Report No: ICR00055 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT IMPLEMENTATION COMPLETION AND RESULTS REPORT (Loan 89340) ON A LOAN IN THE AMOUNT OF US$287 MILLION TO INDIA FOR THE TAMIL NADU HEALTH SYSTEM REFORM PROGRAM DECEMBER 20, 2024 Health, Nutrition & Population South Asia The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT CURRENCY EQUIVALENTS (Exchange Rate Effective {November 30, 2024}) Indian National Currency Unit = Rupee (INR) INR 84.58= US$1 US$ 1 = SDR 1 FISCAL YEAR July 1 – June 30 For Official Use Only Regional Vice President: Martin Raiser Country Director: Auguste Tano Kouame Regional Director: Stefano Paternostro Practice Manager: Aparnaa Somanathan Task Team Leaders: Dinesh M. Nair, Aarushi Bhatnagar, Rahul Pandey ICR Main Contributor: Di Dong The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ABBREVIATIONS AND ACRONYMS ANC Antenatal Care ATLS Advanced Trauma Life Support BMWM Biomedical Waste Management BTLS Basic Trauma Life Support CHC Community Health Center CME Continuous Medical Education CPF Country Partnership Framework DLI Disbursement-Linked Indicator DLR Disbursement-Linked Result DoHFW Department of Health and Family Welfare ESSA Environmental and Social Systems Assessment FM Financial Management GDP Gross Domestic Product GoTN Government of Tamil Nadu HMIS Health Management Information System IFT Interfacility Transfer IRI Intermediate Results Indicator For Official Use Only IVA Independent Verification Agency M&E Monitoring and Evaluation MCH Maternal and Child Health mCPR Modern Contraceptive Prevalence Rate MTM Makkalai Thedi Maruthuvam NABH National Accreditation Board for Hospitals and Healthcare Providers NCD Non-Communicable Disease NFHS National Family Health Survey NHM National Health Mission NQAS National Quality Assurance Standards PAP Program Action Plan PDO Program Development Objective PFMS Public Financial Management System PforR Program for Results PHC Primary Health Center PHR Personal Health Record PMU Program Management Unit PSC Program Steering Committee QoC Quality of Care RA Results Area RCH Reproductive and Child Health RF Results Framework SBCC Social and Behavior Change Communication SDG Sustainable Development Goal STEPS Noncommunicable Disease risk factor surveillance TNHSP Tamil Nadu Health Systems Project TNHSRP Tamil Nadu Health System Reform Program TNMSC Tamil Nadu Medical Services Corporation WB World Bank The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT TABLE OF CONTENTS DATA SHEET ................................................................................................................................................. i I. PROGRAM CONTEXT AND DEVELOPMENT OBJECTIVES .....................................................................................1 II. OUTCOME .......................................................................................................................................................5 III. KEY FACTORS AFFECTED IMPLEMENTATION AND OUTCOME .......................................................................... 10 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .................................... 11 V. LESSONS AND RECOMMENDATIONS .............................................................................................................. 15 ANNEX 1. RESULTS FRAMEWORK, DISBURSEMENT LINKED INDICATORS, AND PROGRAM ACTION PLAN .................... 16 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION .............................................................. 35 ANNEX 3. PROGRAM EXPENDITURE SUMMARY ........................................................................................................ 37 ANNEX 4. BORROWER’S COMMENTS ........................................................................................................................ 38 For Official Use Only ANNEX 5. SUPPORTING DOCUMENTS ....................................................................................................................... 39 ANNEX 6: RESULTS CHAIN AND THEORY OF CHANGE................................................................................................. 40 ANNEX 7: CHANGES IN PDO INDICATORS AND DLIS DURING RESTRUCTURING ........................................................... 41 ANNEX 8: ACHIEVEMENTS OF PDOS, IRIS, AND DLIS .................................................................................................. 43 ANNEX 9: ADDITIONAL INFORMATION ON RESULTS ACHIEVED BY THE PROGRAM ..................................................... 46 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT DATA SHEET @#&OPS~Doctype~OPS^dynamics@icrpfrbasicdata#doctemplate BASIC DATA Product Information Operation ID Operation Name P166373 Tamil Nadu Health System Reform Program Product Operation Short Name Program-for-Results Financing (PforR) India TN Health System Reform Program Operation Status Approval Fiscal Year For Official Use Only Closed 2019 IPF Component? No Original EA Category CLIENTS Borrower/Recipient Implementing Agency Department of Finance, Department of Health and Government of India Family Welfare, Government of Tamil Nadu DEVELOPMENT OBJECTIVE Original Development Objective (Approved as part of Approval Package on 19-Mar-2019) The Program Development Objective (PDO) is to improve quality of care, strengthen management of non-communicable diseases and injuries, and reduce inequities in reproductive and child health services in Tamil Nadu. @#&OPS~Doctype~OPS^dynamics@icrfinancing#doctemplate FINANCING i The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Financing Source Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 287,000,000.00 287,000,000.00 287,000,000.00 IBRD-89340 287,000,000.00 287,000,000.00 287,000,000.00 Non-World Bank Financing 4,990,750,000.00 0.00 0.00 Borrower/Recipient 4,990,750,000.00 0.00 0.00 Total 5,277,750,000.00 287,000,000.00 287,000,000.00 RESTRUCTURING AND/OR ADDITIONAL FINANCING Amount Disbursed Date(s) Type Key Revisions (US$M) • Results 03-Jun-2022 Portal 126.89 • Disbursement Estimates • Reallocations For Official Use Only @#&OPS~Doctype~OPS^dynamics@icrkeydates#doctemplate KEY DATES Key Events Planned Date Actual Date Concept Review 31-May-2018 05-Apr-2018 Decision Review 12-Nov-2018 12-Nov-2018 Authorize Negotiations 10-Dec-2018 30-Nov-2018 Approval 19-Mar-2019 19-Mar-2019 Signing 04-Apr-2019 04-Jun-2019 Effectiveness 04-Jul-2019 29-Jul-2019 ICR/NCO 30-Dec-2024 -- Change Financing Product Sequence.01 -- 24-Apr-2018 Restructuring Sequence.01 Not Applicable 03-Jun-2022 Mid-Term Review No. 01 31-Dec-2021 19-Nov-2021 Operation Closing/Cancellation 31-May-2024 31-May-2024 @#&OPS~Doctype~OPS^dynamics@icrratings#doctemplate RATINGS SUMMARY ii The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Outcome Bank Performance M&E Quality Highly Satisfactory Highly Satisfactory High ISR RATINGS Actual Disbursements No. Date ISR Archived DO Rating IP Rating (US$M) 01 27-Jun-2019 Satisfactory Satisfactory 0.00 02 11-Oct-2019 Satisfactory Moderately Satisfactory 0.00 03 11-Mar-2020 Satisfactory Satisfactory 2.12 04 02-Sep-2020 Satisfactory Satisfactory 52.02 05 26-Mar-2021 Moderately Satisfactory Moderately Satisfactory 52.02 For Official Use Only 06 22-Dec-2021 Moderately Satisfactory Moderately Satisfactory 57.75 07 17-Jun-2022 Moderately Satisfactory Moderately Satisfactory 145.74 08 13-Dec-2022 Satisfactory Satisfactory 160.40 09 09-Jun-2023 Satisfactory Satisfactory 181.84 10 02-Nov-2023 Satisfactory Satisfactory 200.08 11 23-May-2024 Satisfactory Satisfactory 209.28 @#&OPS~Doctype~OPS^dynamics@icrsectortheme#doctemplate SECTORS AND THEMES Sectors Adaptation Mitigation Major Sector Sector % Co-benefits (%) Co-benefits (%) FY17 - Health 80 1 0 FY17 - Health FY17 - Public Administration - Health 20 17 0 Themes Major Theme Theme (Level 2) Theme (Level 3) % FY17 - Environment and Natural Resource FY17 - Climate change FY17 - Adaptation 4 Management iii The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT FY17 - Non- FY17 - Disease Control 30 communicable diseases FY17 - Child Health 20 FY17 - Human FY17 - Health Service Development and 63 Delivery Gender FY17 - Health Systems and Policies FY17 - Health System 63 Strengthening FY17 - Reproductive and 20 Maternal Health FY17 - Social FY17 - Participation and Development and FY17 - Social Inclusion 5 Civic Engagement Protection For Official Use Only iv The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ADM STAFF Role At Approval At ICR Practice Manager Rekha Menon Aparnaa Somanathan Regional Director Stefano Paternostro (Acting) Global Director Timothy Grant Evans Juan Pablo Eusebio Uribe Restrepo Practice Group Vice President Annette Dixon Mamta Murthi Country Director Junaid Kamal Ahmad Auguste Tano Kouame Regional Vice President Hartwig Schafer Martin Raiser ADM Responsible Team Leader Rifat Afifa Hasan Dinesh M. Nair Co-Team Leader(s) Aarushi Bhatnagar, Rahul Pandey ICR Main Contributor Di Dong Page 0 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT I. PROGRAM CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL Context 1. In the years preceding the appraisal of the Tamil Nadu Health System Reform Program (TNHSRP), India experienced fast economic growth but only moderate improvement in health outcomes. Between 2014/15 and 2018/19, India's annual growth of real gross domestic product (GDP) averaged 7.5 percent, being the world’s fastest-growing major economy1. However, health outcomes only improved modestly. Between 2000 and 2016, infant and maternal mortality fell by around 50 percent, yet still higher than global averages for a country with India’s GDP per capita. 2. Tamil Nadu’s public health sector had effectively increased health service coverage, but system and institutional challenges remained, requiring a new phase of reforms to achieve the next level of performance. Tamil Nadu was India’s sixth most populous state, the second largest economy, with a strong-performing public health system. The Tamil Nadu Department of Health and Family Welfare (DoHFW) managed a range of public healthcare facilities through seven directorates and two societies to provide preventive and curative services. Reproductive and child health (RCH) outcomes in Tamil Nadu already met the relevant 2030 Sustainable Development Goals (SDGs), partially related to the massive RCH service capacity expansion since 2000, including the establishment of 103 Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) centers. However, with the demographic transition, Non-Communicable Diseases (NCDs) (including cardiovascular disease, cancer, hypertension, diabetes, etc.) had taken over as the major disease burden in Tamil Nadu (69 percent), with transport injuries and suicide also being top killer conditions2. The Tamil Nadu health system was not well equipped to tackle the NCD burden, with relatively low NCD screening coverage, lack of healthy lifestyle promotion and NCD preventions, limited capacity and suboptimal quality for NCD treatment. Only less than 30 percent of the population above age of 30 had ever been screened for hypertension or diabetes3. The screening coverage for cancers was even lower. Among those diagnosed with hypertension, only 15 percent of women and five percent of men had their blood pressure under control, with the majority of patients not having satisfactory treatment outcomes, indicating serious challenges in NCD treatment and service quality. RCH service utilization varied across districts, with the best-performing quintile and the worst-performing quintile having a 30-percentage-point difference in utilization and quality of basic RCH services (such as full immunization for children, full antenatal care for pregnant women, and use of modern contraceptive methods). In addition, Tamil Nadu’s health system suffered from several institutional and governance challenges that hindered the system’s performance. Those included the fragmented and siloed approach of health service delivery across seven directorates and two societies, the limited data system that could be used for data-driven decision-making and accountability, the lack of clinical governance within health facilities, and limited citizen voice. 3. The TNHSRP was designed to support the government’s new phase of health programs to achieve SDG goal 3 “to ensure healthy lives and promote well-being for all at all ages”4. Addressing the health system challenges was the priority in the new phase of the government health program (“p”) outlined in Vision 2023 and the 2018 -19 Policy Note, which 1 Ministry of Finance. State of the Economy in 2018-19: A Macro View-Union Budget 2 ICMR (Indian Council of Medical Research), PHFI (Public Health Foundation of India), and IHME (Institute for Health Metrics and Evaluation). 2017. India: Health of the Nation's States ‐ The India State‐level Disease Burden Initiative. 3 National Family Health Survey 2015-2016 (NFHS-4) 4 Specially, the TNHSRP was designed to support GoTN to achieve SDG3.4 (reduce NCD mortality), SDG3.6 (reduce deaths and injuries from road traffic accidents), SDG3.7 (universal access to reproductive health services), and SDG3.8 (Universal Health Coverage). Page 1 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT were the key policy documents to guide Tamil Nadu to achieve SDG3. Accordingly, TNHSRP was designed with the objectives to (i) improve quality of care (QoC); (ii) strengthen management of NCDs and injuries; and (iii) reduce inequities in RCH services. In addition, TNHSRP also supported cross-cutting initiatives to strengthen the overarching institutional and health sector governance capacity. TNHSRP was developed in alignment with the World Bank Group Country Partnership Framework (CPF) for India for FY18-22, Report No. 126667-IN, discussed by the Board of Executive Directors on September 9, 2018, and extended to FY25 by the corresponding Performance and Learning Review dated October 23, 2023, particularly to support the ‘what’ of human capital investments (through improving quality and access to health care), and two of the ‘hows’ in the CPF (strengthening public sector institutions and generating lessons for other states through Lighthouse India). Theory of Change (Results Chain) 4. The theory of change or results chain at appraisal is included in Annex 6. The results chain was structured to address key challenges in the Tamil Nadu health sector. The key inputs and activities to achieve specific outcomes were grouped under three key results areas (QoC, NCD, and injuries care, and RCH equity) plus a cross-cutting result area (institutional and governance capacity). Rationale for Program-for-Results (PforR) Support and Program Scope and Boundaries 5. The rationale for PforR support was strong. The instrument was considered appropriate for (i) alignment with the Government of Tamil Nadu’s (GoTN) vision and political commitment to shift from an input-based management approach to a performance-based one to enhance health sector effectiveness and accountability; (ii) allowing maximum flexibility to DoHFW to plan and implement priority activities to achieve desired outcomes, through the well-established government program and institutions, and the fiduciary system which had a demonstrated track record; (iii) nudging the DoHFW and its seven directorates and societies to realign planning, budgeting, expenditures, and coordination to defragment the program implementation to ensure results; and (iv) offering opportunities to strengthen health sector institutions through system reforms, better data collection and results monitoring system, as well as introducing better performance incentives to various directorates, societies and health facilities. 