The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) Andhra Pradesh Health Systems Strengthening Project (P167581) SOUTH ASIA | India | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2019 | Seq No: 2 | ARCHIVED on 12-Dec-2019 | ISR39463 | Implementing Agencies: Republic of India, Department of Health, Medical and Family Welfare, Govt. of Andhra Pradesh Key Dates Key Project Dates Bank Approval Date: 15-May-2019 Effectiveness Date: 09-Sep-2019 Planned Mid Term Review Date: 30-Apr-2022 Actual Mid-Term Review Date: Original Closing Date: 30-Sep-2024 Revised Closing Date: 30-Sep-2024 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The Project Development Objectives are to improve the quality and responsiveness of public health services and increase access of the population to an expanded package of primary health services. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Improve Quality of Care:(Cost $2219.23 M) Improve Responsiveness of Public Health Services:(Cost $111.37 M) Increase Access to an Expanded Package of Primary Health Services:(Cost $1109.56 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Satisfactory Moderately Satisfactory Overall Risk Rating Moderate Moderate Implementation Status and Key Decisions The State has initiated actions to improve quality of care at primary health facilities, contributing to the National Quality Assurance Standards (NQAS) certification of 46 facilities, which includes 26 primary health centers (PHCs) and 20 community health centres (CHCs). An additional 7 facilities have achieved more than 70 percent quality accreditation score, following a state level internal assessment by the Department of Health and Family Welfare (DoHFW), Government of Andhra Pradesh, demonstrating progress along component 1 of the project. It has also developed draft clinical protocols for screening and risk stratification of non-communicable disease (NCD) patients, and specific protocols for management of hypertension and diabetes at the Primary Health Centre (PHC) and Sub-Centre (SC) level and referrals to higher-level facilities, which are critical first steps for expanding provision of NCD services at the primary care level outlined under component 3 of the project. Technical discussions are also ongoing on the establishment of information technology systems to support better patient management within the public health system, which 12/12/2019 Page 1 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) is the focus of component 2 of the project. This progress along all three project components, while slower than originally planned, is encouraging and expected to pick up pace over the coming months. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate Moderate Moderate Macroeconomic Low Low Low Sector Strategies and Policies Low Low Low Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Sustainability Low Low Low Fiduciary Moderate Moderate Moderate Environment and Social Moderate Moderate Moderate Stakeholders Low Low Low Other -- -- -- Overall Moderate Moderate Moderate Results PDO Indicators by Objectives / Outcomes Improve quality of care IN00771124 ►Increase in number of CHCs and PHCs with quality certification (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 28.00 46.00 198.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Each CHC or PHC that is NQAS certified following an independent external assessment by the National Health Systems Resource Center. Comments: 46 includes 20 CHCs and 26 PHCs Improve responsiveness of public health services IN00771123 ►Increase in the average patient reported experience score (Text, Custom) 12/12/2019 Page 2 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) Baseline Actual (Previous) Actual (Current) End Target Baseline to be Baseline to be Baseline to be 5 percentage point Value established for patient established for patient established for patient increase from baseline reported experience reported experience reported experience Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Baseline data for patient reported experience in PHCs and CHCs. For capturing baseline data, the following will be measured: The average patient experience score across facilities where the patient Comments: feedback system is operational. The system should be operational in at least 50 CHCs and 100 PHCs to establish baseline. Increase acess to an expanded package of primary health services IN00771125 ►Increase in percentage of patients diagnosed and at risk of hypertension and diabetes, managed as per protocol at the SC or PHC (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Baseline to be Baseline to be Baseline to be Increase in baseline established following established following established following Value value by 2 percentage development of clinical development of clinical development of clinical point protocols protocols protocols Date 01-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 For intermediate target 1: NCD-related screening and risk stratification protocols For intermediate target 2: Clinical treatment, management and referral protocols for diabetes and hypertension fpr all levels of facilities For intermediate targets 3&4 and end target Numerator: Number of patients diagnosed and at Comments: risk of hypertension and diabetes managed at the PHC or SC Denominator: Total number of patients diagnosed and at risk of hypertension and diabetes that have been identified as per protocol to be managed at the PHC or SC IN00771136 ►Increase in the percentage of pregnant women who receive full antenatal care (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 44.00 44.00 44.00 72.00 Date 28-Feb-2019 30-Jun-2019 30-Jun-2019 30-Jun-2024 Full antenatal care (ANC) is defined as Pregnant women receiving at least four ANC visits, at least one TT Comments: injection, and taken IFA tablets or syrup for 100 or more days. This will be defined as “Of those women who delivered in the past year, the % who received full ANC care”. Intermediate Results Indicators by Components Improve Quality of Care IN00771137 ►Increase in the number of CHCs and PHCs with more than 70 percent quality accreditation score following the State-level internal assessment (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 53.00 53.00 390.