India - Second State Health Systems Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. P-6813-IN MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 235.5 MILLION TO INDIA FOR A STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II FEBRUARY 20, 1996 This document has a restricted distribution and may be used by recipients only in the perfornance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (As of October 1995) Currency Unit = Rupee Rupee 34.6 = US$1.00 METRIC EQUIVALENTS 1 Meter (m) = 3.28 Feet (fi) 1 Kilometer = 0.62 Miles GOVERNMENT FISCAL YEAR April 1 - March 31 ABBREVIATIONS AND ACRONYMS GOI Government of India GOK Government of Karnataka GOP Government of Punjab GOWB Government of West Bengal IDA International Development Association IEC Information, Education and Communication MIS Management Information System NGO Non-Governmental Organization PHN Population, Health and Nutrition PHSC Punjab Health Systems Corporation PTI Program of Targeted Interventions SC Scheduled Castes SOE Statement of Expenditures ST Scheduled Tribes  FOR OFFICIAL USE ONLY INDIA STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II CREDIT AND PROJECT SUMMARY Borrower: India, acting by its President Beneficiaries: States of Karnataka, Punjab, West Bengal and Punjab Health Systems Corporation (PHSC) Povertv: Program of Targeted Interventions (PTI). This project is classified as a PTI because a large proportion of project beneficiaries will be from the poor and vulnerable segments of the states' population. In Karnataka and West Bengal, about two-thirds of expected project beneficiaries would belong to the lowest 40% of the population in terms of income distribution. In Punjab, a relatively large share of the investment under the project would be targeted in the Upper Bari Doab and rural Southem Malwa regions where 30% and 25% respectively of the overall population live below the poverty line. Amount: IDA Credit of SDR 235.5 million (US$350.0 million equivalent) Terms: IDA Standard, with 35 years maturity On-Lending Terms: The Government of India would make the proceeds of the Credit available to the States of Kanataka, Punjab and West Bengal under standard arangemts for development assistance to the States of India. Punjab will further transfer the funds to PHSC as a grant. GOI would assume foreign exchange risk. Financinz Plan: Local Foreign Total --------------------------------- US$Million------------------------- GOK 25.0 0.0 25.0 GOP 16.4 0.0 16.4 GOWB 25.3 0.0 25.3 IDA 255.4 94.6 350.0 Total 322.1 94.6 416.7 Economic Rate of Return: Not Applicable Staff Appraisal Report: Report No. 15106-IN This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.   MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO INDIA FOR A STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II 1. The following memorandum and recommendation on a proposed Credit to India is submitted for approval. The Credit, for SDR 235.5 million (US$350 million equivalent), would be on standard IDA terms with a maturity of 35 years. The Credit would help finance the State Health Systems Development Project II. 2. The proceeds of the Credit would be on-lent to the Governments of Karnataka, Punjab and West Bengal in accordance with standard arrangements for development assistance to the states of India; Punjab will further transfer the funds to the Punjab Health Systems Corporation (PHSC) as a grant. Under current policies and regulations of the Government of India (GOI), on-lending to Karnataka, Punjab and West Bengal takes the form of 30% grant/70% loan at 12% interest rate per annum over 20 years. GOI would assume the foreign risk. 3. Country/Sector/State Back&round. During the past two decades, India has developed a health care system in which the Government sector finances and manages a basic health care infrastructure. Government-provided services are the dominant source of preventive care, such as immunization, ante- natal care and infectious disease control. The private sector predominantly provides ambulatory care services for acute illnesses or illnesses not requiring hospitalization. The private health sector, which accounts for 80% of overall health expenditures, is financed almost entirely from out-of-pocket sources, placing a disproportionate burden on the poor. Moreover, private health services are inaccessible to large sections of the population and do not cover many of the diseases which are most common to the poorest and most vulnerable sections of society. As a result, substantial gaps remain in the effective delivery of health care services to the population. Key health indicators show that the health status of India's population remains low. Communicable diseases continue to be major health problems; maternal mortality is high; acute respiratory and diarrheal diseases account for a large proportion of childhood mortality; and preventable mortality and morbidity, especially among the poor, exact a high toll. Moreover, with the increasing age profile of its population, India is moving into an epidemiological transition with the double burden of significant communicable diseases and increasing incidence of non- communicable diseases. 