The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) REPORT NO.: RES56295 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF ANDHRA PRADESH HEALTH SYSTEMS STRENGTHENING PROJECT APPROVED ON MAY 15, 2019 TO INDIA HEALTH, NUTRITION & POPULATION SOUTH ASIA Regional Vice President: Martin Raiser Country Director: Auguste Tano Kouame Regional Director: Nicole Klingen Practice Manager/Manager: Aparnaa Somanathan Task Team Leader(s): Amith Nagaraj Bathula The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) ABBREVIATIONS AND ACRONYMS ANM Auxiliary Nurse Midwife AP Andhra Pradesh APVVP Andhra Pradesh Vaidya Vidhan Parishad ASHA Accredited Social Health Activist CEmONC Comprehensive Emergency Obstetric and Newborn Care CHC Community Health Center CHFW Commissioner of Health and Family Welfare DH Directorate of Health DLI Disbursement-Linked Indicator DoHFW Department of Health, Medical and Family Welfare DPH&FW Directorate of Public Health and Family Welfare e-SC Electronic Subcenter EHR Electronic Health Records ESMF Environmental and Social Management Framework GoAP Government of Andhra Pradesh GoI Government of India HWC Health and Wellness Center IVA Independent Verification Agency MCH Maternal and Child Health MIS Management Information System MLP Mid-level Service Provider NCD Noncommunicable Disease NHM National Health Mission NQAS National Quality Assurance Standards PDO Project Development Objective PHC Primary Health Center PPP Public-Private Partnership QA Quality Assurance SC Subcenter SPIU Strategic Planning and Innovations Unit WHO World Health Organization The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) BASIC DATA Product Information Project ID Financing Instrument P167581 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 15-May-2019 30-Sep-2024 Organizations Borrower Responsible Agency Republic of India Project Development Objective (PDO) Original PDO 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. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IBRD-89450 15-May-2019 27-Jun-2019 09-Sep-2019 30-Sep-2024 328.00 242.11 85.89 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No i The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) 1 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A. PROJECT STATUS 1. The US$328 million Andhra Pradesh Health System Strengthening Project (AP HSSP) was approved on May 15, 2019 and became effective on September 9, 2019. The closing date is September 30, 2024. Based on the request of Department of Economic Affairs (DEA), Ministry of Finance (MoF), Government of India (GoI), the project was first restructured on May 5, 2020. The restructuring introduced changes in (a) Components Scope and Costs, (b) Disbursement Linked Indicators (DLIs) and Disbursement Linked Results (DLRs), (c) Results Framework to refine some Project Development Objective (PDO) and intermediate indicators, (e)implementation Arrangements, and (f) the Technical, Economic and Financial, Environment and Social Analysis to account for the above changes. The second restructuring introduced the following changes: (a) new sub-component to include provision of COVID-19 activities; (b) new disbursement category for the COVID-19 expenditures; and (c) reallocation between financing between disbursement categories to accommodate the new disbursement category and update of safeguards given new activities added in the project restructuring. The second restructuring was done on June 9, 2021. The restructuring introduced (i) added a new disbursement category for the COVID-19 expenditures to be financed up to 100% retroactively to the date of the BFP letter; and (ii) change relevant DLIs to reduce funds allocated to DLIs and reallocate US$ 15 million to new category for emergency COVID-19 response. 2. The Project has disbursed US$242.11 million (approximately 74 percent of the total loan amount) as of August 2, 2023. The Project is a results-based investment project financing operation, disbursing against the achievement of nine DLIs, measured by milestones of progress of 26 DLRs. As of July 18, 2023, 16 DLRs have been fully achieved. Two DLRs (2.3 and 7.2.b) are currently in progress and are likely to meet their targets by the end of September 2023. Two other DLRs (6.2.b and 7.2.c) are expected to be achieved by March 2024. The remaining five DLRs (2.1, 5.1, 5.2.a and b, 7.2.a) and corresponding results indicators have made limited progress. 3. Progress in achieving the Project Development Objectives (PDOs) and the project implementation progress are rated as Moderately Satisfactory. The project has made significant progress in enhancing the quality of care, improving the responsiveness of public health services, and increasing access to an expanded package of primary health services. It has successfully met the year four targets for three out of four PDO indicators. These indicators are specifically related to Community Health Centers (CHCs) and Primary Health Centers (PHCs) obtaining quality certification, the increase in the percentage of patients diagnosed and at risk of hypertension and diabetes being managed according to the protocol at the sub-center (SC) or Primary Health Care Centre (PHC) level, and the number of districts where at least 90 percent of pregnant women receive full ante-natal care. However, the PDO indicator focusing on the average patient experience score is yet to be achieved. In terms of the fifteen intermediate results indicators, the project has achieved or surpassed the year four targets for nine indicators. The remaining six indicators are on track and expected to be achieved, albeit with minor delays. 4. Project implementation status: Under component 1: Enhance Quality of Care, the project has achieved its targets for DLR 1.1 and DLR 1.4, which focus on improving internal quality accreditation scores and data reporting on the Quality Dashboard, respectively. Eight out of the ten DLRs have been fully accomplished, while progress on the remaining two DLRs is mixed. DLR 2.1 has made limited progress due to the unavailability of specialist doctors for Comprehensive Emergency Obstetric and Newborn Care (CEmONC services, while DLR 2.3 related to routine maintenance and repair of biomedical equipment at the CHC level 2 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) has made significant progress with the agency selected and operations commenced in February 2023. 5. Component 2 focuses on improving the responsiveness of public health services, with DLI 4 on track to implement an integrated online patient management system. DLR 4.1 (integrated online patient management system) has been completed in 542 out of 1,400 facilities, with verification for the remaining 858 facilities to be completed by the end of December 2023. However, reporting on patient experience (DLI 5) has experienced significant delays due to rollout of intervention and the need for behavioral change among patients to encourage them to report their experience. 6. Component 3 aims to increase access to an expanded package of primary health services, with eight out of twelve DLRs successfully achieving their targets. DLR 6.1 and DLR 8.1 have contributed significantly to the overall project disbursement. DLR 7.2(b) is on the verge of being achieved, with only a few key actions remaining related to analysis of data to establish the NCD baseline. However, DLR 7.2(a) associated with the STEPS (Noncommunicable Disease Risk Factor Survey and Survey Analysis) survey has been significantly delayed due to non-availability of firms willing to bid has against tender. 7. There is no overdue audit report for the Project. The World Bank relies on the existing audit mechanisms of the GoAP for the audit of the Project. The seventh audit report for the fiscal year starting April 1, 2022 and ending September 30, 2022 has been received. B. Rationale for restructuring 8. The Government of Andhra Pradesh has conducted a thorough review of the state health sector strategy and progress in the health program, leading to the evolution of the state health sector strategy to enhance its approach to health service delivery. As a result, the government has requested the Bank to restructure the project (reference number 5/4/2016-FB.V dated June 26, 2023) to align it with state health priorities. 