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Each CHCs and PHCs that earns a score of 70 percent or more on the NQAS assessment tool, as Comments: administered by the state-level internal Quality Assurance (QA) team. 12/12/2019 Page 3 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) 53, includes 25 CHCs and 28 PHCs IN00771142 ►Establish and operate a quality tracking dashboard covering PHC and CHC facilities for supporting quality improvement and maintenance (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 100 PHC and CHC No dashboard currently No dashboard currently No dashboard facilities included in Value exists exists currently exists quarterly dashboard reports Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 For Intermediate Target 1: (a) An online system that tracks quality scores for health facilities that have achieved and are on the path of NQAS certification in order to facilitate maintenance and improvement of quality standards by health facilities. The system should provide reports for health administrators and facility managers to act upon. (b) contracts with service providers in place to facilitate quality improvement Comments: and quality monitoring for all districts. For Intermediate Targets 2 to end target: Increase in facilities for which quarterly data is being reported (for at least two quarters) on the Quality Dashboard. Note, each CHC or PHC that has achieved NQAS certification and for which reporting on quality scores is available on the quality dashboard for at least two quarters will be considered. IN00771145 ►Percentage of CHCs that are using performance-based contracts with private service providers to provide a core package of services contributing to quality of care (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 37.00 37.00 37.00 70.00 Date 28-Feb-2019 30-Jun-2019 30-Jun-2019 30-Jun-2024 Numerator: Number of CHCs that are using performance-based contracts with private service providers to provide a core package of services contributing to improved quality of care Denominator: Total number of Comments: CHCs in the state The core package of services include -(i) teleradiology (x-ray); (ii) laboratory diagnostics; (iii) biomedical equipment maintenance; and (iv) sanitation services. Each CHC is expected to be covered through performance-based contracts with private service providers for these 4 services. IN00771148 ►Increase in the percentage of CHCs achieving at least 90% sanitation score monthly for a period of at least six months in a year (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 80.00 89.00 90.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Numerator: Number of CHCs that achieve at least 90% sanitation score monthly for a period of at least six months in the Fiscal Year Denominator: Total number of CHCs that have performance-based sanitation contracts in place in that Fiscal Year. Comments: 175 CHCs out of total 195 CHCs achieved at least 90% monthly sanitation score for a period of at least 6 months in FY 2019-20. IN00771151 ►Improvement in the pharmaceutical stock management system at the PHCs and CHCs (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Existing system Existing system provides Existing system provides provides information information on current information on current on current stock, but Quarterly stock- status stock, but has limited stock, but has limited Value has limited advanced reports for PHCs and advanced functions such advanced functions such functions such as auto CHCs generated as auto alerts indicating as auto alerts indicating alerts indicating low low stock low stock stock 12/12/2019 Page 4 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Intermediate Target 1: Formularies for PHCs and CHCs defined Intermediate Target 2: An updated facility-level pharmaceutical stock management system which includes specific advanced functionality, including but not limited to: (i) automatic flagging of no and low stock of pharmaceuticals according to the Comments: specific health facility formulary; and (ii) automatic estimation of order requirements. The upgraded system (upgrade of existing system or new system) should be rolled out and in use in at least 50 PHCs or CHCs for a period of one month before being submitted for verification. Intermediate Target 3 to end target: Quarterly stock status reports being generated for PHCs and CHCs where the system is rolled out Improve Responsiveness of Public Health Services IN00771138 ►Increase in the number of health facilities with an operational integrated online patient management system (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 1,400.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Each health facility that uses the new integrated online patient management system as defined in the contract between the service provider and the DoHFW. ‘Health facilities’ include teaching hospitals, district Comments: and area hospitals, CHCs and PHCs. ‘Use’ is defined as, at least, (a) health records of chronic OPD and IPD patients being entered in the online system for at least 1 month; and (b) health facility staff trained in the use of the system. IN00771140 ►Increase in the percentage of patients accessing their individual EMR (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 6% increase from Value 0.00 0.00 0.00 baseline Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Numerator: Number of patients accessing their individual EMR Denominator: Number of patients whose Comments: EMRs are entered in the EHR system IN00771143 ►Private pharmacies empaneled to dispense the state-financed drugs to patients (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target No policy or No policy or No policy or Roll-out as per Value empanelment of private empanelment of private empanelment of approved policy pharmacies pharmacies private pharmacies Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2021 Intermediate Target 1: State Cabinet approval or Government Order issuance of the policy with respect to Comments: private pharmacies being able to dispense state-financed outpatient prescription medications to patients free of charge. End Target: Report detailing the status of roll out of policy IN00771146 ►Increase in the number of facilities where the system for measuring and reporting on patient experience is operational (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 1,400.