6. Extensive technical, institutional, and fiduciary assessments were conducted at the appraisal stage to clearly identify the results areas (RA) to address the Program’s development challenges and define the program boundary (Table 1). The total expenditure framework for the government program (“p”) was US$5.3 billion, covering the salaries, professional services, publicity, training, expenses, minor works, and consumables for the seven DoHFW directorates and societies in charge of health service delivery. The World Bank (WB) financing (“P”) was US$287 million, focusing on pushing the envelope to implement new and innovative activities under the government program. Table 1. Program Boundary and Eligible Expenditures DoHFW Directorates and Societies within Program Boundary Eligible expenditure categories Excluded expenditures Directorate of Public Health and Preventive Medicine (primary care) Salaries Major constructions Directorates of Medicine and Rural Health Services (secondary care) Payments for professional and special services Medicines Directorates of Medical Education (tertiary care) Advertising and publicity Japan International Tamil Nadu Food Safety and Drug Administration Department Training Cooperation Agency ‐ Directorate of Indian Medicine Minor works, repairs, and maintenance, financed Tamil Nadu Urban National Health Mission (NHM) State Health Society Consumables to a limited extent (machinery and Healthcare Project Tamil Nadu Health System Project Society equipment, materials and supplies, and High‐risk activities computers and accessories) Page 2 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Program Development Objective (PDO) 7. The PDO was to improve quality of care, strengthen management of non-communicable diseases and injuries, and reduce inequities in reproductive and child health services in Tamil Nadu. Key Expected Outcomes and Outcome Indicators 8. The three key expected outcomes were (i) improved QoC; (ii) strengthened management of NCDs and injuries; and (iii) reduced equity gaps in RCH services, measured by six PDO indicators (Table 2). Table 2: PDO Indicators PDO‐Level Results Indicators Quality NCD & Equity of care injury PDO#1 increased number of public facilities with quality certification (primary, secondary, and tertiary care) (with a focus √ √ on priority districts) PDO#2: improved scores in quality dashboard for primary, secondary, and tertiary facilities √ PDO#3: increased screening in public sector facilities for cervical and breast cancers √ PDO#4: increased share of adults with hypertension or diabetes whose blood pressure or blood sugar are under control √ √ PDO#5: improved provision of quality trauma care services √ √ PDO#6: increased utilization of reproductive & child health services in priority districts. √ Program Results Areas and DLIs 9. The Program had three RAs and a set of cross-cutting interventions that contributed to achieving the different RAs. Each RA was associated with specific disbursement-linked indicators (DLIs), for a total of eight DLIs. Annex 1 reflects a detailed description of the DLIs, targets, and financed amounts. 10. Result Area #1: Improved Quality of Care (original: US$81.9 million, revised: US$85.147 million, disbursed: US$85.147 million). This RA supported the implementation of a basket of best practices for improving QoC through enhancing governance, transforming the health workforce, and generating demand, as outlined in the Lancet Global Health Commission on High Quality Health Systems in the SDG era. Specifically, the Program supported (i) the development and adoption of the Tamil Nadu QoC Strategy (DLI1); (ii) setting up quality governance initiatives such as quality committees and quality circles in all levels of health facilities (DLI1); (iii) developing and launching a digital quality dashboard for primary, secondary, and tertiary facilities (DLI1); (iv) expansion of continuous professional development program for entire health workforce and introducing decision support tools (DLI1); (v) certification of health facilities by National Quality Assurance Standards (NQAS) and National Accreditation Board for Hospitals and Healthcare Providers (NABH) (DLI2); (vi) adoption of operational plan for environmental strategy (DLI7); and (vii) piloting of patient experience survey in health facilities (Intermediate Results Indicator [IRI] 2). 11. Result Area #2: Strengthened Management of Non-Communicable Diseases and Injuries (original: US$66.6 million, revised: US$74.1355 million, disbursed: US$74.1355 million). Support under RA2 included (i) development and adoption of TN NCD strategy; (ii) carrying out STEP-wise approach to NCD risk factor surveillance (STEPS) surveys in year one and year five; (iii) launch of the Makkalai Thedi Maruthuvam (MTM) scheme for home-based NCD service delivery (for screening, NCD drug delivery, palliative care, physiotherapy sessions, and referral); (iv) improving health promotion and NCD prevention through comprehensive social behavior change communication (SBCC). These activities contributed to the improvement in NCD outcomes measured by an increased share of adults with hypertension or diabetes whose Page 3 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT blood pressure or blood sugar are under control (DLI3). RA2 also supported extensive investment in injury prevention and trauma care, such as (i) training on trauma life support; (ii) training on mental health (IRI4); (iii) establishment of a Suicide Hotline (IRI5); (iv) expansion of ambulance services and strengthening of interfacility transfer (IFT) protocols (IRI6); (v) establishment of trauma registry; and (vi) improving emergency surgical performance. These contributed to improved provision of quality trauma care services (DLI4). 12. Results Area #3: Reduced Equity Gaps in Reproductive and Child Health (original: US$56.5 million, disbursed: US$56.5 million). The RA focused on improving RCH services use in nine priority districts which lagged on RCH indicators and had a relatively large proportion of tribal populations. Under RA3, the Program supported (i) mobile medical units to tribal blocks for free minor ailment treatment, NCD screening, antenatal screening, and lab tests; (ii) better quality provision of RCH services in primary and secondary care facilities; (iii) setting up maternity stay wards in remote areas to improve continuum of care before, during, and after delivery; and (iv) launch the SBCC on RCH, adolescent health and mental health (IRI7). These programs contributed to increased utilization of RCH services in priority districts (DLI5). 13. Cross-cutting Initiatives to Strengthen Institutional and State Capacity (original: US$81.25 million, revised: US$70.5 million, disbursed: US$70.5 million). The Program supported cross-cutting initiatives to enhance the sector's governance capacity and effectiveness to aid the achievement of the above three RAs, including: (i) strengthened content, quality, accessibility, and use of data for decision-making (DLI6); (ii) strengthened coordination, integration, performance-based management, learning, and other cross-cutting functions for better results (DLI7); and (iii) increased transparency and accountability through citizen engagement (voice, agency, and social accountability) (DLI8). B. SIGNIFICANT CHANGES DURING IMPLEMENTATION Revised PDOs Outcome Targets, Result Areas, and DLIs 14. The Program underwent a level two restructuring in February 2022 after the mid-term review to address challenges caused by the COVID-19 pandemic and evolving government priorities, Program needs, and implementation feasibility. The restructuring did not revise the PDO or the RAs. Changes to each PDO indicator, DLI, and disbursement-linked result (DLR) are summarized in Annex 7, with the full details included in Annex 1. Briefly, this restructuring involved: (i) introduction of new indicators and sub-indicators---DLI1, PDO 4/DLI3, PDO 5/DLI 4, and DLI7; (ii) establishment of DLI baseline and end targets with newly available data---PDO 2 and PDO 4/DLI3; (iii) downwards and upwards adjustment of indicator end targets--PDO 1/DLI2, and PDO 3; (iv) cancellation of indicators--PDO 5/DLI4, and DLI6; and (v) revision of annual targets and timeline---DLI1, PDO3, DLI7, and DLI8. The restructuring also included revisions to the financial allocation of each result area, with more funding moved from cross-cutting RA to RA1 and RA2. Other Changes NA Rationale for Changes and their Implication for the Original Theory of Change 15. The restructuring adjusted for the COVID-19 shocks, implementation progress, and evolving government activity plans to ensure the achievement of PDOs through a better and more feasible path. The Program RAs, key PDO, and DLI focus areas remained unchanged through the restructuring. However, sub-indicators to measure the PDO and DLI achievements were revised and refined to reflect (i) the evolving government strategies and new priorities that emerged after COVID-19---for example, dropping the health management information system (HMIS) revamping, but instead introducing a new integrated personal health registry; developing a digital platform TANQuEST for online continuous Page 4 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT health professional education; and expansion of emergency care and trauma care capacity. Following this, some DLIs were replaced by new DLIs in the same RA along the same result chain, with several new DLRs added to provide additional financial incentives for new activities that could enable better achievement of the PDOs; and (ii) minor modifications and clarifications of DLI definitions and verification protocols based on more detailed activity planning and early implementation experience. The restructuring also revised the baseline, end targets, and annual targets of some indicators to account for (i) the availability of more recent data to establish baselines and targets; (ii) a more realistic implementation timeline after COVID-19 lock-down related delays; (iii) a more detailed government activity implementation plan based on ground reality and needs; and (iv) adjustments of the DLI end targets based on early implementation experiences and feasibility assessment, including an upward adjustment of end targets for some DLRs and downward adjustment for others. 16. Despite the challenges and delays in Program implementation during COVID-19, this restructuring did not compromise the ambitiousness of the Program but instead expanded on additional reform initiatives to further enhance the resilience of the Tamil Nadu health system5. While COVID-19 delayed the implementation of some activities (particularly on population NCD screening and citizen engagement), the restructuring did not lower the end targets for those indicators, with the expectation of catching up after COVID-19. New reform momentum and strong political will emerged during COVID-19 to further strengthen the Tamil Nadu health system to enhance its quality and resilience. Leveraging this unique window of opportunity, this restructuring expanded the Program to introduce several ambitious and challenging reform initiatives that were not possible at the Program preparation stage. These covered investments to enhance capacity for emergency care and trauma care (including equipping ambulance purchased during COVID-19 for emergency and trauma care, upgrading more trauma care facilities, and establishing postgraduate training programs for emergency medicine) (under PDO4/DLI5), introducing MTM home-based NCD care delivery, implementing NCD quality initiatives at facilities (under DLI3), adopting TANQuEST online platforms for NCD quality education (under DLI1), and adoption of integrated population health registry (PHR) for population health management (under DLI6). In addition, cross-cutting institutional governance initiatives were further strengthened by setting up a Program Steering Committee (PSC) chaired by the Principal Secretary and appointing Nodal officers to ensure accountability and ownership (under DLI7), which was difficult to achieve before COVID-19 with the seven directorates working in silos. Ten new DLRs related to those new activities were added across different results areas to provide financial incentives to achieve those important outputs and outcomes. Overall, the restructuring revised the result framework (RF), which provided a more feasible path to incentivize Program implementation and achievement of PDOs, but also enabled more effective monitoring and evaluation (M&E) of PDO achievements. II. OUTCOME A. RELEVANCE Relevance of PDO 17. The Relevance of PDO is rated High. The PDO was aligned with the World Bank Group’s CPF for India (FY18–22), which was extended to FY25, therefore covering the whole Program duration. Specifically, TNHSRP’s PDO supported the CPF's “Focus Area 3: Investing in Human Capital”, through improving quality and access to healthcare. It also supported 5Based on PforR ICR guideline, this restructuring does not require a split rating. Even though some outcome indicators have been revised, the scope of the Program has expended through the restructuring, and the changes in outcome indicators reflect a different and better path to achieve the same expected outcomes. Page 5 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT two ‘hows’ in the CPF--#3 of strengthening public sector institutions and #4 of supporting a Lighthouse in India by generating lessons for other states. The Program leveraged Tamil Nadu’s strong public health delivery system, providing an opportunity for the WB to engage in an advanced health reform agenda through a systems-based approach. This innovative operation aimed to improve service delivery, benefit the private sector through enhanced stewardship and regulatory capacity, and serve as a model for other states facing similar challenges, ultimately contributing to the CPF's broader goals. 18. TNHSRP’s PDO was well aligned with GoTN’s health strategies and plans to achieve the SDG goals. Specifically, the three PDO outcomes each corresponded to an SDG sub-target: SDG3.4 (reduce NCD mortality), SDG3.6 (reduce deaths and injuries from road traffic accidents), SDG3.7 (universal access to reproductive health services), and SDG3.8 (Universal Health Coverage). Relevance of DLIs 19. The Relevance of DLIs is rated High. The DLIs were a subset of the RF indicators measuring a mix of outputs, processes, and outcomes along the result chain. As indicated in Annex 6 (Results Chain/Theory of Change), DLI 2, DLI 3, DLI 4, and DLI 5 measured key Program development outcomes on quality of care, NCD treatment success, trauma care service quality, and equity in RCH services use. DLI 1, DLI 4, DLI 6, DLI 7, and DLI 8 were related to key health program implementation and governance processes that were on the critical path to achieving the Program’s objectives. DLIs and the RF were also aligned with Tamil Nadu’s Vision 2023 strategy and the 2018-19 Policy Note, which were the key policy documents to guide Tamil Nadu’s health sector development. The set of Program DLIs had a good balance between specific health service delivery indicators (DLI1, DLI2, DLI3, DLI4, DLI5, DLI6) and broader policy reform and institutional strengthening indicators (DLI1, DLI3, DLI6, DLI7, DLI8). Notably, the Program included several governance capacity-related DLIs, which would otherwise not gain sufficient attention and become underfunded in a typical government health program, such as conducting a STEPS survey to gather information on NCD prevalence, treatment gaps, and outcomes (DLI3); the implementation of operations research to inform Program implementation (DLI7), and establishing a PSC (DLI7). Making those indicators DLIs stimulated increased funding and commitment to those important activities. The DLI matrix maintained its relevance throughout implementation, even with the restructuring. The DLIs were well defined, each with a clear definition and protocol to evaluate achievement (with data source, verification entity, and procedure). They were reasonably ambitious, judiciously distributed over the implementation period, and clearly identified in terms of scalability and rollover. The DLRs’ timings and monetary values were calibrated for cumulative/sequential achievement of DLI targets and moving implementation forward. Rating of Overall Relevance 20. Overall relevance is rated High. It is justified by the high relevance of the PDOs, DLIs and DLRs, as well as their alignment with the Program as designed during preparation and adjusted during implementation. B. ACHIEVEMENT OF PDOs (EFFICACY) 21. The Program fully achieved its PDO to (i) improve QoC, (ii) strengthen the management of NCDs and injuries, and (iii) reduce inequities in RCH services in Tamil Nadu. Efficacy is assessed by achievement under each of the three RAs in the PDO. The Program restructuring in 2022 does not trigger a split rating. Although some outcome indicators were revised, the changes in outcome indicators reflected a different and better path to achieve and measure the same expected outcomes. Moreover, the scope of the Program activities expanded in each RA through the restructuring. Page 6 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Assessment of Achievement of Each PDO Outcome Objective 1 (RA1) Improving quality of care in Tamil Nadu 22. Achievement of objective 1 is rated as High. Achievement of objective 1 is assessed by PDO1/DLI2, PDO2, DLI1, and IRI2, all of which were fully achieved or overachieved compared to the original targets set. The detailed indicator baseline, end target, and actual achievements are summarized in Annex 8. Additional results achieved are in Annex 9. 