9. Therefore, the proposed restructuring will: (a) Expand the scope of core package of services contributing towards quality of care in sub-district level hospital to include Area Hospitals (AHs) along with CHCs. Given the demographic transition, the majority of the women are delivering at the AHs. Thus, investments to improve quality of service delivery at sub- district level health facilities are being prioritized. (b) Bring complementarity to the ongoing patient feedback systems established under Government of India (GOI) and State government initiatives from Aapna Hospital, Aarogyashree and patient feedback collected as part of National Quality Assurance Standards (NQAS). Given the robust feedback system, linking the mentioned initiatives with the grievance redressal system is essential. Thus, a more selective approach will be followed, with geographic details of feedback to address grievance, reduced sample size (yet statistically significant) to focus on quality over quantity and focused intervention limited to 1,000 facilities representing different levels. Additionally, a standardized system will be established for review of patient experience system at district / facility level. (c) Align monitoring of progress on case management and service delivery for NCDs to the State’s population based Non Communicable Diseases – Communicable Diseases (NCD-CD) survey. The comprehensive survey, using Community Based Assessment Checklist (CBAC), has generated the data to assess NCD prevalence in the state for patients diagnosed at risk of hypertension and diabetes. (d) Reallocate unspent allocations under this COVID-19 emergency category. 3 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) II. DESCRIPTION OF PROPOSED CHANGES 10. The proposed restructuring introduces changes to: (a) DLR definitions and DLR targets; (b) PDO and intermediate indicators definitions and targets; and (c) component costs. The details of the changes are described below: A. DISBURSEMENT-LINKED INDICATORS AND RESULTS MATRIX 11. The proposed changes will be reflected in the Annex 1 as the Schedule 3 (DLI Schedule) of the Loan Agreement as follows: 12. DLR 2.1 “ Number of CHCs providing core package of services contributing towards quality of care”. With the administrative transition in the state, the AHs are geographically located at the sub district level, have a higher functionality and are more accessed by the population for several services including deliveries. Considering this DLR focuses on improving quality of care of these types of facilities, it is justified to include AHs under the description and protocol of the DLR verification. 13. DLR 5.1 “Development and implementation of a system for measuring and reporting on patient experience”. The changes include calibration of the DLR definition sample size for patient feedback and scope of health facilities. (a) The current definition of operational system of patient feedback mechanism includes criteria of -a minimum set of standardized questions across all facilities, easily accessible to all patients and allows for anonymity. Ongoing complementary patient feedback systems include Mera Aspataal, Dr. Y.S.R. Aarogyashree schemes and the NQAS certification program. As the principle for patient feedback is based on the voluntary nature of providing said feedback, feedback validation is crucial by responding and addressing the feedback from patients. Therefore, anonymity from the definition of operational system will be removed. (b) the threshold for ‘operational’ system is revised to a lower threshold of monthly patient feedback from 10 percent outpatient in teaching, district, and AHs to at least 2 percent inpatients, and 5 percent outpatients in CHCs and PHCs per month to 2 percent. This has been done considering the high patient load in the health facilities, hence 2 percent of patients providing the feedback is statistically significant to provide the insight for improving quality of health services. (c) target is revised from 1,400 to 1,000 health facilities to implement the ‘operational’ system of patient experience. This has been revised considering quality implementation of this activity, which still represents the health facilities at different levels. 14. DLR 5.2 (a) “Baseline established for patient-reported experience in PHCs and CHCs” is revised for its definition of baseline for patient experience operational system from “system should be operational for at least one month in at least 50 CHCs and 100 PHCs to establish baseline" to “system should be operational for at least one month in 100 facilities (PHC and CHC)”. 15. DLR 5.2 (b) the current definition of “Increase in the patient-reported experience from the baseline” is “The increase from baseline should be reported at least after 12 months following the establishment of baseline.” Is revised to “ Standardized System is established for review of patient experience feedback at the istrict level on quarterly basis”. This change is proposed considering that the standardized system for review of the patient 4 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) experience will help the state to monitor the feedback on a routine basis. The frequency will be quarterly review of patient experience feedback as per the guidelines approved and issued by DoH&FW included at the district level. 16. DLR 7.2 (a) the current definition of “STEPS (STEPwise Approach to Surveillance) Survey on NCD completed” is “ This DLR will be achieved when a STEPS Noncommunicable Disease Risk Factor Survey and Survey Analysis is undertaken to measure the prevalence of NCD risk factors in the adult population of AP, the knowledge of health status, use of health services, and NCD control status following the WHO-recommended methodology.” This is revised to “Survey analysis of NCD completed” defined as “This DLR will be achieved when a Noncommunicable Disease Risk Factor Survey and Survey Analysis is undertaken to measure the prevalence of NCD risk factors in the adult population of AP, the knowledge of health status, use of health services, and NCD control status.”. This new survey offers essential data to evaluate NCD risk factors and prevalence of NCDs within the state and will help establish a baseline for patients diagnosed with hypertension and diabetes, as well as those at risk. The state intends to utilize this data to determine the prevalence of NCDs among the adult population and gather other pertinent information to aid in developing evidence-based interventions for addressing NCDs in the state. As this is a routine survey conducted by the healthcare staff, the 50percent threshold will be indicative towards the state prevalence. The summary of DLR changes is provided in Annex 1. B. REALLOCATION OF FUNDS BETWEEN DISBURSEMENT CATEGORIES 17. As part of the COVID-19 emergency, the project was restructured to allocate US$15 million from category one to the newly created category four. It is proposed to reallocate the unspent funds of US$2.65 million to DLR2.1. Therefore, a reallocation of funds from category four to category one. The corresponding changes to withdrawal cost table is presented below: Table 1: Proposed Revised Withdrawal table Category Original amount of the Revised amount of Percentage of expenditures credit allocated as per the credit to be financed (inclusive of last restructuring allocated taxes) (expressed in US$) (expressed in US$) (1) Eligible Expenditure Program (EEP) 312,180,000 314,822,350 100 percent under the Project (2) Front-end Fee 820,000 820,000 Amount payable pursuant to Section 2.03 of this Agreement in accordance with Section 2.07 (b) of the General Conditions (3) Interest Rate Cap or Interest Rate 0 0 Amount due pursuant to Collar premium Section 4.05 (c) of the General Conditions (4) Goods, works, consulting services, 15,000,000 12,357,650 non- consulting services, Training and Incremental Operating Costs under Part A.5 of the Project for Provision of emergency COVID-19 Care Total Amount 328,000,000 328,000,000 5 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) C. RESULTS FRAMEWORK 18. The Project Development Objective (PDO) will not change. It is proposed to (a) refine the definition of one PDO indicator, (b) adjust four intermediate result indicators (IRIs), and (c) change the targets for two of the four IRIs to reflect the changes to the DLI matrix outlined under Section A. While the detailed changes are provided under the Results Framework Annex, a summary is outlined below along with the updated definition of indicators. 