kmnmaka
in
and West Bengal have
user fees is in place, and Distnct Health Conunnteer. m I..-
(v) an Ordinance has been passed by die Governme
nt of Punjab, establishing die PHSC,
” :ies, audits and accounts, and
(vi) regulations relating to Board procedures, P^'™[ P0^
user charges have been drafted and provided by I BSC to IDA
1- for icvitr.v;
M) in Kanmnka, <be
Governs B~d.'
Wing have been established, and key staff have been appro >
or
(viii) in Punjab, key staff, including the Managing Ditector
of the PHSC, have been
appointed;
ftx) in West Bengal, key staff, including Project Dncctor, have be-n line- ,
(x) in Karnataka and West Bengal, Government: Oitdewor^
authority to DOHFW to nuuutge essential opemtton.il
construction mid mniiitcnoncc activities.
7V’X-
.M
b
J \\ ■
4
I
I
/
( ” 1 ■
!' rhi u:ii v ?. t 1996
/Agreed Minutes ot Negotiations
Agreements and I Jnder^^rmdni?sj} cachet I
The following elaborates die agreements reached iclatrne to the legal documents and other
3.
understandings.
DEVELOPMENT CREDIT AGREEMENT
'
4
Article II. Section 2.01 Credit{Amoimt, It was agreed to increase the credit amount from
USS342.2 million equivalent to USS35O.O million equivalent. Die agreed amount would be equal
to SDR 235.5 million. Mie additional amount of USS7 S million equivalent would finance
medicines, and Manacerncnt Information Systems (MIS) supplies mid Information, Education and
Communications (IEC) materials in West Bengal (US$2.3 nnllion equivalent) and I iinjab (USS 5.0
million equivalent).
—5
Ankle II. Section 2 02 Closing Date
It was amw-l that the Closing Date would be
Drought forward from June 30. 2002 to Marcn 3 1, 2002.
6.
Article III Section Ji1.1. I I :/"A<’r 1
frnni ('nI (}()] - Niifnni’.-d that, diromtiiout
the life of die project, it would follow die stmidmd procediiie for telwi-.im’. about diree months
anticipated oroject expenditures m ccvancc to die Project Str'.i.'w to cm.er expenditures under the
h.i advances, L’twii icce-.pt. the Project States shall
project, subject to periodic acmsmiem or die
arioir; tn ev.rncicn re* nonsible for
.11 qumterly .’ilk
release such funds together v.idi rlmir own
carrying out die protect, co be used exc*.usi\ciy for expen'.iimie.. cliviblc under the project. In
Punjab, upon receipt, such funds wiil be promptly tmnsfcned to PHS(. as required for timely
project implementation.
7
Article V Section 5 01 ter Remedies of the .Association, Aller discussion it was agreed to
keep this remedy related to the Hedth Sector Development Prrv.iain. Hie Indian Delegation noted
that the Lerner of Hoaith Sector Development Program describes a program of policies and a coo ns
and felt that the content of the Letter was not tantamount to a mutually agiced obligation on the
part of the Borrower. It was further stated tltat the commitment by die Project States to the Letter
of Health Sector Development Program should not therefore be a monitorable acahty on which
remedies could be invoked. The ID/A Delegation responded that die project was an investment
operariou with substantial policy content, and diis provision formed die basis for remedial action in
case an event occurs that makes it improbable that the Ilralth Sector Development Program for
each Project State or a significant part thereof will be carried out. I he IDA Delegation further
explained that the commitment of the Project States to car lying out such a program is an important
part of IDA support for the project It was, therefore, deemed necessary to retain tliis covenant
8.
Schedule 1: Withdrawal of the Proceeds of the Cred it. Hie 1 r i d i an D e I egati o n hi ghh ghtrd
the (her that health is a state subject, and diis project covers three states. /Vs such, it is important
that any state be aware of how it lias been performing. In case the share of projected IDA
allocations to any particular state has to be changed, it should be done through a transparent
process where each state knows what is hnppcning to its share. 1 luxibility cannot be at die expense
of transparency'.
'Diis necessitates dint information lupniding piojrct implementation and
disbursement is available for each implementing state.-Hence the infoiinmion in Schedule 1 should
be disaggregated by Project Suites. 'lire IDA Delegation pointed cart that this would provide a
piecemeal solution to monitoring disbursements by GDI and v.'udd irdiir.e flexibility with regard to
categories of disbursements across stmes. Nonetheless, nt the nisistrnt '* of the Indi.in Delegation,
T'-T2.'
|
Agreed Minutes of Negotiations
Fcbiuaiy 2, 1996
1
/
i .. Ptnir’ct States. It was noted that this
« was aarecil ihal Schedule I would be teswl'-’"' "
,„;e,k-M lor oilier projects in die
format of showing Schedule I by I’.oject Slate would no. ,.u o I
future.
cost financing issue was discussed
Schedule I
-t COst financing as well as to retain the
for the final vear of the project. The cutToXe! of recurrent cost fnancmg by the Assocratmn f...
clnnred from the end of the fiscal year to die
off dates for the declining levels of furancmg were <
end of the calendar year.
Schedule 2: PesenDUon of
Project
szs x;:X"z».s: a
-»
'Schedule 2: ImoiemenutioiLPtocrmn of die Project Auc-r
e the Special Account from USS15
11
Schedule 3- SpecinLiV^-O'LU111.
I million t’o USS 17 nullion equivalent
It was agreed to mere:
PROJECT
r. ■
It was m’tced dial the Comptroller
ArncieJLllJicyif'!- ' ’’I P’L'" 1 m-”r>..
■
nn[i accounts
12.
and Auditor General of India would be the nmepen..-n
of Section 4.01 of the
of the Governments of Karnataka. Punjao and
■ -,; ■
!n nddmon. in Punjao,
Drr.xiooment Credit Agreement and S^:o" j U ’. ” " "
of the Punjab Health Systems
an indtmendent ccmrnercml annum would audit
..niiable to the auditors die SAR.
Comcrauon. ‘It was agreed drat dre Project S a j.-jevant information would be
ueniunt. UJ
Proiect Agreement and tire Development Cred.t Au-m-m
the auditors ]
provided by die Project Management in eacn state to t
1
Schedule 1' Procurement and Consultantjerviccs
()th...r_P,ocinnnentJ?^.l>^ 'DA reviewed
13
Section 1, Part _CL_J-^ms^J_
—7" ".
Gnth'-r rcquiicrnents on procurcncnl
procurement documents and agreed that at
aspects prior to Board presentation are „
anticipated
be Iteincwl Itoin d« C.edic .»dcr NCB p,
lh"”s Zm. 2 - p— r*- »f
the Inst few years, that for all contracts t~------
U tn domestic bidders when competing with
(a) no special preference wall be accordenterprises, or enterprises
foreign bidders, or given to state owned enterpn-c.,,
from any given state;
(b) except with die prior concurrence of the Association, there v
JI".-ith bidders, cL v.mh the lowest evahiatcd ladder,
no negotiation of
-•-T to bidding the system of
except with the prior approval of th" Assi'Ci.ition pnU
b,:„:l.ct" of pliers will not be used; and
rejecting bid'; outside a ptedelrtmined rnmem or 1
(c)
(d)
t r>
I7UC coutincts entered into by-the Boh.
i
p - *
DilCCtOlUtC Genend of Supplies and
\ \W',vr
1
c:. ot I Negotiations
February 2, 1996
it was agreed drat Schedule I
would be disai’grcrptcH bv Project States. Il v-format of showing Schedule
was noted diat this
I by Project State would
not set a precedent for other’ projects in the
• future.
in detail It
no ^~^^X^L£l”nncnig_ 1 he iccuircnt cost finnncinp issue wi- die
J
I he recurrent cost f
m octal 1. It was agreed not to increase the Ipv,.i r r
51 C V’a'> dlscussed
■ 40% level of recurrent cost fmmtcmr 7 1 A °f rCt:1
"':t financing as 'veil
recur',rCnt
rent C
cost
well as to retain the
off dates for the declinmg levels of find, c 7 w00'"'.'0"
, 'i"
'n'c cu£end of the calendar year.
'5
C”d of lllc fiscal year to die
Schedule 2: Description of die Prpjrrr
>Strimmhenirtg Under this component,
Pumab throutth onvate and volm77
promot.on of health care aedvides in
11.
Schedufe 3- SpeciaLAf count
milion to USS 17 million equivalent
li v. ns attreed to mere::- the Special -Account from USS 15
PROJECT .ACJREE.MK■ < 1
\ a
and Auditor General of Inch- would
of 4, Gov™:™ of iV.™ P
_Einnncia 1 Cov—ir’nr It ”-’’s 'irrc‘'d tb-n tl.» ('
F ■“i "
’
tl:e ConiP^obcr
ooono,
,te
.pp.,,,;, „d a=„„ra
Dr.-doomoi C.-edit
A, j"
' '"J
‘l'-'
,’f S=™ < 01 of the
an independent conum-ren/Tm. S“' ° 7^ ’'= Pro,ect Al’rr"rn"nt- >" addition, in Punjab,
Corporation. 'It was aereed-liat the'p'^77
1
as:=annI' of ,h"
Health Systems
Proie'-* aj
f'Jicc. States would make available to the auditors th'’ SAR
~ L|r —
$?CDon I, Part C name
y- i
t
n
procurement documents and agreed thTT7hir7’’“—rocpdnra^ IDA rcydtnsed
aspects prior to Board presentation am7 f
. T "0
requirements on procurement
the last few years, that for all contracts^ T
i r
P"™15 Pr0J'CCa °f
an contracts to be financed from the Credit underNCB procedures:
(a)
i
’
‘
special preference will be accorded to domestic bidders when competing with
foreign bidders, or given to stnte
owned enterprises, small scale enterprises, or enterprises
&orn any given state;
(b) except with the p’*--- prior concuirrujce of the Association, there will be no negodadou of
price with bidder:;, even with the k
.......... O’.vr'.f cv.rlii.Ur.-] biddrf;
(c) except with die
prior approval of the Association prior to bidding, die system of
rejecting bids outside a predetermined rnmp.in or ‘’bracket” of prices will not be
(d)
rate contmcw entered into by the lb,\
Diiectoiatc General of Supplies and
f
February 2, 1996
i/A\grecd Minutes of Nctiouaiious
Disposal (DGS&D) will not be acceptable as *
l'
/
4
contracts will be acceptable for
should also be invited fmm one or more
imcmationrd shopjnn-.-, p.medim... '1
■
,,|) ll,.,.,,nii:1ct-..
foreign suppliers lor compa. .sons wnh D< .o,,
.ms It was agreed that, for “Other
A otherj’rpcmem'mt .roc
Suu;s on
j4
ScctipnJJiin-TJ9Y3 2.
•. the allotted amounts would be p
Catezorics of Procurement
sizes of die Credit amounts.
the basis of die respective!
Schedule 2: Imslcnientnua,n Promanv
II
substitute for NCB procedures. Such
1Qcal sllt,ppmg procedures. For
.
f the health sector allocation to the
‘Zi S-Xvelop.nent Program, with some minor
15
Para 1
7110 covcn:ml on
overall b^T^as moved to die Letter ° .ested by the Indian Delegation.
modifications relevant to each state xs sugg
Association for essential drugs and
cectnble to the
16
Para I <cY Details reaardme nonns ac
referral Ic-acl hospitals are 1
at fnst
' supplies^ mzuttenance of em.mm-.mt arid buildup
in Attachments 1 ^nd 2.
