Document of The World Bank Report No. 13402-IN STAFF APPRAISAL REPORT INDIA ANDHRA PRADESH FIRST REFERRAL HEALTH SYSTEM PROJECT NOVEMBER 2, 1994 South Asia Country Department II (India) Population and Human Resources Operations Division CURRENCY EOUIVALENTS (As of June 1994) Currency Unit = Rupee Rupee 32.6 = US$1.00 Rupee 1.0 = US$0.03 METRIC EOUIVALENTS 1 Meter (m) = 3.28 Feet (ft) 1 Kilometer = 0.62 Miles FISCAL YEAR April 1 - March 31 i ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome AP Andhra Pradesh APHMHIDC AP Health & Medical Housing Infrastructure Development Corporation APVVP Andhra Pradesh Vaidya Vidhana Parishad ASCI Administrative Staff College of India CHC Community Health Center CSSM Child Survival & Safe Motherhood Project DALY Disability Adjusted Life Years EMTC Equipment Maintenance and Training Center FW Family Welfare GDP Gross Domestic Product GOAP Government of Andhra Pradesh GOI Government of India HIV Human Immunodeficiency Virus HMIS Health Management Information System ICB International Competitive Bidding ICDS I First Integrated Child Development Services Project IDA International Development Association IEC Information, Education and Communication IPP 6 Sixth India Population Project IPP 8 Eight India Population Project ISHA Indian Society of Health Administrators LCB Local Competitive Bidding MCH Maternal and Child Health MIS Management Information System MOHFW Ministry of Health and Family Welfare, GOI NGO Non-Governmental Organization NHP National Health Policy NSS National Sample Survey PAR Performance Audit Report PCR Project Completion Report PHC Primary Health Center PHN Population, Health and Nutrition PHR Population & Human Resources PWD Public Works Department SC Scheduled Castes SOE Statement of Expenditure ST Scheduled Tribes STD Sexually Transmitted Disease SUBC Subcenter TB Tuberculosis UIP Universal Immunization Program WDR World Development Report WHO World Health Organization ii INDIA ANDHRA PRADESH FIRST REFERRAL HEALTH SYSTEM PROJECT Table of Contents Page No. CREDIT & PROJECT SUMMARY ......................... v I. STATE/SECTOR BACKGROUND A. Health Sector in India. 1 B. The State of Andhra Pradesh. 2 C. Health Sector Issues. 7 D. Lessons from Experience. 9 E. Linkages with other PHN Projects in Andhra Pradesh .11 F. Country Assistance Strategy and Rationale for IDA Involvement .13 II. THE PROJECT A. Project Objectives ........................ 15 B. Approach ........................ 16 C. The Reform Program ................................. 16 D. Project Description ........................ 20 III. PROJECT COST. FINANCING. IMPLEMENTATION AND DISBURSEMENTS A. Project Costs ........................ 24 B. Financing Plan ..................................... 27 C. Procurement Arrangements ......................... 28 D. Disbursement Profile .31 E. Status of Project Preparation .32 F. Implementation Plan .33 G. Recurrent Cost and Sustainability .34 H. Indigenous Populations .35 I. Environmental Aspects .36 J. Land Acquisition .36 K. Accounting and Auditing .36 This report is based on an appraisal mission that visited India in May 1994. The mission comprised Tawhid Nawaz (Senior Economist and mission leader), Indra Pathmanathan (Public Health Specialist), Christopher Potter and Pradeep Kakkar (Management Consultants and IEC Specialists), David Porter (Equipment and Support Services Consultant), Sajitha Bashir (Economist Consultant), Shreelata Rao-Seshadri (Social Issues Consultant), Eid Dib (Procurement Specialist and Architect Consultant), Subash Chakravarthy (Architect Consultant) and Anthony Measham (Advisor). Salim Habayeb (Senior Public Health Physician) and Dean Jamison (Director, University of California, Los Angeles, Center for Pacific Rim Studies) contributed during project preparation. Kevin Casey (Procurement Specialist and Architect) contributed on procurement aspects. Nischint Bhatnagar assisted in the preparation of this document. The peer reviewers were Willy De Geyndt (ASTHR) and Jagadish Upadhyay (EA2HR). The Project is endorsed by Richard Skolnik, Chief, Population and Human Resources Operations Division, and Heinz Vergin, Director, India Country Department. iii Page No. IV. PROJECT BENEFITS A. Benefits ......................................... 37 B. Program Objective Categories.37 C. Risks ........................................... 38 V. AGREEMENTS REACHED AND RECOMMENDATION .............. 39 iv Page No. TABLES 1.1 Lessons Applied From IDA Experience in PHN Lending to the Proposed Project .............................. 10 2.1 Linkages with Other PHN Projects in AP ................... 12 3.1 Cost By Component ................................ 25 3.2 Cost By Categories of Expenditure ....................... 26 3.3 Procurement Arrangements ........................... 29 3.4 Estimated Expenditures and Disbursements .................. 31 ANNEXES Annex 1 Project Costs .................................... 42 Annex 2 Health Sector Development Policy Program in Andhra Pradesh .... . 50 Annex 3 Public Expenditures on the Health Sector in Andhra Pradesh ...... . 55 Annex 4 Cost Recovery ................ ................... 64 Annex 5 Organization and Management System of APVVP .. ....... . . . . 71 Annex 6 Workforce Issues ................ .................. 85 Annex 7 Clinical and Diagnostic Service Norms at APVVP Hospitals ..... . . 111 Annex 8 Clinical Training: Improving Quality and Effectiveness ....... . . . 124 Annex 9 Equipment Norms for APVVP Hospitals .... .......... . . . . . 131 Annex 10 Equipment Maintenance and Training Services at APVVP Hospitals . . 137 Annex 11 Strengthening Referral and Support for Primary Care ........ . . . 149 Annex 12 Quality Assurance Program in APVVP Hospitals . . ......... . . . 155 Annex 13 Information, Education and Communication Strategy . . . . . . . . . . . . 160 Annex 14 Tribal Strategy ................................... 164 Annex 15 Summary of Construction Program ..170 Annex 16 Procurement Arrangements ..187 Annex 17 Implementation Plan ..198 Annex 18 Performance Indicators ..208 Annex 19 Supervision Plan .................................. 232 Annex 20 Forecast of Expenditures and Disbursements . .236 Annex 21 Documents Available in Project File ..237 v INDIA ANDHRA PRADESH FIRST REFERRAL HEALTH SYSTEM PROJECT CREDIT AND PROJECT SUMMARY Borrower: India, acting by its President Beneficiarv: State of Andhra Pradesh Amount: IDA Credit SDR 90.7 million (US$133.0 million equivalent) Poveriy: One of the main objectives of the Project is to provide better quality and greater access to health care services to improve the health status of poor and underserved people including women, scheduled tribes and scheduled castes. The project contains specific strategies for interventions targeted for these groups. Terms: IDA Standard with 35 years maturity On-lending terms: The Government of India would make the proceeds of the Credit available to the State of Andhra Pradesh (AP) under standard arrangements for development assistance to the States of India. GOI would assume foreign exchange risk. Description: The ultimate goal of the project would be to improve the health status of the people of AP, especially the poor and the underserved, by reducing mortality and morbidity. The objectives of the project would be to assist the Government of AP (GOAP) to: (i) improve efficiency in the allocation and use of health resources through policy and institutional development; and (ii) improve system performance of health care through improvements in quality, effectiveness and coverage of health services at the first referral or secondary level to better serve the neediest sections of society. The project would include three components: Institutional Strengthening through Policy Reform and the Development of Implementation Capacity. (i) Improving the institutional framework by: strengthening sectoral capacity for development of policy; implementing cost recovery mechanisms; and improving sectoral resource allocation. (ii) Strengthening institutions and their implementation capacity at Andhra Pradesh Vaidya Vidhana Parishad (APVVP) and communitv. area, and district hospitals by: improving capacity for project implementation through the strengthening of vi management capacity and structure and through the provision of training; enhancing capacity for equipment management and maintenance, and procurement of goods and services; strengthening monitoring and evaluation capacity including improvement of the hospital management information system and improving supervision of civil works; Improving Quality, Access and Effectiveness of Services at District Hospitals. (i) Renovating 21 district hospitals. (ii) Upgrading clinical effectiveness and quality at district hospitals by: updating and applying norms and standards for clinical, technical and support services; instituting quality assessment mechanisms; enhancing staff skills in clinical and technical areas; providing updated equipment and material; and expanding capacity of support services. Improving Quality, Access and Effectiveness of Services at Area and Community Hospitals. (i) Renovating/extending 49 area hospitals and 80 community hospitals. (ii) Upgrading clinical effectiveness and guality at area and community hospitals by: updating and applying norms and standards for