19. PDO Indicator (Revised): The definition of PDO 2 (Increase in the average patient reported experience score) Each health facility that has an operational system in place for measuring patient reported experience that meet the following criteria: (a) a minimum set of standardized questions across all facilities; (b) easily accessible to all patients; and (c) allows for anonymity” and end target are revised as follows: (a) Original operational definition: “at least 10 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 one month. ‘Health facilities’ include teaching hospitals, area and district hospitals, CHCs and PHCs. The technological platform (kiosk, tablet, or other) does not have to be the same across all facilities.” (b) Revised operational definition: “Each health facility that has an operational system in place for measuring patient reported experience that meet the following criteria: (a) a minimum set of standardized questions across all facilities; and (b) easily accessible to all patients. ‘Operational’ is defined as at least 2 percent of inpatients in teaching, district, and area hospitals and 2 percent outpatients in CHCs and PHCs per month using the system to report on their experience for at least one month. ‘Health facilities’ include teaching hospitals, area and district hospitals, CHCs and PHCs. The technological platform (kiosk, tablet, or other) does not have to be the same across all facilities.”. This change reflects the updated approach of the Government whereby existing patient feedback systems are regularly monitored at district and facility level to take necessary actions that address the grievances to support improvement in quality of health service. (c) The end target will be revised from 5 percent point increase in baseline to “Standardized System is established for review of patient experience feedback at the district level on quarterly basis (at least two meetings in a year) in 13 districts”. 20. Intermediate Results Indicator (Revised): (a) IRI 3 “Increase in the number of CHCs covered by a core package of services contributing towards quality” is being restated to “Increase in the number of AHs and CHCs covered by a core package of services contributing towards quality”. This change is consistent with the revised formulation of DLI 2/ DLR 2.1 outlined earlier and reflects increased scope considering demographic transition. (b) The target for IRI 9 “Increase in the number of facilities where the system for measuring and reporting on patient experience is operational” is being revised from 1400 to 1000 health facilities. This change is consistent with the revised formulation of DLI 5 outlined earlier and focus of establishing quality system for capturing patient feedback. (c) The definition for IRI 10 (Percentage of districts organizing quarterly review meetings on patient feedback) “Percentage point increase, from baseline established under DLR 5.2 (a), in the average patient experience score across facilities where the system designed under DLR 5.1 is operational. The increase from baseline should be reported at least after 12 months following the establishment of baseline.” Has been restated as 6 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) ““Standardized System is established for review of patient experience feedback at the district level on quarterly basis “”. This change is consistent with the state government standard system for review of patient feedback and to take necessary actions for redressal. (d) The target for IRI 10 (Percentage of districts organizing quarterly review meetings on patient feedback) is revised to Standardized system is established and implemented for review of patient reported experience at district level. The increase from baseline 0 to 70 percent districts conducting quarterly review of patient reported experience after completion of pilot study. (e) The definition of IRI 15 (Research and evaluation undertaken to support the innovative approaches to delivery of primary health care) “STEPS Noncommunicable Disease Risk Factor Survey and Survey Analysis is undertaken to measure the prevalence of NCD risk factors in the adult population of AP, the knowledge of health status, use of health services, and NCD control status following the WHO-recommended methodology.” Has been restated as “Noncommunicable Disease Risk Factor Survey and Survey Analysis is undertaken to measure the prevalence of NCD risk factors in the adult population of AP, the knowledge of health status, use of health services, and NCD control status”. This change is consistent with utilization of available population- based data on NCDs, instead of duplicating the efforts. 21. These changes were discussed and agreed with the DoHFW, Government of Andhra Pradesh during the mid- term review mission in April 2022 and were outlined in their letter requesting for a restructuring (F.No. 5/4/2016-FB.V) dated June 26, 2023. Related discussions were finalized with the state during last Implementation support mission on May 5, 2023. The Project and Loan agreements will be amended accordingly. III. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ PBCs ✔ Reallocation between Disbursement Categories ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ 7 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Financing % Current Allocation Actuals + Committed Proposed Allocation (Type Total) Current Proposed IBRD-89450-001 | Currency: USD iLap Category Sequence No: 1 Current Expenditure Category: EEP 312,180,000.00 228,933,242.75 314,822,352.52 100.00 100 iLap Category Sequence No: 3 Current Expenditure Category: PREMIUM FOR CAPS/COLLARS 0.00 0.00 0.00 iLap Category Sequence No: 4 Current Expenditure Category: Gds, Wks,Ncs,Cs,Tr,IOC Pt A.5 15,000,000.00 12,357,647.48 12,357,647.48 100.00 100.00 8 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) iLap Category Sequence No: FEF Current Expenditure Category: FRONT END FEE 820,000.00 820,000.00 820,000.00 Total 328,000,000.00 242,110,890.23 328,000,000.00 . 9 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) . Results framework COUNTRY: India Andhra Pradesh Health Systems Strengthening Project Project Development Objectives(s) 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. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improve quality of care Increase in number of CHCs and PHCs with quality PBC 2 0.00 50.00 84.00 120.00 158.00 198.00 certification (Number) Improve responsiveness of public health services Increase in the average patient Baseline to be Baseline established for 5 percentage point reported experience score established for patient patient reported increase from baseline (Text) reported experience experience Action: This indicator has been Revised Increase acess to an expanded package of primary health services Clinical protocols for Increase in percentage of Baseline to be treatment/management patients diagnosed and at risk Clinical protocols for Baseline Established Increase in baseline established following of hypertension and Increase in baseline value of hypertension and diabetes, PBC 14 NCD screening and risk through EMR installed at value by 1 percentage development of clinical diabetes at the PHC and by 2 percentage point managed as per protocol at the stratification defined PHC and CHCs point protocols subcenter level and SC or PHC (Text) referral to higher-level 10 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 facilities defined Increase in the number of districts with at least 90% of PBC 18 5.00 6.00 7.00 9.00 11.00 11.00 pregnant women receiving full ante-natal care (Number) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Improve Quality of Care Increase in the number of CHCs and PHCs with more than 70 percent quality accreditation PBC 1 0.00 116.00 180.00 247.00 317.00 390.00 score following the State-level internal assessment (Number) Establish and operate a quality tracking dashboard covering System to track quality 42 PHC and CHC facilities 60 PHC and CHC facilities 79 PHC and CHC facilities 100 PHC and CHC facilities PHC and CHC facilities for PBC 3, No dashboard currently improvement and included in quarterly included in quarterly included in quarterly included in quarterly supporting quality 4 exists maintenance established dashboard reports dashboard reports dashboard reports dashboard reports improvement and maintenance (Text) Increase in the number of AHs and CHCs covered by a core PBC 5 0.00 0.00 10.00 25.00 45.00 65.00 package of services 11 