FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF THE KARNATAKA HEALTH SYSTEM DEVELOPMENT AND REFORM PROJECT

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1 Public Disclosure Authorized Docume of The World Bank FOR OFFICIAL USE ONLY Report No: RES22733 Public Disclosure Authorized Public Disclosure Authorized RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF THE KARNATAKA HEALTH SYSTEM DEVELOPMENT AND REFORM PROJECT CREDIT NO 5161-IN SEPTEMBER 27, 2012 TO THE REPUBLIC OF INDIA March 9, 2016 Public Disclosure Authorized Health, Nutrition and Population Global Practice South Asia Region This docume has a restricted distribution and may be used by recipies only in the performance of their official duties Its coes may not otherwise be disclosed without World Bank authorization

2 ABBREVIATIONS AND ACRONYMS DEA DOHFW INR ISA KHSDRP NABH NCD PDO SAST SDR TOR US$ Departme of Economic Affairs Departme of Health & Family Welfare Indian Rupee Implemeation Support Agency Karnataka Health System Developme and Reform Project National Accreditation Board for Hospitals and Healthcare Providers Non-Communicable Disease Project Developme Objective Suvarna Arogya Suraksha Trust Special Drawing Rights Terms of Reference United States Dollar Regional Vice Preside: Coury Director: Senior Global Practice Director: Practice Manager/Manager: Task Team Leaders: Annette Dixon Onno Ruhl Timothy Gra Evans Rekha Menon Jorge Coarasa, Somil Nagpal 2

3 INDIA Karnataka Health Systems Developme and Reform Project CONTENTS A SUMMARY 5 B PROJECT STATUS 6 C PROPOSED CHANGES 7 ANNEX 1: Results Framework and Monitoring 9 3

4 DATA SHEET India Karnataka Health System Developme and Reform Project (P071160) SOUTH ASIA Health, Nutrition & Population Report No: RES22733 Basic Information Project ID: P Lending Instrume: Specific Investme Loan Regional Vice Preside: Annette Dixon Original EA Category: Partial Assessme (B) Coury Director: Onno Ruhl Curre EA Category: Partial Assessme (B) Senior Global Practice Director: Practice Manager/Manager: Team Leader(s): Timothy Gra Evans Original Approval Date: 22-Aug-2006 Rekha Menon Curre Closing Date: 31-Mar-2016 Jorge A Coarasa, Somil Nagpal Borrower: Responsible Agency: Governme of Karnataka Departme of Health and Family Welfare Restructuring Type Form Type: Full Restructuring Paper Decision Authority: Coury Director Approval Restructuring Level: Level 2 Financing ( as of 03-Mar-2016 ) Key Dates Project Ln/Cr/TF Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P IDA Effective 22-Aug Oct Jan Mar Mar-2016 P IDA Effective 27-Sep Nov Jan Mar Mar-2016 P TF Closed 07-Oct Oct Oct Aug Aug-2014 Disbursemes (in Millions) Project Ln/Cr/TF Status Currency Original Revised Cancelle d Disburse d Undisbur sed % Disburse d P IDA Effective USD P IDA Effective USD