4. The Government's long-term strategy, as enunciated in the National Health Policy (1983), is to give high priority to the control of fertility, infectious diseases of public health importance and preventable causes of maternal and childhood mortality and morbidity. This is an appropriate policy given India's burden of disease. However, investment allocations do not fully reflect the priorities highlighted in the Government's policy and implementation of health programs continue to be weak. Public spending on health is about 1.3% of GDP which is lower than in comparable Asian countries. The bulk of public spending on health is accounted for by the states, which are primarily responsible for implementing health programs. As a result, financing and policy reform to increase efficiency and improve effectiveness of health programs needs to be targeted at the state level. 5. Each state faces specific challenges, but there are some common themes at the state level which need to be addressed. These include: (i) inadequate allocation of public resources to the health sector,  2 which results in underfunding of drugs and essential supplies, lack of maintenance of equipment, and shortage of doctors and medical personnel; (ii) suboptimal allocation of resources within the health sector which is reflected in the neglect of first referral facilities and an overemphasis on tertiary care; (iii) low level of revenue collection from user charges; (iv) weak management at all levels of health care and ineffective sectoral planning; (v) inadequate support services and infrastructure; (vi) ineffective referral system providing weak institutional and technical linkages; (vii) limited capacity for the surveillance of major communicable diseases; (viii) insufficient access to health services, especially for poor and vulnerable groups; and (ix) insufficient capacity to monitor the development of the private health sector. 6. The states of Karnataka, Punjab and West Bengal have expressed an early commitment to undertake health reform. These three states have been included in the proposed project because they are ahead of the others in setting up a framework to develop a package of policy reform. In addition, West Bengal has been chosen because of the high level of poverty in large areas of the state and Punjab because it can set an example for other states in areas of policy reform. These states provide an interesting geographical, cultural, ethnic and epidemiological diversity. The administrative capacity to undertake a project of this type is relatively strong in these states. The states also share common elements that are key to the effective functioning of health systems, such as service norms, training, management information systems (MIS), referral systems, surveillance systems for major communicable diseases, equipment management systems, quality assurance, and information, education and communication (IEC) networks. The development and implementation of the proposed project in each state would be mutually beneficial for lesson learning and sharing of implementation experience with respect to these key elements. The combined population of these three states is about 140 million people (1995). 7. IDA Strateag and Rationale for Involvement. The World Bank Group's Country Assistance Strategy for India (Report No. 14509-IN), which was discussed at the Board on June 20, 1995, supports GOI's efforts to provide an enabling environment for broad-based, efficient private sector-led growth while accelerating the development of human resources. In the human resource sectors, the strategy is to enhance access to basic services for the poor and to support well-targeted safety net programs that protect the most vulnerable groups in Indian society. As part of this approach, the Bank's strategy in the health sector is to assist India in reducing the level of mortality and morbidity through a two-pronged approach. The first is to reduce the burden of the most significant diseases through the support of priority programs; the second is to strengthen the performance of state health systems to deal with the evolving burden of disease. The overall strategy is to benefit the poorest sections of society who use public health services the most. The basis of this strategy for the health sector in India is rooted in an on-going dialogue between GOI and IDA, and is reflected in the recent sector work: "India: Policy and Finance Strategies for Strengthening Primary Health Care Services" (Report No. 13042-IN; May 15, 1995). 