„f rcfci-ncc of the Strategic Planning
li
!’
1
!
i
........—.
.. bc |cvica in accordance with the
that tr.e: ;hart’es shall
p
Tuc parties
18.
IO m Attachment
program asd time'jble referred
4
.
a and 5 (ijij. Details on apiL-.d
■ -
.Esus
19.
cHiverv nonns at first referral hospitals are
provided in Attachment 4
schedule of appointment of key
nr.iced
Details icaaidma an
Attachment 5.
70
P a ra ? (U—51111—LUJrsonnd :hi: pwvii led in
headquarters personnel and other kev pe
,
..riieamsp^d in
,
o^ fiY k was anreed tint tl.e pt:tt.n.nn
Ess.
21.
acceptable.
H
P,,, , <c>
ork plan provided tn Attachment
The Assraano,. codlnncd to d» ■»»“”
6 is acceptable.
!
„ •
in other social sector projects, during
oa
Pam.
effectiveness tn
13'
■ 'T. the impl-miratancn annngements would
sustainability in each stale the
supervisiom the P
t)1= nsk 1D final
(
through a
achieving project objectives,Eclumism • for IIlfHllUll 1TUT, l'“ ""“'“Yell is Ite tomeial sitoion
scope of an ongoing me
eval».envs.sll®«l»»«
all state
ot
^v,
comprehensive mid-term review to
ar.iced that at
,.
if
of the health sector, v.as discussed
■;t:iinabihty n•achieve
financial
m
additional measures to
discussed.
. n,,.r.|,1p,.ll-n.^trnt^_ISlra^
24.
Pam- 111—......
Jj.ih511 and Jk'H'kwanl
IZe delivery in tiibal and b:ud..•
Strategy for service-----
. rncru; is p.ovi.ied in Attachment 9.
. ... -4 < ‘'~
agreed
t
|;rbtuniy 2, 1996
Agreed Minutes of Negotiations
I
5
t DeUeatron stated that the project Staff
Tbr Government Uli-l*
Hnr*; not contain
f
hn-. issucti regulations with
mid service improvements.
• We are still
26.
and found them satifactopwill adopt procurement
info,med us that it
of die regulations we will
awsittas PMSC sJ'““Li'”'B“k E"idcl““'. Upon receipt
Sine" tire notification establishing
has been met. S'Condition of Board Presentation
‘ “i”'toX
,d , has been gazetted,
l
the C-.Oi Health Sector Development
L p "„b Heal* Sy>'“™ Co.ponmon
Receipt of signed Letters
conmtion of Board Presentaoon or
thej punj^o
.u nol be necessaryv ..
tot Was anuetpa
Ncg0U:lll0ia, will be a cc:.'
PFOgram, that were
"’
OwM"
B“
'
)
I
I
.
i
I
the pjtject.
i/'
Ifiv'-n
/\ V'V'1
5
I
i•
Cv)
//•.•
Agreed Minutes of Negotiations
February 2, 199^;
6
ON BEHALF OF INDIA
ON BEHALF OF IDA
Mr. Rohit Modi
Deputy Secretary
Department of Economic Affairs
Ministry' of Finance
I
Mi. Tawhid Nawaz
”
Sr. Economist
Population &. Human Resources Divisio
India Department
I
»
»
A—V7
u'
■?
I*
Mrs. Shailaja Chandra
Additional Secretary
Ministry' of Health and Family Welfare
Government of India
0 Mr Syed Ahrr^Sir
Sr. Counsel, South .Asia
Legal Department
I
I
c
- f
Mr Cc'.SLrtre:n
Sr. Disbursement Ofncer
Disbuisemeiit Department
ON BEHALF OF KARNATAKA
i
/•
k
I
n
/rY<-
LA
Mr. B.K. Bhattacharya
Additional Chief Secretary &. Principal Secretary
Finance Department
Government of Karnataka
.—yC— a-------
Mr. Gautam Basu
I Secretary
Health and Family Welfare
Government of Karnataka
I
I
t
(?x )
!
Agreed Minutes of Negotiations
7
fcljinniy 2, 199
ON BEHALF OF WEST BENGAL
8L
Mr. Asok Gupta
Principal Secretary
Finance
| . r Government of West Bengal
r
I
/' ys. Lina Chakrabam
j^J^incipul Sx^ctcllua
Healthjand Family Welfare
Government of West Bengal
ON BEHALF OF PUNJAB
Mr. G.P.S. Sabi
Health and Family Welfare and
Secretary' to Chief Minister
Government of Punjab
Mr. Rajan Kashyap
Principal Secretary
Finance
Government of Punjab
QN BEHALF OF THE PUNJAB HEALTH SYSTEMS CORPt )R ATI ON
_________ ____________________
Mr. D.S. Bains
k
Managing Director
Punjab Health Systems Corporation
i
I
. r. •
' **
*^
.
,.
‘r
r
» .
*
•
’
.
’
•
; y--.2: ■'
*
•.
•
•
’
•- -
•
'
V
I
•
Gfov AUG 11 'S5
11:12An AB SA2PH Z32 47703S7
.
P.E-22
• •;*
The World Bank
'.fx ^'TERNATiakAL BANK FOR RECONSTRUCTION AND DEVELOP,WENT
international development association
1818 H Street N.w.
Washington, D.C. 20433
U.SA
(202) 477-1234
August 9, 1995
Mr. M.S. Dayal
Secretary Health
Ministry of Health and Family Welfare
Room 345, A Wing, Nirman Bhawan
New Delhi 110001, INDIA
Dear Mr. Dayal:
INDIA: Proposed State Health Systems Development Project II
We would like to express our appreciation for the cooperation extended by your
Government to the pie-appraisal mission that visited India in July-August, 1995. The ample
collaboration, counesy and assistance provided by your Ministry and the Secretaries of Health
and i amily Welfare in Karr: taka, Punjab and West Bengal, have enabled the mission to
undertake its task successfully.
This letter confirms i le general cc utent and recommendations of the wrap-up meeting
held in Delhi on August 4, .995 with Mr. indarjit Chaudhuri, Additional Secretary, MOHFW.
The aide-memoire was discussed with Mr. I. Chaudhuri and with representatives from the
Governments of Karnataka, West Bengal and Punjab and the Department of Economic Affairs,
GOT A final version of the aide-memoire for West Bengal, Karnataka and Punjab are
attached. The project would improve efficiency in the allocation of health resources through
institutional and policy development and improve the performance of the health care system
through improvements in the quality, effectiveness'and coverage of health care services at the
first referral level and selective coverage at the primary level in the states of Karnataka, Punjab
and West Bengal.
We appreciate your continued involvement in the project and the dedication of
Mi. I. Chaudhun, and the Secretaries of Health and Family Welfare of the Governments of
Karnataka, Punjab and West Bengal and their staff in the preparation of the project. We are
very pleased to note the excellent collaboration between the three states in the preparation of
the proposed project, particularly with regard to state level health policy issues. These will
greatly contribute towards attaining the objectives that the proposed project is seeking to
achie- e.'
We would like to reiterate the importance of following up on the actions listed in the
aide-memoire of the mission in each state in order to facilitate an IDA appraisal mission in the
coming months. In particular, the three statesneed to continue to make the sub stanna I progress
they are making with regard to revising project costs in line with discussions with the mission,
completing site and facilities surveys, finalizing the beneficiary assessment studies, completing
RCA
D VUJI M145 C FAX (202) 477-6391
\
Cable Address: 1NTBAFRAC
Cable Address: INDEVAS
1
AUG 11 '95
11:13AM WE SAZPH 232 47722S7
P.3/22
Mr. M.S. Dayal
August 9, 1995
the review of their workforce requirements, elaborating the system of referral for health care
services, completing the existing drug list on the basis of services to be provided under the
proposed project and finalizing procurement packages and implementation schedules. In
addition, Punjab needs to put in place a viable management structure to manage and implement
the project prior to the appraisal mission in early October.
As is customary we are copying this letter to Mrs. Rani Jadhav, Joint Secretary in the
Department of Economic .Affairs in MOF, Mr. Gautam Basu, Secretary Health and Family
Welfare of the Government of Karnataka, Mr. G.P.S. Sahi, Principal Secretary Health and
Family Welfare of the Government of Punjab and Mrs. Lina Chakravorti, Principal Secretary
Heahh and Family Welfare of Government of West Bengal.
Sincerely,
/Cz.
Richard Skolnik
Chief
F filiation and Human Resources Division
South. Asia Country Department H
(Bhutan, India, Nepal)
Enclosure: Aide-Me:noire
cc:
Mr. Indarjit Chaudhnri, Additional Secretary, MOHFW
Mrs. Ram Jadhav, Joint Secretary, Department of Economic Affairs, MOF
Mr. Gautam Basu, Secretary Health and Family Welfare, Government of Karnataka
Mr. G.P.S. Sahi, Principal Secretary Health and Family Welfare Government of
Punjab
Mrs. Lina Chakravorti, Principal Secretary Health and Family Welfare, Government of
West Bengal
I
P.5/ZZ
INDIA
PROPOSED STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II
WEST BENGAL
INTERNATIONAL-DEVELOPMENT ASSOCIATION
AIDE-MEMOIRE (AUGUST 1995)
1.
An International Development Association (IDA) team consisting of Messrs./Mme.
T. Nawaz (mission leader), S. Rao-Seshadri, K. Hinchliffe and D. Porter visited West
Bengal between July 31 and August 3, 1995 to review preparation and pre-appraise the
proposed State Health Systems Development Project II in West Bengal. The mission would
like to express its gratitude to the Chief Minister of West Bengal, Mr. Jyoti Basu, the Health
Minister, Mr. Prasanta Sur, the Finance Minister, Mr Asim Dasgupta and the Chief
Secretary, Mr. N. Krishnamurthi for meeting the team to discuss project development
activities. The mission had detailed discussions with Mr. Asim Dasgupta and the Principal
Secretary Finance, Mr Ashok Gupta, on key issues regarding the proposed project. The
mission would like to thank L.rs. Lina Chakravorti, Principal Secretary, Health and Family
'Welfare Department. Govern i .ent of West Bengal, who arranged all meetings and
discussic ..s with the mission ::om her hospital bed. The kind cooperation and hospitality of
her colic.igues in the Health cad Family Welfare Department is gratefully acknowledged
A review meeting on the aide-memoire wi.> held with Mrs. Lina Chakravorti and members
of the project core team on August 3, 1995 in Calcutta,
2.
This aide-memoire records the overall progress made in the preparation of the
proposed project, summarizes the main findings and recommendations of the pre-appraisal
mission and the understandings reached with the Government of West Bengal on a proposed
plan to appraise the project in October, 1995.
PROJECT OBJECTIVES AN() COMPONENTS
3.
Objectives; The Govei ament and the Bank reconfirmed that the main objectives of the
proposed project remain : (i) u, improve efficiency in the allocation of health resources
through policy and institution;.- development; and (ii) to improve the performance of the
health care system through improvements in the quality, effectiveness and coverage of health
care services at the first refen al level and .selective coverage at the primary level. The
achievement of these objectives would contribute to improving the health status of the people
of West Bengal, especially the poor and the underserved, by reducing mortality, morbidity
and disability.
