India - Uttar Pradesh Health Systems Development Project

Report No. PID7450 Project Name India-Uttar Pradesh Health Systems (+) Development Project Region South Asia Sector Population, Health and Nutrition Project ID INPE50657 Implementing Agency Department of Medical, Health and Family Welfare Government of Uttar Pradesh, India Date Prepared January 21, 1999 Appraisal Date September 1, 1999 Project Board Date February 2000 1. Project Objectives. The objectives of the proposed project are to assist the Government of Uttar Pradesh to: (i) improve efficiency in the allocation of health resources through policy and institutional development; (ii) improve the performance of the health system through improvements in the quality and effectiveness of health services at the primary and first referral levels, and increase access to health services in selected areas that have the greatest needs. 2. Project Description. The project covers the first two phases of an expected long term engagement in the Uttar Pradesh health sector. The project is a sector investment and maintenance loan, with significant policy content and institutional development, in addition to improvements in health service delivery across the state. Phase I. "Initiating the Reforms". The initial phase of the program is designed to initiate the reforms and meet some emergency needs of the sector, and includes: A. Policy Reforms Initiating the basic of processes for health policy development, including the establishment of a health policy unit (Policy Planning Group) and a forum for public-private partnerships, and finalizing critical policies for essential drugs, user charges, and manpower placement. B. Institutional Development Undertaking the initial steps to establish key systems for health information, manpower planning, financial management, and logistics management. C. Health Service Improvements Filling in the most urgent needs in public sector health delivery, such as providing ambulances, installing critical medical equipment for vaccines delivery and emergency obstetric care, filling key personnel gaps, and financing travel allowances for outreach workers. Phase II. "Establishing the reform framework and using current capacity".  The second phase of the program is expected to last up to five years, and is intended to firmly establish the reforms, make existing public infrastructure fully functional, and initiate a meaningful partnership with the private sector. It includes the following elements: A. Policy Reforms Establishing policy development processes, and revising key policies in the areas of: resource allocation; reforming user charges; developing a manpower plan to address recruitment, redeployment, skills training, and providing incentives; establishing the ground rules for public-private partnerships in the areas of information sharing, regulations, public protection, and quality assurance; and undertaking pilot studies in areas of contracting, networking between the public and private sectors, and regulations. This component will involve studies, workshops, training, study tours, technical assistance, office support, and public relations exercises. B. Institutional Development Establishing management systems in the areas of planning and budgeting, financial management, health information, building and equipment maintenance, disease surveillance, food and drug quality control, and hospital waste management. As well, efforts to better coordinate centrally sponsored schemes (disease control, nutrition, and reproductive health) will be supported. This component will involve studies, software development, training, technical assistance, and office and hardware support. C. Health Services Improvement Making existing health facilities functional through rehabilitation and re- equipping block level primary health centers (PHCs), community health centers (CHCs), and district hospitals; adding outpatient departments to CHCs where they are not available; filling staffing gaps and providing resources to better supervise staff. Expanding reproductive and child health initiatives at the PHC level, centrally-sponsored disease control and nutrition programs, and encouraging family welfare services through the private sector (financed by other sources). Health education and promotion activities would also be supported, consolidating efforts across projects and program areas as appropriate, with the purpose of raising demand for health services and improving healthy behavior. Extending services in under-served areas by upgrading block level PHCs to CHCs, constructing a very limited number of district hospitals and basic polytrauma centers. III. A follow-up loan is planned to cover a third phase: "Consolidating reforms and expanding services". This phase is intended to expand institutional reforms and financing options; and expand health services through the public sector and through new partnerships with the private sector. Preparation of phase III is expected to begin after a mid-term review of phase II, and depend on learning from pilot interventions. - 2-  3. Project Implementation. Institutional arrangements are currently under preparation. At the top of the proposed structure is a Project Governing Board, chaired by the Chief Secretary and including other Principal Secretaries and a representative from GOI (and possibly the private sector and consumer group representatives), which would have responsibilities for overall project coordination and policy. A Project Implementation Committee, led by the Principal Secretary Health and including Departmental Directors and the Project executive team, would be responsible for overseeing routine implementation issues, and coordinating with the Medical, Health and Family Welfare Departments. A Project Management Unit (PMU) placed in the DOMHFW would be responsible for day to day project implementation. The PMU would be comprised of a central executive with five regional directors, with technical officers in the area of management, accounting, engineering, and health, with the district Chief Medical Officer providing a project officer from existing staff in each district. A Policy Planning Group, comprised of key policy- makers and researchers outside the DOMHFW, is proposed to undertake analytic work and develop and assess policies for the DOMHFW. 4. Project Cost and Financing. The project cost is estimated at US$125 million. Disbursements under the credit would be against civil works, medical equipment and supplies, drugs, vehicles, training and consultancy services, and incremental operating expenditures. Civil works would be grouped in small packages and geographically scattered; national competitive bidding would be the predominant procedure. 5. Environmental Impact. The project is classified as category B of environmental classification. The project will have a net benefit in environmental issues. Although hospitals produce waste, including a small amount of infectious and hazardous materials, the proposed project will help to address the issue of the management of health care waste. Government is preparing a plan for this. 6. NGO and Beneficiary Participation. End beneficiaries, community groups, and NGOs are being consulted during the preparation phase through extensive household surveys, exit interviews at health facilities, and focus groups discussions, to ensure that needs of patients are being met and incorporated into project design. Monitoring of use by end beneficiaries, and of patient satisfaction, are to be incorporated into the health management information system, and will be used for local management and performance assessment of the entire project, and are among the triggers for an expected subsequent loan. 7. Impact on Women. One of the key issues under the project is how to overcome cultural barriers, gender discrimination, and low levels of education in encouraging healthy behaviors and increasing demand for better and more accountable health services. As part of preparation, a beneficiary needs assessment of the project is being conducted, as well as an assessment of the burden of disease in Uttar Pradesh. The project is intended to improve health services for women, including for reproductive health care at the primary and first referral levels. Contact Point: The InfoShop The World Bank 1818 H Street, N.W. - 3 -  Washington, D.C. 20433 Telephone No. (202)458 5454 Fax No. (202) 522 1500 Task Leader: David Peters Senior Public Health Specialist Health, Nutrition & Population South Asia Region Tel: 91-11-4617241, ext. 105 Team Leader: Tawhid Nawaz Senior Economist Health, Nutrition & Population South Asia Region Tel: (202) 458-0363 Note: This is information on an evolving project. Certain activities and/or components may not be included in the final project. Processed by the InfoShop week ending March 19, 1999. - 4-  Annex Because this is a Category B project, it may be required that the borrower prepare a separate EA report. If a separate EA report is required, once it is prepared and submitted to the Bank, in accordance with OP 4.01, Environmental Assessment, it will be filed as an annex to the Public Information Document (PID) . If no separate EA report is required, the PID will not contain an EA annex; the findings and recommendations of the EA will be reflected in the body of the PID.