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 contributing towards quality of care (Number) Action: This indicator has been Revised Increase in the percentage of CHCs achieving at least 90% sanitation score monthly for a PBC 6 80.00 82.00 84.00 86.00 88.00 90.00 period of at least six months in a year (Percentage) Existing system provides Pharmaceutical Improvement in the information on current inventory management Quarterly stock status Quarterly stock status Quarterly stock- status pharmaceutical stock stock, but has limited Formularies for PHCs system upgraded or PBC 8 reports for PHCs and reports for PHCs and reports for PHCs and CHCs management system at the advanced functions such and CHCs defined developed with CHCs generated CHCs generated generated PHCs and CHCs (Text) as auto alerts indicating advanced management low stock functions Establish a system for routine maintenance and repair for PBC 7 No system in place. Functional System in place bio-medical equipment at the CHC level (Text) Improve Responsiveness of Public Health Services Increase in the number of health facilities with an operational integrated online PBC 9 0.00 11.00 58.00 1,400.00 1,400.00 1,400.00 patient management system (Number) 12 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Baseline established Increase in the percentage of from EMR system 2% increase from 4% increase from patients accessing their 0.00 0.00 6% increase from baseline installed at teaching baseline baseline individual EMR (Text) hospitals in Year 1 Increase in the number of facilities where the system for measuring and reporting on PBC 10 0.00 11.00 58.00 900.00 1,000.00 1,000.00 patient experience is operational (Number) Action: This indicator has been Revised Percentage of facilities and districts organizing quarterly PBC 11 0.00 50.00 55.00 60.00 65.00 70.00 review meetings on patient feedback (Percentage) Action: This indicator has been Revised Increase Access to an Expanded Package of Primary Health Services Increase in the number of PBC 12, functional health and wellness 0.00 400.00 1,000.00 2,000.00 3,000.00 3,000.00 13 centres (HWCs) (Number) Increase in the number of subcenters with trained mid- 300.00 1,400.00 2,700.00 4,000.00 5,300.00 5,900.00 level service providers (Number) Increase in the percent of adult PBC 16 12.00 23.00 34.00 45.00 56.00 67.00 population screened and 13 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 stratified by risk as per clinical protocols for hypertension and diabetes (Percentage) Increase in the percent of male population screened and stratified by risk as per 1.00 8.00 14.00 21.00 28.00 35.00 clinical protocols for hypertension and diabetes (Percentage) Increase in the percent of female population screened and stratified by risk as per 23.00 35.00 45.00 55.00 65.00 70.00 clinical protocols for hypertension and diabetes (Percentage) Increase in the percentage of women above age 30 years screened for cervical cancer at PBC 17 26.00 35.00 45.00 55.00 65.00 70.00 subcenters or PHC facilities (Percentage) Population-based survey Research and evaluation of NCD risk factor undertaken to support the prevalence not Baseline study for End-line study for Analysis of Survey data innovative approaches to PBC 15 undertaken and e- evaluation on e- evaluation on e-subcenter undertaken delivery of primary health care subcenter model overall subcenter completed completed (Text) effectiveness not evaluated 14 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Revised IO Table SPACE Performance-Based Conditions Matrix DLI IN01355004 ACTION DLR. 1.1. Increase in the number of CHCs and PHCs with more than 70 percent quality accreditation score following the PBC 1 State-level internal assessment Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 33,029,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 US$70,000 for the first 53 CHCs or FY2019/2020 116.00 0.00 PHCs and US$87,000 for each CHC or PHC thereafter US$70,000 for the first 53 CHCs or FY2020/2021 180.00 0.00 PHCs and US$87,000 for each CHC or PHC thereafter US$70,000 for the first 53 CHCs or FY2021/2022 247.00 0.00 PHCs and US$87,000 for each CHC or PHC thereafter 15 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) US$70,000 for the first 53 CHCs or FY2022/2023 317.00 0.00 PHCs and US$87,000 for each CHC or PHC thereafter US$70,000 for the first 53 CHCs or FY2023/2024 390.00 33,029,000.00 PHCs and US$87,000 for each CHC or PHC thereafter Action: This PBC is New DLI IN01354705 ACTION PBC 2 DLR 1.2. Increase in number of CHCs and PHCs with quality certification Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Number 15,300,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$110,000 for the first 28 CHCs or FY2023/2024 158.00 15,300,000.00 PHCs and US$71,882.35 for each CHC or PHC thereafter Action: This PBC is New 16 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) DLI IN01355005 ACTION DLR 1.3. Establish and operate a quality tracking dashboard covering PHC and CHC facilities for supporting quality PBC 3 improvement and maintenance Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 1,591,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No dashboard currently exists FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 Online Quality Dashboard System established and FY2023/2024 1,591,000.00 one time operational Action: This PBC is New DLI IN01355535 ACTION DLR. 1.4. Increase in the number of CHCs and PHCs for which quarterly data is being reported (for at least two consecutive PBC 4 quarters) on the Quality Dashboard Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 4,000,000.00 0.00 Period Value Allocated Amount (USD) Formula 17 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 100.00 4,000,000.00 US$40,000 per CHC or PHC Action: This PBC is New DLI IN01355006 ACTION PBC 5 DLR 2.1. Increase in the number of AHs and CHCs covered by a core package of services contributing towards quality of care Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 21,642,352.52 51.03 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$331222.26 per facility over FY2023/2024 65.00 21,642,352.52 baseline 18 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Action: This PBC is New DLI IN01355007 ACTION DLR 2.2. Increase in the percentage of CHCs achieving at least 90% sanitation score monthly for a period of at least six PBC 6 months in a year Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 9,750,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 80.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$975,000 per percentage point FY2023/2024 90.00 9,750,000.00 increase over achievement of DLR 2.2 (b) or 86%, whichever is lesser Action: This PBC is New 19 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) DLI IN01355009 ACTION PBC 7 DLR 2.3. Establish a system for routine maintenance and repair for bio-medical equipment at the CHC level Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 3,950,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No system in place. FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 Functional system in place for routine FY2023/2024 maintenance and repair for bio-medical 3,950,000.00 One time full payment equipment till the CHC level Action: This PBC is New DLI IN01355008 ACTION PBC 8 DLR 3.1. Improvement in the pharmaceutical stock management system at the PHCs and CHCs Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 6,250,000.00 0.00 Period Value Allocated Amount (USD) Formula 20 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Existing system provides information on current Baseline stock, but has limited advanced functions such as auto alerts indicating low stock FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 System upgraded to include above stated FY2023/2024 6,250,000.00 One time advanced options Action: This PBC is New DLI IN01355010 ACTION PBC 9 DLR 4.1. Increase in the number of health facilities with an operational integrated online patient management system Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 42,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 21 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) FY2023/2024 1,400.00 42,000,000.00 US$30,000 per facility Action: This PBC is New DLI IN01355011 ACTION DLR 5.1. Increase in the number of facilities where the system for measuring and reporting on patient experience is PBC 10 operational Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 