The World Bank Kerala Health Systems Improvement Program (P503872) @#&OPS~Doctype~OPS^blank@pidaprpfrcoverpage#doctemplate Program Information Document (PID) Appraisal Stage | Date Prepared/Updated: 19-Sep-2024 | Report No: PIDPA00086 The World Bank Kerala Health Systems Improvement Program (P503872) @#&OPS~Doctype~OPS^dynamics@pidaprpfrbasicinformation#doctemplate BASIC INFORMATION A. Basic Program Data Project Beneficiary(ies) Region Operation ID Operation Name Kerala Health Systems India SOUTH ASIA P503872 Improvement Program Financing Instrument Estimated Appraisal Date Estimated Approval Date Practice Area (Lead) Program-for-Results Health, Nutrition & 09-Sep-2024 17-Dec-2024 Financing (PforR) Population Borrower(s) Implementing Agency Department of Health & Department Of Economic Family Welfare, Affairs Government of Kerala Proposed Program Development Objective(s) To improve access to and quality of an enhanced range of health services and health system resilience in the state of Kerala. @#&OPS~Doctype~OPS^dynamics@pidpfrprojectfinancing#doctemplate COST & FINANCING (US$, Millions) Maximizing Finance for Development Is this an MFD-Enabling Project (MFD-EP)? No Is this project Private Capital Enabling (PCE)? To be decided SUMMARY Government program Cost 5,000.00 Total Operation Cost 500.00 Total Program Cost 499.30 Other Costs (Front-end fee,IBRD) 0.70 Total Financing 500.00 Financing Gap 0.00 FINANCING Page 1 The World Bank Kerala Health Systems Improvement Program (P503872) Total World Bank Group Financing 280.00 World Bank Lending 280.00 Total Government Contribution 220.00 @#&OPS~Doctype~OPS^dynamics@pidaprdecision#doctemplate Decision The review did authorize the team to appraise and negotiate Page 2 The World Bank Kerala Health Systems Improvement Program (P503872) B. Introduction and Context Country Context 1. India’s performance in health has improved substantially over time, yet wide variation exists across states and indicators. India’s under-five mortality rate (36 per 1,000 live births), infant mortality rate (30 per 1,000 live births), and maternal mortality ratio (103 per 100,000 live births) are all close to the average for countries with India’s income level, reflecting significant achievements in access to skilled birth attendance, immunization, and other priority health services.1 The rapidly growing prevalence of non-communicable diseases (NCDs) now contributes to a dominant share of the overall disease burden in India while the unfinished agenda of reproductive, maternal, newborn, child and adolescent health, undernutrition and communicable diseases still continues. In addition, India continues to be vulnerable to large scale outbreaks and impacts of climate change on health. This has long-term implications for health, learning, productivity, and economic performance. Sectoral and Institutional Context 2. Kerala, a southwestern state of 33.3 million people, has been a strong performer with better health outcomes, especially in maternal and child health, compared to most states in India. Kerala has achieved the SDG 2030 targets for neonatal (3.4 per 1,000 live births), infant (4.4 per 1,000 live births), under-five mortality (5.2 per 1,000 live births) rates and for maternal mortality ratio (19 per 100,000 live births).2 Kerala’s striking health gains, can be attributed to sustained emphasis to promote public health and primary health care (PHC), the improved status of women in Kerala3, decentralized governance through the Local Self Government Institutions (LSGIs), high levels of literacy, especially girls’ education, and effective community ownership and participation in health promotion. 3. Despite these significant health improvements and investments, the Kerala health system faces unprecedented challenges due to the epidemiological transition towards chronic diseases, a rapidly growing elderly population, increased vulnerability to disease outbreaks and climate change impacts, that puts large sections of the population at risk. These challenges are fairly distinct to Kerala and coupled with a decrease in public funding for health, and the increasing role of private health care at much higher out-of-pocket (OOP) cost has placed Kerala’s healthcare system under severe strain. Although the government health budget has increased from INR 71 billion in 2019/20 to INR 100 billion for 2024/25 in real terms, the rate has been way below the increase in overall government expenditure and GSDP. 4. Kerala faces challenges of a burgeoning burden of NCDs amidst profound epidemiological shifts and persistent gaps in emergency healthcare. NCDs constitute eight of the top ten contributors to Disability Adjusted Life Years (DALYs) lost in the state, impacting nearly three out of ten adults aged 60 years and older. Hypertension and diabetes alone affect an estimated 5.8 million and 3.7 million individuals respectively, yet control rates remain low. The cancer incidence is 169 per 100,000 population. Concurrently, Kerala reports over 4,000 deaths due to road traffic accidents annually. 