clinical, technical and support services; instituting quality assessment mechanisms; enhancing staff skills in clinical and technical areas; providing updated equipment and material; and expanding capacity of support services. (iii) Improving functioning of referral by: improving linkages and referral between different levels and with the private sector; strengthening management of the referral system; implementing referral and clinical management protocols; and establishing an incentive system for users and staff. The project would finance civil works, equipment and furniture, vehicles, medical/laboratory and other supplies, medicines, professional services, training, studies and evaluations, and incremental salaries and costs on a declining basis. Benefits: First, the policy reforms envisaged under the project would improve the efficiency and effectiveness of health care services. The strengthening of AP's first referral health system would optimize resource use, avoid duplication and waste and reduce overcrowding at tertiary facilities. Second, improvements in the health status of the people of AP would ultimately increase the potential earning capacity of the poor by reducing mortality, morbidity and disability. Third, strengthening first referral hospitals and making them more client-friendly would also encourage patients to seek timely care resulting in higher cure rates at lower costs. Fourth, the project would help regulate and reduce patient flow to the tertiary hospitals, where treatment per patient is more expensive. Fifth, the strengthening and upgrading of the secondary level would lend vital support and credibility to the primary health care system for implementing the various national and vertical health programs, and for providing basic vii health care in rural areas. Finally, an adequately functioning first referral health system would strengthen linkages with private health care through improved functioning of referral mechanisms. Risks: Institutional: Since this would be the first project to reorient the health system of a state in India, the capacity of existing institutions to undertake systemic improvements and establish a more rational health delivery system has not been tested in India. The institutional strengthening aspects that are in-built in the project would reduce this risk. These institutional aspects include: strengthening the strategic planning capacity in the Department of Health, Medical and Family Welfare; enhancing APVVP's implementation capacity through strengthening its management structure, systems and procedures, culture of service delivery, resources and training; and enhancing the capacity of the Infrastructure Development Corporation to undertake supervision monitoring of the construction program. Financial: Potential hurdles to instituting user charges may be faced by the state government because of the politically sensitive nature of the issue. The state government has reiterated its commitment through a letter on Health Sector Policy that it would institute user charges while protecting those who cannot afford to pay. The on-going study on the burden of disease and cost-effectiveness would provide an empirical basis to determine appropriate user charges giving the government greater flexibility and better information for charging user fees. The overall financial status of the state is a risk in terms of the adequacy of funds allocated to the health sector, especially allocations to the secondary level of health care. The government of AP, through a Health Sector Policy letter, has committed to providing sufficient resources to meet the financial needs generated by the project. viii Estimated Project Cost: Component Local Foreign Total -------------------US$ Million------------------- Institutional Strengthening 3.8 0.3 4.1 Improve Quality, Access and Effectiveness 46.5 8.5 55.0 at District Hospitals Improve Quality, Access and Effectiveness 63.5 14.5 78.0 at Area and Community Hospitals TOTAL BASELINE COSTS 113.8 23.3 137.1 Physical Contingencies 9.9 2.3 12.2 Price Contingencies 7.8 1.9 9.7 TOTAL PROJECT COSTS 131.5 27.5 159.0 ' Including taxes and duties estimated at US$ 8.8 million equivalent Financing Plan: Local Foreign Total -------------------US$ Million------------------- GOAP 26.0 0 26.0 IDA 105.5 27.5 133.0 Total 131.5 27.5 159.0 Estimated Disbursements: IDA Fiscal year --------------------------------US $ Million--------------------------------- FY95 FY96 FY97 FY98 FY99 FY00 FY01 FY02 Annual 4.0 9.3 15.8 21.4 21.2 21.2 31.9 8.2 Cumulative 4.0 13.3 29.1 50.5 71.7 92.9 124.8 133.0 Economic Rate of Return: Not Applicable. INDIA ANDHRA PRADESH FIRST REFERRAL HEALTH SYSTEM PROJECT I. STATE/SECTOR BACKGROUND A. Health Sector in India 1.1 Introduction. Health is a critical investment for improving the level of human resource development and economic growth. While life expectancy at birth in India has increased from about 44 to 60 years during the past thirty years, key health indicators show that the health status of its people is low. Birth and death rates are still high at 29.3 and 9.8 respectively, as is the infant mortality rate of 80 per thousand live births; communicable diseases including tuberculosis (TB), malaria and leprosy continue to be major public health problems; Human Immunodeficiency Virus (HIV) infection is rising; maternal mortality is high; acute respiratory and diarrheal diseases continue to be the major causes of child mortality; and preventable mortality and morbidity, especially among the poor, extract a high toll on the society. Moreover, with the changing age composition of the population towards an increasing fraction of older people, India is moving into an epidemiological transition with the double burden of significant communicable diseases and increasing non-communicable conditions such as cardiovascular diseases, cancer, diabetes and cataract blindness. Thus, improving the health status of its 846 million people (1991 census), and meeting the health needs of a population that is increasing by 17 million annually presents a major challenge for India. 1.2 Health Policy. India's public policy for health has been based on an implicit assumption that primary health care is a basic right to which people should not be denied access due to inability to pay or for other socio-economic reasons. A major thrust of the Government's health policy in the late 1970s and 1980s was the development of publicly financed and managed universal basic health service infrastructure. The Government's long term strategy as enunciated in the National Health Policy (NHP) of 1983 is to give high priority to the control of fertility, infectious diseases of public health importance, and preventable causes of maternal and childhood mortality and morbidity. It includes quantified targets for the 1990s and the year 2000. With the exception of childhood immunization, current achievements already lag behind these targets. The NHP emphasizes the role of the state in providing basic universal health care through the development of publicly run health facilities and draws attention to the strengthening of cooperation between the public and private sectors. The Eighth Plan (1992-1997) has identified health as one of the six priority areas, and public investments in health are therefore critical for human resource development and poverty alleviation in India. 2 1.3 Health Care Delivery in India. In 1991, total health spending in India accounted for about 6 percent of GDP, or about US$13 per capita per year. Of this, government contribution including center, states and municipalities accounts for about 1.3% of Gross Domestic Product (GDP) or about US$2.7 per capita (22 percent of total health spending). Within the government spending category, states spend about 87 percent and the center spends about 10 percent, excluding external assistance; and municipalities and external assistance account for the remaining 3 percent. While India spends about an equal percent of its income on health as other Asian countries at similar levels of per capita income, the percentage of government spending on health is actually lower in India than in those Asian countries. Furthermore, a large component of public spending on health is directed towards tertiary care and medical education, and on public health interventions that are not the highest priority. Therefore, the total amount of resources, both public and private, available for high priority, cost-effective health services, is small. B. The State of Andhra Pradesh 1.4 General Features. AP is situated in South India and extends from the east coast to the Deccan plateau. The state has 23 districts spread across three distinct geographical regions: Coastal Andhra, which is the most developed region in the state, consists of large coastal plains and fertile deltas; Rayalseema, which is the most drought prone; and Telengana in the interior, which is the least developed region in terms of social development. In 1991, AP's population was 66.3 million. It is the fifth most populous state in India. A majority of the state's population live in the rural areas (73 %), while the urban population (27%) resides in 250 urban towns and cities. About 16% of the state's population belong to scheduled castes (SC) and 6.3 % to scheduled tribes (ST); the scheduled tribe population is high in the three districts of Adilabad (17%) and Visakhapatnam and Warangal (14%). According to the 1991 population census, the literacy rate among the population aged seven years and above was about 45 percent (56 percent for males and 34 percent for females). The percentage of population living below the GOI poverty line was estimated to be 38 percent. 