24,250,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 1,000.00 24,250,000.00 US$ 24,250 per health facility Action: This PBC is New 22 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) DLI IN01355012 ACTION PBC 11 DLR 5.2. (a & b) Percentage of facilities and districts organizing quarterly review meetings on patient feedback Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 4,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 70.00 4,000,000.00 One time Action: This PBC is New DLI IN01355013 ACTION PBC 12 DLR 6.1. Increase in the number of functional health and wellness centres (HWCs) Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Number 61,500,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 FY2019/2020 0.00 23 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$20,500 per HWCs over the FY2023/2024 3,000.00 61,500,000.00 baseline Action: This PBC is New DLI IN01355896 ACTION PBC 13 DLR 6.2. (a) Baseline study for evaluation on HWCs completed and (b) End-line study for evaluation on HWCs completed Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 5,700,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline No baseline No endline FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 Baseline and end line completed 5,700,000.00 One time Action: This PBC is New 24 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) DLI IN01355002 ACTION DLR 7.1. (a&b) Increase in percentage of patients diagnosed and at risk of hypertension and diabetes, managed as per PBC 14 protocol at the SC or PHC Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 6,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline to be established following development Baseline of clinical protocols FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 Protocols in place 6,000,000.00 One time Action: This PBC is New DLI IN01355018 ACTION PBC 15 DLR 7.2 (a) Research and evaluation undertaken to support the innovative approaches to delivery of primary health care Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome No Text 3,500,000.00 0.00 Period Value Allocated Amount (USD) Formula 25 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Population-based survey of NCD risk factor Baseline prevalence not undertaken and No system in place to capture patient management data FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 A system in place to capture screening and FY2023/2024 3,500,000.00 Onetime payment patient management data to establish baseline Action: This PBC is New DLI IN01355014 ACTION DLR 7.2. (b&c). Increase in the percent of adult population screened and stratified by risk as per clinical protocols for PBC 16 hypertension and diabetes Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Intermediate Outcome Yes Percentage 11,000,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 12.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 26 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) FY2022/2023 0.00 US$ 5,000,000 per percent point FY2023/2024 67.00 11,000,000.00 increase Action: This PBC is New DLI IN01355017 ACTION DLR 8.1. Increase in the percentage of women above age 30 years screened for cervical cancer at subcenters or PHC PBC 17 facilities Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 28,600,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 26.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$650,000 per percentage point FY2023/2024 70.00 28,600,000.00 increase over baseline Action: This PBC is New 27 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) DLI IN01355003 ACTION PBC 18 DLR 9.1. (a,b,&c) Increase in the number of districts with at least 90% of pregnant women receiving full ante-natal care Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 32,760,000.00 0.00 Period Value Allocated Amount (USD) Formula Baseline 5.00 FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 US$5,460,000 per district increase FY2023/2024 11.00 32,760,000.00 over achievement of DLR 9.1(b) or 9 districts whichever is lesser Action: This PBC is New DLI IN01295128 ACTION Increase in the number of community health centers and primary health centers certified as having achieved National PBC 19 Quality Assurance Standards Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Number 0.00 0.00 Period Value Allocated Amount (USD) Formula 28 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Baseline FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 FY2023/2024 0.00 Action: This PBC has been Marked for Deletion DLI IN01295129 ACTION Increase in the number of community health centers and primary health centers certified as having achieved National PBC 19.1 Quality Assurance Standards Type of PBC Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Number 40.00 0.00 Period Value Allocated Amount (USD) Formula Baseline FY2019/2020 0.00 FY2020/2021 0.00 FY2021/2022 0.00 FY2022/2023 0.00 29 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) FY2023/2024 198.00 40.00 Y amount per facility Action: This PBC has been Marked for Deletion Verification Protocol Table: Performance-Based Conditions DLI_TBL_VERIFICATION DLR. 1.1. Increase in the number of CHCs and PHCs with more than 70 percent quality accreditation score following the PBC 1 State-level internal assessment Each CHCs and PHCs that earns a score of 70 percent or more on the NQAS assessment tool, as administered by the state- Description level internal Quality Assurance (QA) team. Achievement is an increase from the current baseline value, which is ‘0’. Quality Assessment Reports/QA team, DoHFW, and Online Quality Dashboard System (when established)/ Data source/ Agency DoHFW Verification Entity IVA Based on the achievement report provided by the DoHFW, the IVA will (a) review the quality assessment reports submitted by the QA team, DoHFW and confirm the number of facilities that have Procedure met or exceeded the required score and (b) randomly select 2 facilities of each type and confirm the validity of the scores. DLI_TBL_VERIFICATION PBC 2 DLR 1.2. Increase in number of CHCs and PHCs with quality certification Each CHC or PHC that is NQAS certified following an independent external assessment by the National Health Systems Resource Center. Description Achievement is an increase from the current baseline value, which is ‘0’. NQAS certification/ Data source/ Agency DoHFW 30 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) IVA Verification Entity The IVA will review the NQAS assessment documents and confirm the number of facilities that have received NQAS Procedure certification from the external assessors DLI_TBL_VERIFICATION DLR 1.3. Establish and operate a quality tracking dashboard covering PHC and CHC facilities for supporting quality PBC 3 improvement and maintenance Increase in the number of CHCs and PHCs for which quarterly data is being reported (for at least two quarters) on the Quality Dashboard. Description Each CHC or PHC that has achieved NQAS certification and for which reporting on quality scores is available on the quality dashboard (established under DLR 1.3) for at least two quarters achievement is an increase from the current baseline value, which is ‘0’. Online Quality Dashboard System/DoHFW Data source/ Agency IVA Verification Entity The IVA will review the online quality dashboard and confirm that quality reports for two quarters are available for the Procedure NQAS certified facilities. DLI_TBL_VERIFICATION DLR. 1.4. Increase in the number of CHCs and PHCs for which quarterly data is being reported (for at least two consecutive PBC 4 quarters) on the Quality Dashboard DLR 1.4 is defined as: Increase in the number of CHCs and PHCs for which quarterly data is being reported (for at least two quarters) on the Quality Dashboard. Description Each CHC or PHC that has achieved NQAS certification and for which reporting on quality scores is available on the quality dashboard (established under DLR 1.3) for at least two quarters achievement is an increase from the current baseline value, which is ‘0’. 