The World Bank is supporting the Department of Health and Family Welfare (DoHFW), Government of Tamil Nadu (GoTN), in the implementation of the ‘Tamil Nadu Health System Reform Program’ (TNHSRP), through IBRD financing of US$287 million across the state. Focusing on critical institutional strengthening, the project aims to improve quality of care, strengthen the management of non-communicable diseases (NCDs), and reduce the inequities in reproductive and child health (RCH). The Program activities are organized around three results areas as outlined below and as illustrated in the theory of change.
One key approach to improve quality of care under the Program is national accreditation for primary-, secondary-, and tertiary-level health facilities in the public sector. Two types of accreditation will be sought: National Quality Assurance Standards (NQAS) for primary- and secondary-level facilities and National Accreditation Board for Hospitals & Healthcare Providers (NABH) for tertiary-level facilities (medical colleges).
Recognizing that there is no single silver bullet to improve quality of care, the Program also supports other interventions that form a comprehensive set of approaches.They include strengthening continuous medical education; developing and disseminating clinical protocols/guidelines and clinical decision support tools; monitoring quality of care using facility dashboards for public reporting; introducing and scaling up quality improvement initiatives (including performance-based incentives, quality committees, hospital quality networks and other interventions).
The second results area focuses on the management of NCDs, associated risk factors and injuries.NCD interventions under the Program represent the continuation and further scaling-up of the successful Tamil Nadu NCD initiatives previously supported by the World Bank, mainstreamed into Tamil Nadu’s health sector activities and fed into the National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The service delivery approach for NCD management will be strengthened at the lowest level through health and wellness centers and PHCs. In addition, the Program will include the development of NCD care cascades for selected tracer conditions (for example, hypertension and diabetes); strengthening of lab services; improving health provider capacity to address mental health; improving data on NCDs and mental health for better planning and management; and strengthening social and behaviour change communication (SBCC). Previously, the GoTN had developed information, education, and communication materials; these will be updated and incorporated into a more comprehensive SBCC strategy that includes multiple layers of engagement with patients, health providers, and communities through various channels of communication.
Given the high prevalence of road traffic accidents and other injuries, the Program scope will include injuries and trauma.Tamil Nadu has an advanced Emergency Medical Services (EMS) work plan which adequately covers both pre-hospital and in-hospital EMS. The Program will support the implementation of the EMS work plan, including emphasis on further strengthening the 108 ambulance service to improve pre-hospital care, provision of 24x7 trauma care services at Level 1 and Level 2 emergency departments to improve in-hospital care, and establishment of a trauma registry.
Interventions in the Program to reduce inequities between districts focus on a combination of supply- and demand-side interventions to support increased utilization of RCH services. Supply-side interventions include improved budget allocations for priority districts, better provision of RCH services as measured by NQAS accreditation of primary and secondary care facilities and establishment of maternity stay wards in remote areas. Demand side interventions include the development and implementation of the SBCC strategy tailored to these priority districts.
The Program also supports systematic, cross-cutting reforms which will impact the above three results areas as well as the health sector more broadly. Theseinclude: (a) strengthening HMIS, (b) increasing transparency and accountability with increased quantity, better quality and better use of data; (c) strengthening health administration and management at different levels, including improving integration/coordination between different health directorates as well as between centrally-sponsored schemes and state-financed efforts (d) conducting annual district and state health assemblies which are civic forums built on the Panchayati Raj system to boost citizen voice and agency and catalyze a social movement in health and (e) supporting operational research, implementation research, and health system research to inform decision-making, enable course corrections and generate lessons for Tamil Nadu as well as other states. These interventions aim to improve “how” the sector operates and complement the technical interventions in the three results areas (“what” specifically the sector does).
A key element of this Program is that it adopts a results-based financing approach called ‘Disbursement Linked Indicators (DLIs)’, in which disbursement of funds from the World Bank is triggered by achievement of a set of previously agreed results indicators. This is departure from earlier approaches where the World Bank would finance inputs to implement agreed activities. The DLIs have been identified and agreed in consultation with the DoHFW, GoTN. Each DLI target has been assigned a unit cost value (US$/DLI achieved). When the milestone is achieved and reported by the DoHFW, a third party agency verifies its achievement, after which the funding associated with the indicator is disbursed by the World Bank to the GoTN.