4Components. It was aho reafiirmed that the project would have the following major
areas of investment, (i) Management .DeyeVopment and Institutional Strengthening including
(a) improving the institutional framework for^-policy development; (b) strengthening the
management and ircplemeniat?on capacity of institutions including structures, procedures,
1
/I
7
9
management miormation systems, culture of service delivery, resources and training;
(c) developing surveillance capacity for the major communicable diseases; and (ii) Improving
Service Quality. Access and Effectiveness by: (a) extending/renovating rural hospitals
sub-district and district hospitals, and district-based state general hospitals; (b) upgrading
their clinical effectiveness, (c) improving the referral mechanism and strengthening linkages
with the primary and tertiary health care levels; (d) improving basic health services in
underdeveloped and remote areas, including the Sunderbans.
POLICY FRAMEWORK
5.
Discussions beWeen the Bank and the Government on key policy issues continued to
progress very satisfactorily. The Finance Minister informed the mission that the Government
is committed to a policy package of health sector reforms reflecting key sectoral development
issues for the primary and secondary levels of health care. These include the need to:
(i) increase budgetary allocations to the health sector; (ii) allocate most of the incremental
funds for the health sector to The primary and secondary levels of care; (iii) safeguard the
operations and maintenance component of the health budget to ensure adequate supplies of
drugs and essential medical materials and maintenance of equipment and infrastructure;
(iv) set up a Strategic Planning Cell under the Health Secretary to undertake analyses of
health sector issues; (v) strengthen me He-dth Department’s role and provide it with
autonomy in managing essent .d operational activities such as civil works and construction
and man :enance activities in <ollaboratior with local government; (vi) contract out selected
services, (^specially supporting sendees; (v,i) enhance linkages in health care delivery’ with
the priva e and voluntary sectors; and (viiij implement service improvements ano user
charges, fhe Finance Ministe: stated that ine Government was commined to underraking
specific actions on key issues noted in a draft letter of Health Sector Development Policy.
The draft letter, prepared by die Government and addressing the important policy issues
noted above, was discussed with the Health Secretary and her colleagues. This will be
finalized by the time of the rrpraisal mission
6.
Uyer Charges. A Goveinment Order dated February’, 1995 is currently under review.
It was agreed that user fees foi services such as paying beds, cabins, charges for diagnostics
and OPD registration fees would be more widely implemented based on the recommendations
of this review. It was agreed that 30% of beds at district, state general and sub-divisional
.hospitals would be designated as paymg beds. Methods of identifying and targeting the poor
for exemptions were fully discussed. The Government stated that the JRY poverty criterion
set by the Planning Commission, GOI, which applies only to rural areas, would not cover
large sections of the population due to extensive urbanization in the state. It was therefore
agreed that the current system of providing exemption on the basis of an ’Indigent
Certificate from the local elected representative, given to families with an income below Rs.
1,500 per month, would be a viable system. It was also agreed that emphasis would be on
implementing the system more rigorously. The Government, through the Finance
Department, currently reallocates 50% of funds collected through user charges to the
collecting ?nstitution. It was agreed that revenue collected through user charges at district,
1
1 '95
WE
ZEZ 477£?!97
r“.
S£“£S£=SE““'' f. -^y—5 u"Lb| L>ie Pni^te Sector, li was agreed that the Government will contract out
services to the private sector, such as laundry, cleaning services,- and catering wherever
feasible and explore opportunities for contracting out specialist and diagnostic services The
Government proposes to appoint doctors at rural health facilities on a contract basis to
overcome medical staff storages m rural areas. It was agreed that the Government would
work co'laborauvely wtth both the private and voluntary sectors which may have a
comparative advantage m improving access to health care services for disadvantaged groups
? ymy arey The Health .secretary informed the mission that the West Bengal Clinical
heaim Sre'facmtier^
' 'Credltauon and registration of medical personnel and private
8.
Gender Issues. In add-tion to providing women with improved access to better quality
hospital . ervices, particularly for essential obstetrics care, the project would strengthen
reproductive health services at all levels, particularly in underdeveloped and inaccessible
areas. The project proposal includes a strong IEC component to sensitize the public to
women s health issues generaLy, and promote the ’life-cycle’ approach to women’s health.
9'
Li-ika es with Oher . .alth Sector Aoiects. The proposed project complements and
consohd;- :es the investments rtade by on-going Population and Health projects in West
Bengal s’ pported by the Bank, and also rhe cunent and prospective health projects assisted
by bilateral donors such as OGA and KFW. It provides policy and implementation
co-ordinauonjith other health and family welfare projects. The proposed project would also
rill some of the input gaps in primary health care in the Sunderbahs.
PROJECT PREPARATION PROGRESS AND RECOMMENDATIONS
Oyrall Progress. Substantial progress has been made in project preparation activities
since the xast mission. The revised project proposal (July, 1995) has incorporated the
recommendations of the last aide-memoire. An important recommendation of the mission was
with regard to staff quarters. The mission suggested that the number of new staff quarters
proposed was on the high side and it was agreed that the number of new quarters would be
united to those m remote areas. Elsewhere, the program would mainly be one of renovating
existing staff quarters. Other components of the project have been very well developed.
However, project costmg needs to be fine-tuned on the basis of extensive discussions with
this mission.
. ^L'Id7-"d™slstration i-gd.Management. The project management arrangements,
additional staffing requirements and functional responsibilities have been very well
documented in the revised proposal. The Finance Minister informed the mission that because
of me scope of this project, the Government was proposing to strengthen the Health
1
' 1 • 1 D'—Sr-iL-F-'H
P.&/22
-'‘-'7
-4-
Department s role by providmg it with autonomy in managing essential operational activities
such as civil works and construction and maintenance activities in collaboration with local
Government. The functions of the Strategic Planning Cell were clarified and agreed upon. It
was also agreed that the Strategic Planning Cell would report to the Health Secretary.
12'
Service Norms. A project preparation workshop involving key stakeholders in project
design and organized by the Department of Health and Family Welfare in May, 1995 defined
die roles and functions of the various types of health facilities and referral hospitals. The
findings of the workshop have been issued by the Department of Health and Family Welfare
and were used for revising the project. Hie mission reviewed these norms in detail and
agreed with the Government with regard to some minor modifications.
. ^fg-Surveys. and Preparation of Physical Works An extensive survey jf all health
facilities at the secondary lev.;! is well underway, The mission reviewed some of the survey
documents and found them satisfactory. Given the progress to date, it ? expected that the
survey will be completed, and the reports issued by September, 199*. The Government has
also prepared the preliminary designs of 10 hospitals which are s’c^ed for upgradation and
they were discussed with the mission.
Analysis ofJEquipmen. Inventories. Information 'concerning the nature and state of the
currenr inventory hao been ga.’.acred from each faciJ'iy that will receive inputs under the
proposed project. The core teim needs to analy-^ the inventory returns and to complete the
computer zation of this inforn ition. Based cu me clinical service norms, the mission, jointly
with Lu£ ^.Tovemment, has reviewed and ^;ined the equipment lists for various types of
hospitals.
Equipment Manageme*.t_and Maintenance, The Department of Health has elaborated
an action plan and the specific mechanisms to ensure state-wide coverage not only of project
investments but all cur cat equipment and plant used by its health services. This work would
be contrav.^d to a Government company, Electro-Medical and Allied.Industries Ltd., which,
along with the .acility survey ceam(s), would assess local capability to provide technical
suppex t
nospital equipment maintenance, and explore the possibility of using private
r^-kiu.Further analysis ol the mamtenance and repair coverage plan and the detailed
proposals ior in-house manpower and workshop facilities should be undertaken for discussion
•with the appraisal mission,
yȣorkforce. Based on Lie sendee norms agreed upon, the proposed levels of staffing
for medical and nursing cadres have been reviewed during the mission. In addition, a
package of incentives is being ('evcloped to improve the recruitment, deployment and
retention of staff in areas where difficulties of posting and retaining staff are being
experienced. Where it is difficult to retain staff in remote areas, the Government is proposing
to hire medical professionals on a contractual basis.
11 : 15-r
4770397
JXT* *
modules.
S MZ11=X™S^
F.S/ZZ
beiM
“d
5=2^^
policies, information systems, asset management and maintenance, EEC, HMIS and
conducted^ SySt£mS’
Government has identified institutions where such training wiU be
^9Pkn f°r Developing Surveillance CapaciTv for Major Communicable Diseases. A
oevelopment plan for a state-wide system for major communicable disease surveillance,
included m the proposal, nas teen discussed with the mission. Based on the burden of
disease in the state, sixteen m^jor commur.icable diseases have been identified by the
Government. These and othu hseases will be brought under the surveillance system and
channels ave been defmed th tough which information will flow. Parallel efforts will be
Private medical practitioners. The surveillance system will be
linked to HMIS. A link with the Strategic Planning Cell needs to be established; community
participation uj the surveillance network needs to be more clearly elaborated. These issues
will be further discussed with the appraisal mission.
20.
E^alth.Management Information System.The mission discussed the concept
for HMIS presented in the proposal and recommended that computer-based MIS is provided
at the district level linked by modem to the computer system to be provided at the district
health suiveillance office. A -torkshop will be held to work out the content of the form to
be used. The HMIS system wi;' also establish a link with the referral mechanism
?k
■Detailed Project Costs. Project costs have been revised and need further revision
mcorpora'mg the changes discussed with the mission. It was agreed that the detailed revised
cost tables will be sent to the Bank by August 20, 1995. After revision, preliminary total
P7jeCtTTCc°S“’cogencies, are expected to be approximately Rs. 690 crores or
about USS172 million. Recurrent costs are expected to be about Rs.45 crores annually at
project completion. The Finance Minister and the Principal Secretary, Finance informed the
mission that the Government will have no problem in bearing this additional recurrent cost
burden.
1
r. 10/ZZ'
//2 t
- 6 -
22'., topJementation Sched_ule_a5d_Pro£-irgment Plan. Am implementation schedule of the
civil works program has been prepared by the Government and reviewed by the mission.
Procurement packages for civil works arc being finalized. The implementation schedules of
the equipment and software components need to be finalized as well. The Government has
Sr mPx™e r'
AUgUSt 2°’ 1995’ Members Of
West
^e team visited
die Bank s NDO and collected and discussed relevant Bank guidelines on procurement
Procurement packages will be discussed with the appraisal mission.
23.
Land Acquisition. Because the proposed project involves renovation and extension of
existing facilities, it is anticipated that the need for land acquisition will be minimal The
Government has provided assurance that none of the sites where hospitals will be upgraded
- Will entail involuntary resettlement of any persons.
-
24.
Brug. Lut. The Government provided a drug list to the mission, which is being
reviewed The mission suggested that the technical specifications of the elements common
wnh the Andhra Pradesh drug list be incorporated by West Bengal since the Andhra Pradesh
list had already been cleared by the Bank
I5'
— for
of iV/edical. Waste. The proposal for the disposal of medical waste
has been reviewed by the mis.von. It has teen clarified that the plan for medical waste
disposal saould mclude al] ho.pitals, including ternary hospitals not included in the project.
Trammg modules wid need to be developed for staff at different health facilities responsible
for medic il waste disposal. Amangements for the temporary storage of waste prior to
disposal need to be developed and the technical specifications of incinerators and purolators,
including :apaciiy, at various :icilities need to be finalized.