31 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Online Quality Dashboard System/DoHFW Data source/ Agency IVA Verification Entity The IVA will review the online quality dashboard and confirm that quality reports for two quarters are available for the Procedure NQAS certified facilities. DLI_TBL_VERIFICATION DLR 2.1. Increase in the number of AHs and CHCs covered by a core package of services contributing towards quality of PBC 5 care Number of CHCs and AHs that provide a core package of services contributing to improved quality of care Denominator: Total number of CHCs and AHs in the state The core package of services includes (a) radiology (X-ray); (b) laboratory diagnostics; and (c) CEmONC services This will be measured as: · availability on X-ray reports for at least 1 month prior to date of verification Description · availability of lab reports for at least 1 month prior to date of verification on at least 5 tests – (i) complete blood count (ii) platelet by cell counter (iii) serum creatinine (iv) blood glucose; and (v) Hemoglobin testing - from the mandated CHC diagnostic service list · availability of CEmONC services based on standardized guidelines issued by the MoHFW. At present, none of the CHCs and AHs have these 3 services available. Therefore, baseline value is ‘0’. By the end of the project, 65 CHCs and AHs are expected to have all 3 services. Progress Report, APVVP / Data source/ Agency DoHFW IVA Verification Entity 32 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Based on the achievement report provided by the DoHFW, the IVA will (a) progress report from APVVP to confirm CHCs and AHs are covered by the core package of services and Procedure (b) randomly select 5 percent of facilities and confirm through a field visit the coverage of the core package of services. DLI_TBL_VERIFICATION DLR 2.2. Increase in the percentage of CHCs achieving at least 90% sanitation score monthly for a period of at least six PBC 6 months in a year Numerator: Number of CHCs that achieve at least 90% sanitation score monthly for a period of at least six months in the fiscal year (does not need to be consecutive six months) Description Denominator: Total number of CHCs that have performance-based sanitation contracts in place in that fiscal year. Each percentage point increase from the baseline of 80% will be counted as achievement. Sanitation Dashboard reporting facility-based scores daily/DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will confirm the reported average monthly sanitation score for each reported facility for the reported period through a review of the daily reported scores in the online sanitation Procedure report system. No site visits are required. DLI_TBL_VERIFICATION PBC 7 DLR 2.3. Establish a system for routine maintenance and repair for bio-medical equipment at the CHC level Functional system in place for routine maintenance and repair for bio-medical equipment till the CHC level The system is defined as functional if: Description (i) 75% of critical bio-medical equipment is functioning at the time of verification (ii) No critical equipment is in disrepair for more than a month (iii) there is an MIS tool for monitoring equipment availability, functioning and repair status at the CHC level 33 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Equipment MIS/DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will confirm the status as per the equipment MIS. It will Procedure visit a 5% sample of CHCs to confirm data provided through the equipment MIS is accurate. DLI_TBL_VERIFICATION PBC 8 DLR 3.1. Improvement in the pharmaceutical stock management system at the PHCs and CHCs An updated facility-level pharmaceutical stock management system which includes specific advanced functionality, including but not limited to, (a) automatic flagging of no and low stock of pharmaceuticals according to the specific health facility formulary and (b) automatic estimation of order requirements. The upgraded system (upgrade of existing system or Description 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. Updated pharmaceutical stock management system/DoHFW Data source/ Agency IVA Verification Entity The IVA will, based on achievement report provided by the DoHFW, (a) review the functionality of the system in line with the description; and Procedure (b) check that a system with the described functionalities is in use in a randomly selected 5 facilities where it is rolled out. DLI_TBL_VERIFICATION PBC 9 DLR 4.1. Increase in the number of health facilities with an operational integrated online patient management system Each health facility that uses the new integrated online patient management system as defined in the contract between the service provider and the DoHFW. Description ‘Health facilities’ include teaching hospitals, district and area hospitals, CHCs and PHCs. 34 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) ‘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. Achievement is an increase from the current baseline value, which is ‘0’. Integrated online patient management system/DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will (a) view the integrated online patient management system and confirm that it is in ‘use’ and Procedure (b) visit a random sample of 5 percent PHCs, CHCs, and area hospitals and 2 district and 2 teaching hospitals to confirm that the system is in ‘use’ in that facility as described in the ‘description of achievement’. DLI_TBL_VERIFICATION DLR 5.1. Increase in the number of facilities where the system for measuring and reporting on patient experience is PBC 10 operational Each health facility that has an operational system in place for measuring patient reported experience that meet the following criteria: (a) a minimum set of standardized questions across all facilities; and (b) easily accessible to all patients. ‘Operational’ is defined as at least 2 percent outpatient and inpatients per month using the system to report on their Description experience for at least one month. ‘Health facilities’ include teaching hospitals, area and district hospitals, CHCs and PHCs. The technological platform (kiosk, tablet, or other) does not have to be the same across all facilities. Online system for reporting patient experience/ Data source/ Agency DoHFW IVA Verification Entity 35 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Based on the achievement report provided by the DoHFW the IVA will (a) verify that the system for measuring patient-reported experience as outlined in the definition is operational and Procedure (b) visit a random sample of 5 percent PHCs, CHCs, and area hospitals and 2 district and 2 teaching hospitals to confirm that the system is ‘operational’ in that facility as described in the ‘description of achievement’. DLI_TBL_VERIFICATION PBC 11 DLR 5.2. (a & b) Percentage of facilities and districts organizing quarterly review meetings on patient feedback DLR 5.2 (a) is defined as: DLR will be achieved when pilot study for patient reported experience in PHCs and CHCs. Pilot study to include analysis of average patient experience score across 100 facilities where the system is operational under DLR 5.1. The system should be operational for at least one month to initiate the pilot study for understanding the level of patient experience and efficiency of the system. DLR 5.2 (b) is defined as: Description Standardized system is established to review patient experience feedback at district level. System is defined as: Quarterly review of patient experience feedback as per the guidelines approved and issued by DoH&FW. System should essentially include Quarterly Reviews of Patient Feedback scores and applicable key action points at district level under the leadership of DM&HO or any competent authority as per the guideline/orders issued by DoH&FW. District quarterly review reports with MoM (Minutes of Meeting)/ Data source/ Agency DoHFW IVA Verification Entity 5.2 a: No independent verification is required. Based on the report submitted by the DoHFW, the World Bank will confirm Procedure that the pilot study has been conducted 5.2 b: Based on the achievement report provided by the DoHFW the IVA will 36 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) (a) Review the reports submitted and MoM by districts. DLI_TBL_VERIFICATION PBC 12 DLR 6.1. Increase in the number of functional health and wellness centres (HWCs) The number of functional HWCs Functional HWCs are defined as those with (a) qualified doctor available through teleconsultation, (b) at least one trained ANM or MLP, (c) necessary equipment for NCD screening, (d) availability of at least 70% drugs as per the essential medicines list as defined by the Director of Public Health and Family Welfare, GoAP on the date of verification; (e) availability of an Description information system/application to manage individual NCD