5. Kerala is also the fastest aging state in India which further compounds the NCD burden and poses significant challenges for healthcare services. The state’s share of the elderly4 was 16.5 percent of the population in 2021. 1 Office of the Registrar General & Census Commissioner, India, Sample Registration System (SRS) 2 Niti Aayog SDG Index 3 Kerala leads India on Gender specific development indicators, including female life expectancy, education etc. which are often quoted as evidence of the high status of Kerala’s women, and this is widely held to be a symptom of and a reason for, the region’s remarkable advances. Jeffrey R. (1992) Politics, Women and Wellbeing: How Kerala became a ‘Model’, London: Macmillan. 4 Aged above 60 years. Page 3 The World Bank Kerala Health Systems Improvement Program (P503872) Additionally, due to higher life expectancy for females, women constitute most of the elderly in the state and many of them are widowed.5 More than half of elders in Kerala (57 percent) self-report diagnosis of one of other NCD’s and many of them suffer from multiple morbidities and psychosocial challenges due to loneliness. 6. To address these challenges, the Government of Kerala (GoK) has initiated “people -centered approaches “to strengthen access to and quality of health services. These include the Aardram6 Mission, the Amrutham Arogyam and the Karunya Aarogya Suraksha Padhathi (KASP)7, a health insurance scheme; however the problems continue to grow and persist. 7. Kerala faces acute public health and climate resilience challenges. As a highly climate-vulnerable state, it contends with rising health risks from extreme weather and climate effects, intensifying issues like waterborne, vector- borne, and heat-related illnesses, especially among the vulnerable. The state's dense forests heighten the risk of zoonotic and vector-borne diseases, with repeated Nipah outbreaks highlighting the threat. High population density, significant migrant and tourist presence, and an elderly population with co-morbidities further compound these risks. The World Bank-supported Resilient Kerala Program, seeks to strengthen public health systems and outbreak resilience in four targeted districts however the program needs to be taken to the remaining 10districts in the state. 8. While Kerala has managed One Health (OH) responses to outbreaks like Kyasanur Forest Disease (KFD) and Nipah virus, gaps persist. OH coordination is often reactive without a sustained mechanism, data sharing between animal husbandry and Health officials is unsystematic, and inter-sectoral coordination for zoonosis control is ineffective, complicating containment of outbreaks like Nipah. Additionally, rampant antibiotic use in humans and livestock has escalated antimicrobial resistance (AMR), underscoring the need for a unified OH approach. 9. To propel its healthcare system forward, Kerala needs to invest in the foundational pillars of its health system, including developing a workforce tailored to current demands, streamlining the related supply chain and harnessing digital technology for effective healthcare management. Despite boasting India's highest health worker-to-population ratio, the state faces critical human resource (HR) management challenges, including uneven personnel distribution and reliance on short-term contracts. The eHealth system's limited coverage (40 percent of health facilities) and fragmented information systems present significant obstacles to ensure continuum of care. 10. The unregulated growth of private healthcare services and the rising out-of-pocket (OOP) expenditures are areas of concern While people of Kerala depend on the public health sector more than in the rest of India, private healthcare services are growing significantly. National Sample Survey Organization (2017-18)8 findings indicate higher preference of private hospitals for in-patient care in Kerala ranging from 57 percent to 77 percent between the income quintiles one and five. 11. The state stands at a critical juncture marked by a transition towards chronic diseases, an aging population, heightened vulnerability to disease outbreaks, and the impacts of climate change. Addressing these challenges 5 Report on Assessment of Government Schemes and Programs for Elderly in Kerala. April 2022. Prepared by Centre for Socio-economic & Environmental Studies (CSES). Submitted to the Directorate of Social Justice, Kerala. 6 https://arogyakeralam.gov.in/2020/04/01/aardram. 7 https://sha.kerala.gov.in/karunya-arogya-suraksha-padathi/. Karunya Arogya Suraksha Padhathi (KASP) is a health care scheme of Kerala that aims to provide a health cover of INR 5 lakhs per family per year for secondary and tertiary care hospitalizations. It consolidates four different schemes including Pradhan Mantri Jan Arogya Yojana (PMJAY), Rashtriya Swasthya Bima Yojana (RSBY), Comprehensive Health Insurance Scheme (CHIS), and Senior Citizen Health Insurance Scheme (SCHIS). 