8. IDA investment in the proposed project is justified for the following reasons. First, the project is consistent with IDA's strategy of strengthening state health systems by optimizing resource use. Second, the project would strengthen the states' capacity to implement priority health programs and provide basic health care in rural areas. Third, the project would consolidate the investments made by a number of other IDA-supported projects in the population, health and nutrition (PHN) sectors, and add incremental value to the health care system at the state level. Fourth, the project is in line with the overall IDA strategy of poverty reduction in India through its focus on underprivileged people, especially women, Scheduled Castes (SC) and Scheduled Tribes (ST). Finally, the proposed project would assist Kamataka, Punjab and West Bengal to establish the foundation for a sustainable and coherent approach to health care. 9. Project Objectives. The proposed project would be an investment operation with substantial policy content. It will assist the Governments of Karnataka, Punjab and West Bengal to put in place a  3 first referral health care system which would provide vital support and credibility to primary health care services and the rest of the health sector. The objectives of the proposed project would be to assist these states to: (i) improve efficiency in the allocation and use 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 at the first referral level and selective coverage at the primary level to better serve the poor. The ultimate goal of the project would be to improve the health status of the people, especially the poor, by reducing mortality, morbidity and disability. 10. Project Content. The project would consist of policy reform in the health sector and specific investment activities. The Reform Program would: (i) Increase Financing and Imorove Resource Allocation for the Health Sector by (a) ensuring adequate budgetary allocations to the health sector; (b) increasing the share of health sector resources to the primary and first referral levels of care; and (c) safeguarding 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; (ii) Strengthen the Capacity of the Implementin, Agencies in Sector Analysis and Management by (a) setting up a Strategic Planning Cell in each state to undertake analyses of health sector issues; and (b) providing the implementing agencies greater authority to manage essential operational activities; (iii) Enhance the Role of the Private and Voluntary Sectors in the Delivery and Management of Health Services by (a) contracting-out selected services; and (b) promoting linkages in health care delivery with the private and voluntary sectors; and (iv) Implement a User Charge Policy by: (a) implementing existing user charges more rigorously; (b) retaining and using revenue collected at the institution level; and (c) exempting the poor from user charges. 11. Project Investments. The project would finance the following activities: (i) Management Development and Institutional Strengthening by: (a) improving the institutional framework for policy development; (b) strengthening the management and implementation capacity of institutions; and (c) developing a surveillance capacity for major communicable diseases and response capabilities; (ii) Improvinz Service Quality. Access and Effectiveness at the First Referral Level by: (a) upgrading community, sub-divisional and district hospitals; (b) upgrading effectiveness of clinical and support services; and (c) improving the referral mechanism and strengthening linkages with the primary and tertiary health care levels; and (iii) Improving Access to Primary Health Care in Remote and Underdeveloped areas by: (a) upgrading quality and improving access to primary health care services in the Sunderban area of West Bengal; and (b) increasing access to primary health care services among the SC/ST population in Karnataka. 12. Lessons from Experience. The design of this project incorporates important lessons from the experience of social sector projects in India. Five PHN projects in India have been completed, all satisfactorily, with three having several very positive outcomes. The successes and weaknesses of these projects have shown the importance of: early staffing of management teams and their continuity, decentralized planning of investments and stakeholder participation. Other critical lessons have been learned about the importance of: flow of fund and procurement arrangements, attention to maintenance of equipment and buildings and the need to focus on the qualitative aspects of the investments. The design of this project takes into account the above lessons. In addition, an important lesson learned from the first health systems project in India supported by IDA -- the Andhra Pradesh First Referral Health System Project -- has been to ensure that linkages with other PHN projects in Karnataka, Punjab and West Bengal be provided by 'complementing previous investments in the state and by coordinating implementation issues. For example, the strengthening of the first referral level for obstetrics and child care in this project through the provision of essential clinical and diagnostic services will complement the primary  4 level of services being provided under Population VIII, Population IX and the Child Survival and Safe Motherhood projects (see SAR Table 1.2). 