patients and to generate a registry of all NCD patients. Trained ANM or MLP staff is defined as an ANM or MLP that has completed training on NCD screening, management, examination and consultation process assisted through telemedicine. Progress report/DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will (a) review the progress reports on HWCs and confirm the reported numbers of functional HWCs and (b) randomly select 5% HWCs and through field visits and confirm they meet the specified criteria. Procedure The sample should primarily include newly established HWCs but also include a small number of previously reported HWC to ensure that they continue to operate. DLI_TBL_VERIFICATION PBC 13 DLR 6.2. (a) Baseline study for evaluation on HWCs completed and (b) End-line study for evaluation on HWCs completed DLR 6.2 (a) and (b) - This DLR will be achieved upon the establishment of a baseline and end-line study for the HWC model of delivery. Description The details of the study design will be agreed in advance by the DoHFW and World Bank. 37 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Baseline and end-line study report/DoHFW Data source/ Agency World bank Verification Entity No independent verification will be required. Based on the reports submitted by the DoHFW, the World Bank will confirm Procedure that the baseline and end-line evaluation studies of the HWC had been undertaken as agreed. DLI_TBL_VERIFICATION DLR 7.1. (a&b) Increase in percentage of patients diagnosed and at risk of hypertension and diabetes, managed as per PBC 14 protocol at the SC or PHC DLR 7.1 (a) and (b) is defined as: (NO CHANGE) (a) The development of specific clinical protocols for treating or managing diabetes and hypertension patients at the primary health care level (PHC or subcenter), including referral guidelines and Description (b) Issuance of these protocols and guidelines by the DoHFW within the state, including an orientation on the same to all doctors at the PHC and relevant service providers at the SC. Protocols/ Data source/ Agency DoHFW IVA Verification Entity Based on the documents provided by the DoHFW, the IVA will (a) confirm that the hypertension and diabetes treatment and management protocols, including referral guidelines— Procedure targeted at management and treatment of patients at the PHC and SC levels—have been approved and issued and (b) an orientation of all PHC doctors and ANMs or MLHPs on the same has been organized. DLI_TBL_VERIFICATION PBC 15 DLR 7.2 (a) Research and evaluation undertaken to support the innovative approaches to delivery of primary health care DLR 7.2 (a) (RESTATED) - This DLR will be achieved when a NCD 2.0 survey data analysis is undertaken to measure the Non- Description Communicable Diseases (NCD) prevalence at state and districts. Data source/ Agency Protocols issued/DoHFW 38 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) World Bank Verification Entity No independent verification will be required. Based on the report submitted by the DoHFW, the World Bank will confirm Procedure that the survey and report had been conducted. . DLI_TBL_VERIFICATION DLR 7.2. (b&c). Increase in the percent of adult population screened and stratified by risk as per clinical protocols for PBC 16 hypertension and diabetes DLR 7.2 (b) is defined as: (NO CHANGE) Baseline data for the percentage of patients diagnosed and at risk of hypertension and diabetes, who are managed as per protocol (adopted in DLR 7.1) at PHCs or SCs. Specific indicators from the protocol adopted in DLR 7.1 will be jointly agreed by the World Bank and the DoHFW to measure ‘managed as per protocol’. For capturing baseline data, a system is required that can measure the following: Numerator: Number of patients diagnosed and at risk of hypertension and diabetes managed as per protocol at the PHC or SC Description 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 (in the catchment of the 3000 HWCs) DLR 7.2 (c) is defined as: (NO CHANGE) Numerator: Number of patients diagnosed and at 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. Achievement is defined as an increase from the baseline (referenced in DLR 7.2 (b)) in the percentage of patients diagnosed and at risk of hypertension and diabetes, who are managed as per protocol (adopted in DLR 7.1) at PHCs or SCs. 39 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) EHR, NCD application, APeRx/DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will (a) review the data reported by the DoHFW and confirm the numbers from the online data systems and Procedure (b) randomly select 10 facilities and from these randomly select 5 patients identified as being managed to confirm that treatment is being provided according to the protocols. DLI_TBL_VERIFICATION DLR 8.1. Increase in the percentage of women above age 30 years screened for cervical cancer at subcenters or PHC PBC 17 facilities DLR 8.1 is defined as: (NO CHANGE) Numerator: Cumulative number of women screened at least once as reported by subcenters or PHCs, including those women seen by mobile medical units or other outreach events. Denominator: The estimated number of women over the age of 30 as reported by the Praja Sadhikara Survey. Description Achievement is defined as an increase in the percentage of women above 30 years of age who have been screened for cervical cancer at least once above the baseline of 26%. The baseline of 26% was determined based on the number of women who have been screened as of November 2018 (1,955,454) divided by the estimated number over the age of 30 from the Praja Sadhikara Survey, which is 7,500,000. NCD application /DoHFW Data source/ Agency IVA Verification Entity 40 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Based on, the achievement report provided by the DoHFW, the IVA will review the data reported by the DoHFW and Procedure confirm the numbers from the online data system. DLI_TBL_VERIFICATION PBC 18 DLR 9.1. (a,b,&c) Increase in the number of districts with at least 90% of pregnant women receiving full ante-natal care DLR 9.1 is defined as: (NO CHANGE) Numerator: Number of districts where, of the total estimated pregnant women during the past year, at least 90% pregnant women received full ANC ‘Full antenatal care’ is defined as at least four ANC visits, at least one TT injection, and taken Iron Folic Acid tablets or syrup Description for 100 or more days. Public health facilities include all health facilities reporting to the DoHFW. The data do not include women who have delivered at private facilities. This indicator will be measured annually. HMIS portal /DoHFW Data source/ Agency IVA Verification Entity Based on the achievement report provided by the DoHFW, the IVA will review the data reported by the DoHFW and confirm Procedure the numbers from the online data systems. DLI_TBL_VERIFICATION Increase in the number of community health centers and primary health centers certified as having achieved National PBC 19 Quality Assurance Standards Description Data source/ Agency 41 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Verification Entity Procedure DLI_TBL_VERIFICATION Increase in the number of community health centers and primary health centers certified as having achieved National PBC 19.1 Quality Assurance Standards Description XXX Data source/ Agency YYY Verification Entity IVA ghjgjgj Procedure 42 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) Annex 1 Attachment to the World Bank’s Letter dated 20 September, 2023 Loan No. 8945-IN Revised Schedule 3 (Disbursement-Linked Indicators, Disbursement-Linked Results, and Disbursement-Linked Indicator Values applicable to the Project) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount IMPROVE QUALITY OF CARE 1. Increase in the number 53.92 17.13% DLR 1.1 Increase in the number of CHCs and PHCs with more than 70 percent quality of CHCs and PHCs (NO CHANGE) accreditation score, following State level internal assessment by the DoHFW achieving and maintaining Baseline: 0 CHCs and PHCs quality standards (NO Target: 390 CHCs and PHCs CHANGE) Value: US$33,029,000 Formula: US$70,000 for the first 53 CHCs or PHCs and US$87,000 for each CHC or PHC thereafter DLR 1.2 Increase in the number of CHCs and PHCs with quality certification. (NO CHANGE) Baseline: 0 CHCs and PHCs Target: 198 CHCs and PHCs 43 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount Value: US$15,300,000 Formula: US$110,000 for the first 28 CHCs or PHCs and