Tribal Plan. The mission discussed the need to develop a tribal plan for the project
h°W the pr0JecT ^vities will benefit tribal peoples. As agreed previously,
die Tribal Plan integral to specified project components, is being developed based on the
findings of the beneficiary/social assessment’ study discussed below and other available
informatics.
26.
Assessment and Ute Private Sector Studies. The core team and
. ORG researchers responsible for these studies have met on a regular basis to discuss the
main findings and use them to fine-tune project design. A draft report of the studies has been
provided t > the mission. The document will be finalized based on comments to be provided
by the mission.
28.
Pertonnance_Indicators. A. list of performance indicators was discussed and agreed
upon. The core team will Hne-iune this list, to be reviewed with the appraisal mission.
^9.
N^x
GAen the excellent progress made by the Government in preparing the
~rr.. Steps. Given
project, it is expected that an appraisal mission could be scheduled for October, 1995, on the
understanding dial the remainin i activities recommended by this mission are completed.
1
f
INDIA
PROPOSED STATE HK^LTH SYSTEMS DEVELOPMENT PROJECT H
(PUNJAB)
INTERNATIONAL DEXTLOPMENT ASSOCIATION
■AIDE-MEMOIRE (JULY 19951
J1116™111®1331 Devebpment Association (IDA) team consisting of Messrs. /Mme.
T. Nawaz mission leader), S Rao-Seshadn, K. Hmchliffe and D. Porter visited Punjab
betw-een July 24-26, 1995 to review preparation and pre-appraise the proposal for the Health
Project H in Punjab. The mission would like to express its gratitude to
the Chief Minister of Punjab, Mr. S. Beam Singh, and the Health Minister of Punjab,
Mr. H.S. Erar for meeting the team to discuss key issues regarding the project. The mission
also met with Mr. A.S. Poom, Chief Secretary, Mr. R. Kashyap, Principal Secretary
Finance, Mrs P. Khetrapal Singh, Secretary Finance and Accounts, and Mr A. K.’Dubey,
Secretary Planning, Government of Punjab. The mission would like to thank
Mr G.P.S. Sahi, Principal Secretary Health and Family Welfare Department and his
colleagues for their cooperation and hospitality. A review meeting on the issues covered by
this aide memo ire was held v. ill Mr Sahi and his staff on July 26, 1995 in Chandigarh
t nt
This aide-memoire reo: res the ovc. Jl progress made in the preparation of the
proposed project, summarizes he main fir.hngs and recommendations of the pre-appraisal
mission, nnd the understands s reacaed with the Government of Punjab on a proposed plan
to apprai ’.. the project in Octc i ^r 1995.
PROJECT OBJECTIVES .AND COMPQNENTS
Objectives, ihe Government and the Bank reconfirmed that the main objectives of the
project would be to. (i) improve efficiency in the allocation of health resources through
policy and institutional development; and (ii) improve the performance- of the health care
system thiough improvements in the qualiv/, effectiveness and coverage of health care
services at the first referral level and selective coverage at the primary level. The
achievement of these objectives would conn ibute to improving the health status of the people
of Punjab, especially the poor tnd the underserved, by reducing mortality, morbidity and
disability.
.
Cgjiponents. It was reaffirmed that the project would have the following major areas
of investment, (i) Management Developmenr and Instimtional Strengthening including
(a) improving the institutional framework for policy development; (b) strengthening the
management and implementation capacity of institutions including structures, procedures,
management information systems, culture of sendee delivery, resources and training;
(c) develop mg surveillance capacity for the major communicable diseases; and (ii) Improving
3^ry.ice_Qualir\\ Access_and Effectiveness byj^a) extending/renovating communityarea and
1
r. 1
fr Lc
2
±^:L™P"d5:2L?Lradm?. ■±£r dim^ effectiveness; and
miprovmg the referral
mechanism and strengthening Hr.Vac,
jes with the primary and tertiary health care levels.
POLICY FRAMEWORK
budgetaxy allocations to the health sector;'® alScaumM
^crememlZds for the
health sector to the primary and secondary levels of care; (iii) safeguard the operations and
maintenance component of the health budget to ensure adequate supplies of drmrs and
essential medical materials and maintenance of equipment and infrastructure; (iv) set up a
Strategic Planning Cell under the Health Secretary to undertake analyses of health sector
issues; (v; contract out selected services, especially supporting services; (vi) enhance linkages
m health care delivery with the private and voluntary sectors; and (vii) implement service
improvements and user charges. A draft letter of Health Sector Development Policy prepared
by die Government and addre.iing the important policy issues noted above was discussed
^th the Health Secretary ano lis colleagues. The Chief Minister and other senior members
of the Pt jab Government, in:hiding the Health Minister and the Principal Secretary
Finance, ..rated that the Gove^ment was c:mmitted to undertaking specific actions on some
key issues contained m the dn.i letter. Th.: letter will be finalized by the time of the
appraisal nission.
J--?-g.r.Charges. It was apreed -that user fees for diagnostic and treatment services
would be mord widely implemented and further enhanced as rehabiliuted facilities are phased
m. It was agreed that the 1994 Government Order giving notification of a new schedule of
charges which is still pending, would be issued with a change to exempt the population
below the poverty line from the OPD registration fee. Practical methods of identifying and
targeting the poor for exemptions were explored in detail. The mission agreed with the
Government's proposal to use its existing system for identifying and targeting the poor for
free service on the basis of beu^g eligible to hold a yellow card. The Government
reconfirm.-.d that the funds collected through user charges would be retained at the point of
collection, ft was agreed that mer fees would only be used for non-salary recurrent cost
purposes.
■ ,
L-lnkar.es Win, the Pnvaieand Voluntary Sectors. It was agreed that the Government
will contract out services to'the. private sector, such as laundry, cleaning services, and
catering wnerever feasible. During the mission, the prospects for recruiting suitable NGOs
were discussed. It was agreed 'hat the Government would work collaboratively with both the
private and voluntary sectors ir general and, where necessary, contract out the delivery of
ealth care to Lie voluntary sector which has a comparative advantage in improving access to
health services for disadvantaged groups in remote areas.
f
Gender Issues and Reproductive
K^M',aive Health,
HiaW J11
•P««l U- ae proposed project would
°°5 ,mI “ sensitize
S“slt“ the
Ihe public
P“bUc to
W the '"lifecycle’life-cycle" approacl
approach to women
wometrs
’s
hed„. The Government well continue elaborating their ideas on activities beating on
wocen’s- health, beyond those induded
included im the IK component, for molusion in ±e project.
women
PROJECT PREPARATION PROGRESS AND RECOMMENDATIONS
Pr°^ress- Progress with regard to project preparation activities since the last
mission has been quite satisfactory. The revisions made in the project proposal reflect most
i
points raisedthe aide-memoire of the last mission. As noted in the last aidev-moire une,
0) e revised proposal has targeted project investments on the Upper
’.,7k 1,°%
W
C Pei'entaSe of population below the poverty line, at about 40%, is
aV:rage' Howei-er, three important areas of concern remain: (i)
the number of staff quarters poposed is disproportionately high; (ii) the survey of facilities
as not been initiated, although satisfactory progress has been made in collecting information
on the current equipment inventory; and (iii) the Government’s proposal to set up a
corporati m to manage and implement the project could unduly delay project developmem.
Tms is expected to require co-.unitment and immediate action at the highest level of the
Government. The Govemmen: and the mis.-ion agreed that these issues would need to be
given top pnonty for the proj mt to be appiaised in October. Details on these aspects are
provided jelow m ma relevan, paragraphs.
l0;
.T5 • lg,CT Ad™ini5tration nnd Managg.-ient. To facilitate health care delivery at the first
reterral level, me highest leve .; of Punjab Government expressed to the mission their
eagerness to implement and mmagexhe proposed project through the establishment of a
corporate set-up, much like the approach followed in .Andhra Pradesh. The mission pointed
out the risks of opting for this approach since any delay in estabhshing a project
SU?CtUr! W0Ul7 delay project-'’-°cessing at this late stage and undermine the good progress
achieved in other aspects of pi eject development. The Government informed the mission that
i
UP 3 corpOTat£ strucmre had already been initiated and the Chief Minister,
the Heahl. Minister and the Chief Secretary stated that the Government would have
established a corporation and worked out all the details of its functioning, including the legal
and admmistrative implications, prior to the appraisal mission planned in October.
V" v
^un’“T and Pry-para jon of Physical Works. It was agreed during the last mission
that the Government would undertake an extensive survey of all health facilities at the
secondary level similar to the work being done by Karnataka and West Bengal. The last
mission agreed to arrange gram, funds to cover part of the costs of conducting site surveys
and evaluating the existing inventory of equipment at facilities that it is proposed to include
withm the scope of the project. The Government and the mission agreed that this work
needed to be undertaken exped.tiously. However, progress got delayed since the last mission
bom because the Health Secreuuy had been changed and the consulting firm, with whom
discussions had progressed on ihe works, reneged on the terms of the contract ar the last
moment. Ihe new Health Secretary has taken up the site survey as a matter of urgency and
1
p.
4
informed the mission that most of the of the facilities would have been surveyed by October
Tne.rmssion agreed that given high priority, the survey could be completed in two months in
12.
Sen ice \ c'rm^^A PJ^^P^P^tion^wo^shop involving key stakeholders in project
design and organized by rhe Departin'
id' meSV*'reV1!mS
Proiect-
an agreed uith the Government with regard to some modifications.
?;
»™ to leuil
Anafrs?s of Eqwment Inventories. A postal survey has been undertaken to
a
“™‘“ Of
at
furies. This emailed suff
t each facility completmg a proiorma questionnaire in which they recorded most of the
relevant data. The posta) survey questionnarre d.d not included Jy Z“for WorXon
on service activity data, and this matter now needs to be followed up by the project
stren^ened^rh11'
PreV10113 Imssion
understood that the Government had already
L ngthened the project preparation team by appointing a technical adviser with expertise in
and.mamt£nance of ^spi^ equipment to take responsibility for analog and
T1° i ■ e^PU1T
-“turns. In fact, this has not happened and the work is
present!} oemg done by a nor-technical officer from the Department of Health The mission
t
T
mOre efftcnve t0
a teCimicaI exP£rT
originally proposed to
s
ish * hat necessary mainmnanoe or repair work on existing equipment and what
^cufol'^p^rXcrLT'
“ br“E
<
na^Ce and-^naggment. The Department of Health has elaborated
action plan and the specific mechanisms to ensure state-wide coverage not only of project
estments but all current equipment and plant used by its health services. The technical
MDaberrieC?lted’
7th
faCmty SUrVey team(s)- wouId contribute by assessing local
\ Pr0V1 p te.ClmiCal SUp?OlX fOr h0SP1Q1 cW™ including the possible of
dXhed
i^f Funhker
of
maintenance and repair coverage plan and of the
thk irhPr°^0SH1S fOrfm^OUSe ounpower and workshop facilities should be undertaken by
this technical adviser for discussion with the appraisal mission.
S r111’
Pro-'ec: Pr0Posai ttas laid out a good
good plan
plan for
for strengthening
strengthening the
the
inci^m^
b£twesn
different tiers of the health system. The plan was reviewed,
m l dmg the proposed incentives to encourage patients to use the referral mechanism.
reStedTat^aS
adniniStratlVe Adelines are being developed and will be
Chmcal, Skill, and Mana
Other Special
Special Train
Training.
training plan
plan for
cf;
•^nrij^ngntand
^mgMa_QU3er
ing, A
A training
for
strengthening clinical skills has •jeen developed
by the
the Government.