13. Project Costs. The total cost of the project is estimated at about Rs.16,691.4 million or US$416.7 million equivalent including taxes and duties estimated at US$22.2 million equivalent. The project costs in Karnataka, Punjab and West Bengal would be US$136.4 million, US$106.1 million and US$174.2 million respectively. IDA would finance about US$350.0 million or about 88.7 percent of total project costs net of taxes; the balance of US$66.7 million would be financed by the Governments of the three project states, Kamataka (US$25.0 million), Punjab (US$16.4 million) and West Bengal (US$25.3 million). The direct and indirect foreign exchange cost is estimated at US$94.6 million. The project would finance civil works, equipment and furniture, vehicles, medical and laboratory supplies, medicines, other supplies, MIS/lEC supplies, professional services, training, studies and evaluations, workshops, and operational expenses and salaries of incremental staff on a declining basis. Retroactive Financing for project preparation in the amount of US$10 million, about 2.8 percent of the proposed Credit, is provided to cover eligible expenditures incurred after May 1. Retroactive financing would support initial staff appointments, technical surveys and soil tests, preparation of preliminary designs and initial construction activities. Amounts and methods of procurement and the disbursement schedule are shown in Schedule B. A timetable of key project processing events and the status of Bank Group operations in India are presented in Schedules C and D. The Staff Appraisal Report (SAR), No. 15106- IN, dated February 20, 1996, is being distributed separately. 14. Project Implementation. In Karnataka and West Bengal, the project will be managed and implemented by the Department of Health and Family Welfare (DOHFW). In Punjab, the project will be managed and implemented by the Punjab Health Systems Corporation (PHSC). Lists of staff or Coommittee Members, organizational charts, and the functional levels of project management in each state are shown in the SAR Annex 6. 15. Fiscal Analysis. Recurrent Costs. Incremental annual recurrent costs including contingencies at project completion are expected to be about Rs. 360 million in Karnataka, about Rs. 250 million in West Bengal, and about Rs. 150 million in Punjab. This would amount to 5.2%, 3.7% and 5.1% of total revenue expenditures for the DOHFW in Karnataka, West Bengal, and Punjab respectively. The incremental recurrent costs of the project imply an increased share for health of total Government expenditures of around 0.3 percentage points in Karnataka, 0.3 percentage points in West Bengal and 0.2 percentage points in Punjab. These increments should not be a problem for the states to provide. In addition, an analysis of potential revenue generated by implementing user charges, based on information from Karnataka, shows that Rs. 136 million could be generated annually from paying beds and wards, charges for diagnostic tests and surgery, out-patient charges and charges for health certificates. This is equal to about 29% of all non-salary recurrent expenditures at the end of the project, and would defray about 9% of the incremental expenditures generated by the project. This amount of additional revenue could have a significant effect on the levels of service quality. 16. Sustainability. An analysis of selected aspects of public finances and recent trends in expenditures on health suggest that, in Karnataka, the project is sustainable. In Punjab and West Bengal, expenditures have been increasing; however, the past rate of increase in health expenditures would not be sufficient to absorb the incremental costs related to the project. Health expenditures in these two states, therefore, need to be maintained as a constant share of overall expenditures throughout the life of the project to significantly minimize the risks to sustainability. In the case of Punjab, the necessary resources to sustain this commitment can be achieved through a small increase in revenue. In the case of West Bengal, some  t 5 5 re-orientation of its fiscal policies may be required to ensure sustainability. The section on risks elaborates the proposed mechanism to address this issue. 17. Project Benefits. This project is not suitable for a cost-benefit type analysis because of the difficulty in quantifying benefits and data limitations. However, a combination of qualitative and quantitative analysis was used to better understand the comparative cost effectiveness of some potential health interventations and the scope and magnitude of project benefits. These are discussed in detail in the SAR in paragraph 4.3 and Annex 4. A major benefit of the proposed project is that it would assist the states of Karnataka, West Bengal and Punjab to put in place a coherent approach to establishing a cost- effective and sustainable health system. This would indirectly benefit the states' population as a whole. First, the broader sectoral policy reform envisaged under the project would increase the efficiency of the health sector by