23. The Program made great efforts to certify public health facilities at primary, secondary, and tertiary levels for the national quality certification program (PDO1/DLI2). Before the Program, facility quality accreditation barely existed in public health facilities in Tamil Nadu. During the Program period, the number of medical colleges (tertiary facilities) with NABH certification increased from zero to four. The number of secondary facilities with full NQAS accreditation increased from three to 75, among which 15 facilities were in the priority districts. Three hundred Community Health Centers (CHCs) and Primary Health Centers (PHCs) obtained NQAS certification, increased from the baseline of four. Among these, 60 were in the priority districts. The significant scaling up of quality certification across health facilities in Tamil Nadu ensured that more health facilities became compliant with the specific national quality and patient care standards. 24. A quality scorecard was developed and routinely reported electronically in a significant number of health facilities in Tamil Nadu, and the overall quality score significantly improved during the Program period (PDO2, and DLI1). Based on global good practice and local consultations, the quality scorecard was developed for various levels of health facilities, consisting of 12-14 indicators on structural inputs, clinical processes, and patient outcomes (Annex 9). The scorecard was adopted by 570 (27 percent) primary facilities and 248 (85 percent) secondary facilities in Tamil Nadu, with the quality scores reported routinely to the DoHFW (DLI1). This was the first major effort in Tamil Nadu to systematically introduce routine quality assessment and monitoring mechanisms across all levels of health facilities. The monitoring of quality complemented with targeted quality improvement initiatives led to a significant improvement in health facility ’s quality with respect to structural inputs, clinical processes, and selected patient outcomes. Over the TNHSRP period, the overall facility quality score improved from 55 in 2022 to 65 in 2024 (PDO2). 25. TNHSRP promoted the implementation of quality improvement initiatives in all levels of health facilities, offering quality training to the health professionals and emphasizing patient experience, which were critical enablers to better QoC. The Tamil Nadu QoC strategy was developed, and a set of quality initiatives with comprehensive operational plans were developed under the Program (Annex 9). Subsequently, 570 primary facilities and 248 secondary facilities set up “Quality Committees,” and nine tertiary hospitals established “Quality Circles,” which were dedicated teams to work on facility quality improvement (DLI1). Patient experience surveys were conducted in five percent of all secondary and tertiary facilities to focus on the patient experience as part of health care quality (IRI2) (Annex 9). Surveys were analyzed by dedicated staff to identify areas for improvement from a patient perspective. To fill in the gap in continuous professional health workforce education on QoC, the TANQuEST digital platform was introduced (Annex 9), with a range of professional modules (including management, communication, ethics, pandemic management, hospital infection control, research methodology, digital data management), and 1272 health care professionals had received TANQuEST training on QoC by the end of the Program (DLI1). Objective 2 (RA2) Strengthen the management of NCDs and injuries in Tamil Nadu Page 7 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT 26. Achievement of objective 2 is rated as High. Achievement of objective 2 is assessed by PDO3, PDO4/DLI3, PDO5/DLI4, and IRI3-6, all of which were fully achieved or overachieved compared to the targets set in the original design or restructuring (Annex 8). Additional results achieved are summarized in Annex 9. 27. The Program improved the screening, treatment, and outcomes of major NCD burdens in Tamil Nadu focusing on cancer, hypertension, diabetes, and mental health. To fill in the data gap on NCD and risk factors, STEPS survey was conducted in 2019-20 to take stock of the baseline and in 2023-24 to track the progress of NCD control under TNHSRP (DLI3). STEPS survey in 2019-20 identified major gaps in patients’ awareness of their hypertension and diabetes status, low treatment coverage, and poor treatment outcomes (Annex 9). Based on data and evidence, a detailed NCD strategy was developed (DLI3). To better offer NCD services closer to patients, the MTM program was launched with field-based teams conducting home-based NCD screening, drug delivery for hypertension and diabetes, palliative care, and physiotherapy sessions. An SBCC strategy was also implemented to raise awareness and promote healthy behaviors to prevent NCDs (IRI7). Upon TNHSRP closing, STEPS survey in 2023-24 confirmed improved NCD awareness, treatment coverage, and outcomes. More hypertension patients became aware of their diseases (32 percent in 2019-20 vs 46 percent in 2023-24), and more patients were on hypertension treatment (23 percent in 2019 -20 vs 39 percent in 2023-24). The screening rate increased for both cervical cancer (baseline 15.8 percent to 17 percent) and breast cancer (19 percent to 23 percent) (PDO3). An evaluation of the MTM program (DLI3) demonstrated that the MTM program led to an increase in drug indent from primary care facilities by 92 percent for diabetes and 78 percent for hypertension, indicating significant expansion of NCD treatment coverage through primary care. STEPS survey results also showed a sizable improvement in hypertension and diabetes management outcomes. The percentage of hypertension patients having blood pressure under control increased from the baseline of 7.3 percent to 17 percent upon Program completion (PDO4/DLI3). The proportion of diabetes patients having successful control of blood sugar improved from 10.8 percent to 16.7 percent. Mental health capacity was significantly boosted by the Program, from minimal capacity at baseline to 41 percent of primary and secondary care facilities having at least one staff trained on mental health by Program completion (IRI3). A toll-free hotline was established to provide counseling and help on health issues, including suicide contemplation and attempts (IRI4). 28. Furthermore, the Program significantly improved trauma care in Tamil Nadu. An integrated trauma registry was developed and used in 54 trauma centers across TN (PDO5/DLI4), which could facilitate seamless information flow and prompt process management for pre-hospital, in-hospital, and rehabilitation care. The timeliness of emergency surgery improved significantly, with 85 percent of cases requiring emergency surgeries operated within six hours of admission, compared to the baseline of 45.9 percent (DLI4). The Program also heavily invested in supporting the creation and strengthening of emergency departments in 25 medical college hospitals and set up 13 level-1 and 29 level-2 trauma and emergency care facilities (DLI4). These allowed for the creation of an MD Emergency Medicine clinical training program and a career path for the emergency medicine specialty in Tamil Nadu, benefiting long-term capacity development in emergency medicine. Two hundred and five ambulances were better equipped under the Program to become Advanced Trauma Life Support (ATLS) ambulances that are capable of providing level-1 care (IRI5). Capacity building on level-3 and level-4 care was conducted for over 1300 doctors and nurses (IRI6). These significantly enhanced the tertiary-level trauma care capacity in Tamil Nadu. Objective 3 (RA3) Reduce inequities in reproductive and child health services in Tamil Nadu 29. Achievement of objective 3 is rated as High. Achievement of objective 3 is assessed by PDO6/DLI5, and IRI7, all of which were fully achieved or overachieved compared to the targets. Page 8 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT 30. The Program reduced equity gaps in RCH services, particularly in priority districts. At baseline across all the districts, the best-performing and worst-performing quintile had a 30-percentage-point difference in the utilization and quality of basic RCH services. Using data from the National Family Health Survey NFHS-4 survey, nine priority districts with lagging RCH outcomes (including three districts with a relatively large proportion of scheduled tribe populations) were selected for Program intervention. A comprehensive RCH service package was developed based on the gaps identified, including at least four antenatal visits, Iron and folic acid supplementation, Tetanus-Diphtheria vaccine for pregnant women, blood glucose monitoring, high-risk mothers camp, nutritional kits for anemic mothers, vitamin K prophylaxis at birth, home- based newborn and post-natal mother care, scheduled post-delivery visits, breastfeeding promotion, nutrition counseling, drop-back transport, and modern conceptive use. Infrastructure, equipment, and institutional capacity for delivering those services were strengthened at primary care centers, CEmONC, Medical College Hospitals, call centers, and through dedicated health staff such as Village Health Nurses and Accredited Social Health Activists. The SBCC strategy, including adolescent health and RCH service promotion, was implemented to generate public demand for RCH services (IRI7). Upon TNHSRP competition, data from NFHS5 indicated a significant increase in the utilization of core RCH services, including full antenatal care (ANC) from 28.8 percent to 41.3 percent, full immunization from 57.9 percent to 70.4 percent, and modern contraceptives (mCPR) use from 38.5 percent to 43.5 percent (PDO6/DLI5). Cross-cutting: Strengthen Institutional and State Capacity 31. Achievement of the cross-cutting governance enhancement initiatives is also rated as High. PHR was developed and piloted in one district as a key initiative to strengthen content, quality, accessibility, integration, and use of data for decision-making (DLI6/IRI8). The Program also completed several key actions to enhance coordination, integration, performance-based management, and learning. Thirty operation research studies were carried out, covering a wide range of topics related to the Program implementation and made concrete recommendations (DLI7) (Annex 9). A high-level PSC, chaired by the Principal Secretary of the DoHFW, was established in the program's second year to provide high-level oversight and stewardship (DLI7). The PSC conducted monthly meetings to review the Program's progress and challenges and agreed on mitigation measures to be implemented by each directorate and society. This has been recognized as the most effective mechanism to enhance cross-departmental coordination. Energy efficiency and liquid waste management audits for health facilities were carried out, with preliminary results suggesting huge cost savings from adopting energy efficiency measures (DLI7/IRI9). In addition, a state health assembly (SHA) was conducted, with 65 percent of districts also conducting their district health assembly (DHA), to enhance citizen engagement and create a platform for the public to speak about their needs and demands (DLI8/IRI10). Rating of Overall Efficacy 32. Overall efficacy is rated High. The Program achieved its three objectives: QoC, management of NCDs and injuries, and equities in RCH services in Tamil Nadu, as evaluated by the RF indicators and additional information. There were no material shortcomings in the operational achievement of its objectives. C. JUSTIFICATION OF OVERALL OUTCOME RATING 33. The overall outcome rating is Highly Satisfactory given both the Program’s relevance and efficacy are rated as High. D. OTHER OUTCOMES AND IMPACTS Page 9 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT 34. Gender. Tamil Nadu fared better on gender equity than the national average, as reflected in the declining maternal mortality and higher female workforce participation. However, there were still gender-specific health risks and utilization gaps. The Program contributed to improving women’s health and reducing the gender gap in health service utilization in Tamil Nadu. Specific activities and outcomes benefiting women included (i) increased rate of screening for cervical cancer and breast cancer (PDO3); (ii) increased utilization of full antenatal services by pregnant women in priority districts (PDO6/DLI5); (iii) increased use of modern contraceptives (PDO6/DLI5), and (iv) implementation of a SBCC strategy that raised public awareness for the diseases that affect only women as well as maternal health service utilization (IRI7). 35. Poverty Reduction and Shared Prosperity. The Program focused on improving service availability, quality, and utilization in disadvantaged priority districts that lagged on economic and health indicators and had a high proportion of tribal population. Under RA 3, the percentage of RCH service utilization in priority districts increased substantially, from 28.8 percent to 41.3 percent for full antenatal care, from 57.9 percent to 70.4 percent for full immunization, and from 38.5 percent to 43.5 percent for mCPR. Under RA 1, the facility quality certification program ensured that 20 percent of certified health facilities were in priority districts. The improved QoC and service utilization in priority districts were likely to reduce the disparities in health outcomes. Moreover, the poor utilize free public health services more. Therefore, overall improvement in public health service availability and quality were likely to benefit the poor population more. III. KEY FACTORS AFFECTED IMPLEMENTATION AND OUTCOME A. KEY FACTORS DURING PREPARATION 36. Grounded in GoTN’s strong political will and readiness to undertake ambitious reforms, TNHRSP was prepared to support DoHFW in designing and implementing a complex reform agenda around three key RAs to elevate the Tamil Nadu health system performance to the next level. Tamil Nadu’s stable policy environment and reliable public health sector provided a solid foundation for further advancing those complex health agendas. TNHRSP set ambitious but realistic objectives and focused on the three key RAs of quality, NCD and trauma care, and equity in reproductive and child health. TNHRSP also introduced cutting-edge innovations, and global best practices on QoC enhancement and NCD management. B. KEY FACTORS DURING IMPLEMENTATION Factors subject to the control of the government and/or implementing agencies 37. Bringing in oversight and support from the top level of the DoHFW effectively overcame the challenge of inter- departmental coordination with DoHFW’s fragmented institutional arrangements. Despite the clear roles and responsibilities assigned to each of the seven directorates and societies, there was weak inter-departmental coordination. The high-level PSC was established in the second year to provide high-level oversight and stewardship to improve coordination across all the directorates and societies. The PSC, headed by the Principal Secretary of the DoHFW, conducted monthly meetings to review the progress and challenges and agree on mitigation measures to be implemented by each directorate and society. In addition, the TNHSRP Program Management Unit (PMU) adopted strategic staffing to recruit staff from other directorates and societies within DoHFW on an “external service” basis to facilitate easier internal- departmental coordination and a better flow of institutional knowledge. Factors subject to the control of the World Bank 38. Recognizing the internal and external factors causing delays in the Program's implementation, the WB team actively worked with the DoHFW to address implementation challenges. Regular supervision missions were conducted Page 10 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT to identify the challenges and issues in a timely manner, and solutions were jointly developed. The Program was restructured in 2022 to better achieve the development objectives. The Bank