5 P TF Closed USD Policy Waivers Does the project depart from the CAS/CPF in coe or in other significa respects? Yes [ ] No [ X ] Does the project require any policy waiver(s)? Yes [ ] No [ X ] A Summary of Proposed Changes The curre restructuring of the project proposes to extend the Closing Date of the Karnataka Health Systems Developme and Reform Project (KHSDRP) (Credit No IN) for a period of one year, from March 31, 2016 to March 31, 2017 The Original Credit (No IN) will be fully disbursed by the curre Closing Date of March 31, 2016 This is in accordance with the Governme s request dated February 15, 2016 The proposed extension would allow a successful completion of planned activities under the project and ensure the full achieveme of the project developme objectives Specifically, the proposed extension would enable activities under the Additional Financing (AF) (approved on September 27, 2012 for US$ 70 million equivale) phase to be completed In addition to coinuing some original project activities, the AF was to pilot new activities on emergency and trauma care, preveion and corol of noncommunicable diseases and health insurance, including a unique scheme to provide financial protection to the victims of road traffic accides The aim in piloting these innovative approaches is develop options to inform policy making on these critical issues in Karnataka and beyond Due to the innovative nature of these activities, most of which are being undertaken for the first time in India, preparation took longer than expected and implemeation has only fully started during the last six mohs Therefore, the proposed extension will focus on completing implemeation and allowing sufficie time for these pilots to be appropriately evaluated The Results Framework is being aligned with the proposed extension by adjusting the final target dates of those indicators releva to the activities that will coinue for one more year Lastly, the disburseme estimates are revised in line with the extended implemeation period Change in Implemeing Agency Yes [ ] No [ X ] Change in Project's Developme Objectives Yes [ ] No [ X ] Change in Results Framework Yes [ X ] No [ ] Change in Safeguard Policies Triggered Yes [ ] No [ X ] Change of EA category Yes [ ] No [ X ] Other Changes to Safeguards Yes [ ] No [ X ] Change in Legal Covenas Yes [ ] No [ X ] Change in Loan Closing Date(s) Yes [ X ] No [ ] Cancellations Proposed Yes [ ] No [ X ] Change to Financing Plan Yes [ ] No [ X ] Change in Disburseme Arrangemes Yes [ ] No [ X ] Reallocation between Disburseme Categories Yes [ ] No [ X ] Change in Disburseme Estimates Yes [ X ] No [ ] Change to Compones and Cost Yes [ ] No [ X ] Change in Institutional Arrangemes Yes [ ] No [ X ] 5

6 Change in Financial Manageme Yes [ ] No [ X ] Change in Procureme Yes [ ] No [ X ] Change in Implemeation Schedule Yes [ ] No [ X ] Other Change(s) Yes [ ] No [ X ] Appraisal Summary Change in Economic and Financial Analysis Yes [ ] No [ X ] Appraisal Summary Change in Technical Analysis Yes [ ] No [ X ] Appraisal Summary Change in Social Analysis Yes [ ] No [ X ] Appraisal Summary Change in Environmeal Analysis Yes [ ] No [ X ] Appraisal Summary Change in Risk Assessme Yes [ ] No [ X ] B Project Status Most project-supported activities are proceeding well, and project objectives coinue to be achievable Five of the eight Project Developme Objective (PDO) indicators and six of the nine iermediate outcome indicators have achieved or surpassed end-of-project targets The remaining indicators are on track to achieve end-of-project targets All the activities agreed during the last implemeation support mission are on track The Non-Communicable Disease (NCD) corol pilot in two districts: implemeation of the NCD pilot has started in the two selected districts (Dakshin Kanada and Dhavangiri) Staff, drugs, equipme and coracts with local medical colleges for diagnostic services are in place Procureme of drugs and equipme is ongoing but ierim arrangemes have been put in place so the pilots can run smoothly while this is being completed The focus needs to shift to close monitoring of pilot implemeation from both the district and the state levels Of particular importance is following up to ensure paties found positive after screening receive adequate treatme Also, it is critical to work with the technical support agency to ensure routine data collection and analysis to understand trends and ideify technical and operational issues that need mid-course correction A coract has been signed with an information, education and communication (IEC) agency that will support the behavior change aspect of the pilot Investme in primary and maternal health care services (civil works and manageme): The project has made progress in civil works coributing to primary and maternal health care services Of the 336 works under original credit, 333 works are completed and the remaining three are at final stage of completion Of the 59 civil works under the AF, 12 have been completed, and the remaining 47 are at differe stage of implemeation and scheduled to be completed by the end of the proposed extension period The procureme of consultancy services for innovative/green technology for construction and renovation of health facilities is completed Procureme of services for health facility infrastructure assessme and software for monitoring of civil works have also been completed Organizational developme (Training & Quality Assurance): The procureme of an agency to conduct soft-skills training for froline health workers was completed and training of 10,000 staff across the state is ongoing Very good progress has been made to iegrate the quality assurance functions started by the project io the state National Health Mission, allowing sustainability post project completion The project coinues to make progress in supporting the National Accreditation Board for Hospitals and Healthcare Providers (NABH) accreditation of selected hospitals Two hospitals have completed their final assessme for full accreditation and four more are expected to complete it in the next few mohs An additional 30 hospitals (secondary and primary health facilities) are being supported towards ery level accreditation 6