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 This indicator refers to a system for measuring patient reported experience that will be designed and Comments: rolled out, meeting the following criteria: (a) a minimum set of standardized questions across all facilities; (b) easily accessible to all patients; and (c) allows for anonymity. ‘Operational’ is defined as at least 10 12/12/2019 Page 5 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) percent inpatients in teaching, district and area hospitals and 5 percent outpatients in CHCs and PHCs per month using the system to report on their experience for at least a month. ‘Health facilities’ include teaching hospitals, area and district hospitals, CHCs and PHCs. IN00771149 ►Percentage of districts organizing quarterly review meetings on patient feedback (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 70.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Numerator: Number of district quality committees that organize quarterly meetings (4 meetings) in a year Comments: on patient feedback Denominator: Total number of districts Quarterly meetings will be measured through directives for action issued at the meeting based on a review of feedback Increase Access to an Expanded Package of Primary Health Services IN00771139 ►Increase in the number of functional e-subcenters (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 40.00 40.00 40.00 6,190.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Functional e-subcenters are defined as those with: (i) qualified doctor available through teleconsultation; (ii) at least one trained ANM; (iii) necessary equipment for NCD screening; and (iv) drug ATM with drugs in-stock and available for dispensing. Trained ANM staff is defined as an ANM that has completed orientation training on the examination and consultation process assisted through telemedicine. Comments: Necessary equipment for NCD screening defined as that is listed in the contract with the service provider. The drugs that are to be in stock are those that are to be listed in the contract with the service provider. Furthermore, it will be considered functional, when there is a track record of providing consultation through telemedicine for at least 1 month. IN00771141 ►Increase in the number of subcenters installed with solar power energy (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Solar power used for Solar power used for Solar power used for only Value only large teaching only large teaching Roll-out as per plan large teaching hospitals hospitals hospitals Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Intermediate Target 2 is defined as (a) a State Cabinet decision or Government Order issuance to introduce solar power at subcenters which are off-grid; and (b) a roll out plan developed by the DoHFW Comments: with targets, budgets and timeline for roll out outlined. Intermediate Target 3 to End Target is defined as the number of sub-centers that are installed with solar power as their primary source of electricity, as per the roll out plan mentioned in Intermediate Target 2 IN00771144 ►Increase in the number of subcenters with trained mid-level service providers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 300.00 300.00 779.00 5,900.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 This indicator is defined as the number of sub-centres where trained mid-level service providers have Comments: been placed by the DoHFW IN00771147 12/12/2019 Page 6 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) ►Increase in the percent of adult population screened and stratified by risk as per clinical protocols for hypertension and diabetes (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 12.00 12.00 12.00 67.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Numerator: Total number of adults aged above 30 years screened and stratified by risk as per protocol for Comments: hypertension and diabetes Denominator: Total number of adults aged above 30 years IN00771150 Increase in the percent of male population screened and stratified by risk as per clinical protocols for hypertension and diabetes (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 1.00 1.00 35.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 IN00771152 Increase in the percent of female population screened and stratified by risk as per clinical protocols for hypertension and diabetes (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 23.00 23.00 23.00 70.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 IN00771153 ►Increase in the percentage of women above age 30 years screened for cervical cancer at subcenters or PHC facilities (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 26.00 26.00 26.00 70.00 Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2024 Numerator: Cumulative number of women screened at least once as reported by subcenters or PHCs, Comments: including those women seen by mobile medical units or other outreach events. Denominator: The estimated number of women over the age of 30 IN00771154 ►Research and evaluation undertaken to support the innovative approaches to delivery of primary health care (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Population-based survey Population-based survey Population-based of NCD risk factor of NCD risk factor survey of NCD risk prevalence not prevalence not factor prevalence not End-line study for Value undertaken and e- undertaken and e- undertaken and e- evaluation on e- subcenter model overall subcenter model overall subcenter model subcenter completed effectiveness not effectiveness not overall effectiveness evaluated evaluated not evaluated Date 28-Feb-2019 30-Jun-2019 31-Oct-2019 30-Jun-2023 Data on Financial Performance 12/12/2019 Page 7 of 8 The World Bank Implementation Status & Results Report Andhra Pradesh Health Systems Strengthening Project (P167581) Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P167581 IBRD-89450 Effective USD 328.00 328.00 0.00 0.82 327.18 0.3% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P167581 IBRD-89450 Effective 15-May-2019 27-Jun-2019 09-Sep-2019 30-Sep-2024 30-Sep-2024 Cumulative Disbursements Restructuring History There has been no restructuring to date. Related Project(s) There are no related projects. 12/12/2019 Page 8 of 8