US$71,882.35 for each CHC or PHC thereafter DLR 1.3 Quality tracking dashboard (NO CHANGE) system established to support quality improvement and maintenance across all districts Baseline: No quality tracking system in place Target: System in place Value: US$1,591,000 DLR 1.4 Increase in the number of CHCs and PHCs for which quarterly data is (NO CHANGE) being reported (for at least two consecutive quarters) on the Quality Dashboard Baseline: 0 CHCs and PHCs Target: 100 CHCs and PHCs Value: US$4,000,000 Formula: US$40,000 per CHC or PHC 2. Increase in the number 35.34 11.23% DLR 2.1 Number of CHCs and AHs that are providing a core package of services contributing to of CHCs and AHs covered (RESTATED) quality of care. by a core package of Baseline: 0 services contributing towards quality of care Target: 65 44 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount (RESTATED) Value: US$21,642,352.52 (VALUE INCREASED) Formula: US$331,222.26 per facility over baseline DLR 2.2 (NO CHANGE) (a) Increase in (b) Increase in (c) Increase in the the percentage the percentage percentage of of CHCs of CHCs CHCs achieving achieving at achieving at at least 90% least 90% least 90% sanitation sanitation score sanitation score score monthly monthly for a monthly for a for a period of period of at period of at at least six least six months least six months months in a in a year, in a year, year following the following the achievement of achievement of DLR 2.2(a) DLR 2.2(b) Baseline: 80% Baseline: DLR Baseline: DLR CHCs 2.2(a) 2.2(b) achievement achievement Target: 82% CHCs Target: 86% Target: 90% CHCs CHCs 45 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount Value: Value: Value: US$1,950,000 US$3,900,000 US$3,900,000 Formula: Formula: Formula: US$975,000 per US$975,000 per US$975,000 percentage percentage per point increase point increase percentage over over point increase achievement of achievement of over baseline DLR 2.2 (a) or DLR 2.2 (b) or 82%, whichever 86%, whichever is lesser is lesser DLR 2.3 (NO CHANGE) System in place for routine maintenance and repair for bio- medical equipment at the CHC level Baseline: No functional system to monitor and ensure timely bio-medical equipment maintenance Target: Functional system in place Value: US$3,950,000 46 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount 3. Improvement in the 6.25 1.98% DLR 3.1 (NO CHANGE) Pharmaceutical inventory pharmaceutical stock management system for use at management system at PHCs and CHCs upgraded with the PHCs and CHCs to advanced management reduce stock out risks (NO functions CHANGE) Baseline: Current system does not have advanced functions such as defined facility-based formulary, automatic flags for low or no stock, and automatic estimation of order requirements. Target: System upgraded to include above stated advanced options Value: US$6,250,000 IMPROVE RESPONSIVENESS OF PUBLIC HEALTH SERVICES 4. Increase in the number 42.00 13.34% DLR 4.1 (NO CHANGE) Increase in the number of health facilities with an operational integrated online of health facilities with an patient management system operational integrated Baseline: 0 Target: 1,400 online patient Value: US$42,000,000 (No Change) management system (NO CHANGE) Formula: US$30,000 per facility 5. Development and 28.25 10.16% DLR 5.1 System designed and operational in the health facilities 47 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount implementation of a (RESTATED) Baseline: 0 system for measuring and reporting on patient Target: 1,000 (TARGET REVISED) experience Value: US$24,250,000 (RESTATED) Formula: US$24,250 per health facility (UNIT COST INCREASED) DLR 5.2 (a) Pilot study (b) Standardized system is (RESTATED) for patient established and implemented for reported review of patient reported experience in experience at district level 100 PHC and CHC Baseline: No district level review of patient reported experience in place Target: 70 percent districts conducting quarterly review of patient reported experience Value: Value: US$2,500,000 US$1,500,000 (NO CHANGE) Formula: US$250,000for each district conducting quarterly review of patient reported experience 48 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount INCREASING ACCESS TO AN EXPANDED PACKAGE OF PRIMARY HEALTH SERVICES 6. Increase in the number 67.20 21.35% DLR 6.1 Increase in the number of functional health and wellness centers (HWCs) of functional health and (NO CHANGE) Baseline: 0 HWCs Target: 3000 HWCs wellness centers (NO Value: US$61,500,000 CHANGE) Formula: US$20,500 per HWCs over the baseline DLR 6.2 (a) Baseline (b) End-line (NO CHANGE) study for study for evaluation on evaluation on HWCs HWCs completed completed Baseline: No Baseline: No evaluation evaluation Target: Target: End-line Baseline study study completed completed Value: Value: US$2,850,000 US$2,850,000 49 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount 7. Increase in the 20.5 6.51% DLR 7.1 (a) DoHFW (b) DoHFW percentage of patients (NO CHANGE) approves and approves and diagnosed and at risk of issues clinical issues clinical hypertension and diabetes protocols for protocols for who are managed at the NCD screening treatment and SC or the PHC and risk management of (RESTATED) stratification hypertension of patients. and diabetes at the PHC and SC level and referral to higher-level facilities. Baseline: No Baseline: No protocols in protocols in place place Target: Target: Protocols in Protocols in place place Value: Value: US$2,000,000 US$4,000,000 50 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount DLR 7.2 (a) ) NCD 2.0 (b) Baseline (c) Increase in (RESTATED) survey data established of the percentage analysis and the percentage of patients report of patients diagnosed and completed diagnosed and at risk of at risk of hypertension hypertension and diabetes, and diabetes, managed as per managed as per protocol at protocol at PHCs or SCs PHCs or SCs Baseline: No Baseline: No Baseline: As established under survey system in place DLR 7.2 (b) to capture Target: Survey patient Target: 2 percentage point completed management increase from baseline data Target: A system in place to capture screening and patient management data to establish baseline 51 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount Value: Value: Value: US$10,000,000 US$3,500,000 US$1,000,000 (NO CHANGE) (NO CHANGE) (NO CHANGE) Formula: US$5,000,000 per percentage point increase over baseline (NO CHANGE) 8. Increase in the 28.60 9.08% DLR 8.1 Increase in the percentage of women above 30 years of age screened for cervical percentage of women in cancer at SCs or PHC facilities the target age group Baseline: 26% screened for cervical cancer at SCs or PHCs Target: 70% (NO CHANGE) Value: US$28,600,000 Formula: US$650,000 per percentage point increase over baseline 52 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount 9. Increase in the number 32.76 10.41% DLR 9.1 (a) Number of (b) Number of (c) Number of of districts with at least (NO CHANGE) districts districts where, districts where, 90% of pregnant women where, of the of the total of the total receiving full antenatal total estimated estimated care (NO CHANGE) estimated pregnant pregnant pregnant women during women during women during the past year, at the past year, the past year, least 90% at least 90% at least 90% pregnant pregnant pregnant women women women received full received full received full ANC care, ANC care, ANC care following the following the period of DLR period of DLR 9.1(a) 9.1(b) Baseline: 5 Baseline: DLR Baseline: DLR 9.1(a) 9.1(b) Target: 7 achievement achievement Target: 9 Target: 11 53 The World Bank Andhra Pradesh Health Systems Strengthening Project (P167581) As % of DLRs Total Financing Total DLIs Allocated to DLI DLR No. FY2019/20 FY2020/21 FY2021/22 FY2022/23 FY2023/24 (US$, millions) Financing (Year 1) (Year 2) (Year 3) (Year 4) (Year 5) Amount Value: Value: Value: US$10,920,000 US$10,920,000 US$10,920,000 Formula: Formula: Formula: US$5,460,000 US$5,460,000 US$5,460,000 per district per district per district increase over increase over increase over baseline achievement of achievement of DLR 9.1(a) or 7 DLR 9.1(b) or 9 districts districts whichever is whichever is lesser lesser * None of the DLRs are time-bound. The Fiscal Years in which they are expected to be achieved as per this Schedule are strictly for indicative purposes. These DLRs can accordingly be met up and until the Closing Date. 54