7 Road Safety: Implemeation progress of the agreed activities under this compone has improved The needs assessmes and baseline surveys were completed for the three pilot districts, the Esseial Standards for Trauma Care for various levels of hospitals have been completed, training for 2,307 staff on advanced and basic trauma care training has started, a paper-based injury information system is under implemeation and the blood bank networking process is ongoing The equipme for emergency and trauma care services ideified during the needs assessme for 25 Taluk and district level Hospitals is under procureme Health insurance: The scheme providing tertiary care coverage for people below the poverty line coinues to be implemeed with significa success The Suvarna Arogya Suraksha Trust (SAST) has achieved all the milestones linked to the original credit, four out of seven milestones under the AF are achieved Several of the activities for the remaining AF milestones have been completed, with the costing study also now ongoing and expected to be completed in the next two mohs Milestones consisting of an assessme of the frequency, geographic distribution, injury severity, insurance coverage and other releva characteristics of road traffic accides casualties in Karnataka is close to completion The audit reports have been received on time and considered acceptable to the Bank The report for the FY16 will be received by December 31, 2016 C Proposed Changes Project Developme Objectives Original PDO Developme Objectives/Results To improve health service delivery, public-private collaboration, and financing, particularly for the benefit of underserved and vulnerable groups in Karnataka Change in Project's Developme Objectives Change in Results Framework Explanation: Minor changes are being proposed to the Results Framework to reflect the extended implemeation period Specifically, the end-of-project target for indicator on number of health claims paid by health insurance pilot program benefitting Below Poverty Line (BPL) households (number, custom), "number of women screened for cervical cancer in pilot districts (Number, Custom)", health facilities constructed, renovated, and/or equipped (number), number of claims paid to private sector hospitals by the governme health insurance program supported by the project (cumulative) and "number of hospitals empaneled to provide care to road accide victims under the governme program (cumulative) (Number, Custom)" will be extended uil March 31, 2017 Change in Loan Closing Date(s) Explanation: Financing The proposal is to extend the Closing Date of the Karnataka Health System Developme and Reform Project (KHSDRP) from March 31, 2016 to March 31, 2017 to allow successful completion of planned activities and achieveme of the project developme objectives The Additional Financing phase included coinuation of some activities undertaken under the original credit as well as piloting of new activities on emergency and trauma care, preveion and corol of non-communicable diseases and health insurance, including a unique scheme to provide financial protection to the victims of road traffic 7

8 accides Due to the innovative nature of these activities, most of which are being undertaken for the first time in India, preparation took longer than expected and implemeation has started during the last six mohs of the Project The aim of these activities was to test innovative approaches to inform policy making in these critical issues in Karnataka and beyond The extension would focus on completing implemeation and allowing the pilots to run for sufficie time to be appropriately evaluated Ln/Cr/T F IDA IDA TF Status Original Closing Date Curre Closing Date Proposed Closing Date Previous Closing Date(s) Effective 31-Mar Mar Mar Mar-2012 Effective 31-Mar Mar Mar Mar-2016 Closed 31-Aug Aug Aug-2013 Disburseme Estimates Change in Disburseme Estimates Explanation: The change in Credit Closing Date will have implication on disburseme estimate The revised estimates are in the table below Fiscal Year Curre (USD) Proposed (USD) ,126, ,126, ,698, ,698, ,464, ,464, ,087, ,087, ,430, ,430, ,557, ,768, ,658, ,658, ,670, ,598, ,670, ,531, ,000,00000 Total 217,365, ,365,