improving the environment in which the health sector operates. Second, there would be substantial cost savings in each state through the implementation of streamlined service norms and rationalization of service provision at different levels of the system. The technical and quality improvements at the institutional and health facility levels would enhance effectiveness and efficiency by encouraging patients to seek timely care, resulting in higher cure rates at lower costs. Third, patients currently utilizing existing services would benefit from better quality services. Other qualitative benefits would be: the enhanced credibility and vital support to the primary health care system through the strengthening of first referral facilities; and externalities associated with improvements in waste disposal methods and improvements in the surveillance system for major communicable diseases. Finally, the proposed project would have a direct long-term impact on improving the health status of the people of each state and would thus contribute to increasing the earning potential of the poor. 18. Agreements Reached. At Negotiations, the Governments of Karnataka, Punjab and West Bengal provided assurances that they would: (a) ensure that the share of health sector resources to the primary and secondary levels of health care would be increased in each year of project implementation; (b) ensure that recurrent expenditures would be provided on a timely basis for drugs, essential supplies and maintenance of equipment and buildings; (c) maintain the arrangements for managing and collecting user charges, the mechanism for exempting the poor and the system for reallocating funds collected at the hospital level, established prior to negotiations; (d) take all necessary actions to ensure that the DOHFW in Karnataka and West Bengal, and PHSC in Punjab would maintain authority in managing essential operational activities; (e) carry out a detailed mid-term review of project progress, including management and financial reviews, jointly with GOI and IDA, not later than June 30, 1999; (f) adopt staffing and technical norms at its hospitals under the project and as agreed with IDA within six months after upgrading each facility; (g) review with IDA, by April 30 of each year, the progress of project implementation; and (h) carry out the project in the tribal areas of Karnataka and West Bengal in accordance with an agreed strategy. 19. Program Obiective Categories. A social assessment was undertaken for this project, including beneficiary assessments and extensive stakeholder participation in each state. This analysis provided the following information, and was utilized to fine-tune project design. Project Beneficiaries. In addition to the systemic benefits noted in paragraph 17, the proposed project would directly benefit approximately 10 million out-patients and 0.7 million in-patients currently utilizing existing hospital services in Karnataka, Punjab and West Bengal through the provision of better quality health services. In addition, the project is expected to directly benefit an estimated 3.3 million incremental out-patients in West Bengal, 1.2 million in Karnataka, and 0.7 million in Punjab; and an estimated 0.4 million incremental in-patients in West Bengal, 0.3 million in Karnataka, and 0.12 million in Punjab. Poverty Aspects. A large proportion of project beneficiaries will be from poor and vulnerable segments of the states' population. In Karnataka and West Bengal, about two-thirds of expected project beneficiaries would belong to the lowest 40% of  6 the population in terms of income distribution. In Punjab, a relatively large share of the investment under the project is targeted in the Upper Bari Doab and Southern Malwa regions where 30% and 25% of the population, respectively, live below the poverty line. Based on this data, the proposed project is classified as a Program of Targeted Interventions (PTI). Gender Issues. The project would provide much greater access to women, particularly rural women, and improve the quality of services they receive. More specifically, by strengthening the referral mechanism and linking the community hospitals with primary health centers, the project would assist in providing timely access to emergency obstetric care. The project would also promote a life-cycle approach to women's health, taking into account some of the main recommendations of the Cairo Conference on women's reproductive health, such as screening for reproductive tract infections and sex-Ily transmitted diseases, providing appropriate IEC to promote the value of the girl-child, and increab .g women's awareness of their options in terms of health care. Indigenous Population (Scheduled Tribes). The project's tribal stra _y is aimed at increasing the demand for hospital services in tribal areas by improving the quality of services and providing effective IEC to better inform tribal populations of the benefits of using health services at hospitals in tribal areas. The project would: (a) strengthen linkages between primary and secondary health services in tribal areas; (b) provide an incentive package to doctors and other medical staff to serve in tribal areas; and (c) reduce the cost to tribal populations of using the public health system. Environmental Aspects. The proposed project would not raise any environmental concerns. The project would enhance medical waste disposal at health facilities where necessary. 