team worked closely with the client to discuss course corrections and mitigation strategies to overcome challenges and meet evolving needs. Factors outside the control of government and/or implementing entities 39. The COVID-19 pandemic severely impacted Tamil Nadu and impeded Program implementation. However, the GoTN was innovative in adapting to COVID-19 to meet evolving health needs and catch up on Program implementation. Tamil Nadu was one of the hardest-hit states by the pandemic and ranked fourth in the country by the total number of cases. The COVID-19 lockdowns led to disruptions in regular health service delivery and stalled progress on some key Program activities in 2020 and 2021, particularly those requiring face-to-face contacts, such as NCD screening (PDO3), health assemblies (DLI8), trainings, and facility certification (DLI2). DoHFW’s strategy was to refocus and accelerate TNHSRP implementation while caseloads were relatively low and adopt new operating modalities should caseloads surge again. Innovations included expanding the ambulance fleet to transport both COVID-19 patients and pregnant women, facilitating diabetes screening at PHCs with glucometers, providing longer two-month supplies of hypertension and diabetes medications, and engaging non-governmental organizations for doorstep delivery of drugs supplied by PHCs. The MTM home-based care program was launched to expand community outreach for NCD services. GoTN also made additional administrative efforts for central authorities to prioritize Tamil Nadu’s health facility certification. Moreover, the pandemic escalated the public demand for better emergency response, leading to the DoHFW decision to repurpose Program savings from other activities to the investment in emergency and trauma care. IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF MONITORING AND EVALUATION M&E Design 40. The M&E of the Program was largely well-designed. The Program’s theory of change was clear and well-articulated. The RF at appraisal and after restructuring comprised adequate, specific, measurable, and realistic indicators to monitor the Program towards PDOs. There were six PDO indicators, with at least two indicators covering each PDO domain and Program RA. The DLI matrix contained eight DLIs with 23 DLRs. Some DLIs and DLRs were composite indicators with multiple parts and/or multiple categories. Even though this increased the complexity of M&E, it was logical and aligned with concrete Program implementation plans across different types of health facilities. A minor shortcoming in M&E design was that the NCD indicators were not gender segregated. Verification protocols for all DLI/DLRs were clearly established at appraisal and updated with restructuring. The PMU had managed WB operations in the past and was considered capable of implementing the M&E. 41. A key strength of the Program M&E design was to include DLIs on additional data collection activities to promote data-driven policymaking in the Tamil Nadu health sector. These included the design and rolling out of the quality scorecard to be reported regularly by the health facilities (DPO2); design and piloting of PHRs (DLI6/IRI 8-added after restructuring); and carrying out STEPs surveys every two years (DLI3) to assess Program achievements on NCD outcomes. DLIs provided stronger incentives for robust data collection and evidence-based program implementation. M&E Implementation Page 11 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT 42. M&E performance was satisfactory throughout implementation. The RF was adjusted during the restructuring to reflect changes made to PDO and IR indicators and timelines. The PMU was adequately staffed to coordinate the data collection with key implementation entities and implement the M&E design, with experienced staff and program assistants to support data collection and monitoring of the RF. The PMU routinely conducted data analysis, reported to the PSC monthly, and reported to the World Bank every six months. The Program assigned existing staff at the district and health facility levels to manage routine data collection, analysis and reporting. Achievements of DLIs were verified by an independent verification agency (IVA)-IQVIA. IVA reports were received on time. All planned major data collection activities have been carried out (PHR, STEPS survey, quality scorecard, and MTM process evaluation). M&E Utilization 43. M&E findings were disseminated with key stakeholders and used to inform the Program implementation and strategic adjustment. During Program implementation, monthly PSC review meetings were held to monitor progress, identify issues, and discuss course correction measures with all seven implementing directorates and societies. At the district level, a new position of quality manager was recruited to analyze health facility quality data monthly and work closely with facilities to identify quality challenges and targeted improvement strategies. Upon Program completion, in August 2024, a knowledge conclave event was organized in Chennai with key stakeholders from the DoHFW and health sector officials from other states and foreign countries. The knowledge event systematically reflected on the lessons and challenges of the Program and facilitated knowledge exchange with other states and countries in the areas of NCD, quality, and equity. The M&E findings could also benefit other state Programs and the broader WB portfolio in India and other countries. The lessons were also documented in a series of case studies for broader dissemination. Justification of Overall Rating of Quality of M&E 44. Overall M&E quality is rated as High. M&E design was comprehensive, effective, and adequate to measure the Program’s progress and implementation challenges. M&E findings were disseminated with key stakeholders and used to inform the implementation and strategic adjustment of the Program. The DoHFW’s routine M&E mechanism also improved with the Program and is likely to have long-term benefits on health sector governance and performance. B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE 45. Social. The social recommendations from the Environmental and Social Systems Assessment (ESSA) were embedded within the RAs and in the Program Action Plan (PAP) and were completed. Despite challenges due to the COVID-19 pandemic, the Program successfully established an active platform to voice community concerns, especially the poor and marginalized, in health system planning and engage with policymakers and service providers on a single platform as Health Assemblies. Learning from international best practices, this was the first of its kind in India. The Program also made good progress in setting up early screening for NCDs, including screening for breast cancer and cervical cancer and putting people on treatment. A SBCC strategy was also deployed for improving the health and nutrition of the adolescent population under equity aspects. 46. Environmental. The environmental actions identified were implemented according to the PAP. As one of the DLIs, an environment strategy for the health sector in Tamil Nadu was developed and implemented. The two Program actions on performance audit of the Common Biomedical Waste Treatment Facilities were periodically undertaken by the State Pollution Control Board, and continuous learning and training on several environmental aspects, such as biomedical waste handling and disposal for COVID waste, was also undertaken. Energy audit in healthcare facilities was carried out indicating Page 12 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT huge cost savings in adopting energy efficiency measures while lowering the environmental footprint, particularly in terms of reduced Greenhouse Gas Emissions. 47. Financial Management (FM). The FM systems of the Program performed well throughout the Program period. The FM risk was consistently assessed as "Moderate,” and performance was rated as "Satisfactory". The budget for the Program was adequately provided by GoTN under the agreed budget lines. No substantial delays were noted in the release of funds. The budget execution reports summarizing spending by the health directorates on Program budget lines were generated from the State Integrated Financial and Human Resource Management System portal and shared with the Bank during the six-monthly implementation support missions. The Program expenditures were adequate to cover the DLI amounts disbursed by the Bank. The audited financial statements of Tamil Nadu Medical Services Corporation (TNMSC), Electronics Corporation of Tamil Nadu (ELCOT), NHM Society, and the Tamil Nadu Health Systems Project (TNHSP) Society and the audit certificate of the Comptroller and Auditor General of India were submitted to the Bank. These audit documents did not report any accountability issues. The PAP actions on strengthening the accounting and auditing practices at NHM Society were substantially met. The NHM Society used the Government if India’s Public Financial Management System (PFMS) for release of Program funds and expenditure monitoring. Training programs on the effective use of PFMS, accounting, and bookkeeping functions were given to the Block, PHC, CHC, and SC level staff. The concurrent audit systems at the Society were in place and audits were done regularly. 48. Procurement. The procurement risk of TNHSRP was consistently assessed as "Moderate", while the procurement performance of the Program was rated as "Satisfactory" throughout the Program life. Three PAP action items to promote bidder’s participation (establishing a procurement-related complaint handling system, conducting an annual vendor conference, and disclosure of contract awards above the threshold of INR 20 million) and one DLI (roll-out of e- procurement system and award of 20 percent of Program tenders by TNMSC using e-procurement system) were all achieved by the three procuring agencies - TNMSC, ELCOT and TN Public Works Department. The PAP action to ensure compliance with the Bank's Anti-Corruption Guidelines for the PforR Programs was also achieved with the office of the Principal Secretary (Health) providing six monthly reports on fraud and corruption complaints to the WB. No cases of fraud and corruption-related allegations/investigations were reported. C. BANK PERFORMANCE Quality at Entry 49. The GoTN’s commitment to the various ambitious reforms in the TNHSRP was built on the long trust and collaborative model with the WB health team, which had supported Tamil Nadu’s health reforms over the past 20 years. The collaborative model of co-creating innovative solutions formed the basis of the Program design and implementation. With the ambition to take Tamil Nadu’s health system performance to the next level, DoHFW and WB jointly explored several new transformative activities at the appraisal stage and included them in the Program design, including setting ambitious targets on the NCD treatment outcome as a PDO indicator and DLI, conducting two rounds of STEPS surveys, and introducing systematic QoC programs and institutionalizing quality scorecard to measure health facility service quality metrics. The WB team's collaborative model and strong Technical Assistance (TA) support gave the DoHFW confidence to deep dive into the unknown. 50. The WB team conducted comprehensive technical, fiduciary, and E&S assessments, and identified critical actions needed to keep the Program on track, including in a detailed PAP. The economic analysis projected a good return on Page 13 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT investment. Poverty, gender, and E&S aspects were systematically assessed and integrated into the Program design, as DLIs, IRIs, and through PAP actions. Quality of Supervision 51. The WB team undertook regular supervision missions to ensure smooth Program implementation. The Bank reports were timely, comprehensive, and realistic in identifying problems, proposing solutions and ratings. The Bank reports were of high quality and took a forward-looking approach to flag anticipated challenges and proactively identify mitigation solutions. During the mid-term review, the WB team promptly identified key implementation challenges and restructured the Program to ensure a better and more feasible path to achieve the PDOs. The WB team also frequently dialogued with the seven implementation directorates and societies, and the DoHFW leadership to facilitate inter-departmental coordination. 52. The WB team obtained additional trust fund resources and provided extensive technical support to the Program design and implementation, bringing best practices and experts to support TNHSRP. With support from the Korea-World Bank Partnership Facility (KWPF), the WB team started a US$750,000 small grant project on Transforming the Quality of NCD Care in Tamil Nadu (TF0B4093). Support under this small grant included: (i) overseas study tours to Korea and Sri Lanka, knowledge exchange events and trainings for the DoHFW staff to learn from the best practices on quality improvement for NCD care; trainings on analytical methods for NCD and quality; (ii) technical assistance to develop an NCD strategy, health promotion strategy, NCD population screening program, MTM home-based care program, SBCC for multi-layers and multisectoral engagement, and monitoring and evaluation for NCDs. The WB team conducted additional technical missions to work with the PMU and other key DoHFW stakeholders closely and brought the various international and Indian experts (from John-Hopkins University, Indian Council of Medical Research - National Institute of Epidemiology, Ramalinga Swami Centre of Equity and Social Determinants of Health, Public Health Foundation of India, and Centre for Communication and Change India), to support the Program design and implementation. Justification of Overall Rating of Bank Performance 53. Overall, Bank Performance is rated Highly Satisfactory. Intensive and continuous supervision and TA supported the client in adopting an ambitious and cutting-edge Program design and achieving strong results despite challenges due to COVID-19. D. RISK TO DEVELOPMENT OUTCOME 54. Risk to the development outcomes of TNHSRP is considered low. Upon completion of the Program, the institutional capacity developed at the DoHFW and various levels of health facilities (particularly in trauma care, NCD care, quality of care, RCH, governance, and M&E) was expected to be sustained and contribute to improved long-term health system performance. With the closing of TNHSRP and discontinuation of dedicated Program funding, the activities and initiatives would need to be incorporated into the routine work program of respective directorates and societies. The various directorates and societies developed a short-term plan to absorb some Program activities into their routine work program and continue scaling up those activities. For instance, NCD screening and management programs, trauma care, and RCH programs were already absorbed into DoHFW’s routine budget and planning. Further scaling up and continuation of PHR, TANQuEST, facility quality scorecard, and patient experience survey were also discussed, and likely requiring additional policy and budget investment by DoHFW for the long term. Page 14 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT V. LESSONS AND RECOMMENDATIONS 55. A successful PforR builds on strong long-term client engagement and capacity building. The TNHSRP drew lessons and experiences from the WB’s engagement in the Tamil Nadu health sector over the past two decades, through which strong trust, good institutional capacity, and a comprehensive government program were developed. The Tamil Nadu Health System Project (TNHSP)(P075058)—a US$210 million credit (2005–15) adopted an input-based approach to equip public health facilities with necessary inputs to deliver RCH services, developed innovative pilots for clinic-based NCD management, and started setting up the programs for emergency trauma care and quality of care mechanism. Through this project, DoHFW and health facilities had improved capacity in planning, implementing, and managing such projects, with the state-level procurement capacity also significantly enhanced. This paved the way for TNHSRP to adopt a PforR approach to support the new phase of the government health program in those results areas by scaling up successful models from previous pilots and introducing cutting-edge innovations to take the health system reform to the next level. Switching from Investment Project Financing to PforR changed the nature and focus of client dialogue from specific activities to strengthening policy and strategy development, removing institutional governance barriers, aligning incentives for performance, and institutionalizing M&E for accountability. 