8 National sample Survey Organisation Report, 2017-18 Page 4 The World Bank Kerala Health Systems Improvement Program (P503872) necessitates an evolution of Kerala's healthcare system towards a redefined value-based9 model focused on enhancing accessibility, improving service quality, enhancing resilience and optimizing available resources. This can be done by harnessing the state unique strengths of decentralized health infrastructure, active involvement of local self-governments, and community engagement. PforR Program Scope 12. The overall State government program is broadly defined by the Kerala State Planning Board’s Fourteenth Five Year Plan for Medical and Public Health, 2022-2027. The Plan’s vision is for Kerala to move “Towards planetary health – moving with equity, efficiency, quality and cultural competency through partnerships and learning�. The Plan: (a) aims to move towards universal health coverage by strengthening the public sector, with a focus on reaching groups historically unreached, (b) emphasizes the importance of empowering local governance to ensure fair and accessible healthcare, (c) recognizes the need for a shift towards life-long illnesses and to address the impact of social determinants of health, (d) highlights the impact of climate change on public health, and (e) underscores the need to develop healthcare infrastructure and HR to reduce OOP expenditure and improve overall public health system transformation. While the DoHFW is expected to spend around US$5 billion over the next five years on the health sector, its overall budget covers several activities beyond the direct scope of the proposed operation. 13. The proposed Program for Results (PforR) program boundary is estimated at US$500 million over the program period. The Bank will finance US$280 million out of the total PforR program estimated cost (56 percent of PforR) while the counterpart funding from the Kerala state will be US$220 million. The PforR includes specific expenditure categories under the two key directorates of the DoHFW, the Directorate of Health Services and the Directorate of Medical Education, eHealth Kerala and Kerala Medical Services Corporation Limited, selected for their alignment with the two Program results areas. The excluded expenditure categories include: (a) activities included under the Resilient Kerala Program (P174778), and (b) the NHM which receives support through the federally implemented Essential Health Services Delivery Program (P178146). In addition, the health insurance scheme, the Karunya Aarogya Suraksha Padhathi has not been considered under the Program, as it is undergoing streamlining to improve efficiency. 14. The activities supported by these RAs are well aligned with other developing partners working in the health sector in India. The World Bank (WB) will work closely with the World Health Organization, United Nations Children's Fund, World Organization for Animal Health, Resolve to Save Lives and other development partners and Foundations to ensure coordinated technical assistance. C. Proposed Program Development Objective(s) 15. Program Development Objective(s) To improve access to and quality of an enhanced range of health services and health system resilience in the state of Kerala. 9Value-based care is a healthcare approach that focuses on delivering high quality, efficient and cost-effective care to patients. It prioritizes outcomes and patient satisfaction rather than the volume of services provided. This model encourages healthcare providers to coordinate and collaborate across different specialties and settings, aiming to optimize patient health outcomes while controlling healthcare costs. By aligning incentives with quality care, value-based care promotes preventive care, early intervention and patient engagement, ultimately improving the overall healthcare experience and population health. Page 5 The World Bank Kerala Health Systems Improvement Program (P503872) The Program will support an enhanced range of services including integrated care pathways for non-communicable diseases such as hypertension, diabetes and cancers, comprehensive home-based care for elderly, a multilevel trauma and emergency care system and multisectoral approaches for promoting One Health and addressing climate challenges. 