1.5 Health Status and Epidemiology. AP is a representative Indian state and is about the national average in terms of health status and epidemiological profile. The birth rate at 28, death rate at 8.7 and the infant mortality rate at 80 per thousand live births, are similar to the national averages. State level hospital data in AP show that about 70% of the causes of death in 1990 were attributable to: disorders in the nervous and circulatory systems (20%), respiratory disorders (16%), maternity and infancy related causes (11%), accidents and injuries (10%), digestive disorders (mainly diarrhea, 7 %) and various types of fevers (6%). A recent analysis of patient registers at primary health centers (PHCs) shows that the common diseases for which treatment was sought by tribal adults were respiratory infections, malaria, alimentary diseases and aches and pains. For tribal children, the common ailments were gastro-enteritis, respiratory infection, malaria, scabies and skin infections. 3 1.6 Organization of the Public Health Care System. The public health system in AP consists of three tiers. At the bottom are primary health care facilities where basic health services are provided, with emphasis on preventive and promotive aspects such as family planning, maternal and child health (MCH), treatment of minor ailments, malarial treatment and spraying, sanitation, and public health education. The management of this level of health care is under the Directorate of Health Services, except for family planning and MCH services which are under the Directorate of Family Welfare. In the middle are the first line referral hospitals or secondary level hospitals, consisting of hospitals of various bed strengths, ranging between 30 and 350 beds, at the community, area and district levels.' These secondary hospitals provide inpatient and outpatient care with diagnostic and treatment facilities not available at the primary level. They are managed by the APVVP which was established through a legislative enactment in 1986 to improve the functioning of secondary level facilities. APVVP's objectives are to provide access to adequate patient care in rural areas, reduce pressures on the overstretched tertiary hospitals and mobilize resources from the market as a supplement to state budgetary allocations to improve, upgrade and maintain secondary level institutions. APVVP is a Government agency reporting to the Government through the Secretary, Department of Health, Medical and Family Welfare. While APVVP functions in effect like a Directorate within the Department of Health, Medical and Family Welfare, the use of a corporate vehicle provides significant potential for improved efficiency in contracting, disbursement and management matters as well as in providing increased non-governmental participation in the health sector. The flexible organizational structure of APVVP has not been adequately utilized in the past. The proposed project would make it possible to fully use the organizational flexibility assigned to APVVP through investments in first referral or secondary hospitals. At the top of the health structure are the tertiary, including teaching hospitals, which are staffed and equipped to provide more specialized treatments and generally having a capacity exceeding 500- 600 beds. They are managed by the Directorate of Medical Education. 1.7 In addition to the three major Directorates mentioned above, five smaller Directorates report to the Department of Health, Medical and Family Welfare. These include those that manage the AIDS program, Preventive Medicine, Employees State Insurance, Indian System of Medicine and Drug Control. These Directorates have smaller budgets, resources and staff compared to the three major Directorates and APVVP. 1.8 Availability of Health Services. In 1994, the AP Government has the following facilities. At the primary level, there are: 10,555 subcenters (SUBCs), 1,306 primary health centers (PHCs), 175 community health centers (CHCs) and 45 mobile units. At the secondary or first referral level, there are 150 community, area and district First referral or secondary hospitals consist of community hospitals that have a bed strength of about 30-50 beds, area hospitals that have about 75-100 beds and district hospitals that have about 250-350 beds. The level of services offered increase from community to area to districts hospitals. The services that will be offered at each level are shown in Annex 7. 4 hospitals and 22 dispensaries. The community hospitals are located in rural and remote areas of the state, the area hospitals in smaller towns, the district hospitals mostly at district headquarters and urban centers and the dispensaries are located in urban areas. At the tertiary level there are 38 tertiary hospitals attached to 9 medical colleges, and 2 super specialized hospitals. In addition, there are in the state 23 district TB centers, 25 TB clinics, and 194 leprosy control units which straddle the primary and secondary levels. The main shortcoming in the provision of services is at the secondary level, which cannot provide the critical support needed at the primary level because of technical and other weaknesses discussed below. The number of beds at secondary hospitals in the public sector is inadequate relative to the size of the state's population. Indian Planning Commission norms based on demographic factors suggest that 70% of all public hospital beds should be at secondary level facilities. Secondary hospitals in AP in fact account for only 32% of the total number of beds at public facilities. In 1994, there are 9,651 beds at secondary hospitals (0.15 beds per 1,000 population) out of a total of 30,624 beds in the public sector (0.46 beds per 1,000 population). If the Indian Planning Commission norms were to be complied with then there would need to be a sizeable increase in bed strength at secondary level facilities, some of this at the cost of beds at tertiary facilities. 1.9 In addition, there has been a significant growth of private sector facilities in recent years. It is estimated that there are over 2,100 private hospitals providing about 42,000 beds (0.63 beds per 1,000 population). There are an estimated 1,100 practitioners of Indian system of medicine providing health care services to about 2-3% of the population. The private sector therefore comprises wide range of health providers, ranging from the household doctors in the villages to the corporate sector in the cities and charitable hospitals and dispensaries. However, many of these providers are unqualified, licensing is weak or non-existent, quality is varied and the services offered do not cover communicable diseases which afflict the poor, and they cost far in excess of those provided by the public sector. 1.10 In terms of the total number of beds that would be required to service the state's population, the Indian Planning Commission's demographic criterion of 0.67 hospital beds per population of 1,000 people in the public sector would suggest that there is a shortage of about 12,000 beds. It is, however, more relevant to use a criteria based on the epidemiological profile or burden of disease in AP in considering the total number of hospital beds required to service the state's population. Project preparation estimated the total number of beds required for AP on the basis of burden of disease and illness episode criteria. The analysis provided evidence that a shift in bed strength towards non- communicable diseases as indicated by recent data on the Survey of Causes of Death was needed. This analysis, using the burden of disease approach, estimated that about 90,000 beds would be required to provide adequate level of clinical services for the population of AP. Given that there are about 42,000 beds at private hospitals and about 30,624 beds at public hospitals in AP, there is still a sizeable deficit of about 17,000 beds overall. The private sector would be able to fill some of the gap, but private facilities are not available everywhere and some of the critical services dealing with communicable 5 diseases which, disproportionately affect the poor, are not provided by private facilities. The increase in bed strength at public facilities under the project will fill some of the gaps left by the non-availability of private services. 