9 Annex 1: RESULTS FRAMEWORK Project Name: Team Leader(s): Product Line: Coury: India Region: Karnataka Health System Developme and Reform Project (P071160) Jorge A Coarasa Bustamae IBRD/IDA SOUTH ASIA Requesting Unit: Responsible Unit: Approval FY: Lending Instrume: SACIN GHN Project Stage: Created by: Modified by: Specific Investme Loan Restructuring Status: DRAFT Bathula Amith Nagaraj on 16- Feb-2016 Bathula Amith Nagaraj on 04- Mar-2016 Project Developme Objectives Original Project Developme Objective: To improve health service delivery, public-private collaboration, and financing, particularly for the benefit of underserved and vulnerable groups in Karnataka Results Core sector indicators are considered: Yes Results reporting level: Program Level Project Developme Objective Indicators Status Indicator Name Core Unit of Measure Baseline Actual(Curr e) End Target No Change Direct project beneficiaries Number Value No Change Female beneficiaries Perceage Value No Change Perce of births/deliveries occurring in a health facility Sub Type Suppleme al Perceage Value No Change Perceage Value Date 31-Mar Mar Mar

10 Status Indicator Name Core Perce of birth/deliveries occurring in a health facility among the poor No Change Perce of population receiving outpatie care in governme facilities in 7 less-developed districts Revised Revised Number of health claims paid by health insurance pilot program benefitting Below Poverty Line (BPL) households Number of health claims paid by health insurance pilot program benefitting Below Poverty Line (BPL) households Number of women screened for cervical cancer in pilot districts Number of women screened for cervical cancer in pilot districts No Change perce change in number of road traffic accide paties transported by governme ambulance system (108 system) in pilot districts Iermediate Results Indicators Status Indicator Name Core No Change Health personnel receiving training (number) Unit of Measure Baseline Actual(Curr e) Perceage Value End Target Number Value Date 31-Mar Jun Mar-2017 Number Value Number Value Date 31-Mar Jun Mar-2017 The end target is shifted to next year Number Value Perceage Value Unit of Measure Date 31-Mar Mar Mar-2016 Baseline Actual(Curre ) End Target Number Value Date 22-Aug Jun Mar

11 Status Indicator Name Core No Change Births (deliveries) attended by skilled health personnel (number) Revised Health facilities constructed, renovated, and/or equipped (number) Health facilities constructed, renovated, and/or equipped (number) No Change Perce of governme Primary Health Ceers (PHCs) providing roundthe-clock services No Change Training materials on noncommunicable disease activities for clinical staff are developed No Change Guidelines and standards for trauma care services are developed Revised number of claims paid to private sector hospitals by the governme health insurance program supported by the project (cumulative) number of claims paid to private sector hospitals by the governme health insurance program supported by the project (cumulative) No Change number of private hospitals empaneled by SAST that Unit of Measure 11 Baseline Actual(Curr e) End Target Number Value Date 31-Mar Jun Mar-2016 Number Value Date 31-Mar Jun Mar-2017 Number Value Perceage Value Yes/No Value No Yes Yes Yes/No Value No Yes Yes Date 30-Jun Mar-2016 Number Value Date 31-Jan Jan Mar-2017 Number Value Date 31-Jan Jun Mar-2016 Number Value Date 31-Mar Jan Mar-2016

12 Status Indicator Name Core Revised have submitted at least 100 claims (cumulative) number of hospitals empaneled to provide care to road accide victims under the governme program (cumulative) number of hospitals empaneled to provide care to road accide victims under the governme program (cumulative) Unit of Measure Baseline Actual(Curr e) End Target Number Value Date 31-Jan Jan Mar-2017 Number Value Date 31-Jan Jan Mar