20. Risks. The proposed project carries several risks that have affected, to varying degrees, PHN projects in India. These include poor procurement, late disbursement, untimely and inadequate flow of funds, poor maintenance of buildings and equipment, and inadequate attention to software and qualitative aspects. Most of these risks have been substantially reduced through careful project design, as indicated in the SAR, Table 1.1. There are two additional risks associated with this project. First, the capacity of existing institutions to undertake systemic improvements and to establish a more rational health delivery system has not been tested in India. Institutional strengthening, including strengthening of the management structure in all three states would be emphasized in the proposed project to address this risk. In Punjab, the newly established PHSC might have some start-up problems. The Government of Punjab, at the highest level, has made a commitment to enable the PHSC to effectively implement the project. Second, as with other projects in India, the overall financial status of the states is a risk. As noted earlier, the financial risk is somewhat less in Karnataka than in Punjab and West Bengal. To help reduce the risk to financial sustainability in each state, an on-going mechanism for monitoring overall state finances as well as the financial situation of the health sector would be undertaken through a comprehensive mid-term review. If necessary, additional measures to achieve financial sustainability of project benefits would be agreed based on that review. 21. Recommendation. I am satisfied that the proposed credit would comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. James D. Wolfensohn President Attachments Washington D.C. February 20, 1996  Schedule A INDIA: STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II Estimated Project Costs and Financing Plan (Rupee Million) (USS Mii'on) % % Total Component Foreign Bane Local Foreign Total ail Foreign Total Exchange Cost 1. Management Development & Institutional Strngthening la- Improve Institutional Framework for Policy Develpment 58.3 16.4 74.7 1.7 .5 2.1 22% 1% lb - Strengthen Management & Implementation Capacity 667.5 105.4 772.9 19.2 3.0 22.2 14% 6% Ic - Develop Surveillance Capacity O 1j3 79. La A 2 121 11 Subtotal 789.6 137.1 926.7 22.7 3.9 26.6 15% 7% 2. Improve Service Quality, Aces and Effectivenes 2a. Renovate&ExtendCommunity, Area& District Hospitals 4,085.9 740.8 4,826.7 117.4 21.3 138.7 39% 0% 2b - Upgrade Clinical Effectiveness 3,982.7 1,431.8 5,414.5 114.4 41.1 155.6 43% 0% 2c - Improve Referral Mechanism 2Q2.8 280 0 482. la Lfl f2 4.1 ox Subtotal 8,271.4 2,452.6 10,724.0 237.7 70.5 308.2 86% 0% 3 -ImproveAccutoBasicHealthServim 611.0 233.8 844.9 17.6 6.7 24.3 7% 0% Total BASELINE COSTS 9,672.1 2,823.5 12,495.6 277.9 81.1 359.1 100% 0% Physica Contingencies 890.5 279.6 1,170.1 25.6 8.0 33.6 9% 0% Prine Contingencies 2,340.9 684.9 3,025.7 18.5 5.4 24.0 7% 0% Total PROJECT COSTS 12,903.5 3,788.0 16,691.4 322.1 94.6 416.7 116% 0% Financing Plan: Local Foreign Total -------------------------US$ Million-------------------------- GOK 25.0 0.0 25.0 GOP 16.4 0.0 16.4 GOWB 25.3 0.0 25.3 IDA 255.4 94.6 350.0 Total 322.1 94.6 416.7   Schedule B Page 1 of 2 INDIA: STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II Summary of Proposed Procurement Arrangements (US$ Millions) Procurement Method Intenationli National CompetiBve Competitive International LC Other Bidding Bidding Shopping Shopping Mehds /a Total CIVIL WORKS Civil Works - 134.2 /b - - 18.0 152.2 (114.1) (15.3) (129.4) GOODS Furniture - 8.5 /c - 2.8 - 11.4 (7.7) (2.6) (10.2) Equipment 54.9 12.7 4.2 12.7 - 84.5 (49.4) (11.4) (3.8) (11.4) (76.0) Vehicles 14.3 - - 0.3 - 14.6 (12.9) (0.3) (13.1) Medical Lab Supplies - 2.7 0.4 2.3 - 5.4 (2.4) (0.3) (2.1) (4.9) Medicines - 22.0 1.5 3.7 - 27.2 (19.8) (1.3) (3.3) (24.5) Other Supplies - 7.4 - 11.1 - 18.5 (6.7) (10.0) (16.7) MIS/IEC Materials - 5.2 - 1.7 - 6.9 (4.7) (1.6) (6.2) CONSULTANCIES Project Preparation & Implementation (incl Training, Workshops, Fellowships) - - - - 10.7 10.7 (10.7) (10.7) Instirutional Development (includes Local Consultants, Studies, Professional Services Fees, NGO Fees) - - - 18.1 18.1 (16.3) (16.3) MISCELLANEOUS Salaries of Additional Staff - - -- 39.3 39.3 (25.5) (25.5) Operational Expenditures - - - 17.8 - 17.8 (11.1) (11.1) Building Maintenance - - - 3.1 3.1 (1.7) (1.