1.11 Utilization of Health Services. The national sample survey (NSS) utilization data from the 42nd round show that an overwhelming majority of households utilized the allopathic system of medicine both for hospitalization (98%) as well as for ambulatory care (96%). The preference for allopathic system was universal and not influenced by household characteristics such as income, social class or literacy. With regard to preference for type of hospital, the usage of public health facilities does not appear to be very high despite the presence of a fairly extensive public health infrastructure. This is true both for hospitalization, where public facilities accounted for 37% of utilization in rural and 47% in urban areas as well as for ambulatory care where public facilities accounted for 16% of utilization in rural and 19% in urban areas. The use of private hospitals was more common for hospitalization (55 % for rural and 47 % for urban areas), while the use of private doctors was more common for ambulatory care (47% in rural and 38% in urban areas). Among ST households, utilization of public hospitals were much higher (62%) compared to other groups (55%); however, ST households choose private practitioners much less (36%) compared to other household groups. The relatively low level of utilization of public facilities among the general population is largely because of poor access to public facilities, poor quality of services provided and unavailability of staff, drugs and essential supplies. 1.12 Of the 40% who used government hospitals, about two-thirds belonged to the lower four strata of the decile groups. Government facilities were used mainly for treatment of communicable diseases. About 98% of government services were free (although there were indirect costs to the individual) compared to only 7% of services in the private sector. Of the kinds of ailment treated by the private sector, preliminary analysis suggest that 35% of cases treated were related to childbirth, 30-40% were fevers and injuries and 20-30% were for surgery. 1.13 Public Health Expenditure. The public health care component of the budget in AP at Rs. 5 billion represents about 5.6% of the total state revenue budget and 5.1 % of the total state revenue and capital budget. The share of health in the revenue budget declined from 5.8% to 5.6% between FY92 and FY95. The Government provided the rationale that the relatively low share of public expenditures for the health sector in AP is that, because of historical reasons, a large share of public expenditure has been absorbed by the irrigation and drainage sectors. Although this share has declined in recent years, the power sector now absorbs a large share of current allocations. Annual public health expenditure is only 1.3% of the state's Net Domestic Product, which is about the average for India as a whole (Annex 3). 1.14 In FY92, a large share of public health expenditures in AP was allocated to the provision of primary health care services, the largest component of which included 6 expenditures on Family Welfare (20%) and programs for the prevention and eradication of communicable diseases (17%). Analysis of the composition of public expenditures on health during the last decade highlights the budgetary emphasis on primary health care. The share of primary services steadily increased from 46% in FY81 to a peak of 56% in FY86, after which it declined to about 49% in FY90. 1.15 Hospital services exhibited a consistent and significant reduction in their share of expenditures from about 41 % in FY81 to about 34% in FY90. This analysis of subsectoral allocations highlights some important issues. First, the allocation of expenditures for hospital services is relatively low in AP, compared to other low income countries. Only 4 countries in the 29 countries reviewed by Barnum and Kutzin (1993) spent less than 40% of their health budget on hospital services. Second, allocations to hospital services in AP have been adversely affected even in years when the overall health budget has grown, whereas allocations to primary health care services were vulnerable to reductions only in years when the overall health budget was constrained. Third, resource allocations within the hospital sector are skewed in favor of tertiary level hospitals. During the last decade, the allocation of total public resources for the hospital sector between secondary and tertiary level hospitals has been in the ratio of 51:49 respectively. The norms recommended by the Indian Planning Commission is a ratio of 67:33 in favor of secondary level hospitals. Moreover, the tertiary sector received two- thirds of plan resources allocated to the hospital sector and claimed a greater share of incremental resources. 1.16 The budgetary allocation to APVVP reflects almost all of the government's funding support to secondary hospitals. Currently almost the entire expenditure of APVVP is financed by grants-in-aid provided by the state government. These grants amounted to Rs. 390 million in FY92, Rs. 450 million in FY93 and Rs. 480 million in FY94. The projected grant for FY95 is Rs. 460 million. Of the total non-plan budget for the health sector of Rs 2.6 billion in FY92, APVVP received only 15%; this share fell to 13% in FY94 and to about 12% in the budget estimates of FY95. Plan funds for APVVP have been negligible -- Rs. 9 million in FY92 and Rs. 11 million in FY93 and FY94. However, the non-salary recurrent cost budget has been shrinking and the share of salaries in APVVP has increased from about 67% in FY92 to about 75% in FY95 (Annex 3, Table 5). With a rising share of salaries and total grants remaining constant, the norms for expenditure on drugs, supplies and other consumables have been held constant in nominal terms. Since price inflation for these commodities have been greater than average, real expenditures on critical inputs other than personnel has declined substantially in recent years. During the last two years, even nominal expenditures per bed for drugs and consumables have declined. APVVP management has tried to protect expenditures on essential drugs with the result that expenditures on supplies, diet and maintenance activities have also suffered during this period. 1.17 Hence, the main conclusion is that the low level of funding for secondary hospitals is due to three factors: the small share of health as a percentage of overall 7 public spending; the small share of hospital spending as a percentage of health spending; and a skewed distribution of funds within the hospital sector in favor of the tertiary hospitals (Annex 3). As a result of this weak support to the secondary or first referral level, the secondary system up to the district hospital level has been unable to provide adequate support to the primary health care system. C. Health Sector Issues 1.18 Allocation of Resources. As discussed above, public resources allocated to the health sector are inadequate to meet basic health care needs, and these resources at 1.3 % of state Net Domestic Product are low when compared to several Asian countries with similar levels of per capita income. Moreover, within the health sector, secondary hospitals have been continuously neglected at the expense of tertiary care and underfunding has resulted in shortage of drugs and essential supplies, lack of maintenance of equipment, shortage of doctors and medical personnel. 1.19 Management and Planning. Overall, the health sector in AP suffers from a low level of efficiency and there are few incentives for hospitals to improve their performance. Two important reasons for this are weak management at all levels and lack of an effective planning capacity. Administrative responsibility and financial accountability are artificially separated between the related agencies. For example, while accountability for running the institutions lies with the hospital superintendents, key decisions on manpower development, procurement of drugs and essential supplies, extension of facilities, and mobilization and allocation of resources for maintenance purposes, are made at the different Directorates of the Department of Medical, Health and Family Welfare. Considerable improvements are needed in planning and management aspects with respect to first referral facilities. Moreover, there is a need to develop a strategic planning capacity to analyze the epidemiological profile and the burden of disease, cost-effective means of achieving the best use of limited resources and the medical manpower situation as well as monitor and guide the development of the private health sector. 1.20 Ouality of Services. Secondary hospitals in AP continue to face operational deficiencies and are functioning poorly due to lack of non-salary recurrent funds. Support services and infrastructure at secondary hospitals are inadequate. There are shortages of diagnostic facilities, equipment for performing laboratory procedures, safe blood supply, communications network, transport facilities, trained personnel, and repair and maintenance services for machinery and equipment. In order to provide better quality of services at existing facilities, adequate measures need to be instituted so that operational funds are available at each facility. There is also a critical need to update equipment, establish norms on a range of clinical and support services and provide in-service training in clinical, equipment, and management skills. 8 1.21 The quality of services is also affected because of the absenteeism of doctors and other medical staff in less developed areas of the state. Incentives need to be provided to doctors, nurses and other medical staff for relocating to remote and tribal areas of the state and for encouraging them to stay in their post for the duration of their assignment. These incentives could be in the form of suitable accommodations, preferential admissions for children of doctors resident in tribal areas in government-run residential schools and places for them in schools for scheduled tribes and scheduled castes, transfer to an urban area after 4-5 years of service, regular and paid home leaves, enhanced promotion or training opportunities and training scholarship after a successful tour of duty. The AP Tribal Health Service, created in 1994, already provides for doctors recruited for this service to be formalized into regular service after 4-5 years in tribal areas. 