56. A PforR can significantly benefit from extensive WB technical assistance and additional trust fund resources. With an ambitious design, TNHSRP explored innovative areas for the client. Such cutting-edge reforms would be impossible without strong technical assistance and co-design of various programs. In TNHSRP, the WB played a key role in introducing new concepts and global best practices, facilitating global knowledge exchange, providing technical inputs to design specific policies, strategies, tools, and instruments, and bringing in the best international and domestic experts. Despite less WB involvement in implementing a PforR, extensive technical-level support emerged as an important area of client engagement to maximize the operation’s impact. 57. Implementation arrangements involving multiple stakeholders necessitate strong and top-level leadership oversight to facilitate effective coordination. With PforR operations growing more complex and multi-sectoral, it could become more difficult for the PMU to coordinate and monitor implementation by all the stakeholders effectively. Achieving the Program’s objectives necessitated strong and sustained stewardship and technical leadership both within the PMU and at the highest level of agency. The TNHSRP experience with the high-level PSC chaired by the Principal Secretary underscores the need for robust leadership and cohesive coordination mechanisms to navigate the complexities of multi-departmental programs and ensure effective implementation. 58. A PforR can generate significant relevant technical knowledge for the rest of India and other countries. TNHSRP pioneered many innovative health programs on implementing QoC strategy, health facility quality scorecard, data-driven decision making, home-based NCD care delivery, and integrated personal health records that could be relevant beyond Tamil Nadu. A PforR can generate rich knowledge on the “how-to”, including the processes to develop the Program and operationalize across health facilities. Systematic knowledge generation, documentation, and exchange through platforms such as Lighthouse India can facilitate the sharing of best practices. The TNHSRP’s Knowledge Conclave, with over 100 participants from 11 states and foreign countries, is an example of such efforts. Page 15 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 1. RESULTS FRAMEWORK, DISBURSEMENT LINKED INDICATORS, AND PROGRAM ACTION PLAN @#&OPS~Doctype~OPS^dynamics@icrpfrresultframework#doctemplate A. RESULTS FRAMEWORK PDO Indicators by PDO Outcomes Improved Quality of Care and Reduced Equity Gaps in Reproductive and Child Health Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year (i) Tertiary facilities Oct/2018 (i) Tertiary facilities Jun/2024 i) Tertiary facilities May/2024 with entry level with entry level with entry level NABH accreditation: NABH certification: NABH accreditation: 0(ii) Secondary 4 (ii) Secondary 3(ii) Secondary facilities with NQAS facilities with NQAS facilities with NQAS certification: 3(iii) certification: 75 of certification: 75 of Primary facilities which 15 are in the which 15 are in with NQAS priority districts (iii) priority districts (iii) certification: 4 Primary facilities Primary facilities Increased number of public facilities with NQAS with NQAS with quality certification (primary, certification: 300 of certification: 300 of secondary, and tertiary) (Text) which 60 are in the which 60 are in priority districts priority districts Comments on achieving targets This indicator measures the number of facilities receiving quality certification during the Program period. Specifically, it monitors the: • number of medical colleges (tertiary facilities) with entry level NABH certification; • number of District Head Quarter, Taluk and non-Taluk Hospitals (secondary facilities) with full NQAS certification; • number of CHCs and PHCs (primary facilities)ith full NQAS certification. The indicator also monitors the number of facilities of each level receiving quality certification in priority districts. The priority districts are: Ariyalur, Dharmapuri, Ramanathapuram, The Nilgris, Theni, Thoothukkudi, Tirunelveli, Tiruvannamalai, Virudhunagar. Page 16 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Tertiary facilities with entry 0 Oct/2018 4 Jun/2024 3 May/2024 level NABH certification (Text) 3 Oct/2018 70 of which 14 are Jun/2024 75 out of which 15 May/2024 Secondary facilities with NQAS in the priority are in the priority certification (Text) districts districts 4 Oct/2018 300 of which 60 are Jun/2024 300 out of which 60 May/2024 Primary facilities with NQAS in the priority are in priority certification (Text) districts districts Improved Quality of Care Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year NA – to be measured Oct/2018 65 Jun/2024 65 May/2024 after quality Improved scores in quality score card dashboard is for primary, secondary, and tertiary established level facilities (Text) Comments on achieving targets A quality score card will be developed for primary, secondary, and tertiary level facilities. This indicator will track the improvement on the quality score-card score of these facilities on an annual basis. The baseline and target scores will be established once the score-card is developed. Strengthened Management of Non-Communicable Diseases and Injuries Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Cervical cancer: Oct/2018 Cervical cancer: Jun/2024 Cervical cancer: May/2024 15.8%Breast cancer: 16%Breast cancer: 17%Breast cancer: Increased screening in public sector 19.5% 19% 23% facilities for cervical and breast Comments on achieving targets% of women age 30+ screened for cervical and breast cancer in public sector facilities Numerator: number of cancers (Text) women age 30+ screened for cervical/breast cancers in public sector facilities Denominator: number of women age 30+ Cervical cancer (Percentage) 15.80 Oct/2018 16.00 Jun/2024 17.00 May/2024 Breast cancer (Percentage) 19.50 Oct/2018 19.00 Jun/2024 23.00 May/2024 Improved Quality of Care and Strengthened Management of Non-Communicable Diseases and Injuries Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Page 17 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Hypertension under Apr/2021 Hypertension under Jun/2024 Hypertension under May/2024 control:7.3%Diabetes control: 3 control:17%Diabetes under control: 10.8% percentage point under control: increase from 16.7% Increased share of adults with baselineDiabetes hypertension or diabetes whose under control: 6 blood pressure or blood sugar are percentage point under control (Text) increase from baseline Comments on achieving targets (i) % of individuals age 30+ with hypertension whose blood pressure is under control;(ii) % of individuals age 30+ with diabetes whose blood glucose level is under control. Numerators and denominators specified in the DLI verification protocol. 7.3% Apr/2021 3 percentage point Jun/2024 17% May/2024 Hypertension under control increase from (Text) baseline - 10.3% 10.8% Apr/2021 6 percentage point Jun/2024 16.7% May/2024 increase from Diabetes under control baseline - 16.8% (Text) Comments on achieving targets The achieved value of blood glucose under control is 16.7 percentage point with a computed 95% confidence interval (CI) range of 14.7 -18.9. Considering the targeted value (of increase by 6 percentage percent) is within the CI range - GOTN is eligible for full achievement of the target. (i) # of trauma Oct/2018 (i) # of trauma Jun/2024 i) # of trauma May/2024 centers using trauma centers using centers using registry: 0(ii) % of trauma registry: trauma registry: surgical ED 54(ii) % of surgical 54(ii) % of surgical admissions: ED admissions: 55% ED admissions: 45.9%(iii) IFT 85%(iii) Emergency Improved provision of quality trauma protocols not department care services (Text) available(iv) established in 25 Emergency MCH(iv) 13 Level-1 department not trauma centres, 29 established(v) Level- Level-2 trauma 1 and level-2 trauma centres established care centers not available Page 18 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Comments on achieving targets (i) Number of trauma centers using trauma registry (ii) % of surgical ED admissions - Numerator and denominator specified in the DLI verification protocol. (iii) IFT Ptotocolos available (iv) Emergency department established: Yes (v) Level-1 and level-2 trauma care centers established: yes # of trauma centers using 0 Oct/2018 54 Jun/2024 54 May/2024 trauma registry (Text) % of surgical ED admissions 45.9% Mar/2021 55% Jun/2024 85% May/2024 (Text) Reduced Equity Gaps in Reproductive and Child Health Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year (i) Full ANC: 28.8% Oct/2018 (i) Full ANC: 41.3% Jun/2024 (i) Full ANC: May/2024 (ii) Fully immunized: (ii) Fully immunized: 41.3%(ii) Fully 57.9% (iii) mCPR: 70.4% (iii) mCPR: immunized: 70.4% 38.5% 43.5% (iii) mCPR: 43.5%Cumulative target achieved Comments on achieving targets This indicator monitors the utilization of select RCH services in the 9 priority districts: Ariyalur, Dharmapuri, Increased utilization of reproductive Ramanathapuram, The Nilgris, Theni, Thoothukkudi, Tirunelveli, Tiruvannamalai, Virudhunagar. The priority and child health services in priority districts were identified based on their performance on RCH indicators and proportion of ST population. Three districts (Text) RCH indicators will be monitored: full immunization, full antenatal care, and use of modern methods of contraception. Numerators and denominators specified in the DLI verification protocol. Full antenatal care (ANC): Pregnant women receiving at least four ANC visits, at least one TT injection, and taken IFA tablets or syrup for 100 or more days. Full immunization: Children 12-23 months receiving vaccinations against tuberculosis, diphtheria, pertussis, tetaus, polio, and measles. Modern contraceptive prevalence rate (mCPR). Modern methods include male and female sterilization, injectables, intrauterine devices (IUDs/PPIUDs), contraceptive pills, implants, female and male condoms, diaphragm, foam/jelly, the standard days method, the lactational amenorrhoea method, and emergency contraception. Full ANC (Percentage) 28.80 Oct/2018 41.30 Jun/2024 41.30 May/2024 Fully immunized 57.90 Oct/2018 70.40 Jun/2024 70.40 May/2024 (Percentage) mCPR (Percentage) 38.50 Oct/2018 43.50 Jun/2024 43.50 May/2024 Page 19 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Intermediate Results Indicators by Result Areas Result #1: Improved Quality of Care Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year (i) Number of Nov/2018 (i)Number of Jul/2024 (i) Number of May/2024 primary, secondary, facilities primary, secondary, and tertiary level implementing at and tertiary level facilities least 1 endorsed facilities implementing at quality implementing at least 1 endorsed improvement least 1 endorsed quality initiative from the quality improvement list of evidence- improvement initiative from the based interventions initiative from the list of evidence- specified in the QoC list of evidence- based interventions Strategy: Primary: based interventions specified in the QoC 570, Secondary: 248 specified in the QoC Implementation of quality Strategy: 0 ………….. and tertiary:9 (ii) Strategy: 570 improvement interventions in (ii) Number of Number of facilities primary facilities primary, secondary, and tertiary care primary, secondary, reporting on quality and 248 secondary facilities (Text) and tertiary facilities scorecard quarterly: and tertiary facilities reporting on quality Primary: 570 and (ii) Number of dashboard Secondary: 248 primary, secondary, quarterly: 0 and tertiary facilities reporting on quality dashboard quarterly: 570 primary and 248 secondary and tertiary facilities Comments on achieving targets This indicator tracks the implementation of at least one endorsed quality improvement initiative from the list of evidence-based interventions specified in the QoC Strategy and the number of facilities reporting on the quality score-card quarterly. The indicator monitors each intervention at the primary and secondary/tertiary facilities. Page 20 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT The quality score-card will include indicators to measure quality of care along the three dimensions of quality: structural inputs, clinical processes, and patient outcomes. The GoTN and the World Bank will develop this score-card jointly. The indicators will vary by level of facility. Following development of the score-card, primary, secondary, and tertiary facilities will be monitored for quarterly reporting on the quality score-card. Numerators and denominators specified in the DLI verification protocol. 0.00 Nov/2018 5.00 Jul/2024 5.00 May/2024 Piloting of patient experience Comments on achieving targets A detailed patient experience questionnaire – expanding the concept of the Mera Aspatal survey to measure questionnaire for secondary & patient satisfaction – is being developed for patients visiting secondary & tertiary facilities. This indicator will tertiary care facilities (Percentage) track the % of secondary & tertiary faciities piloting this patient experience questionnaire. Numerator: number of secondary & tertiary facilities piloting the patient experience questionnaire. Denominator: total number of secondary & tertiary facilities Result #2: Strengthened Management of Non-Communicable Diseases and Injuries Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Increased share of primary & 0.00 Nov/2018 40.00 Jul/2024 41.05 May/2024 secondary facilities with at least one Comments on achieving targets This indicator measures the % of primary & secondary facilities with at least one staff trained on mental health. staff trained on mental health Numerator: number of primary & secondary facilities with at least one staff receiving face-to-face training on (Percentage) mental health. Denominator: total numbr of primary & secondary facilities. No Nov/2018 Yes Jul/2021 Yes May/2024 Establishment of suicide hotline Comments on achieving targets TN has a functional toll-free number (104) for counselling on health issues and grievances related to health (Yes/No) services. Under the Program, a hotline linked to the 104 health helpline has been established for counselling related to suicide contemplation and attempts. Better equipped ambulance system 64.00 Nov/2018 164.00 Jul/2024 205.00 May/2024 to improve pre-hospital care -number Comments on achieving targets Number of ATLS ambulances providing Level 1 care during the year. of ATLS ambulances providing Level 1 care (Number) Level 3: Nurses - Nov/2018 Level 3: Nurses - Jul/2024 Level 3: Nurses - May/2024 Improved capacity of trauma care 165; Doctors - 6120; Doctors - 6909; Doctors - providers - number of emergency 100.Level 4: Nurses 4313.Level 4: Nurses 4537.Level 4: Nurses department providers that received - 0; Doctors - 0. - 900; Doctors - 600. - 951; Doctors - 624 Level 3 (BTLS) and Level 4 training (ATLS) (Text) Comments on achieving targets This indicator measures the cumulative number of emergency department providers that received Level 3 (BTLS) and Level 4 training (ATLS) during the Program period Page 21 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Result #3: Reduced Equity Gaps in Reproductive and Child Health Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year No Nov/2018 Yes Jul/2024 Yes May/2023 Implementation of updated social and behavior change communication Comments on achieving targets This indicator tracks progress on the implementation of annual workplans developed as part of a (SBCC) strategy (Yes/No) comprehensive SBCC Strategy. The SBCC strategy will include messages on NCDs and their risk factors (including mental health), road safety, and RCH in priority districts. The strategy development is under process. People who have received essential 0.00 Mar/2019 3,600,000.00 Jul/2024 4,082,246.00 May/2024 health, nutrition, and population (HNP) services (Number) Number of children 0.00 Mar/2019 3,600,000.00 Jul/2024 4,082,246.00 May/2024 immunized (Number) Cross-Cutting Results Indicator Name Baseline Closing Period (Original) Closing Period (Current) Actual Achieved at Completion Result Month/Year Result Month/Year Result Month/Year Result Month/Year Conceptual Model Nov/2018 Population health Jul/2024 Population health May/2024 and Operational registry developed registry under roll Plan for a and rolled out in 1 out in 1 district of strengthened and district of Tamil the state. - integrated Health Nadu completed; Strengthened content, quality, Management however, accessibility, and use of data for Information System verification pending decision making (Text) (HMIS) : No Comments on achieving targets A Conceptual Model and Operational Plan for a strengthened Health Management Information System (HMIS) covering all data sources, data users and data channels including integration with electronic medical records and patient tracking for NCDs will be developed in Year 1. By year 5, Tamil Nadu to rollout a population health registry in at least one district Strengthened coordination, Policies/Strategies: Nov/2018 (i) 1 annual call for Jul/2024 (i) Process for call May/2024 integration, performance-based NoInstitutional research proposals for proposal and management, learning, and other systems: No issued and selected award for year 5, cross-cutting functions for better proposal has been results (Text) awarded.