The mission
developed by
Government. The
mission reviewed
reviewed
this plan and found it satisfactory; some mmo'r additions were suggested. It was clarified that
ZG2 -Tress?
some of the trawing would be coordinated by the district hospitals, where facilities will be
nhan.ed for this purpose. Training in management and other technical skills has been
d'scussed wtth the Government covering personnel policies, finance issues, procurement
p icus, information systems, asset management and maintenance, IEC, HMIS and
«nducSCC SyStemS’
GcVernni£nI has idenWied institutions where such training will be
17
Manage^ Informalio_n£ystems (MIS). The MIS included in the project proposal
th^/om'’7^
Wa? C,°nSldered aPProP^. The mission suggested that deuils regiding
the computerization of the systems needs m be further developed.
S
x? ’ - ^an ^Or Bey eloping S urveillance Capacitv for Major Communicable and
^on-Communica^le Diseases. A development plan for a state-wide system for major
commumoable and non-comn umcable disease surveillance has been drafted and discussed
with the mission. Based on tbs burden of disease in the state, a number of major
commtm-cable and non-communicable diseases have been identified by the Government.
The^e diseases wrU be brought under the surveillance system and channels have been defined
through which information wf.l flow. Parallel efforts will be made to improve reporting by
private medical practitioners. The surveillance system will be linked to HMIS. A link with
e Strategic Planning Cell needs to be established; community participation in the
surveulau:e network has been proposed ami needs to be further explicated. These issues will
be discussed with the appraisa. mission.
, jQtonnatiom Education .and Commu.iication (IEC). The IEC proposal was discussed
with the mission. TEe IEC component has been formulated to focus on the need to raise
public awareness of preventive measures. It will now need to be fleshed out, taking into
account the findmgs of the beneficiary assessment study. Opportunities for contracting out
some of the IEC activities will-De reviewed.
20'
Bailed Project Costing. Project costs have been reviewed and need further revision
incorporating e c anges discussed with the mission. The main changes are with respect to
civil works component, especially the construction of staff quarters. The mission was of the
opinion that the nmnber of staff quarters proposed under the project was disproportionately
high. It was agreed that the Government would make substantial reductions in this area. It
was also a,meed that the detailed revised cost tables will be provided to the mission by
August 20, 1.95. After revision, preliminary total project costs, including contingencies, are
expected to be approximately K.s. 400 crores or about USS100 million. Recurrent costs are
expected to be about Rs.25 crores at project completion. The Principal Secretary, Finance
has informed the mission that the Government will have no problem in bearing this additional
recurrent cost burden.
21.
Dru.:, List. The Government provided a drug list to the mission, which is being
reviewed. , ne mission suggested Uiat the Technical specifications of the elements common
I
HJG 11
’95
P.16/22
11:20mN UE
6
B^.te,'POra“ ,’y P“I,,ab
M
““
P“toh
£ H, Hm^r D“posa' «> MWHrtUaai. The proposal for the disposal of medical wasie
has been reviewed by me rmssion. k has been clarified iha. the plan lor mediSl waste
disposal should include all hospitals, inclcdm. ternary hospiUlsnot incX “ the“mject.
Staff at facility level who wi1!
carry out the disposal function need to be identified from
among the existing personnel.
different health Taedidos
Se
temporary storage of waste prior to disposal need to be developed^e^XS
specificauons of incinerators, including capacity, at various fadlities n^ to b“ ified.
'I3'
Beneficiary/Social Assessment and Private Sector Studies The Beneficiary/Social
I 2d T?hnt
PnVate SeC2r StUdiCS 216 P10^5^ weI1
a preliminary d2ft of phases
I and II have been given to the mission for review and comment. The mS is nLaLd 2
note the very good work being done by the Foundation for Research and Developme^of
Lnderpnvileged Groups in collaboration with the Government.
eiopment
Performance Indicator. A list of p'.-rfonnance indicators
thesf by i.a^^0O1995 Opk 1
’Xtp
':KpllcItly- 1716 Government has agreed to provide
"bed“',ssed“ith
^rinTT^y^-t1-1011' Be<^v-se the ProPGsed project involves renovation and extension of
,..:n
.
nce
ncne °*
Will entau involuntary resettlement of any persons.
27.
sites where hospitals are to be upgraded
upgiaueu
Next Steps An appraisf mission could be scheduled in October 1995 By that time
JSSf ”■? "* “ hjre C0’”,,1'“'1 ‘ S' lbscmlial »«*» *
si“ Xy «d™'’
has mad a
e S mcture
and implement the proposed project. The Government
made good progress wift , :gard t0 other aspec:s of
project R is expect£d
end of September °
concerning the remaining activities will be completed by the
August. 1995
I
IND LA.
PROPOSED STATEJjEALTH SYSTEMS DEVELOPMENT PROJECT 17
Karnataka
IHISENATIONal development association
AIDE-MEMOIRE (JULY 19951
1.
An Intemaxional Development Association (IDA) team consistmg of Messrs /Mmes
fr^S- ^°;Se5hadn’ K’
'
D. PortJvtsiS
State Health Systems Dev/l ’ "5 p° revieW
and pre-appraise the proposed
State Health Systems Development Project D m Karnataka. The mission would like to
2^7 w 213 uC 2
Chl£f
of Kara^ Mr. H. D. Deve GowdtX
H C'
1116 Medical Education Minister
i . .. B. Paul for meeting the team to discuss key issues regarding the project The
Sief Se^taX^ B K1 RSh B'
Chief Secreta^'- Mr. C. Noronha, Additional
Lmer Secremry, Mr BX. Bhattacharya, Additional Chief Secretary Finance and
NfcM Sundaram, Principal Secretary to the Chief Minister and to the Department of
n 'fTn 2150 dlScussed the project development activities with
Mr. I. Chaudhun Addmonil Secretary, Ministry of Health and Family Welfare
Goverament of India The russion wou d like to thank Mr. Gautam Basu, Secretary Health
D.ef.arilenl’ Govern meat of Karnataka, and his coUeaguTfotheir
■ ou su ojP1' jy A review mi*eting on the aide-memoire was held with
Mr. C Basu and Mr. I. Ch-udhuri on J ;,y 30, 1995 in Bangalore.
2.
This aide-memoire r-. cords the overall progress made m the preparation of the
Propos’d Project, summamis the main Endings and recommendanons of the pre-appraisal
mission and the understand, ngs reached r/ith the Government of Karnataka on a proposed
plan to appraise the project , .a October.
piupvscu
PROJECT_OBJECTTVES A ]<D COMPC > NENTS
■
L
kGoVvmment and the Bank reconfirmed that the main objectives of
the project would be to: (i) -mprove efficiency in the allocation of health resources
develoPrrenP “d (ii) improve the performance of the
S*
Sy
^ghimproyements in the quality, effectiveness and coverage of
The
SerV1Ces L e
rererral level and selective coverage at the primary level
Tr
?f S£ objecnvss WOuM conCtbute to improving the health status of the
peopeiTKarnataka esp^cia/y the poor and the.underserved, by reducing mortality
morbid y and disability.
7
6
4.
c omponents: It was reaffirmed that the project would have the following major
areas of mvestment: (i) Mam^ment^elopment and Institutional Strengthening
mpr°vms Ihe ^titutional hamework for policy development;
( ) trengthemng the managen^enr and mipjementation capacity of instiTutions including
structures, procedures, managr mem information systems, culture of service delivery'
resources and training; (c) developing surveillance capacity for the major communicable
I
F.lc/22
1 '=5
SCXe^“d/(li)
and Effectiveness by:
22
g/renovatmg communtty, area and district hospitals; (b) upgrading their clinical
pnmary and ternary healn/cX lev^
WIth *e
rpn^y
.
7 , . , care7
care
first
referral
for levels, and (d) improving access toSTs
md
^and
“d
women.
POLICY FKWEWQRK
5^
Discussions between the Bank and the Government on kev policy issues continued
X ™T,eiy ^Si?OnlyGovemme* iterated its comXS to unp^entT
polity package of health sector reforms that will include key sectoral developm^t issues
ftr ±e primary and secondary levels of health care. These mclude the need to; 0 iSXe
’
SS
T
SeCtOr’ ®
most of the incremental funder
46 Pmnaiy and secondaiy leve15 of care; (iii) safeguard the operations
COmpOD.ent of the hea]th budget to ensure adequate supplies of dSjTand
essential medical matenals and maintenance of equipment andmfrastnXe; (iv) set up a
categic Planning CeU under the Health Secretary to undertake analyses of health sector
issues; (v) strengthen the Health Departments role and provide it whh autonom/m
managing essential operational aenvnies such as civil works and construction and
maintenance activities, (vi) contract out selected services, especially supporting services;
( uj enhance linkages in health care delivery with the private and voluntary sectors; and
(vm) implement service improvements and user charges. A draft letter of Health Sector
Development Policy prepared by the Government and addressing the important policy
issues noted above was discussed with the Health Secretary and his coUeagues.
mrmtment on specific actions was also obtained on some of the key issues contained in
the draft letter from the Chief Minister and other high levels of Government, including the
Finance Secretary. This will be finalized by the time of the appraisal miss.on
h
Charges. It was agreed that user fees for treatment and diagnostic services
would be more widely implemented m a phased manner, and the 1988 Government Order
on user fees would be revised. Methods of identifying and targeting the poor for
exemptions were fully discussed. It was agreed with the Government that the poverty line
set by the Planning Commission, GOI, of Rs. 11,000 per annum, on which the JRY
program is also based, could be used for targeting poor people for exemption from user
c ' ges
e easi ty of insuiuting differential charges for those whose income exceeds
Rs. 50,000 per annum, and are liable for income tax payment, was also discussed with the
Government and would be reconsidered during appraisal. It was agreed that revenue
collected through user charges would not go back to the state treasury but would be
retained at the district level, to be reallocated by District Health Committees amongst
hospitals in the district based on both need and level of revenue collection. It was also
agreed that user fees would be used specifically for non-salary recurrent cost purposes.
Z.’
Linkages with the Private and Voluntary Sectors. It was agreed that the
Government will contraci out services to the private sector, such as laundry, cleaning
services, and catering where ever feasible. During the mission, joint discussions were held
___
SPZPH
4-’?03S7
P.1S/ZZ
between the Government, the Bank and
an NGO representanve to discuss the scope for
participation of the voluntary' sector in implementing the SC/ST and reproductive health
components of the project It was tagreed that the Government would work collaboratively
with both the private and voluntary
the delivers of nnmar,,
sectors m generai and, where necessary, contract out
P
t0
VoluiW sector which has a comparative
^tage in improving access to health care services for disadvantaged grou^Tremote
. ^-k^cs
QthELhgahh sector projects. It was reaffirmed that the proposed
EXL? £ment
C°nS01idaIe mvesCneDts
on-going Po^S
H«dth and Nutation projects in Karnataka by providing policy and IplJnenSon Sordinanon with exther health and family welfare projects', ^rtaularly X regXX
fl^cn d repr2d.uctlve heaJth components of the project The proposed project would
also fill some of the mput gaps m primary health care in tribal areas The scope of KFWs
’
10
SeC°Dd^
facilities mfour “sta^f
WaS
dlscussed- h was agreed between the Government, the Bank
dimlSrin X
m 111056 distncts wouJd be complementary and avoid
dupheanom Discussions were held earlier with KFW to finalize project implementation
PROJECT PREPARATION PROGRESS AND RECOMMENDATIONS
P' . . .
progress. Substantial progress has been made in project preparation
acuvmes since: the last mission. The revised project proposal (July, 1995) has incorporated
Ee recommendations of the last aide-memoire, in particular the Government has rJSed
the list of hospitals and deleted several speciality hospitals that were included in the
previous version of the proposal; _a mental hospital still remains to be deleted. TEe survey
15 PrOereS5mg weU
15 expected to be completed by September,
a first draft of the beneficiary social assessment was provided to the mission and the
prelimmay findmgs are being used to fine-tune the project design; and the norms
developed at the workshop held m Bangalore earlier this year on service norms have been
reviewed by the mission and agreed changes have been incorporated. Overall, the project
proposal is very well conceived.