16. The following indicators will be used to measure progress towards the PDO and table 1 provides the budget allocation for the Disbursement Linked Indicators: • Patients registered for hypertension treatment at primary health care facilities whose blood pressure is controlled. (Percentage) [RA#1] • Pre-hospital trauma and emergency calls responded to by 108 Ambulance staff (Number) [RA#1] • Registered bed bound, home bound and vulnerable elderly living alone receiving comprehensive healthcare services at home (disaggregated by gender) (Percentage) [RA#1] • Primary health care facilities achieving antibiotic smart status10 (Percentage) [RA#2] • Primary health facilities in five climate vulnerable districts made climate resilient (Percentage) [RA#2] Table 1: Budget Allocation for the Disbursement Linked Indicators RA DLI PDO/IRI Measure of Total DLI 1: Patients registered for hypertension treatment at primary health care facilities whose blood pressure is PDO#1 NCD Access and 30 controlled (Number) Quality DLI2: New registered hypertension and diabetes patients at NCD Access IRI 25 primary care facilities (Percentage DLI3: Primary health care facilities reporting "no" stockouts NCD Access of essential tracer medicines for “hypertension and IRI 30 Improved diabetes� over previous year (Percentage) access to and DLI4: Pre-hospital trauma and emergency calls responded to Trauma and quality of by 108 ambulance staff (Number) PDO#2 emergencies care 25 health services – Access DLI5: Trauma and emergency care facilities made Trauma and operational (disaggregated by level) (Number) emergencies care IRI 30 - Access and Quality DLI6: Registered bed bound; home-bound and vulnerable Elderly care - elderly living alone receiving comprehensive healthcare PDO#3 Access and 30 services at home (Percentage) Quality DLI7: Suspected zoonotic disease outbreaks having One Health - laboratory confirmation within one week (Percentage) [ system resilience IRI 25 Enhanced and laboratory health system quality resilience DLI8: Primary health care facilities achieving antibiotic smart One Health - status (Percentage) PDO#4 system resilience 25 and quality 10Includes a set of 10 parameters aimed at strengthening antibiotic use by building awareness, strengthening quality of care, infection control and rational antibiotic practice. Page 6 The World Bank Kerala Health Systems Improvement Program (P503872) DLI9: Primary health facilities in five climate vulnerable Climate resilience 30 PDO#5 districts made climate-resilient (Percentage DLI10: Strengthened, integrated digital health system for Digitalization and IRI 30 improved health service delivery quality Total 280 17. The program aims to achieve the PDO through two interrelated result areas (RA), considering their impact on the existing disease burden and their potential to strengthen health system readiness and capacities to respond to emerging threats. They include: (a) RA#1. Improved access to an enhanced range of health services, and (b) RA#2. Enhanced health system resilience. Kerala faces significant public health challenges from high rates of hypertension, diabetes, and cancers, along with urgent needs for improved treatment adherence and comprehensive care for its elderly population. Kerala also faces significant public health challenges due to recurrent zoonotic disease outbreaks and climate change vulnerabilities. To tackle these challenges effectively, Kerala must enhance One Health interventions, focusing on vulnerability assessments of primary healthcare facilities in at-risk areas, energy needs evaluations, and carbon auditing, including the adoption of solar energy solutions. To deliver on these results, the Program will deploy two complementary approaches: (a) value-based care to achieve the best possible health outcomes in terms of quality and client satisfaction while optimizing the resources and investments made by the state, and (b) system strengthening and building of its foundation elements of human resources, supply chain, and information systems to promote resilience, innovation, collaboration, and sustainability. D. Environmental and Social Effects 18. An Environmental and Social Systems Assessment (ESSA) was carried out for the Program. The ESSA covers an assessment of the DoHFW covering DHS and DME, and associated sector departments that are most relevant for environment and social management for health service delivery in the state. The ESSA confirmed that the current system for managing the environmental and social aspects of the Program is well covered by the country’s regulatory framework and institutional arrangements. However, some systems and capacities would require strengthening for improved implementation and coordination. The RAs and corresponding DLIs do not cover any capital expenditure or major construction and/or actions that are anticipated to have significant adverse impacts on the environment and/or on the community. All interventions will be carried out within the existing footprint of the facilities, and hence no land acquisition and/or any involuntary resettlement is anticipated. The ESSA finds that the environmental and social risk ratings for the Program is rated Moderate. 