1.22 Referral System. The referral system in AP, as in the rest of India, does not function well. Institutional and technical linkages between different tiers are weak and each tier operates as an independent entity, often providing similar levels of care. As a result resource utilization is poor. It is estimated that a third of all cases which are currently treated at tertiary facilities could be adequately treated, and at lower costs, at the secondary level facilities if those facilities were properly equipped and staffed. Moreover, the lower tier institutions such as PHCs are often underutilized due to lack of support on technical matters, such as treatment and diagnosis strategies, from secondary level institutions because of technical weaknesses at those institutions. Mechanisms for improving the access of remote and disadvantaged groups to secondary and higher levels of health care by making the referral system more timely, effective and client-friendly, need to be formulated; clinical skills in secondary hospitals need to updated and upgraded; technical support for the primary level of care needs to be strengthened; and a quality assurance program in secondary level hospitals need to be provided to monitor and improve quality in technical areas. 1.23 Access. At the referral level, access to health care and service delivery is weak. To comply with the government's norms and all the needs of the people, especially the underserved population, sufficient resources are not available. However, a balanced increase in capacity, bed strength and quality of services at the secondary or first referral level would make a significant impact on the health status of the poorer population and those living in least developed areas of the state. 1.24 Disparities exist between the urban and rural parts of the state with respect to access to health facilities and service quality. The urban based secondary hospitals tend to be overcrowded, especially the outpatient facilities, and operate at near full capacity, whereas some of the remote rural facilities remain underutilized because they are unable to provide even basic services. The low demand for health care services at remote rural facilities is due to the poor quality of services. Difficulties of posting doctors, nurses and other medical professional in remote areas, unavailability of drugs and shortage of supply and difficult upkeep of medical equipment add to the problem. As a result, access is 9 unavailable to a large number of the poor who have limited means of obtaining critical health care services in city hospitals and private nursing homes. Such services, which are not provided at primary health care facilities, but should be at secondary level facilities include dental, ophthalmic, orthopedic, pediatric and surgical services. 1.25 Role of the Private Sector. The role of the private sector in delivering quality health care continues to be underdeveloped despite substantial private investment. Recent sector work shows that private sector services are of very varied quality and are provided by a wide range of qualified, less-than-qualified and unqualified practitioners (para 1.9). Many are unregistered, unlicensed and unregulated. Lack of regulations and effective legal remedies contributes to inappropriate practices. AP government's ability to monitor, regulate, register and certify private care providers is weak and needs to be strengthened. The Government should be able to assess the quality of services provided by private care practitioners and evaluate regulations relating to such improvements in service quality. Moreover, private primary care providers could be better utilized to treat many diseases that are of high priority such as TB, malaria, STDs, diarrheas, respiratory infections and high risk births. The state government could provide incentives and schemes to finance, train and integrate private providers in case-finding, referral treatment and monitoring for these priority problems. More contracting out of services to the private sector where possible, especially support services, could be done to cut costs and increase efficiency. Private voluntary organizations could also be encouraged by the government to participate in behavior changing education activities, particularly in tribal areas. D. Lessons From Experience. 1.26 This is the first project in India that involves the health system at the state level. It is more broadly based than the on-going or completed population, health and nutrition (PHN) projects in India. Even so, the experience of social sector projects in India is varied and extensive enough to provide some important lessons for the preparation and implementation of this project. 1.27 There are four completed PHN projects in India for which Project Completion Reports (PCRs) or Performance Audit Reports (PARs) are available2. These are the First, Second and Third Population projects and the First Tamil Nadu Integrated Nutrition project. In addition, the Fourth Population project has also recently been completed and a draft PCR is available. OED has also recently completed an Impact 2 India: PCR - First Population Project (Cr. 312-IN), May 19, 1981; PPAR No. 3748, December 31, 1981. India: PCR - Second Population Project (Cr. 981-IN), June 20, 1989; PPAR No. 8896, June 29, 1990. India: PCR - Tamil Nadu Integrated Nutrition Project (Cr. 1003-IN), November 26, 1989. India: PCR - Third Population Project (Cr. 1426-IN), August 25, 1993. 10 Evaluation Report of the Tamil Nadu Integrated Nutrition project which is available in draft. Overall, the projects have met an important part of their development objectives. Population I and II met most of their aims, but did not have any systemic impact on the Family Welfare program. Population III had significant outcomes in Kerala but not in Karnataka. Population IV appears to have contributed to very significant improvements in contraceptive prevalence and reduction in infant mortality. The Tamil Nadu Nutrition project has been well documented as having a major impact on improving the nutritional status of young children. 1.28 There are currently thirteen on-going PHN projects in India, and the list below shows the seven that are now on-going in AP: * Health sector: National AIDS Control, National Leprosy Elimination and the Cataract Blindness Projects; * Family Welfare (FW) sector: Population VI, Population VIII and Child Survival and the Safe Motherhood (CSSM) Projects; and * Nutrition sector: First Integrated Child Development Scheme (ICDS I) Project. 1.29 Despite many positive outcomes, the completed and ongoing projects have suffered consistently from a variety of implementation problems. These have included: late start-up, poor procurement, slow disbursement, frequent management turnover, untimely and inadequate flow of funds, poor maintenance of buildings and equipment, and inadequate attention to software and qualitative aspects. 1.30 The design of the proposed project would take account of the concerns and problem areas identified above as shown in Table 1. 1. Table 1.1: Lessons Applied From IDA Experience in PHN Lending to the Proposed Project Lessons Corresponding Action to be Taken Reference 1. Inadequate Anention to At the early state of implementation the following Para 2.11, 2.14 Management Aspects actions would be taken: adequate staffing of key Annexes 5, 6 project management personnel at APVVP; enhancement of implementation capacity at APHMHIDC; adequate staffing arrangements at district, area and community hospitals; strengthening of management procedures. In addition, a mid-term review of the management systems would be undertaken. 11 Lessons Corresponding Action to be Taken Reference 2. Slowness in Implementation Strengthen implementation capacity; detailed Para 2.10, 3.25, 3.26 and Weak Supervision implementation plan in place; regular field supervision Annexes 17, 19 by local consultants included in Supervision Plan. 3. Poor Maintenance of Building GOAP will provide adequate resources during project Policy letter, and Equipment period for operations and maintenance services; Para 2.8(c), 2.11, 3.29 capacity of Equipment Maintenance and Training Center (EMTC) to be enhanced. 