..
H J
1°,. . ^°l-e-g Adm™stration and Management. The project management arrangements,
addmonal staffing requirements and fimcuonal responsibilities have been very well
ocument m e. revised proposal. Some changes were agreed upon during the mission
It was agreed that the Health Departments role would be strengthened by providing it
with autonomy m managing essential operanonal activities such as civil works and
construction and maintenance activities. In addition, tins arrangement would improve the
TTP™e^U°n °f *eavil works component of other Health and FW projects, especially
the IPP K project, being undertaken by the state. It was also agreed that the Strategic
Planning Cell would be under the Health Secretary. It was confirmed that an Additional
Secretary would be the Project Coordinator and would be fully supported by an Additional
r
AUG 11 '95
11 •
WB SnZr'ri 20Z 4770^97
4
P.20/E2
H-. . . S^e Surve^and Preparation ofPhvsical Works. An extensive survey of all health
facilities at the secondary level is being undertaken by STEM. The mission reviewed
some of the survey documents and found them satisfactory. Given the progress to date, it
is expected that the survey will be completed, and the reports issued by September, 1995.
Analy^s _of.Eauipment Inventories. Information concerning the nature, and slate of
the current inventory is being gathered from each facility that will receive inputs under the
proposed project This work is progressing at a good pace. STEM has hired an expert to
analyze the inventory returns and is in the process of computerizing this information
Based on the service norms, the mission has reviewed jointly with the Government and
refill :d the equipment lists for various types of hospitals.
•
Equipment Managcrnent and Maintenance. The Department of Health has
elaborated an action plan <2id the specific mechanisms to ensure state-wide coverage not
only )f project investments but all its current health equipment The facility survey
team(s) would contribute by assessing local capabilities to provide technical support for
hospital equipment including the possible role of private contractors. Further analysis of
the in-house workforce and workshop requirements will be undertaken before the appraisal
mission.
14.
Workforce. Based ci the service norms agreed upon, the proposed levels of
staffing for medical and mi sing cadres 2»ave been reviewed during the mission In
addmcn, a package of ince mves is beini; developed to improve the recruitment,
deploy inent and retention c; staff in areas where difficulties of posting and retaining staff
are be ug experienced. In a’cas 'with a p/edominance of SC/ST populations, where the
progn ti for health screenin/, willjbe undertaken within the project, the roles of the PHC
staff, .deluding the PHC do:cor, are being restored and it is planned that service delivery
will b« more community ba <ed.
15Referral Mechanism. The project proposal has laid oui $ good plan for
strengthening the referral mi-^hamsm between the different tiers of the health system. The
plan was reviewed, includinf: the proposed incentives to encourage patients to use the
referral mechanism. Details regarding the issuing of administrative guidelines are being
developed.
16.
clinical Skilly and Management and Other Special Training. A training plan for
strengtl. tiling clinical skills has been developed by the Government The Bank team ha-^
reviewed this plan and fount it sarisfactoiy, and suggested some minor additions It was
clarified that some of the'tras'.ing would be coordinated by the district hospitals, where
facilities will be enhanced fo ’ this purpose. Training in management and other technical
skills have been discussed w/'.Ji the Government covering personnel policies, finance
issues, p rocurement policies, information systems, asset management and maintenance,
IEC> HMIS, and surveillance systems. The Government has idenufied institutions where
such training will be conducted.
f
•
AUG 11 *95
11:23AM WB SA2PH 202 47703S7
5
P.Z1/22
i7' . £lanX°f D^veloPine; Surveillance Capacity for Major Communicable Diseases. A
,devcl°pD^ P^Jor a state-wide system for major communicable disease surveillance has
bem drafted and discussed with the mission It was clarified that 80 of the proposed 180
staff were not additional - this is now being amended in the revised costing of the
component Based on the burden of disease in the state, seven major communicable
diseases have been identified by the Government These and other diseases will be
brought under the surveillance system and channels have been defined through which
information wiU flow. Parallel efforts will be made to improve reporting by private
medical practitioners. The surveillance system will be linked to HMS. A link with the
Strategic Planning Cell needs to be established; community participation in the
sun/eiUance network needs to be more clearly explicated. These issues will be discussed
with the appraisal mission.
, 1 *•_ Management Information System. The MIS included in the project proposal was
reviewed and was considered appropriate. The mission suggested that details regarding the
computerization of the systems needs to be further worked out The Government
organized an excellent demonstration of an MIS system being used by some private
hospitals. It was agreed that modifications to using such a system by the Health
Department would be worked on and discussed with the next mission.
19*
Detailed Project. Costs. Project costs have been revised and need further revision
incorporating the changes discussed with the mission. It was agreed that the detailed
revised cost tables will be provided to the mission by August 20, 1995. After revision,
preliminary total project costs, including contingencies, are expected to be approximately
Rs. 620 crores or about US$154 million. Recurrent costs are expected to be about Rs.40
crores at project completion. The Principal Secretary Finance has informed the mission
that the Government will have no problem in bearing this additional recurrent cost burden.
20.
Drag List The Government provided a drug list to the mission, which is being
reviewed. The mission suggested that the technical specifications of the elements common
with the Andhra Pradesh drug list be incorporated by Kamaraka since the Andhra Pradesh
list had already been cleared by the Rank
1•
Plan for Disposal of Medical Waste. The proposal for the disposal of medical
waste has been reviewed by the mission. It has been clarified that the plan for medical
waste disposal should include all hospitals, including tertiary hospitals not included in the
project Training modules will need to be developed for staff at different health facilities
responsible for medical waste disposal. Arrangements for the temporary storage of waste
prior to disposal need to be developed and the technical specifications of incinerators,
including capacity, at various facilities need to be modified.
22Tribal.Plan. A Tribal Plan integral to specified project components and
demonstrating how the project activities will benefit tribal peoples was discussed in detail
and a specific project component has been added to address this issue.
i
tiff
‘ft.W-.fc.Ji
” AUG 11 '95
I .1 ................................ '
• .fc’fciM .-•^I > t. w-
. .AI-»
-fc
M
asV*
- ---
P.22/22
li:23AH WB SA2PH 202 4770397
6
>
Beneficiary/Social Assessment and Private Sector Studies. The Renefim ary/-Social
Assessment and Private Sector Studies are progressing well and a first draft of phases I
and U have been given to the mission for review and comment The mission is pleased to
note the excellent work being done by ASCI in collaboration with the Government
24.
Performance Indicators. A list of performance indicators was discussed and agreed
upon. The Government will further refine this list, to be reviewed with the appraisal
mission.
IlXiplcmentation Schedule and Procurement Plan. An imp!ementation schedule has
been prepared and reviewed by the mission. The phasing of the hardware and software
components need to be worked out more explicitly. The Government has agreed to
provide these by August 20, 1995. Procurement plans are being developed and will be
discussed with the Bank prior to the appraisal mission.
Land acquisition. Because the proposed project involves renovation and extension
of existing facilities, it is anticipated that the need for land Requisition will be minimal.
The Government has been asked to provide assurance that none of the sites where
hospitals .will be upgraded will entail involuntary resettlement of any persons.
•
Chief Ministor's Health Relief F und. During the meeting with the Chief Minister, a
request was made to the mission to consider whether it would be possible for the Rank to
support a Health Relief Fund already initiated by the Government The Fund is intended to
provide specialised health services to the population below the poverty line afflicted with
life-threatening diseases such as oncological, cardiological, neurological and nephrological
disorders. The mission stated that it would seek the advice of Rank Management on this
proposal by the State since strictly^ it does not fall within the intended scope of the Health
Systems Development Project II.
28.
Next Steps. Given the excellent progress marte by the Government in preparing the
project, it is expected that an appraisal mission could be scheduled for October, 1995, on
the understanding that the remaining activities recommended by this mission are
completed.
. July, 1995
.. _
_
THE I10DLD DAUR 'IFC 'M. I .C.A.
Washington, D.C. 20433 - U.S.A.
FACSIMILE COVER SHEET AND MESSAGE
i
DQTF ■
MESSAGE NO:
NO. OF PAGES:
SENT BV:
FAX REPL? NO:
TO :
March ??
1 SAG
WDKS3G77 FAXX3915
1
(including this page)
SA2PH
202-477-0397
Mr. Gautam Basu, Secretary
Department of Health and Family Welfare,
Karnataka, INDIA
Fr i H a [j .
FAX / MINI CODE NO:
SUBJECT:
INDIA:
Govt.
of Karnataka
901191805532879
Second State Health System Development Project
WASHINGTON, D.C.
21-Mar-1996
non Dn. M.c. niiLunftLin, cccncTnnu, MimcTnu
MIMICTnU of Finance £mof>,
MR. V. GOVI NDARfiJAN, JOINT SECRETARY, DEPT. OF ECONOMIC AFFAIRS,
MOF, MR. P.P. CHAUHAN, SECRETARY, MINISTRY OF HEALTH AND FAMILY
WELFARE (MOHFW), MRS. SHAILAJA CHANDRA, ADDITIONAL SECRETARY,
MOHFW, MRS. LINO CHAKRAVORTI, PRINCIPAL SECRETARY, DEPT. OF
HEALTH AND FAMILY WELFARE, GOVT. OF WEST BENGAL, MR. GAUTAM BASU,
SECRETARY, DEPT. OF HEALTH AND FAMILY WELFARE, GOVT. OF KARNATAKA,
MR. G.P.S. SAHI, PRINCIPAL SECRETARY TO CHIEF MINISTER AND PRINCIPAL
SECRETARY, DEPT. OF HEALTH, GOVT. OF PUNJAB, MR. D. BAINS, MANAGING
DIRECTOR, PUNJAB HEALTH SYSTEMS CORPORATION, PUNJAB, INDIA.
RE:
BOARD APPROVAL OF INDIA SECOND STATE HEALTH SYSTEMS DEVELOPMENT
PROJECT.
WE ARE VERY PLEASED TO INFORM YOU THAT THE ASSOCIATION'S
BOARD OF DIRECTORS APPROVED A CREDIT OF SDR 235.5 MILLION (USS 350
MILLION EQUIVALENT) FOR THE SECOND STATE HEALTH SYSTEMS DEVELOPMENT
PROJECT ON MARCH 21, 1996.
WE WOULD LIKE TO CONVEY OUR
CONGRATULATIONS TO ALL WHO HAVE WORKED ON THE PREPARATION OF THE
PROJECT.
WE LOOK FORWARD TO THE EXPEDITIOUS SIGNING AND
EFFECTIVENESS OF THIS VERY IMPORTANT PROJECT.