-) Equipment Maintenance - - - - 7.0 7.0 (3.8) (3.8) Total 69.2 192.7 6.1 52.5 96.2 416.7 (62.3) (166.8) (5.5) (42.3) (73.3) (350.0) Notes: /a 'Other" methods include Force Account, Direct Contracting and Consulting Services /b Figures in parenthesis are the repective amounts financed by IDA Ic Figures may not appear to add exactly due to rounding  Schedule B Page 2 of 2 DISBURSEMENTS Category SDR Amount US$ Amount % of Expenditures in Millions in Millions to be financed (1) Civil Works 85% (a) Karnataka 21.1 31.4 (b) Punjab & PHSC 23.1 34.3 (c) West Bengal 35.9 53.4 (2) Equipment,vehicles, 100% of foreign furniture, medicines, expenditures, 100% of local supplies and materials expenditures (ex-factory cost) and 80% of local expenditures (a) Karnataka 29.8 44.3 for other items procured locally (b) Punjab & PHSC 21.0 31.2 (c) West Bengal 42.9 63.7 (3) Consultants'services, 100% fellowships, studies and training (a) Karnataka 5.9 8.8 (b) Punjab & PHSC 4.8 7.1 (c) West Bengal 6.1 9.0 (4) Incremental salaries, 90% until December 31, 1998, incremental operations 75% until December 31, 2000 and maintenance costs and 40 % thereafter (a) Karnataka 12.1 18.0 (b) Punjab & PHSC 6.7 10.0 (c) West Bengal 7.4 11.0 (5) Unallocated 18.7 27.8 TOTAL 235.5 350.0 ESTIMATED DISBURSEMENTS IDA Fiscal Year ------------------------------------------US$ Million-------------------------------------------------- FY97 FY98 FY99 FY2000 FY01 FY02 Annual 24.5 57.9 85.9 87.6 67.2 26.9 Cumulative 24.5 82.4 168.3 255.9 323.1 350.0  Schedule C INDIA: STATE HEALTH SYSTEMS DEVELOPMENT PROJECT II Timetable of Key Project Events (a) Time taken to prepare the project: 15 months (b) Prepared by: Governments of Karnataka, Punjab and West Bengal (c) First IDA mission: November, 1994 (d) Appraisal mission departure: October, 1995 (e) Negotiations: January/February 1996 (f) Planned date of effectiveness: June, 1996 List of Relevant PCRs and PPARs Credit/Loan No. Project PCR Date PPAR Date Cr. 312-IN India: First Population Project May 19, 1981 December 31, 1981 Cr. 981-IN India: Second Population Project June 20, 1989 June 29, 1990 Cr. 1003-IN India: Tamil Nadu Integrated November 26, 1989 December 12, 1994 Nutrition Project Cr. 1426-IN India: Third Population Project August 1, 1993 Cr. 1623-IN India: Fourth Population Project December 12, 1994 Cr. 2448-IN India: Social Safety Net Sector June 22, 1995 Adjustment Program This report is based on an appraisal mission that visited India in October, 1995. The mission comprised Tawhid Nawaz (Senior Economist and Mission Leader), Shreelata Rao-Seshadri (Sociologist), Paramita Sudharto (Public Health Specialist), David Porter (Equipment and Support Services Specialist), Eid Dib (Procurement Specialist and Architect), Keith Hinchliffe (Senior Economist), Rani Tudor (Poverty Analyst), Kirti Banerjee (Public Health Specialist) and Nisar Sharif (MIS Specialist, WHO- SEARO). They were assisted by Mam Chand (Procurement Specialist) and Sanjay Vani (Disbursement Specialist) of the New Delhi Office. Salim Habayeb (Senior Public Health Physician) provided substantial contribution and advice during project development. Kevin Casey (Senior Implementation Specialist) and Sajitha Bashir (Economist) contributed during project preparation. Mark Schlagel and Jane Mukira assisted in the preparation of this document. The Peer Reviewers were Jagadish Upadhyay (EA2HR), Marie-Odile Waty (AF3PH), Xavier Coll (HDD) and Qaiser Khan (MN2HR). The report is endorsed by Richard Skolnik, Chief, Population and Human Resources Operations Division and Heinz Vergin, Director, South Asia Country Department II (Bhutan, India, Nepal).   Schedule D Page 1 of 5 THE STATUS OF BANK GROUP OPERATIONS IN INDIA A. STATEMENT OF BANK LOANS AND IDA CREDITS (As of December 31, 1995) US$ Million (net of cancellations) Loan/ FY of ---------------------------------- Credit * Approval Purpose IBRD 1/ IDA l/ Undisbursed 2/ 1/ 143 Loans/ 12149.7 99.8 199 Credits closed 14739.7 24.1 1621-IN 1986 Maharashtra Composite Irrigation - 128.82 50.30 1631-IN 1986 National Agricultural Research II - 57.21 5.14 1750-IN 1987 Bombay Water Supply & Sewerage III - 145.00 49.17 2846-IN 1987 Madras Water Supply 53.00 - 17.29 2845-IN 1987 Talcher Thermal 367.00 - 128.81 1780-IN 1987 Uttar Pradesh Urban Development - 120.95 35.74 1931-IN 1988 Bombay & Madras Population - 57.00 18.82 1923-IN 1988 Tamil Nadu Urban Dev. - 254.73 76.70 3093-IN 1989 Electronics Industry Dev. 8.00 - 4.10 3058-IN 1989 Export Development 120.00 - 7.43 3096-IN 1989 Maharashtra Power 354.00 - 199.81 3024-IN 1989 Nathpa Jhakri Power 485.00 - 323.16 1952-IN 1989 National Seeds III - 147.24 51.74 2022-IN 1989 National Sericulture - 125.05 36.73 2057-IN 1989 Nat'l. Family Welfare Trng. - 72.76 32.88 2994-IN 1989 States Roads 115.00 - 45.04 2010-IN 1989 Upper Krishna Irrigation II - 160.00 18.73 3050-IN 1989 Upper Krishna Ix-tgation II 45.00 - 45.00 2008-IN 1989 Vocational Training - 163.85 85.48 3196-IN 1990 Cement Industry Restructuring 293.18 - 53.37 2115-IN 1990 Hyderabad Water Supply - 79.90 48.48 2064-IN 1990 Industrial Technology Development - 55.00 43.94 3119-IN 1990 Industrial Technology Development 135.00 - 44.63 3237-IN 1990 Northern Region Transmission 485.00 - 394.62 2133-IN 1990 Population