4. Untimely and Inadequate Flow Assurance provided by GOAP that annual review of Para 3.8, 3.26 of Funds to Project project expenditures and resource requirements will be carried out with IDA in order to ensure timely flow of funds; assurance provided by GOI that it would release about three months of project expenditure in advance to GOAP. 5. Poor Procurement Procurement arrangements for works and services in Para 3.9, 3.22 advanced state of preparation; lists of hospitals Arnex 16, 17 prepared, use of standard bidding documents; first phase of construction plan completed; equipment lists prepared and specification lists discussed with IDA. 6. Inadequate Attention to Staffing and technical norms at district, area and Para 2.16, 2.17, 2.18, 3.23, Qualitative Aspects community hospitals agreed upon; referral system and 3.24 linkages with primary care services to be established Annexes 7, 8, 11, 12 according to agreed norms; Clinical training needs developed; management training needs developed; quality assurance program developed collaboratively with clinicians and practitioners from around the state; benchmarks and monitoring methodology developed and agreed with borrower. E. Linkages With Other PHN Projects in AP 1.31 The proposed project would complement and consolidate investments made by on-going PHN projects in AP by providing policy and implementation coordination with other health and FW projects. For example, the strengthening of the first level referral for obstetrics and child care in this project through the provision of essential clinical and diagnostic services would complement the primary level of services being provided under Population VI, Population VIII and CSSM projects. The complementary curative actions that will be strengthened under this project, which are somewhat higher level interventions than primary care services provided by the on-going projects, will also improve the health status of women and children. Table 1.2 below shows the linkages of this project with other PHN projects in AP. 12 Table 1.2: Linkages with Other PHN Proiects in AP Name of Project Primary Health Care Linkages with AP District Health Systems Project Objectives Population VI, VIII Enhance service Child Health: children identified by primary care services as and CSSM delivery for FW, and suffering from severe stages of diarrheal disease, acute respiratory s t r e n g t h e n infection and nutritional disorders will be referred to APVVP management at the hospitals for appropriate treatment. district and block Maternal Health: The CSSM program has identified by name the level, and slum areas First Referral Units (FRUs) for the state, most of which are under o f H y d e r a b a d; APVVP management. Mothers identified as having life threatening s u p p o r t C h i I d complications of pregnancy and child birth will be referred to these Survival program; FRUs for appropriate treatment. e n h a n c e S a f e Technical supervision and training: APVVP will improve the quality M o t h e r h o o d of care at the primary level through: (a) visits to PHCs by Specialists Program. from the hospitals to conduct clinics for patients who need more skilled care; and (b) training at APVVP hospitals for upgrading clinical and technical skills for PHC and SUBC staff; provide on- going training for medical and paramedical staff from PHCs and SUBCs. N a t i o n a I A I D S Involve states in AIDS Cell and Empowered Committee promote coordination between Control p r o g r a m AIDS Program and APVVP. The MIS capability and patient statistics development. gathered by APVVP are of vital use to the AIDS project. Monitor epidemic; Surveillance sites or HIV testing facilities located in APVVP Sc r e e n b I o o d; hospitals to facilitate monitoring of the AIDS epidemic. HIV logistical support. screening to be done within blood banks of APVVP hospitals: the AIDS project provides the kits, training and procedure; APVVP hospitals provide infrastructure, staffing and support services. APVVP facilities provide essential logistical support for storage of equipment, medicines, medical supplies and waste management. R a i s e p u b I i c The [EC component of the AIDS project targets staff of APVVP awareness; develop hospitals for disseminating information. Selected staff of APVVP to clinical management be trained by the AIDS project to provide counselling and medical skills in AIDS and needs of AIDS patients. STD control. National Leprosy Multidrug therapy; The health infrastructure of APVVP is a channel of treatment and Eradication disability care and drug delivery. The staff and hardware provided by the Leprosy prevention. project will function within APVVP infrastructure, providing physiotherapy facilities, operation theaters (OT) and lab facilities. Logistics and MIS. APVVP facilities provide storage and support services for the Leprosy project. MIS and statistical support are also provided. Cataract Blindness Expand service The Cataract Blindness Control Project is financing dedicated Ots and Control d e I i v e r y a n d Blindness wards in district hospitals. APVVP will provide: support i n s t i t u t i o n a I staff who will receive specialized training under the Blindness development. project; logistical support and storage facilities. The referral system in APVVP will complement and facilitate the referral of blind patients to district hospitals for specialist care. ICDS I Strengthen nutrition- The linkages between ICDS I and the AP Health project are mainly related service through their common link with the CSSM project, including delivery. registration of pregnant mothers; vaccination of children; and joint training of field workers. 13 1.32 In addition, international experience has also been considered in the design and scope of the project. The World Development Report (1993) on Investing in Health suggested that a broad sectoral approach within a supporting policy environment produces significant positive results and benefits. It also suggested that a limited package of public health measures and essential clinical interventions is a top priority for government finance. On the components of the public health package the list includes: (i) the expanded program on immunization, including micronutrient supplementation; (ii) school health programs to treat worm infection and micronutrient deficiencies and to provide health education; (iii) programs to increase public knowledge about family planning, health and nutrition; (iv) programs to reduce consumption of tobacco, alcohol and other drugs; and (v) AIDS prevention program with a strong STD component. On the components of the essential clinical services the list includes: (i) prenatal and delivery care; (ii) family planning services (these two components together constitute a Safe Motherhood Program); (iii) management of the sick child; (iv) treatment of TB; (v) case management of STDs; and (vi) treatment of minor infection and trauma otherwise known as limited care. This project, in recognizing the specific administrative, burden of disease and socio-technical issues in India, will provide a number of the services listed above that have so far not been provided in other IDA financed projects in the PHN sector. It will also set the institutional structure that can lead to the provision of some of the other services in the future. F. Country Assistance Strategy and Rationale for IDA Involvement 1.33 IDA Strategy. The Bank Group's Country Strategy for India (April 21, 1994; Report No. P-6141-IN) is to support GOI's efforts to provide an enabling environment for broad-based, efficient private sector-led growth while accelerating the development of human resources. A major aim of the strategy is to enhance access to quality of basic social services for the poor and to support well-targeted safety net programs that protect the most vulnerable groups in Indian society. IDA assistance will focus on raising nutritional levels, reducing fertility, reducing morbidity and mortality from key endemic diseases; and raising educational attainments; and special emphasis will be put upon improving access and efficiency and improving outcomes, as well as strengthening of links between the public and the private and Non-Governmental Organization (NGO) sectors. The focus will be almost exclusively on the poor, with special attention to women, Sts and Scs. 1.34 Sectoral Strategy. In the health sector, IDA's strategy is to assist India in reducing the level of morbidity and mortality through a two-pronged approach. The first is to reduce the burden of the most significant endemic diseases through national programs such as the AIDS Control, Leprosy Elimination and the Cataract Blindness projects and the proposed TB and Malaria projects. The second approach is to strengthen the performance of the health system of the states by providing more efficient and effective health care which will mostly benefit the poor segments of society who use it the most. IDA's strategy in the FW sector is complementary to this approach in that the FW projects are strengthening primary level services through program support of family planning and MCH services across India by investing in infrastructure and support services as well as by deepening support for policy change and program adjustment. The approach to strengthen the performance of the health system will become increasingly important in the coming years as the epidemiological profile evolves and the need for a dynamic health care system increases. Strengthening the health system as such will prepare the sector to deal with the evolving long term burden of disease. The two-pronged strategy thus has the 14 advantage of directly addressing the most significant endemic diseases, and at the same time strengthening and developing a comprehensive health care system. The basis of this strategy for the health sector in India is rooted in our dialogue with India, and in our sector work as reflected in three recent documents: (i) India: Health Sector Financing: Coping with Adjustment, Opportunities for Reform, (1992); (ii) India: Public Expenditure Review: Health Sector Report (1993); and (iii) India: Policy and Finance Strategies for Strengthening Primary Health Care Services (1994). 