(ii) completed. (ii) Page 22 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Program Steering Deploying e- Committee meeting procurement held during every system in TNMSC month of the and 20% of value of year(iii) total contracts of implementation of TNMSC under the operational plan for Program done environmental through e- strategy procurement: Completed (iii) Development of the environmental stategy of the health sector has been completed. (iv) Conducting and reporting on monthly meeting of Program Steering Committee (PSC) of the TNHSRP: completed (v) Designating nodal officers in each directorates and societies under the PforR program boundary for TNHRP with defined TOR and a coordination mechanism in place: Completed. (v) The following under this indicator were achieved earlier: TN Health Page 23 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Policy/Strategy, operational research program guidelines, guidelines on professional development program and environmenttrategy. (vi)(a) Energy Efficiency Audit - Results discussed on 9.10.23 (b) Liquid Waste Management Audit - Completed in 6 Health Care Facilities (c) BMWM - Initiated Comments on achieving targets This indicator tracks development and adoption of the following policies, strategies, and activities. Year 1: • TN Health Policy/ Strategy for Vision 2030; • Development and adoption of an Environment Strategy for the Health Sector in Tamil Nadu. Year 2: • Launch of the operational research program with 1 annual call for research proposals issued and selected proposal awarded. • Deploying e-pocurement system in TNMSC and 20% of value of total contracts of TNMSC under the Program done through e-procurement. Year 3-5: One annual call for research proposals issues and selected proposals awarded, PSC meetings conducted and nodal officers designated Districts conducting Nov/2018 Districts conducting Jul/2024 DHA for 63% Oct/2023 Increased transparency and Health Assembly: Health Assembly: districts and 1 SHA accountability through citizen 0%.State Health 60%.State Health completed engagement (voice, agency, and Assembly: 0 Assembly: 1 social accountability) (Text) Comments on achieving targets Selected districts as per the annual targets to conduct district health assemblies and the state has plans to conduct state health assembly every year. Districts conducting Health 0% Nov/2018 60% Jul/2024 63% ( 24 districts) May/2024 Assembly (Text) State Health Assembly 0 Nov/2018 1 Jul/2024 1 May/2024 (Text) Page 24 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Disbursement Linked Indicators (DLI) Period Period Definition Prior Results Prior Results Period 1 Year 1 Period 2 Year 2 Period 3 Year 3 Period 4 Year 4 Period 5 Year 5 Baseline Prior Results Period 1 Period 2 Period 3 Period 4 Period 5 1:Implementation of quality Achievement Level: improvement interventions in primary, secondary, and tertiary care facilities (Text ) Original/Revised Ad hoc NA (i) QoC At least 1 health (i)- At least 1 (i)- At least 1 health (i) At least 1 health Value implementation of Strategy facility implementing health facility facility implementing facility implementing quality developed and at least 1 endorsed implementing at at least 1 endorsed at least 1 endorsed improvement adopted - US$ quality improvement least 1 endorsed quality improvement quality improvement initiatives by 4,000,000 initiative from the list quality initiative from the list initiative from the list hospitals ……………..(ii) of evidence-based improvement of evidence-based of evidence-based Quality interventions initiative from the interventions interventions dashboard for specified in the QoC list of evidence- specified in the QoC specified in the QoC health Strategy: US$20,000 based Strategy: US$20,000 Strategy: US$20,000 facilities for each primary care interventions for each primary care for each primary care developed and facility for up to 142 specified in the facility up to 143 facility up to 143 launched and facilities and QoC Strategy: facilities, US$30,000 facilities, US$30,000 government US$30,000 for each US$20,000 for for each secondary for each secondary order issued secondary care each primary care and tertiary care care facility up to 62 detailing the facility for up to 62 facility up to 142 facility up to 62 facilities and quality facilities facilities and facilities and US$85,000 for each Page 25 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT improvement US$30,000 for US$85,000 for each tertiary care facility initiatives each secondary tertiary care facility up up to 5 endorsed - care facility up to to 4 facilities...….(ii) At facilities...….(ii) At US$ 7,000,000 62 facilities...….(ii) least 1 health facility least 1 health facilty At least 1 health reporting on quality reporting on quality facility reporting score card during each score card during on quality score quarter of the each quarter of the card during at reporting year: reporting year: least three US$14,800 for each US$14,800 for each quarters of the additional primary additional primary reporting year: care facility up to 190 care facility up to 190 US$14,800 for facilities and facilities and each additional US$22,000 for each US$22,000 for each primary care additional secondary additional secondary facility up to 190 care facility up to 83 care facility up to 82 facilities and facilities from the facilities from the US$22,000 for previous year……..(iii) previous year………(iii) each additional TANQuEST TANQuEST has been secondary care implementation plan piloted in at least one facility up to 83 developed and Medical College for a facilities from the adopted by Tamil period of 6 months: previous year Nadu: US$2,000,000 US$3,000,000 Allocated Amount 0.00 0.00 11,000,000.00 4,700,000.00 9,338,000.00 11,698,000.00 12,761,000.00 Actual Value Actual Amount 2:Increased number of public facilities Achievement Level: with quality certification (primary, secondary and tertiary) (Text ) Original/Revised (i) Tertiary: 0(ii) (i) US$160,000 for Gap analysis (i) US$37,000 for (i) US$160,000 for (i) US$850,000 for (i) US$850,000 for Value Secondary: 3(iii) every secondary completed and every additional every additional every tertiary care every tertiary care Primary: 4Tertiary care facility agreed facility primary care facility secondary care facility certified (up to facility certified (up to = medical certified (up to 34 quality certified (up to 60 facility certified 2 such 2 such collegesSecondary such facilities), improvement facilities), with an (up to 20 facilities)..…...(ii) facilities)…………...(ii) = district, taluk, with an additional plans for additional US$15,000 facilities), with an US$37,000 for every US$160,000 for every and non-taluk US$75,000 for NABH/NQAS for each of the first additional additional primary additional secondary hospitalsPrimary = each of the first 9 certification 10 that are in the US$75,000 for care facility certified care facility certified Page 26 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT PHCs and CHCs that are in the approved priority districts each of the first 4 (up to 80 facilities), (up to 21 facilities), priority that are in the with an additional with an additional districts...………...(ii) priority US$15,000 for each of US$75,000 for each of US$37,000 for districts...……...(ii) the first 20 that are in the first 2 that are in every primary care US$37,000 for the priority districts the priority facility certified every additional districts...……...(iii) (up to 11 such primary care US$37,000 for every facilitis), with an facility certified additional primary additional (up to 70 care facility certified US$15,000 for facilities), with an (up to 79 facilities), each of the first 3 additional with an additional that are in the US$15,000 for US$15,000 for each of priority districts each of the first the first 10 that are in 17 that are in the the priority districts priority districts Allocated Amount 0.00 6,567,000.00 7,125,000.00 2,370,000.00 6,345,000.00 4,960,000.00 8,283,000.00 Actual Value Actual Amount 3:Increased share of adults with Achievement Level: hypertension or diabetes whose blood pressure or blood sugar are under control (Text ) Original/Revised Baseline to be (i) STEPS (i) At least 1 endorsed (i) The percentage Value established after survey initiative from the list point increase in the STEPS is implemented of evidence-based share of hypertensive implemented in with survey interventions adults whose blood 2019 factsheet specified in the NCD pressure is under produced - strategy has been control over the US$ 4,985,500 implemented by the previous survey (with …………….(ii) TN state: statistical NCD Strategy US$3,000,000………(ii) significance) up to 3.0 developed and A process evaluation percentage points adopted - US$ of the Makkalai Thedi increase - US$7.3 4,000,000 Maruthuvam Scheme million for every is conducted: percentage point US$3,000,000 increase Page 27 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ……………………… (ii) The percentage point increase in the share of diabetic adults whose blood glucose is under control over the previous survey (with statistical significance) up to 6.0 percentage points increase - US$3 million for every percentage point increase………(iii) At least 1 endorsed initiative from the list of evidence-based interventions specified in the NCD Strategy has been implemented by the state: US$3,000,000 Allocated Amount 0.00 0.00 8,985,500.00 0.00 0.00 6,000,000.00 42,900,000.00 Actual Value Actual Amount 4:Improved provision of quality trauma Achievement Level: care services (Text ) Original/Revised (i) # of trauma (i) Trauma (i) Increase in the (i) Increase in the (i) Increase in the (i) Increase in the Value centers using registry number of trauma number of number of trauma number of trauma trauma registry: 0 established centers where the trauma centers centers where the centers where the ……………….(ii) % of and is in use in trauma registry is in where the trauma trauma registry is in trauma registry is in surgical emergency at least 1 use - US$35,000 for registry is in use - use - US$35,000 for use - US$35,000 for department trauma center each additional US$35,000 for each additional each additional admissions in -US$ trauma center from each additional trauma center from trauma center from Group A and B 1,000,000 the previous year trauma center the previous year the previous year facilities who ……….. (ii) operating a trauma from the previous operating a trauma operating a trauma Page 28 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT received surgery Protocols for registry up to 13 year operating a registry up to 13 registry up to 14 within 6 hours of requesting trauma centers trauma registry trauma centers trauma centers admission in the IFTs developed up to 13 trauma ………….. (ii) ………….. (ii) same institution: and existing centers ………….. Percentage point Percentage point 6.7% IFTs in relation (ii) Percentage increase in emergency increase in ……………….(iii) % of to these point increase in surgeriesithin 6 hours emergency IFT calls as a % of protocols emergency of admission in select surgeriesithin 6 hours total 108 system analyzed by surgeriesithin 6 medical college of admission in select calls: 41.1% hospital - US$ hours of hospitals- US$461,500 medical college 1,000,000 admission in for every percentage hospitals- select medical point increase up to 3 US$461,500 for every college hospitals- percentage points percentage point US$461,500 for ……………. (iii) Creation increase up to 3 every percentage and strengthening of percentage points point increase up emergency to 3.1 percentage departments in select points medical college hospitals: US$3,195,350……….(iv) Developing level-1 and level-2 trauma and emergency care facilities as part of the regional trauma and emergency care system of the state: US$ 5,000,000 Allocated Amount 0.00 0.00 2,000,000.00 455,000.00 1,885,650.00 10,034,850.00 1,874,500.00 Actual Value Actual Amount 5:Increased utilization of reproductive Achievement Level: and child health services in priority districts (Text ) Original/Revised (i) Women (i) Percentage (i) Percentage point Value receiving full ANC: point increase in increase in women 28.8% ……………… women receiving receiving full ANC Page 29 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT (ii) Children 12–23 full ANC compared to the months fully compared to the previous survey (with immunized: 57.9% previous survey statistical …………….. (iii) (with statistical significance) - Modern significance) - US$1,600,000 for contraception US$1,600,000 for every percentage prev. rate: 38.5% every percentage point increase from Definitions: (a) Full point increase baseline up to 5 ANC means at from baseline up percentage points least four ANC to 7.5 percentage ……………………….. (ii) visits, at least one points Percentage point tetanus toxoid ……………………….. increase in full injection, and (ii) Percentage immunization of having taken IFA point increase in children 12–23 tablets or syrup for full immunization months compared to 100 or more days. of children 12–23 the previous survey (b) Full months (with statistical immunization compared to the significance) - means previous survey US$1,600,000 for vaccinations (with statistical every percntage point against significance) - increase from tuberculosis, US$1,600,000 for baseline up to 5 diphtheria, every percentage percentage points pertussis, tetanus, point increase ………………………….. (iii) polio, and measles from baseline up Percentage point to 7.5 percentage increase in modern points contraceptive ………………………….. prevalence rate (iii) Percentage compared to the point increase in previous survey (with modern statistical contraceptive significance) - prevalence rate US$3,300,000 for compared to the every percentage previous survey point increase from (with statistical baseline up to 2 Page 30 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT significance) - percentage points US$3,300,000 for every percentage point increase from baseline up to 3 percentage points Allocated Amount 0.00 0.00 0.00 0.00 33,900,000.00 0.00 22,600,000.00 Actual Value Actual Amount 6:Strengthened content, quality, Achievement Level: accessibility, and use of data for decision- making (Text ) Original/Revised HMIS in place but Detailed (i) Population health Value fragmented across Conceptual registry developed data streams/ Model and and rolled out in 1 databases Operational district of Tamil Plan Nadustate: developed for US$15,000,000 a strengthened HMIS covering all data sources, data users and data channels including integration with electronic medical records and patient tracking for NCDs Allocated Amount 0.00 0.00 6,000,000.00 0.00 0.00 0.00 15,000,000.00 Actual Value Page 31 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Actual Amount 7:Strengthened coordination, integration, Achievement Level: performance-based management, learning, and other cross-cutting functions for better results (Text ) Original/Revised NA (i) TN Health (i) Operational Annual call for (i) Annual call for (i) Annual call for Value Policy/Strategy research program research research proposals research proposals for Vision 2030 launched with annual proposals issued issued and selected issued and selected developed and call for research and selected proposal awarded - proposal awarded - adopted - proposals issued and proposal awarded US$ 3,000,000……..