BEST REGARDS, RICHARD
SKOLNIK, CHIEF, SA2PH, SOUTH ASIA COUNTRY DEPARTMENT II, WORLD BANK.
=03221433
ij u u
e *. [J tr i ’ i e i ic tr
a 11 «j
[j i' u r.i i t m i
w i l 11
111 i x
l r a ny m 1i u ii ,
a s soon as possible. PHONE: (202) 458-2805
CENTRAL FACSIMILE NUMBER:
TELEX:
(202) 477-6391
RCA - 248423 UORLDBANK
d 1
II :£
WP-466-B/vp
Legal Department
CONFIDENTIAL DRAFT
‘(Subject to Change)
SA limed
February 2. 1996
CREDIT NUMBER
PROJECT AGREEMENT
(Second State Health Systems Development Project)
between
INTERNATIONAL DEVELOPMENT ASSOCIATION
and
State of Karnataka
State of Punjab
State of West Bengal
and
Punjab Health S\stems Corporation
Dated
, 1996
WP-466-B/vp
Legal Department
CONFIDENTIAL DRAFT
‘(Subject to Change)
S Ahmed
Februarx 2, 1996
CREDIT NUMBER
PROJECT AGREEMENT
(Second State Health Systems Development Project)
between
INTERNATIONAL DEVELOPMENT ASSOCIATION
and
State of Karnataka
State of Punjab
State of West Bengal
and
Punjab Health S\stems Corporation
Dated
, 1996
1-
\|’ I K I I I
Definitions
Section 1.01 I htlcss the con.i*. -f < !l: • -j
»« quires, the several Icims dclined in
the Development Credit Agreement, the Preamble to this Agreement and in the (leneral
Conditions (as so defined) have the respective meanings therein set forth.
-I -
ARTICLE II
I lhe Project
Fxc.'iiti
Section 2.01. (a) The Project States and PHSC declare their commitment to the
objectives of the Project as set forth in Schedule 2 to the Development Credit
Agreement, and, to this end. shall carry out the Project with due diligence and efficiency
and in conformity' with appropriate administrative, financial and health practices, and
shall provide, or cause to be provided, promptly as needed, the funds, facilities, services
and other resources required for the Project.
(b)
Without limitation upon the provisions of paragraph (a) of this Section
and except as the Association and the Project States and PHSC shall otherwise agree, the
Project States and PHSC shall carry out the Pr ?
in accordance with the
Implementation Program set forth in Schedule 2 to this Agreement.
(c)
Without limitation upon the provision of paragraph (a) of this Section,
Punjab shall promptly make axailabk the proceeds of the Credit received from the
Borrower to PHSC as part of its gram
’■ ibution in accordance with the provisions of
the Ordinance.
Section 2.02. Except as the Association shall otherwise agree, procurement of
the goods, works and consultants’ services r-.qia.vd tor the Project and to be financed out
of the proceeds of the Credit shall be governed by the pro\ isions of Schedule 1 to this
Agreement.
-5-
Section 2.03. (a) The Project States and PHSC shall carry out the ohliir1 lions <t
forth in Sections 9.03, 9.04, 9.05, 9.06, 9.07 and 9.08 of the General Conditions < relating
to insurance, use of goods and services, plans and schedules, records and repor
maintenance and land acquisition, respectively) in respect of the Project Agreement and
the Project.
(b)
For the purposes of Section 9.07 of the General Conditions, and without
limitation thereto, the Project States and PHSC shall:
(i)
prepare, on the basis of guidelines acceptable to the A —^ciation
and furnish to the Association not later than six (6) in< • ’hs alter
the Closing Date or such later date as may be agreed fcr this
purpose between the Association and the Project States and
PHSC, a plan designed to ensure the sustainability of the
Project:
(ii)
afford the Association a reasonable opportunity to exchange
views with the Project States and PI ISC on said plan: nod
(iii)
thereafter, carry out said plan w ith due diligence and clTciency
and in accordance with appropriate practices, taking int?
account the Association's comments thereon.
Section 2.04. (a) The Project States and PHSC shall, at the request of the
Association, exchange views with the Association with regard to the progress of the
-6
Project, the performance of its obligations under this and other matters relating to the
purposes of the Credit.
(b)
The Project States and PHSC shall promptly infonn the Association of
any condition which interferes or threatens to interfere with the progress of the Project.
the accomplishment of the purposes of the Credit, or the performance by each of them of
its respective obligations under this Agreement.
-7-
ARTICLE III
Financial Covenants
Section 3.01. (a) The Project States and PHSC shall each maintain records and
accounts adequate to reflect in accordance with sound accounting practices their
operations, resources and expenditures in respect of activities related to their respective
parts of the Project, of the departments or agencies responsible for carrying out the
Project or any part thereof.
(h)
I he Project States and PI ISC shall:
(i)
have records and accounts referred to in paragraph (a) of this
Section for each fiscal \car audited, in accordance with
appropriate auditing principles consistently applied, hv
independent auditors acceptable to the Association;
(ii)
furnish to the Association as soon as available, but in any case
not later than nine months after the end of each such year. (A)
certified copies of its financial statements for such year as so
audited and (B) the report of such audit by said auditors, of such
scope and in such detail as the Association shall have reasonabh
requested; and
(i i i)
furnish to the Association such other information concerning
said records, accounts and financial statements as well as the
audit thereof, as iln
reasonably n |-i. 4.
. iation shall from time Io lime
-9-
ARTICLE IV
Effective Date: Termination:
Cancellation and Suspension
Section 4.01 This Agreement shall come into force and effect on the dale upon
which the Development Credit Agreement becomes effective.
Section 4.02. (a) This Agreenu m -.nJ ;|| obligations of the Association and of
the Project States and PFISC thereunder shall terminate on the earlier of the following
two dates:
4i)
the date on which the Development Credit Agreement shall
terminate in accordan
(ii)
(b)
ith its terms; or
the date twenty vears after the date of this Agreement.
If the Development Credit Agreement terminates in accordance with its
terms before the date specified in paragraph fa) (ii) of this Section, the Association shall
promptly notify the Project States and PHSC of this event.
Section 4.03. All the provisions of this Agreement shall continue in full force
and effect notwithstanding any cancellation or suspension under the General ( onditions
- 10-
ARTICLE V
Miscellaneous Provisions
Section 5.01. Any notice or request required or permitted to be given or made
under this Agreement and any agreement between the parties contemplated by this
Agreement shall be in writing. Such notice or request shall be deemed to have been duly
given or made when it shall be delivered by hand or by mail, telegram, cable, telex or
radiogram to the party to which it is required or permitted to be given or made at such
party's address hereinafter specified or at such other address as such party shall have
designated by notice to the party giving Mich notice or making
such request. The addresses so specified are:
For the Association:
International Development Association
1818 H Street, N.W.
Washington. D.C. 20433
United States of America
Cable address:
INDEVAS
Washington. D.C.
For the State of Karnataka:
Chief Secretary to the
(io\ ernmcnl of Karnataka
Bangalore, India
Telex:
197688 (TRT),
248423 (RCA),
64145 (WUI)or
82987 (FTCC)
-II-
I or the Slate of Pun jab:
Secretary to the
(io\ crnincnl of Punjab
I )epartment of Health
Chandigarh. India
For the State of West Bengal:
Chief Secretary to the
Government of West Bengal
t alciilta. India
For Punjab Health Systems Corporation:
Managing Director
Punjab Health Systems Corporation
Chandigarh, India
Section 5.02. Any action required or permitted to be taken, and any document
required or permitted to be executed, under this Agreement on behalf of the Project
States or PHSC, may be taken or executed by the Chief Secretary in the case of
Karnataka and West Bengal, or the Secretary, Department of Health in the case of
Punjab or the Managing Director in the case of PHSC or such other person or persons as
the respective Chief Secretary, the Secretary, Department of Health, or the Managing
Director shall designate in writing, and the Project States and PHSC shall furnish to the
Association sufficient evidence of the authority and the authenticated specimen signature
of each such person.
Section 5.03. I his Agreement may be executed in several counterparts, each of
which shall be an original, and all collectively but one instrument.
IN W1INESS WHEREOF, il. p.iiih • scio. acting through their duly
authorized representatives. I’ r.ee n’
' ibi
incut !<> be signed in their rcspectix e
names in the District of Columbia I ’nil .-J Suiesof America, as of the day and year In st
above written.
INTERNA HON Al DI
I I OPMENT ASSOCIATION
By
Regional Vice President
South Asia
STATE OF KARD • I -kA
STA FF OF
STATEOFVt si BENGAL
PUNJAB HE/iL ill’-. <1 EMS CORPORATION
By
Authorized Representative
HI I .'I f ;
!
Procureiiicni .nid ('onsultants' Services
Section!:
Procurement of Good-' and Works
Part A:
General
Goods and works shall be procured in accordance with the provisions of Sec::on
I of the “Guidelines for Procurement under IBRD Loan . and IDA Credits" published bv
the Bank in January 1995 (the Guidelines) and the following provisions of this Secti?n.
as applicable.
Part B:
1.
International Competilixc B!Jdin*»
Except as otherwise provided in Part C of this Section, goods shall be procured
under contracts awarded in accordance with the provisions of Section II of the
Guidelines and Paragraph 5 of Appendix 1 thereto.
2.
The following provisions shall applv to goods to be procured under contracts
awarded in accordance with the provisions of paragraph I of this Part B.
(a)
Grouping of contracts
I o the extent practicable, contracts for good ; shall be grouped in bid paekatr.
estimated to cost $200,000 equivalent or more each.
(b)
Preference for domestically manufactured goods
The provisions of paragraphs 2.54 and 2.55 of the Guidelines and Appendix 2
thereto shall apply to goods manufactured in the territory' of the Borrower.
- 14-
Part C:
I.
Other Procurement Procedures
Except as provided in paragraphs 2 and 3 hereof. ci\ il works may be procured
under contracts awarded on the basis of national competitive bidding procedures in
accordance with the provisions of paragraphs 3.3 and 3.4 of the Guidelines.
2.
Civil works estimated to cost the equivalent of $45,000 or less per contract, up
to an aggregate amount not to exceed the equivalent of $18.000.000, may be procured:
(i) under lumpsum. fixed price contracts awarded on the basis of quotations obtained
from three qualified domestic contractors in response to a written invitation. The
invitation shall include a detailed description of the works, including basic
specifications, the required completion date, a basic form of agreement acceptable to the
Bank, and relevant drawings, where applicable. The award shall be made to the
contractor who offers the lowest price quotation for the required work, and who has the
experience and resources to successfully complete the contract: or (ii) through direct
contracting in accordance with the provisions of paragraph 3.7 of the Guidelines, and in
accordance with procedures acceptable to the A* ■
iation: or(iii) with the Association's
prior agreement, under force account procedures in accordance with the provisions of
paragraph 3.8 of the Guidelines, provided, however, that civil works procured under such
procedures shall not in the aggregate exceed $10,000,000.
3.
Except as provided in paragraph 4 hereof equipment estimated to cost less than
the equivalent of $200,000 per contract, up to an aggregate amount not to exceed the
equivalent of $12.700,000. may be procured under contracts awarded on the basis of
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national competitive bidding procedures, in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines.
4.