1.35 IDA investment in the project is justified for the following reasons. First, the project would strengthen and upgrade secondary health care facilities without which the primary health care system cannot implement the various national health programs and provide basic health care in rural areas. An effective secondary level of care that provides essential clinical services not provided at the primary level, is critical for providing credibility to the district based health care system as well as for providing technical support to the entire network of primary health centers. Second, IDA support is warranted because this project will consolidate the investments made by a number of other projects, such as the Child Survival and Safe Motherhood (CSSM), Population VI, Population VIII, AIDS Control and Leprosy Elimination projects and add incremental value to the overall health care system in AP. For example, the strengthening of the first level referral for obstetrics and child care in this project through the provision of essential clinical and diagnostic services would complement the primary level of care actions initiated in Population VI, Population VIII and CSSM projects. In addition, the actions of the on-going projects with regard to initiating a referral system from the community to the community hospital level, providing equipment at the first level referral for obstetrics units and defining the facilities needed for emergency obstetrics care will be further strengthened under this project. The complementary actions that will be undertaken by this project, which are somewhat higher level interventions than those provided at the primary level, will also improve the health status of women and children. Third, the project is consistent with IDA's strategy of strengthening state health systems, since it would help the state to: (i) optimize resource use, especially resources such as medical manpower and diagnostic equipment; (ii) avoid duplication and wastage; and (iii) reduce overcrowding at tertiary health care institutions. Fourth, the project is in line with the overall IDA strategy of poverty alleviation in India. The economic rationale is that since the poor cannot always afford health care that improves their productivity and well-being, public investment in the health of the poor, such as essential clinical services that will be provided by the project, can reduce poverty by increasing the earning potential of the poor. 1.36 The reason for selecting AP as the first state to develop a health systems project is its fairly representative characteristics in terms of income level, poverty, demographic indicators and epidemiological profile. It is, however, a fairly advanced state by Indian standards in terms of administrative capabilities. The commitment AP has shown in the preparation of this project and in introducing systemic strengthening of the health sector makes it likely that the project will be implemented successfully. 15 II. THE PROJECT A. Project Objectives 2.1 The objectives of the project would be to assist the Government of AP to: (i) improve efficiency in the allocation and use of health resources through policy and institutional development; and (ii) improve systems performance of health care through improvements in the quality, effectiveness and coverage of health services at the secondary level to better serve the neediest sections of society. The ultimate goal of the project would be to improve the health status of the people of AP, especially the poor and the underserved, by reducing mortality, morbidity and disability. The project would provide a first step towards the creation of a replicative state model that would subsequently be used to reorient the health systems in other states in India. 2.2 The achievement of the first objective will be evaluated on the basis of timely implementation of the policy reforms spelt out in a Health Sector Development Policy Statement of the Government in Annex 2. These include proposals for enhancing the overall size of the health budget, redressing the imbalance in public spending between secondary and tertiary levels of health care, safeguarding the operations and maintenance component of Non-Plan budget allocations for the secondary level of health care, charging of user fees for hospital services at the secondary level, contracting out of selected services, enhancing strategic planning capacity and addressing work force issues. 2.3 The achievement of the second objective will be evaluated on the basis of hospital activity and efficiency indicators as well as quality, access and effectiveness indicators as shown in Annex 18 on Performance Indicators and summarized below. 2.4 Hospital activity indicators including turnover rate, bed occupancy and average length of stay, which are derived from bed occupancy, cumulative inpatient days and admissions during a given period of time, will be measured against the baseline. Also measured will be outpatient consultations and outpatients per bed day. Hospital efficiency indicators including the following will be measured against a baseline: clinical services, such as number of major surgeries and deliveries and their percentages to admissions during a given time period; diagnostic services, such as number of imaging and electro-medical tests and their percentages to admissions during a given time period; non-clinical services such as post-mortems, percentage of post-operative case fatalities and percentage of infection acquired at the hospital; and emergency service index measures such as emergency outpatient and entry ratios. These efficiency measures will be evaluated against the baseline, and compared with the best performing facilities and against comparable international standards. 2.5 Quality, access and effectiveness indicators including the following will be measured: staffing, equipment and drug norms met at each facility; inpatient and outpatient waiting time; patient satisfaction; upgradation of clinical, management and equipment maintenance skills; awareness among target group of services offered; awareness among doctors of how the referral system is expected to function; and funds recovered from user charges. Some of these will be measured against the baseline while others will be measured against the norms that have been developed in a participatory manner and agreed upon at appraisal. 16 B. Approach 2.6 Taking into account the lessons learnt from past Bank projects in the state, the project is designed to contribute to the objectives stated in para 2.1 by helping GOAP put in place a sustainable first referral health system that will provide vital support and credibility to primary health care services and the rest of the health sector in AP. The state's capacity to implement such a program would be based on two closely related elements. First, an organizational structure of preventive and curative aspects of health care at the district level to integrate primary health care services and first referral facilities. Second, a program of health sector policy reform to provide the general framework for health sector development. Accordingly, the project would selectively implement some key sectoral policy reforms (discussed below) that are essential to developing an efficient and effective health system and direct physical investments to first referral or secondary health care facilities which are the weakest link in the system. C. The Reform Program 2.7 Reform of Institutional Structure. The Government of AP has shown considerable commitment to improving its health system by establishing a necessary framework to achieve project objectives. It is ahead of other states in terms of setting up an institutional arrangement to facilitate greater emphasis for the intensive integrated development of both curative and preventive aspects of health care, especially to rectify the institutional weaknesses at the secondary level. As mentioned in para 1.6, this has been done by establishing the APVVP though a legislative enactment to improve the functioning of the health care facilities at the first referral level. APVVP's objectives are to provide access to adequate patient care in rural areas, reduce pressures on the overstretched tertiary hospitals in the cities and mobilize resources from the market as a supplement to the state budget to improve, upgrade and maintain health care institutions. This type of an organization, which provides significant potential for improved efficiency in contracting, disbursement and management matters, is innovative in the health sector in India. In addition, the Government of AP is taking steps to strengthen the linkages at appropriate levels of the health system, through public investment and support of private initiative, to ensure that the objectives of comprehensive medical and health care can be achieved. 