(ii) US$ 3,000,000……..(ii) US$4,000,000 selected proposal - US$ 3,000,000 Operational plan of Operational plan of …………….(ii) awarded - the environmental the environmental Operational US$3,000,000 strategy of the health strategy of the health research ……………………. (ii) e- sector implemented: sector implemented: program procurement system US$1,250,000………(iii) US$1,250,000………(iii) developed and deployed in TNMSC Monthly meetings of Monthly meetings of adopted - and 20% of value of Program Steering Program Steering US$1,750,000 total contracts of Committee (PSC) of Committee (PSC) of …………..(iii) TNMSC under the the Program the Program Updated policy Program done conducted: conducted: for CME through e- US$2,500,000……..(iv) US$2,500,000 program procurement - Nodal officers in each developed and US$3,000,000……..(iii) directorates and adopted - Development and societies for the US$3,000,000 adoption of an Program with defined Environment TOR and a Strategy for the coordination health sector in Tamil mechanism in place: Nadu - US$,000,000 US$2,500,000 Allocated Amount 0.00 0.00 8,750,000.00 8,000,000.00 3,000,000.00 9,250,000.00 6,750,000.00 Actual Value Actual Amount 8:Increased transparency and Achievement Level: accountability through citizen engagement (voice, agency, and social accountability) (Text ) Page 32 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Original/Revised NO Guidelines on (i) At least 30% of (i) At least 40% of all (i) At least 40% of all Value district and all districts districts conducted districts conducted state health conducted health health assembly health assembly assemblies assembly during during the year - during the year - developed and the year - US$3,000,000 ………….. US$3,000,000 adopted US$2,000,000 (ii) Tamil Nadu ………….. (ii) Tamil ………….. (ii) Tamil conducted state Nadu conducted state Nadu conducted health assembly health assembly state health during the year - during the year - assembly during US$250,000 US$250,000 the year - US$250,000 Allocated Amount 0.00 0.00 4,000,000.00 0.00 3,250,000.00 3,250,000.00 3,250,000.00 Actual Value Actual Amount A. PROGRAM ACTION PLAN Action Timing Timing Value Achieved? Completion Measurement Increase bidder participation: (i) establish (i) procurement complaint redressal procurement complaint redressal system; and (ii) Recurrent Continuous Yes system established; (ii) annual supplier organize annual supplier forum/conferences forum/conferences organized Comments Completed Strengthen FM capacity in NHM: (i) assessment to identify gaps in staffing and policies; (ii) training (i) gap assessment report; (ii) training programs for accounting staff; (iii) greater use of Recurrent Continuous Yes programs organized; (iii) PFMS usage expenditure module of PFMS; (iv) strengthen report; and (iv) concurrent audit report concurrent audit system. Comments Completed Page 33 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Enhance transparency: (i) publicly disclose contract (i) report on disclosure by the awards of value greater than INR 20 Million (approx. procurement agencies; and (ii) US$ 285,720); and (ii) collate information on fraud Recurrent Continuous Yes quarterly report on fraud and and corruption-related complaints and provide corruption-related complaints information to WB on a quarterly basis Comments Completed Annual performance audit conducted and BMWM: performance audits for the CTFs have to be Recurrent Yearly Yes reports publicly disclosed by the undertaken competent authority Comments Being done regularily New refresher training course rolled out Introduce continuous refresher trainings on Recurrent Continuous for healthcare staff across all healthcare biomedical and other waste management facilities Comments Being done regularily Page 34 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION A. TASK TEAM MEMBERS Name Role Dinesh M. Nair Team Leader Aarushi Bhatnagar Team Leader Rahul Pandey Team Leader Arvind Prasad Mantha Financial Management Specialist Robin Kumar Thakur Procurement Specialist Anupam Joshi Environmental Specialist Venkata Rao Bayana Social Specialist Sivaramakrishnan Kumar Procurement Team Ritu Sharma Team Member Rifat Afifa Hasan Team Member Bogdan Constantin Constantinescu Team Member Devika Bahadur Team Member 1. @#&OPS~Doctype~OPS^dynamics@icrannexstafftime#doctemplate B. STAFF TIME & COST Staff Time & Cost Stage of Project Cycle No. of Staff Weeks US$ (including travel and consultant costs) Preparation FY18 7.325 46,047.75 FY19 47.143 330,478.27 FY20 9.165 47,539.63 FY22 0.000 8,119.80 Page 35 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT FY23 1.389 13,955.17 Total 65.02 446,140.62 Supervision/ICR FY19 3.175 27,100.27 FY20 36.632 219,383.48 FY21 40.822 183,534.23 FY22 49.903 333,607.00 FY23 46.021 466,990.04 FY24 39.667 581,927.68 FY25 13.205 191,117.19 Total 229.43 2,003,659.89 Page 36 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 3. PROGRAM EXPENDITURE SUMMARY Actual Expenditures (Disbursement) Source of Program Financing Type of Co- Estimates at (US$) Financing Appraisal Percentage of Percentage of Actual Appraisal Actual WB 287,000,000 287,000,000 100% 100% Borrower Parallel 4,990,750,000 4,990,750,000 100% 100% Total 5,277,750,000 5,277,750,000 100% 100% Page 37 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 4. BORROWER’S COMMENTS Respected Sir/Madam, Herewith sharing the One-page report as requested by the World Bank. Differing from the previous TNHSP (2005 – 2015), the current TNHSRP worked on the Program for Results mode which integrated the implementation of newer initiatives as per the needs and goals of Tamil Nadu. The collaboration ensured the objectives and measurable outcomes of every activity. The outputs were measured as Disbursement Linked Indicators (DLIs). An operational plan was developed by the World Bank and regular mid-term reviews focusing on the completion of the activities within the proposed timelines were conducted. On completion of the DLI, it was verified by IQVIA, an independent verification agency after which the disbursement amount was released by the World Bank. It was during the project period various workshops like TN NCD SBCC Strategy development workshop and dissemination programs like Annual Health Assembly (2022, 2023 & 2024), Dissemination workshop for WHO STEPS Survey findings & Environmental Strategy (2023), Dissemination of Operational Research findings (2023) were conducted. These workshops and sessions recognized and facilitated improvement of professional competencies of the Stakeholders. The World Bank in collaboration with TNHSRP team organized a Knowledge Exchange Conclave with the Stakeholders within the country and across the globe. This provided a platform for Tamil Nadu to showcase its efforts and achievements to the global leaders in health. The World Bank has been instrumental in bringing together the health care leaders & professionals from diverse geographical locations and enabling the participants to learn about the best practices, challenges and research done by the State of Tamil Nadu. The technical assistance provided by the Task Team of World Bank greatly enhanced the implementation of newer initiatives such as Trauma Registry, TANQuEST & Operational Research Program. The collaboration with Johns Hopkins Centre & the Ramalingaswami Centre on Equity and Social Determinants of Health for Communications Program for the Development of SBCC Strategy for NCD & Adolescent Health formed a vision to transform the Awareness Education towards Behavioral Change Communication. The support extended by the World Bank team by restructuring the targets and allowing the State’s healthcare system to revive and recover from the COVID pandemic instilled incredible strength. The State of Tamil Nadu deeply appreciates the World Bank team for their approach & relentless efforts towards the sustainability of the project. Thanks & Regards TNHSRP Page 38 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 5. SUPPORTING DOCUMENTS 1. Program Appraisal Document for Tamil Nadu Health System Reform (Report No: PAD3093, February 22, 2019) 2. Loan Agreement for Tamil Nadu Health System Reform Program (June 4, 2019) 3. Program Agreement for Tamil Nadu Health System Reform Program (June 4, 2019) 4. Mission Aide memoirs for implementation support missions (during 2019 to 2024) 5. Implementation status and results reports (during June 27, 2019 to May 23, 2024) 6. Restructuring Paper (June 2022) 7. The Program Completion Report of Tamil Nadu Health Systems Program (2019-2024), by Government of Tamil Nadu 8. Technical Assessment for India: Tamil Nadu Health System Reform Program by the World Bank 9. Integrated Fiduciary Systems Assessment for India: Tamil Nadu Health System Reform Program (P166373) (November 19, 2018) 10. ESSA for India: Tamil Nadu Health System Reform Program by the World Bank 11. Overview of the Tamil Nadu Health System Reform Program (TNHSRP – P166373) 12. DMS and DPH Facility Score card guidelines 13. TANQUEST Guidelines 14. QUALITY OF CARE INTERVENTION – Facility Quality Committee – Formation and Activation 15. Tamil Nadu Quality of care strategy- Accelerating Transformation to a High-Quality Health System in Tamil Nadu Report 16. Developing and implementing a survey to measure Patient experience in Tamil Nadu- Final Report by Oxford Policy Management 17. Quality Improvement under TNHSRP- World Bank Report (May 2024) 18. TNHSRP KE Conclave Brief 1 & 2 QOC and corresponding presentations 19. TNHSRP KE Conclave Brief 3 PHR and corresponding presentations 20. TNHSRP KE Conclave Brief 4 ORP and corresponding presentations 21. TNHSRP KE Conclave Brief 5 Health Assembly and corresponding presentations 22. TNHSRP KE Conclave Brief 6 NCD and corresponding presentations 23. TNHSRP KE Conclave Brief 7 Trauma Care and corresponding presentations 24. Video blogs and scripts (HA, ORP, PHR and QOC) Page 39 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 6: RESULTS CHAIN AND THEORY OF CHANGE Note: NCD: Non-communicable disease; RCH: Reproductive and Child Health; M&E: Monitoring &Evaluation; HMIS: Health Management Information System; CME: Continuous Medical Education; HRH: Human Resources for Health; BMW: Biomedical waste Page 40 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 7: CHANGES IN PDO INDICATORS AND DLIS DURING RESTRUCTURING RA DLI DLRs Changes in indicator Changes in end Change in definition/Cancelation/ target annual New indicator targets DLI#1: Implementation DLR1 (i) QoC strategy No change No change Changed of quality DLR 1 (ii) QoC dashboard Minor clarification of No change improvement definition interventions in DLR 1 (iii) implement quality initiative No change Increased target primary, secondary, (added tertiary and tertiary care facility) facilities DLR 1 (iv) TANQuEST adopted New indicator added DLR 1 (v) TANQuEST piloted New indicator added RA# PDO 1 (DLI#2): DLR 2 (i) gap analysis No change No change 1 Increased number of DLR 2 (ii) facility certified No change Decreased target public facilities with for tertiary quality certification facilities & Increased target for secondary facilities PDO 2: Improved scores in quality scorecard for primary, No change Baseline and end secondary, and tertiary care facilities targets established with new data PDO 3: Increased screening in public sector facilities for cervical Decreased targets Changed and breast cancer No change for cervical cancer and breast cancer PDO 4 (DLI#3): DLR 3 (i) STEPS survey No change No change Increased share of DLR 3 (ii) NCD strategy No change No change adults with DLR 3 (iii) hypertension control No change Baseline and end hypertension or targets established diabetes whose blood with new data pressure or blood DLR 3 (iv) diabetes control No change Baseline and end RA# sugar are under targets established 2 control with new data DLR 3 (v) NCD initiative New indicator added DLR 3 (vi) MTM home care New indicator added PDO 5 (DLI#4): DLR 4 (i) Trauma registry No change No change Improved provision of DLR 4 (ii) IFT No change No change quality trauma care DLR 4 (iii) trauma registry in trauma No change No change services centers DLR 4 (iv) emergency surgery Change in definition DLR 4 (v) emergency department New indicator added DLR 4 (vi) trauma and ED facility New indicator added RA# PDO 6 (DLI#5): Increased utilization of reproductive and child No change No change 3 health services in priority districts DLI#6: Strengthened DLR 6 (i) HMIS conceptual model No change No change CC content, quality, DLR 6 (ii) PHR Change in definition Changed accessibility, and use (From HMIS to PHR) Page 41 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT of data for decision DLR 6 (iii) HMIS Canceled making DLR 6 (iv) HMIS Canceled DLR 6 (v) HMIS Canceled DLI#7: Strengthened DLR 7 (i) Vision 2030 No change No change coordination, DLR 7(ii) Operation research (OR) No change No change Changed integration, DLR 7(iii) CME No change No change performance-based DLR 7(iv) Environment strategy No change No change management, DLR 7(v) OR No change No change Changed learning, and other DLR 7(vi) e-procurement No change No change cross-cutting DLR 7(vii) OR No change No change functions for better DLR 7(viii) Environment strategy results New indicator added implementation DLR 7(ix) Steering committee New indicator added DLR 7(x) Nodal officer New indicator added DLI#8: Increased DLR 8 (i) Guideline for health No change No change No change transparency and assemblies accountability through DLR 8 (ii) District health assembly No change No change Changed citizen engagement DLR 8 (iii) State health assembly No change No change Changed Page 42 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 8: ACHIEVEMENTS OF PDOS, IRIS, AND DLIS PDO indicator IRIs Result 1: Improved Quality of Care PDO Indicator 1 (DLI 2): Increased number of public facilities with quality certification (primary, secondary, and tertiary care) (with a focus on priority districts) (Revised in 2022) IRI 1 (DLI 1): Implementation of quality improvement interventions in primary, secondary, and tertiary (i) care facilities (Revised in September 2022) Baseline EOP target (after AA Status of Baseline EOP (after AA Status (established restructuring) achievement (established restructuring) 2018) 2018) Tertiary 0 4* 4 Achieved # of facilities 0 Primary: 570 Primary: Achieved facilities implementing Secondary: 570 accredited at least one 248 Secondary (NABH) quality 248 Secondary 3 75 75 Achieved improvement facilities (out of which 15 measure accredited are in priority # of facilities 0 Primary: 570 Primary: Achieved (NQAS) districts) reporting on Secondary: 570 Primary 4 300 300 Over‐ quality 248 Secondary: facility (out of which 60 (out of which achieved scorecard 248 accredited are in priority 60 are in quarterly (NQAS) districts) priority districts) IRI 2: Piloting in secondary and tertiary facilities patient experience PDO Indicator 2: Improved scores in quality score card for primary, secondary, and tertiary level Questionnaire facilities EOP: 5% of the secondary and tertiary facilities pilot the patient experience questionnaire EOP: 65 AA: 5% of the secondary and tertiary facilities piloted the patient experience questionnaire [Targets Actual Achievement (AA): 65 [Targets Achieved] Achieved] Baseline: 55 (established in 2022) Result 2: Strengthen management of non‐communicable diseases and injuries IRI 3: Increased share of primary & secondary facilities with at least one staff trained on mental PDO Indicator 3: Increased screening in public sector facilities for cervical and breast cancers (Revised health in February 2022) EOP: 40% of primary and secondary facilities with at least one staff trained on mental health AA: 41.05% of primary and secondary facilities with at least one staff trained on mental health EOP: Cervical cancer: 16% Breast cancer: 19% [Targets Achieved] Actual Achievement (AA): Cervical cancer: 17% Breast cancer: 23% [Targets Achieved] Baseline: As of November 2018, no primary or secondary facility had any staff trained on mental Baseline: (Established in 2018) Cervical cancer: 15.8% Breast cancer: 19% health Page 43 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT IRI 4: Establishment of suicide hotline PDO Indicator 4 (DLI 3): Increased share of adults with hypertension or diabetes whose blood EOP: Establish