The verification of achievement of results is critical as it is the verification of results will only trigger the payment to the government. The verification has to be independent, credible, transparent and objective such that it provides robust evidence for the release (or non-release) of funds. To support the DLI verification process, the GoTN seeks to hire a firm to serve as the Independent Verification Agency (IVA). To support the DLI verification process, the GoTN seeks hire a firm to serve as the Independent Verification Agency (IVA).
I. Purpose of Consultancy
The purpose of this consultancy is to conduct periodic independent verification of the achievement of the DLIs, as agreed under the World Bank-supported TNHSRP.
II. Scope of Work:
The achievement of the DLIs triggers World Bank disbursements to the Program, thus verification is critical. Verification will be done through routine assessment of reported DLI achievement. The achievement of the DLIs triggers World Bank disbursements to the Program. The choice and detailed definition of the DLIs reflect the critical areas the GoTN has to address to push health sector performance to the next level.
They reflect the combined effect of a set of specific technical interventions and systems strengthening interventions. The verification protocol for the DLIs is described in detail in Annexure. An independent verification agency (IVA) will verify achievement of the DLIs based on the agreed protocol. Copies of accreditation certificates will be submitted to the IVA to verify DLI #1.
For DLI #2, the IVA will annually visit a random subset of facilities to check the dashboard data against primary data for timeliness and completeness of the dashboard. Similarly, the IVA will visit a random subset of facilities to check activities and records of government approved quality improvement initiatives.
DLIs #3and #5 will be verified through a household survey administered every other year. If the survey firm is different from the IVA, the IVA will provide oversight for the survey.
DLI #5 will be verified through the submission of the verification report of facility performance on agreed results.
For DLI #4, the IVA will undertake a number of verifications, including (a) verifying that the trauma registry has been developed (year 1) and has been implemented and is operating in the requisite number of facilities (1 in year 1, 24 in years 2-3, 54 in years 4-5); (b) verifying the percent of surgery cases admitted through the emergency department where the surgery was performed within 6 hours; and (c) verifying the percent of total 108 calls that are inter-facility transfers (IFTs), using data from the 108 system.
DLI #6 will be first verified in Year 1 by reviewing the final HMIS strengthening operational roadmap that will be produced and adopted through a Government Order. For subsequent years, verification protocols will be developed for the milestones acceptable to the World Bank after the finalization of the operational roadmap.
For DLI #7, final documents and evidence of formal adoption (Government Order) will be submitted to the IVA as proof of achievement. And also IVA will be verified with evidence of an annual call for research proposals.
For DLI #8, copies of the annual district and state health assembly report will be submitted to the IVA.
In addition to verifying the achievement of DLIs, the IVA will report on implementation and/or data challenges that are noted by the IVA during the verification process. This will help the government and World Bank identify implementation bottlenecks and resolve them to improve the achievement of results.
The Environmental and Social Systems Assessment (ESSA)
It was carried out in line with the World Bank policy and procedure for P for R financing for the identified Program. This covered the five health directorates and two societies which are most relevant for health service delivery in the state. Health care facilities at all levels and the populations in their catchment areas will be the beneficiaries of Program support. The ESSA identified opportunities for strengthening the existing institutional, operational, and regulatory systems and capacities pertaining to environment and social issues in the health sector in Tamil Nadu. The findings of the ESSA are based on field visits to different health facilities, use of checklists to assess biomedical waste (BMW) management, the institutional assessment questionnaire (self-scoring), and discussions with a large number of key stakeholders, including officials of the TNHSP Society, NHM Society, DPH, DME, and DMRHS. The ESSA also benefitted from the experience of the successful implementation of the previous TNHSP and other ongoing World Bank-financed projects in the state.
The Program design also benefited from the extensive consultation done under the previous TNHSP project with tribal communities in establishing the agenda for the tribal health program. The engagement had included consultations with various NGOs working on tribal health issues, tribal communities and their ‘sangams’34, field visits to tribal areas, and consultations with various government departments including the Health, Tribal Welfare, and Forest Departments. Further comments, suggestions and areas that require strengthening were sought during the free and prior-informed consultation with NGOs working on tribal health and members (men and women) of tribal communities during the stakeholder consultation held on 10/24/18 and the draft ESSA was disclosed by the World Bank on 11/21/18. The recommendations were then incorporated and integrated into the design of the Program.