Training VII - 63.96 30.19 2076-IN 1990 Punjab Irrigation/Drainage - 145.28 81.22 2158-IN 1990 Tamil Nadu Integrated Nutrition II - 67.52 28.10 2130-IN 1990 Technician gducation I - 210.74 117.59 2100-IN 1990 Watershed Development (Hills) - 75.00 49.19 2131-IN 1900 Watershed Development (Plains) - 55.00 38.10 2241-IN 1991 Dam Safety - 130.00 119.65 3364-IN 1991 Gas Flaring Reduction 450.00 - 21.49 2173-IN 1991 ICDS I (Orissa & Andhra Pradesh) - 74.35 40.61 3334-IN 1991 Industrial Pollution Control 124.00 - 51.78 2252-IN 1991 Industrial Pollution Control - 31.60 32.21 2234-IN 1991 Maharashtra Rural Water Supply - 109.90 77.95 3258-IN 1991 Petrochemicals II 12.00 - 9.31 3259-IN 1991 Petrochemicals II 202.70 - 94.31 3344-IN 1991 Private Power Utilities II (BSES) 200.00 - 32.41 2215-IN 1991 Tamil Nadu Agricultural Development - 92.80 46.28 3300-IN 1991 Tamil Nadu Agricultural Development 20.00 - 20.00 2223-IN 1991 Technician Education II - 255.73 189.47 2300-IN 1992 Child Survival and Safe Motherhood - 214.50 60.95 2394-IN 1992 Family Welfare (Urban Slums) - 79.00 81.25 2328-IN 1992 Maharashtra Forestry - 124.00 104.61 2350-IN 1992 National AIDS Control - 84.00 59.80 3436-IN 1992 Power Utilities Efficiency 265.00 - 209.13 3498-IN 1992 Second Maharashtra Power 350.00 - 286.58 3470-IN 1992 Second National Highway 153.00 - 153.00 2365-IN 1992 Second National Highway - 153.00 136.40 2329-IN 1992 Shrimp and Fish Culture - 85.00 85.68 2341-IN 1992 West Bengal Forestry - 34.00 17.31 2433-IN 1993 Agricultural Development Rajasthan - 106.00 76.30 2439-IN 1993 Bihar Plateau Development - 117.00 105.60 2450-IN 1993 Jharia Mine Fire Control - 12.00 9.77 2483-IN 1993 Karnataka Rural Water Supply - 92.00 87.90  Schedule D Page 2 of 5 US$ Million (net of cancellations) Loan/ FY of ----------_-- _________________ Credit # Approval Purpose IBRD IDA 1/ Undisbursed 2/ 2528-IN 1993 National Leprosy Elimination - 85.00 69.50 3632-IN 1993 NTPC Power Generation 400.00 - 368.37 3630-IN 1993 Power Finance Corporation 20.00 - 19.60 3577-IN 1993 Powergrid System Development 350.00 - 290.08 2449-IN 1993 Renewable Resources Development - 115.00 118.02 2409-IN 1993 Rubber - 92.00 91.35 2470-IN 1993 Second Integrated Child Dev. - 194.00 196.15 2509-IN 1993 Uttar Pradesh Basic Education - 165.00 140.11 2510-IN 1993 Uttar Pradesh Sodic Lands Reclam. - 54.70 49.88 2572-IN 1994 Forestry Research Education - 47.00 42.74 2573-IN 1994 Andhra Pradesh Forestry - 77.40 75.89 2592-IN 1994 Water Resources Consolidation (Haryana) - 258.00 251.50 2594-IN 1994 Maharashtra Emergency Earthquake - 246.00 208.44 2611-IN 1994 Blindness Control - 117.80 118.22 2630-IN 1994 Population IX (Family Welfare) - 88.60 90.09 3753-IN 1994 Container Transport Logistics 94.00 - 92.39 3779-:N 1995 Industrial Pollution Prevention 93.00 - 88.00 3780-IN 1995 Industrial Pollution Prevention 50.00 - 50.00 2645-IN 1995 Industrial Pollution Prevention - 25.00 25.35 2661-IN 1995 District Primary Education - 260.30 255.48 2663-IN 1995 A.P. District Heatlh - 133.00 133.27 2669-IN 1995 Agricultural Human Resources Development - 59.50 57.13 2700-IN 1995 M.P. Forestry - 58.00 55.51 2733-IN 1995 Assam Rural Infrastructure - 126.00 118.42 2745-IN 1995 Tamil Naud WRCP - 282.90 270.39 3856-IN 1995 Financial Sector Development Project 350.00 - 236.74 3857-IN 1995 Financial Sector Development Project 150.00 - 150.00 3858-IN 1995 Financial Sector Development Project 200.00 - 200.00 3907-IN 1995 Madras Water Supply II ' 275.80 - 275.80 2763-IN 1996 Bombay Sewage Disposal * - 25.00 23.64 3923-IN 1996 Bombay Sewage Disposal * 167.00 - 167.00 2774-IN 1996 Hydrology Project - 142.00 133.93 2801-IN 1996 Orissa WRCP * - 290.90 289.57 Total 18536.36 21662.72 9247.65 of which has been repaid 5742.2 1488.3 12794.21 20174.44 Total now outstanding Amount Sold 133.8 of which has been repaid 133.8 Total now held by Bank and IDA Total undisbursed (excluding *) 3706.2 4755.4 1/ IDA Credit amounts for SDR-denominated Credits are expressed in terms of their US dollar equivalents, as established at the time of Credit negotiations and as subsequently presented to the Board. 2/ Undisbursed amounts for SDR-denominated IDA Credits are derived as the undisbursed balance expressed in SDR equivalents (in turn derived as the difference between the original princip expressed in SDRs (based on the exchange rate as established at the time of Credit negotiati and the cumulative disbursements converted to SDR equivalents at the exchange rates prevaili at the respective dates of disbursements less cancellations expressed in SDR equivalents con to US dollar equivalents at the SDR/US dollar exchange rate in effect on December 31, 1995. * Not yet effective. Source: Statement of Loans & Credits (LOALA) of December 31, 1995.  Schedule D Page 3 of 5 INDIA -- List of Closed SALs and Secals USS Million (net of cancellations) Loan/ FY of ------------------------------- Credit # Approval Purpose IBRD IDA 1/ Undisbursed 2/ 23160-I -992 SA- I--22-.00 ---- .0 23160-IN 1992 SAL I - 220.00 0.00 23161-IN 1992 SAL I - 30.00