Equipment estimated to cost the equivalent of $50,000 or less per contract, up to
an aggregate amount not to exceed the equivalent of: (i) $4,200,000. may be procured
under contracts awarded on the basis of international shopping procedures in accordance
with the provisions of paragraphs 3.5 and 3.6 of the Guidelines; and (ii) $12,700,000.
may be procured under contracts awarded on the basis ol national shopping procedures
in accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
5.
Vehicles estimated to cost not more than the equivalent of $300,000 in the
aggregate may be procured under contracts awarded on the basis of national shopping
procedures in accordance with the provisions of paragraphs 3.5 and 3.6 ol the
Guidelines.
6.
Except as provided in paragraph 7 hereof, medical laboratory supplies estimated
to cost less than the equivalent of $200,000 per contract, up to an aggregate amount not
to exceed the equivalent of: (i) $2,700,000, may be procured under contracts awarded on
the basis of national competitive bidding procedures in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines, and (ii) $400,000 may be procured under
contracts awarded on the basis of international shopping procedures in accordance with
the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
7.
Medical laboratory supplies estimated to cost less than the equivalent ol $50,000
per contract, up to an aggregate amount not to exceed the equivalent of $2,300,000 may
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be procured under contracts awarded on the basis of national shopping procedures in
accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
8.
Except as provided in paragraphs 9 and 10 hereof, medicines, furniture.
Management Information System/Informatinn. Education and Communication
(MIS'IEC) materials and supplies shall be procured under contracts awarded on the basis
of national competitive bidding procedures in accordance with the provisions of
paragraphs 3.3 and 3.4 of the Guidelines.
9.
Medicines estimated to cost less than the equivalent of $50,000 per contract, up
to an aggregate amount not to exceed the equivalent of $1,500,000 may be procured
under contracts awarded on the basis of international shopping procedures in accordance
with the provisions of paragraphs 3 5 and 3.6 of the Guidelines.
10.
Medicines, Furniture, MIS/IEC materials and other supplies estimated to cost
less than the equivalent of $50,000 per contract, up to an aggregate amount not to exceed
the equivalent ol $3,700,000, $2,800 OOP $1,700,000 and $11,100,000 respectively. nia\
be procured under contracts awarded on the basis of national shopping procedures in
accordance with the provisions of paragraphs 3.5 and 3.6 of the Guidelines.
11.
Except as provided in paragraph 12 hereof, maintenance of buildings and
vehicles and equipment may be carried out under contracts awarded on the basis of
national shopping procedures in accordance with the provisions of paragraphs 3.5 and
3.6 of the Guidelines.
17 -
12.
V
Maintenance of buildings, and vehicles and equipment which meet the
requirements of paragraphs 3.7 and 3.8 oi the Guidelines and costing in the acsrecate
less than the equivalent of $3,100,000 in the case of buildings and $7,000,000 in the case
of vehicles and equipment, may be carried out either (i) through direct contractins; or (ii)
force account, in accordance with the provisions of said paragraphs 3.7 and 3.8
respectively, of the Guidelines, and in atcerdance with procedures satisfactory to the
Association.
Part D:
I.
Review by the Association of Procurement Decisions
Procurement Planning
Prior to the issuance of any invitations to pi cqualify for bidding or to bid for
contracts, the proposed procurement plan for the Project shall be furnished to the
Association for its review and approval, in accordance with the provisions of paragraph
1 of Appendix 1 to the Guidelines. Procurement of all goodsand works shall be
undertaken in accordance with such procurement plan as shall have been appros ed by
the Association, and w ith the provisions of said paragraph 1.
2.
Prior Review
With respect to each contract for goods or civil works estimated to cost more
than the equivalent of $200,000 or.$3()0.000 respectively, the procedures set forth in
paragraphs 2 and 3 of Appendix 1 to the Guidelines shall apply.
n-.
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3.
Post Review
With respect to each contract not governed by paragraph 2 of this Part, the
procedures set forth in paragraph 4 of Appendix 1 to the Guidelines shall apply.
Section 11:
1.
Employment of Consultants
Consultants' services shall be procured under contracts awarded in accordance
with the provisions of the "Guidelines for the Use of Consultants by World Bank
Borrowers and by the World Bank as Executing Agency" published by the Bank in
August 1981 [(the Consultant Guidelines)]. For complex, time-based assignments, such
contracts shall be based on the standard form of contract for consultants' sendees issued
by the Bank, with such modifications thereto as shall have been agreed by the
Association. Where no relevant standard contract documents have been issued by the
Bank, other standard forms acceptable to the Bank shall be used.
2.
Notwithstanding the provisions of paragraph 1 of this Section, the provisions of
the Consultant Guidelines requiring prior Association review or approval of budgets.
short lists, selection procedures, letters of invitation, proposals, evaluation reports and
contracts, shall not apply to (a) contracts for the employment of consulting firms
estimated to cost less than $100,000 equivalent each or (b) contracts for the employment
of individuals estimated to cost less than $50,000 equivalent each. However, said
exceptions to prior Association review Jiall not apply to (a) the terms of reference for
such contracts, (b) single-source selection of consulting firms, (c) assignments of a
critical nature, as reasonably determined by the Association, (d) amendments to
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contracts for the employment of consulting firms raising the contract value to $ I OO.'JOO
i
equivalent or above, or (e) amendments to contracts for the employment of individual
consuh.inls mising the contiact value Io $50,000 equivalent 01 above
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SCHEDULE2
Implementation Program
1.
Each Project State shall:
(a)
ensure that within the allocations for the health sector in each Fiscal
Year curing the implementation of the Project the share of resources for Primary and
Secor.dary Levels of Health Services shall be increased in each such Fiscal Year until
FY 02. and
(b)
allocate in each Fiscal Year during the implementation of the Project
adeqcite resources for drugs, essential supplies, and maintenance of equipment and
buildings at facilities providing First Referral Level Health Services in accordance with
norms agreed to with the Association
2.
Each Project State shall maintain its Strategic Planning Cell with adequate staff.
resources and terms of reference acceptable to the Association.
3.
Each Project State and PHSC shall levy user-charges in district and sub-
divisirnal hospitals in accordance with a program and time schedule acceptable to the
Assoc it ion, such program to focus, inter alia, on: (a) permitting the revenues collected
from _ser-charges to be retained at the hospital level; (b) implementing user charges in a
phase: manner after improvements in the quality of basic sen ices and infrastructure
devei:?ment have been completed; (c) developing and applying criteria for exempting
the pc-?r from user charges: and (d) strengthening appropriate management and
coliechon arrangements for maintaining existing user charges, including the
*
21
establishment and maintenance of District Health Committees in Karnataka and W esBengal tor collecting such charges.
4.
Punjab and PHSC shall, as the case may be. take all such measures as mav be
necessary or required: (i) to enable PHSC to < ^rrv out its part of the Project: and (if) t?
ensure that PHSC undertakes health care activities at the secondary level in accordance
with service delivery' norms acceptable to the Association , and in carrying out other
heath care activities shall ensure that its ability to perform its obligations under this
Agreement as determined, inter alia, from a review of the progress achieved in
implementing the annual work plans and in meeting the development and performance
indicators referred to in paragraph 9 hereof is not adversely affected.
5.
I or purposes of enhancing the quality of health care services under the Project.
each Project State and PHSC shall: (i) maintain the key headquarters personnel
appointed for purposes of implementing the Project; (ii) appoint and thereafter maintain
key additional personnel with adequate qualification and experience in accordance with a
schedule of appointment agreed with the Association: (iii) adopt, no later than six
months after completion of the physical improvements in any hospital under the Project.
and thereafter implement, staffing and technical norms acceptable to the Association:
and (iv) provide on an annual basis adequate funds, satisfactory to the Association, lor
the maintenance of previously existing equipment in health care facilities supported
under the Project.
6.
For purposes of carry ing out Part B.3 of ik Project as set forth in Schedule 2 to
the Development Credit Agreement, each Proicct State and PHSC shall, no later than
December 31, 1996; (i) issue appropriate direct-i
to hospitals to strengthen the
management of the referral mechanism between the Primary, Secondary', and Tertiary'
Level Health Services; (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.
7.
Karnataka and West Bengal shall maintain the District Health Committees with
such staff, resources, powers, functions and responsibilities so as to enable them to
facilitate, inter alia, the functioning of the referral mechanism, the collection and
distribution of user charges, maintenance of equipment, waste management, training of
technical staff, quality assurance, surveillance of communicable diseases and the
monitoring and supervision of their respective activities to be carried out under the
Project.
8.
Each Project State shall take all ;i’ h measures as may be necessary’ or required
in order to provide, and thereafter maintain, authority to DOHFW in the case of
Karnataka and West Bengal and to PHSC in the case of Punjab for managing the
activities to be carried out by them under the Project, including construction and
maintenance activities.
j
-23 9.
Each Project State and PHSC shall:
(a)
hy April 30 of each year during the implementation of the Project beginnimi
with April 30, 1997:
(■)
provide to the Association an annual work plan, acceptable to the
Association, setting forth the respective activities under the Project to he cariicd
out during the prevailing Fiscal Year including the budgetary allocations to be
made available for such purpose, as well as the performance benchmarks and
development objectives to be achieved and drawn from the overall framework
agreed to be achieved under the Project inchiding, inter alia, hospital activity
indicators, hospital efficiency indicators, and quality, access and effectiveness
indicators to be measured in accordance with methodology satisfactory to the
Association: and
(ii)
review with the Association the progress achieved in implementing the
Project under the annual work plan for the previous Fiscal Year and the interim
plan referred to in sub-paragraph (c) below of this paragraph (9) with special
reference to the achievement of the performance benchmarks and development
objectives incorporated therein;
(b)
implement each annual work plan in a manner satisfactory7 to the Association,
with the goal, inter alia, of meeting the perform anct benchmarks and the development
objectives set forth therein; and
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(c)
implement the Project until the formulation of the first annual work plan in
accordance with an interim plan agreed with the Association.
10.
Each Project State shall ensure that: (i) its respective incremental budgetary
allocations under the Project for the Primary, and First Referral Lexel Health Services
for each Fiscal Year during the implementation of the Project shall be fully additional to
the allocations made in FY 95; and (ii) the budgetary allocations for the annual work
plans and the interim plan referred to in paragraph 9 hereof are made available on a
timely basis sufficient to meet the resource requirements under such plans.
11.
Karnataka and West Bengal shall implement the Project in tribal areas (as
designated by each such Project State) and West Bengal shall implement the Project in
the Sunderbans Area in accordance with the principles, objectives and policies of the
Tribal and Backward Area Development Strategy with emphasis on: (a) strengthening
linkages between Primary, and Secondary Level Health Sen-ices: (b) providing an
incentive package to doctors and other medical staff to work in the tribal areas of
Karnataka and in the Sunderbans Area of West Bengal; (c) increasing the appropriate
utilization of the medical system by the Scheduled Tribe population, (d) reducing the
cost to Scheduled Tribes of utilizing such system in Karnataka; and (e) increasing the
number of beds at sub-divisional and community-1 hospitals.
12.
PHSC shall carryout Part A.2 (ix) of the Project in accordance with procedures
and arrangements satisfactory to the Association.
4
r
-2513.
I lie Project States and PHSC shall, with the participation of the Borrower and
the Association: (a) jointly carry out by June 30, 1999 a mid-term review of the Project.
including on management aspects and financial sustainability, under terms of reference
satisfactory to the Association: and (b) carry out the recommendations of such review in
a manner satisfactory to the Association.
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