19. Environmental: The key environmental risks identified of the Program include increased quantum of biomedical waste (BMW) getting generated, energy efficiency and occupational health risks. The Program systems operate within a legal and regulatory framework that is adequate to guide environmental impact mitigation, management, and monitoring of the limited, site-specific impacts and issues associated with the refurbishment works, generation of biomedical and other wastes, infection control, occupational, health and safety (OHS), and building safety. Improper handling, storage, transportation, treatment and disposal of BMW poses risks to communities, health care workers, and environment. Proper recycling and disposal of the same is important so that these waste streams do not get mixed with municipal waste or get burned. Other risks and impacts include: (a) worker safety and health and infection control; (b) OHS risks to ambulance staff and patients; and (c) safe oxygen use and fire safety response. The risks and impacts due to civil works (such as dust, noise, OHS, etc.) would be temporary and mitigated using country systems for pollution management, and community and worker safety since the civil works will be restricted to renovation and upgradation of existing buildings within the existing footprint of the buildings. Energy efficiency assessments in health care facilities will help to identify potential Page 7 The World Bank Kerala Health Systems Improvement Program (P503872) areas of emission reduction thereby contributing to addressing climate change challenges. The ESSA recommends working through the Program for: (a) safe management of BMW from households, (b) management of wastewater from health care facilities, and (c) state specific guidelines/protocol for worker safety and infection control for staff at risk due to BMW. 20. Social: While the Program has considerable social benefits, the key social risks are associated with the absence of a well-functioning, responsive grievance redress mechanism in the healthcare facilities and the risk of exclusion from accessing healthcare facilities, particularly for vulnerable groups like Scheduled Tribes, disabled persons, and migrant workers. Currently the grievance redress mechanism in the healthcare facilities under the DHS has critical gaps and this would require strengthening. The DHS provides the institutional mechanism for equitable health program implementation along with detailed roles and responsibilities for district health officials and sub-district level officials. It also focusses on social inclusion and the differentiated needs of the vulnerable groups, including women through multiple schemes. The Program also seeks to address the vulnerabilities of this population to genetic disorders e. g. haemoglobinopathies requiring constant medical attention. The healthcare facilities attempt to provide all-round health care in an inclusive environment, free from discrimination. A screening mechanism will be required to identify any potential adverse social impacts in case of any civil works. 21. The Program aims to bridge the gender gap in healthcare for elderly women through increased quota of interventions for the female elderly, that will include: (a) formal training in elderly care - including an improved understanding of specific challenges faced by elderly women - for frontline professionals such as MLSPs, JPHNs, Palliative Care Nurses, physiotherapists, and medical officers, (b) access to quality comprehensive healthcare services, including home-based individualized care for the elderly, especially elderly women living alone, (c) promoting community-level outreach and screening for elderly women to ensure access to quality services, (d) supporting the development of Program monitoring and reporting systems for capturing sex-disaggregated data, and (e) a Social Behavior Communication Strategy and an action plan that takes into account the differentiated needs of elderly women. E. Financing 22. The program financing is described in table 2. Table 2: Program Financing Source Amount (US$, Millions) % of Total Counterpart Funding 220.00 44% Borrowing Agency 220.00 44% International Bank for Reconstruction and Development 280.00 56% (IBRD) Total Program Financing 500.00 @#&OPS~Doctype~OPS^dynamics@contactpoint#doctemplate Page 8 The World Bank Kerala Health Systems Improvement Program (P503872) CONTACT POINT World Bank Deepika Nayar Chaudhery Senior Health, Nutrition & Population Specialist Hikuepi Sieglinde Brenda Katjiuongua Senior Agriculture Economist Borrower/Client/Recipient Department Of Economic Affairs Manisha Sinha Ms. manisha.sinha@nic.in Implementing Agencies Department of Health & Family Welfare, Government of Kerala Rajan Khobragade Dr acs1keralahealth1@gmail.com FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects @#&OPS~Doctype~OPS^dynamics@approval#doctemplate APPROVAL Task Team Leader(s): Deepika Nayar Chaudhery, Hikuepi Sieglinde Brenda Katjiuongua Approved By Practice Manager/Manager: Aparnaa Somanathan 27-Aug-2024 Country Director: Paul Procee 19-Sep-2024 Page 9