a suicide hotline for the state pressure or blood sugar are under control (Revised in February 2022) AA: TN established a functional toll‐free number (104) for counselling on health issues and grievances related to health services. Under the Program, a hotline linked to the helpline has been developed for EOP: Hypertension under control: 3 percentage point increase from baseline counselling related to suicide contemplation and attempts [Targets Achieved] Diabetes under control: 6 percentage point increase from baseline Baseline: No Actual Achievement (AA): Hypertension under control:17% [Targets Achieved] Diabetes under control: 16.7% [Targets Achieved] Baseline: Hypertension under control:7.3% & Diabetes under control: 10.8% PDO Indicator 5 (DLI 4): Improved provision of quality trauma care services (Revised in February 2022) Baseline EOP target AA Status of (established (after achievement 2018; revised restructuring) in 2022) IRI 5: Better equipped ambulance system to improve pre-hospital care -number of ATLS ambulances providing Level 1 care # of trauma 0 54 54 Achieved EOP: 164 ATLS ambulances providing Level 1 care centers using AA: 205 ATLS ambulances providing Level 1 care [Targets Achieved] trauma Baseline: 64 ATLS ambulances providing Level 1 care registry IRI 6: Improved capacity of trauma care providers - number of emergency department providers that % of surgical 45.9% 55% 85% Over‐ received Level 3 Basic Trauma Life Support (BTLS) and Level 4 training ED admissions achieved EOP: (i) Level 3 Nurses: 6120; (ii) Level 3 Doctors: 4313; (iii) Level 4 Nurses: 900; (iv) Level 4 Nurses: 600 AA: (i) Level 3 Nurses: 6909; (ii) Level 3 Doctors: 4537; (iii) Level 4 Nurses: 951; (iv) Level 4 Nurses: 624 [Targets Achieved] Emergency NA NA Established in NA Baseline: (i) Level 3 Nurses: 165; (ii) Level 3 Doctors: 100; (iii) Level 4 Nurses: 0; (iv) Level 4 Nurses: 0 department 25 Maternal (Revised in February 2022) and Child Health (MCH) Level 1 and NA NA 13 and 29, NA Level 2 care respectively centres Result 3: Reduce inequities in reproductive and child health services Page 44 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT IRI 7: Implementation of updated SBCC (Yes/No, Custom) EOP: Yes [Targets Achieved] PDO Indicator 6 (DLI 5): Increased utilization of reproductive & child health services in priority AA: Yes districts Baseline: No EOP: (i) Full ANC: 41.3%; (ii) Fully immunized: 70.4%; (iii) mCPR: 43.5% AA: i) Full ANC: 41.3%; (ii) Fully immunized: 70.4%; (iii) mCPR: 43.5% [Targets Achieved] IRI 11: People who have received essential health, nutrition, and population (HNP) services Baseline: (i) Full ANC: 28.8%; (ii) Fully immunized: 57.9%; (iii) mCPR: 38.5% EOP: 3,600,000 AA: 4,082,246 [Targets Achieved] Baseline: 0 (Established in 2019) Cross cutting Results IRI 8 (DLI 6): Strengthened content, quality, accessibility, and use of data for decision making (Revised in February 2022) EOP: Population health registry developed and rolled out in 1 district of Tamil Nadu AA: Population health registry under roll out in 1 district of the state. – completed [Targets Achieved] Baseline: A Conceptual Model and Operational Plan for a strengthened and integrated Health Management Information System (HMIS) did not exist as of November 2018 IRI 9 (DLI 7): Strengthened coordination, integration, performance-based management, learning, and other cross-cutting functions for better results (Revised in February 2022) EOP: (i) 1 annual call for research proposals issued and selected proposal awarded; (ii) Program Steering Committee meeting held during every month of the year; (iii) implementation of operational plan for environmental strategy AA: (i) Process for call for proposal and award for year 5: completed [Targets Achieved] (ii) Monthly Steering Committee meetings for TNHSRP are completed [Targets Achieved] (iii)(a) Energy Efficiency Audit - completed [Targets Achieved] (b) Liquid Waste Management Audit - Completed in 6 Health Care Facilities (c) Biomedical Waste Management (BMWM) – Initiated [Targets Achieved] Baseline: Policies/Strategies: No Institutional systems: No IRI 10 (DLI 8): Increased transparency and accountability through citizen engagement (voice, agency, and social accountability) (Revised in February 2022) EOP: Districts conducting Health Assembly: 60%. & State Health Assembly: 1 AA: DHA for 63% districts and 1 SHA completed [Targets Achieved] Baseline: Districts conducting Health Assembly: 0%. &State Health Assembly: 0 Page 45 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT ANNEX 9: ADDITIONAL INFORMATION ON RESULTS ACHIEVED BY THE PROGRAM 1. Tamil Nadu Quality of Care (QOC strategy) The QOC strategy was guided by the WHO National Quality Policy and Strategy and the Lancet Commission on High Quality Health Systems. The QOC strategy has been successful in achieving targets at all levels including Macro, Meso and Micro. Figure 1a. QoC strategy pillars Figure 1b. QoC strategy achievements Note: TAN-QuEST: Tamil Nadu Quality Enhanced Structured Training; DME: Directorate of Medical Education; ORP: operational research programme; EEA: Energy efficiency Audit; BMWM: Biomedical Waste Management; LWM: Liquid waste management; DPH: Directorate of Public Health; DMS: Directorate for Medical and Rural Health Services; MCH: Maternal and Child Health; NQAS: National Quality Assurance Standards; NABH: National Accreditation Board for Hospitals and Healthcare Providers 2. Health facility quality scorecards Facility score cards are provided on a digital dashboard which is used for calculating the scores, providing a summary of patterns and trends, enabling facility staff and quality managers to identify priority areas for intervention. Page 46 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Figure 2a. Facility scorecard digital dashboard Scorecards use 12-14 indicators designed based on a rigorous consultative process and using global literature on measurement of quality of care. Data for selected indicators is already collected at the health facilities as a part of routine information systems. Figure 2b. Indicators monitored through facility scorecards 3. STEPS survey TNHSRP partnered with the National Institute of Epidemiology (NIE) - ICMR to better inform the design and implementation of the Government of Tamil Nadu’s NCD program by implementing STEPS surveys in TN. Two rounds have been conducted so far- baseline round in 2019-20 to set the targets and an endline in 2023-24 to monitor the program achievements. The survey included 3800 patients in 2019-20 and 8114 patients in 2023-24. A comparison between the two rounds of STEPS survey revealed an improvement in all stages of the care cascade among the patients with hypertension and diabetes as shown in Figure 3a. Care seeking at the government health facilities also increased from 45.5% to 62.4% among individuals with hypertension and from 33.9% to 54.1% among individuals with diabetes as shown in Figure 3b. Page 47 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Figure 3a. Improvements in prevalence, awareness, treatment and control of Hypertension and Diabetes between the two STEPs survey rounds Figure 3b. Improvements in care seeking at government health facilities for Hypertension and Diabetes 4. MTM home-based care To address the increasing burden of NCDs effectively, community-based screening services for optimal detection, treatment and follow-up was initiated. The scheme offers a holistic & Comprehensive set of “Home-Based Care Services” including NCD drug delivery, Palliative care services, Physiotherapy sessions, Awareness creation, Referrals, etc. Figure 4a shows the key services included in MTM. Implemented in a phased manner, MTM currently operates across the length & breadth of the State. It has reached more than 1.4 Crore eligible population and is ongoing with innovations adding up. MTM was the major source of care for individuals ≥45 years with hypertension (43.7%) and diabetes (39.6%) in 2023-24. MTM Field team includes Women Health Volunteer, Village Health Nurse, MLHP, Palliative care Nurse and Physiotherapist. Page 48 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Figure 4a. Key services including in MTM A cross-sectional study of 654 WHVs in 216 PHCs was carried out as an evaluation of MTM. The study covered WHV's status and functioning, drug indenting patterns, and health facility utilization by diabetes and hypertension patients in six districts including Chennai, Madurai, The Nilgiris, Dharmapuri, Virudhunagar and Ramanathapuram. The evaluation revealed a considerable decline in indenting of oral anti-diabetic drugs and anti-hypertensive drugs in the medical colleges and government taluk hospitals and a rapid increase of indenting at the primary health centres as shown in Figure 4b. Utilization of primary health facilities among patients with diabetes mellitus and hypertension increased by 92% in 2022 compared to 2018 (Figure 4c) Figure 4b. Indenting pattern of oral anti-diabetic Figure 4c. Health facilities utilization among drugs and anti-hypertensive drugs patients with diabetes and hypertension 5. TANQuEST TANQuEST provides a diverse selection of online and offline training programs on Management (Human Resources, Supply Chain, Inventory, Projects, Programs and Conflicts), Healthcare communications, Hospital Jurisprudence, Ethics, Pandemic Page 49 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT and Disaster Management, Hospital Infection control, Research methodology, field epidemiology, digital data management and computational technologies etc. Figure 5a. TANQUEST Platform for online training programs 6. Population Health Registry (PHR) PHR is another important platform bringing an interlinked digital platform to Tamil Nadu. PHR aims at providing a Unique Health ID to each individual. It provides a complete solution for collecting, storing, analyzing, and sharing family socio- demographic and health data through the digitization of the Family Register. The State Family Database (SFDB) of 6.57 crores have been incorporated and updated into the PHR Database with creation of PHR ID for each citizen. The family members are verified by the field functionaries viz., Village / Urban Health Nurses using the TNPHR mobile application. The performance of the VHNs/UHNs has been monitored at the block, district level using the available dashboards. The verified family member count at the community level serves as the definitive denominator for various health metrics. Page 50 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Figure 6a. Web Admin Portal and Dashboard 7. Operations research Operational Research Program (ORP) aim is to encourage researchers (from across the country) working in public or private institutions, interested in carrying out empirical research that will contribute to strengthening of the healthcare delivery system in Tamil Nadu. This program has initiated 30 studies (from about 202 research proposals received over the last four call for proposals), on diverse topics ranging from primary health care to higher tertiary hospital in Tamil Nadu. Research teams from several private and public Institutions have been engaged in this program. A few Key lessons from studies carried out include: • Composition of Patient Safety Committee in Medical Colleges and District Hospitals - (under theme patient safety by ESIC Medical College & PGIMSR, Chennai) • Composition of Antimicrobial Stewardship Committee at Medical Colleges and District Hospitals-(under Theme Antimicrobial Use by ESIC Medical College & PGIMSR, Chennai) • Early attention is needed for liquid waste management, particularly in older healthcare institutions. The BMW committee should also concentrate on audits of the BMW practices in the HCFs – (under Theme Bio Medical waste by Development Solutions, Delhi) • Rehabilitation program to be improved in TAEI centers.(under the theme TAEI by Tirunelveli MCH.) • Improve Screening Awareness among 18+ age group, Grass-root collaboration with Community-based NGOs and promotion of HPV vaccine (under the theme screening of Breast and Cervical cancer by Tamil Nadu by Dr. M.G.R Medical university Chennai.) Page 51 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT • Follow-up/cohort monitoring of the HHL beneficiaries and Decentralization of the 104 HHL activity at the district level.(under the theme Strengths and weakness of the District Mental Health Program in Tamil Nadu by Institute of Mental Health, ICMR- NIE, SCARF, Chennai). • Introduction of tele-based training modules on DMHP services for medical officers and healthcare workers at PHC. (under the theme Strengths and weakness of the District Mental Health Program in Tamil Nadu by - Karur Govt. Medical College) • Need to start a strategic campaign among women of reproductive age about the merits of vaginal deliveries (under the theme Impact of COVID-19 pandemic on utilization of maternal and child health services in Tamil Nadu by Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry) • District training cell should be established, to provide periodic quality training for staff related to certification. Periodic monitoring systems should be established and inclusion of quality related indicators in regular HMIS is essential for sustenance and renewal (under the theme A Situational Analysis of Quality Certification /Accreditation of Public health facilities in Tamil Nadu Sree Balaji Medical College and Hospital, Chennai). • Ensure adequate allocation of funds for NQAS gaps and quality management based on performance. Rationalization of registers; periodic audit of registers, prescriptions, case sheets, etc. (under the theme Managing and Sustaining Healthcare Transformation in Public Settings - Evidence from Tamil Nadu, NMIMS Mumbai). • The community awareness and utilization of Health and wellness centers need to be scaled up by conducting more outreach activities including health camps. (under the theme Evaluation of functioning of Health and Wellness Centres in Tamil Nadu by St. John’s Research Institute, Bangalore) • Establishment of Telementoring/ Doctor-Doctor Teleconsultation/ Virtual Tumour Boards and Comprehensive Educational campaigns. Expansion of Health Insurance Coverage-Include diagnostic procedures, alternate systems of medicine, palliative care (under the theme Understanding the Correlation between Social Determinants of Delays in Diagnosis, Management and Outcomes for Solid Cancers in Tamil Nadu - A Multicentric Mixed Method Study -PSG Institute of Medical Sciences and Research, Coimbatore • Implement robust scheduling system, and referrals pathways, to efficiently direct patients to facilities with available advanced therapeutic equipment. (under the theme Utilization and Economic Evaluation of Advanced Diagnostic and Therapeutic Healthcare Equipment in Public Healthcare Facilities of Tamil Nadu - ESIC Medical College & PGIMSR, Chennai) 8. Patient Experience Survey Positive patient experience is a critical component of a high-quality health system: all patients deserve to be treated with respect and dignity. Because there is no single framework for measuring patient experience, this study validated and implemented a contextually specific tool for measuring patient experience in Tamil Nadu. The validation process resulted in a 37-item questionnaire that measured five domains of patient experience (respect, autonomy, communication, responsiveness, privacy) as well as related indicators of competent care, the hospital environment, and trust. In total, 544 inpatients across 27 facilities and 504 outpatients across 40 facilities were surveyed for this analysis. Incorporating the 37- item questionnaire into routine health facility data collection will help identify areas that need improvement, track progress over time, and ultimately hold the health system accountable to the population it serves. Page 52 The World Bank Tamil Nadu Health System Reform Program (P166373) ICR DOCUMENT Key findings: • 78% of respondents reported that they usually or always experienced effective communication from their nurses; that is that nurses spoke in a way they could understand. • 44% of respondents said that healthcare staff always asked for consent before doing a physical examination. • Patient experience varied widely across facilities, with a majority of facilities scoring either very poorly or very well. On average, private facilities scored higher than public facilities on all domains of patient experience. Page 53