2.8 Policy Framework. In addition to the institutional changes mentioned above, GOAP will undertake selective health policy reforms that will address key health sector issues (outlined in paras 1.18-1.25), including resource enhancement and improvements in allocation within the health sector, improvements in management and planning capacity, enhancement of quality of services offered at the first referral level, better linkages with primary health care services, greater access to health care delivery and review of private sector role and quality improvement. These policy actions are critical to meeting the project's objectives since they will ensure the safeguard of the institutional basis and service delivery package that are at the core of efficient and effective performance of the first referral health system. Accordingly, the Government of AP has furnished a Health Sector Policy Reform matrix (Annex 2). Availability of IDA assistance for the project would be subject to implementation of actions set out in the Reform Program. Specifically, these reforms would address: 17 (a) Proposal for enhancing the overall size of the health budget. The Government of AP spends only about 1.3% of its Net Domestic Product on health care or about US$2-3 in per capita terms (para 1.13). This contribution is low when compared to several Asian countries with similar or even higher levels of income an is inadequate to meet the basic health care service needs of AP population. The World Development Report (WDR) 1993, recommends that about US$12 per capita are required in low-income developing countries to meet requirements of preventive and promotive services including a minimum package of essential public health and clinical services. The WDR's recommendation when applied to AP implies that the Government would need to increase its contribution several times to provide for an essential package of public health and clinical services. This would be very difficult under the present stringent budgetary scenario. The Government of AP would need to at least maintain the share of health sector allocation to the overall budget, which is currently at 5.6% of the state's revenue budget. Under the Reform Program, GOAP is committed to maintaining the share of health sector allocations within the overall budget at least at the FY94-95 level. (b) Redressing the imbalance in public expenditures between the secondary and tertiary health care levels. Within the health sector resource allocation is skewed in favor of tertiary care services, compared to secondary care services. Allocations of public resources between the secondary and tertiary sectors has been in the ratio of 51:49 respectively while norms recommended by the Indian Planning Commission suggest a ratio of 67:33 respectively (para 1.15). Moreover, tertiary hospitals have received about two-thirds of total Plan resources allocated for the hospital sector and claimed a greater share of incremental resources. Secondary level care has, therefore, traditionally suffered from low level of public funds. Investments at the secondary level will redress some of this imbalance during the implementation years. Under the Reform Program, and reaffirmed at negotiations, GOAP provided assurances that the share of the primary and secondary levels in the total resources (plan and non-plan) allocated for the health sector would be increased each year until the year 2000. (c) Safeguarding the operations and maintenance component of the Non-Plan allocations for the secondary health sector. The non-salary recurrent cost budget of the health sector overall has been shrinking. For example, the share of salaries in APVVP has increased from about 67% in FY92 to about 75 % in FY95 (Annex 3, Table 5). With total grants remaining more or less constant, a rising share of salaries has meant that expenditures on critical inputs other than personnel, such as drugs and essential supplies have declined in recent years. Since price inflation for these commodities have been greater than average, there has in fact been a decline in real expenditures on non-salary recurrent costs. Moreover, during the last two years, even nominal expenditures per bed for drugs and consumables have declined. At negotiations, GOAP provided assurances that it would allocate resources in accordance with agreed norms so as to ensure that adequate supplies of drugs, essential supplies and maintenance of equipment and buildings at secondary hospitals will be provided in accordance with norms set out in Annexes 7, 9 and 10. (d) (i) Charging of user fees for hospital services while protecting the poorest segments of society. Inadequate charging of user fees has not helped to redress the low level of funds for supplies, operations and maintenance at secondary facilities. The APVVP Act of 1986 created a provision for charging user fees so that hospitals are able to generate some additional revenues to top up government contributions. The government has confirmed that APVVP has 18 the legal authority to institute user charges and that no legal restrictions against APVVP exist that prevent it from charging user fees. APVVP's Governing Council's is responsible for taking decisions to introduce specific user charges. However, it needs Government regulation to facilitate implementation. Understanding was reached with the Government of AP and APVVP that they would ensure that while protecting the poorest segments of society, charging of user fees at secondary hospitals would be based on the principles that such charges would be to: (i) target the receipts particularly on non-salary recurrent costs of APVVP hospitals; and (ii) charge for private beds and amenities and procedures that are low in cost-effectiveness in order to pay for those interventions that are high in cost-effectiveness. Cost-effectiveness will be determined from time to time in accordance with a mechanism that is being developed through the Burden of Disease and Cost-Effectiveness study currently being undertaken by the Administrative Staff College of India. (d)(ii) In order to generate revenue and provide services for those willing to pay, district and area hospitals will provide private paying bed facilities and begin to charge for services in a phased manner after improvements in the quality of basic services and infrastructure development have been completed. GOAP's Reform Program includes a time schedule for the implementation of service improvements and subsequent introduction of user charges. At negotiations, GOAP and APVVP provided assurances that at least 20% of all beds at district and area hospitals would be dedicated as paying beds in accordance with this time schedule. Community hospitals are not being slated to introduce paying beds since such opportunities are minimal at community hospitals as they almost exclusively serve the poorest segments of the population. Other charges such as fees for diagnostic procedures and drugs would be phased in as improvements in basic services are provided also in accordance with a time schedule to be agreed. APVVP is also considering enhancing the collection of revenue through the increased sale of APVVP seals at the time of out-patient registration. In addition, APVVP would institute adequate administrative mechanisms for collecting user fees and enhance APVVP's resource generation capacity through the appointment of key staff in its Finance and Audit unit. (d)(iii) Moreover, because of the lack of appropriate management arrangements and authority to act there are few incentives for hospitals and their staff to improve hospital operation and quality of services. In order to provide incentives to hospital staff and management so that the money collected through user charges at the hospital level would be used to improve operations and maintenance at those facilities, APVVP would allow hospitals to retain a portion of fees. At negotiations, GOAP and APVVP provided assurances that a third or more of income generated at individual hospitals through user charges (e.g. paying beds) would be allowed to be retained at the point of collection, with the concerned hospital being allowed to decide in the utilization of such funds subject to the requirement that they not be applied to salaries. Understanding was reached during negotiations that APVVP would endeavor to raise the amount retained at individual facilities to about 40% of income generated from user charges. (e) Contracting-out selected services. Private contractual services are often more efficient and effective than direct labor. In view of the difficulties of employing government staff, such as slow recruitment and poor attendance, contracting-out certain services, especially support services, becomes even more attractive. However, using private contractual services is a politically sensitive issue and there is some concern regarding quality. In the past, the state 19 employed private doctors as part-time consultants, but this was stopped on the basis that it favored the doctor's reputation more than it improved the government sector's clinical services. It has been confirmed that there are no legal barriers inhibiting the use of contractual services for support functions and that the Contract Labor Regulation and Abolition Act (1970), which prohibits certain institutions from contracting-out perennial services, exempt hospitals and health care facilities. In order to cut costs and increase efficiency, the Governing Council of APVVP would therefore review and propose implementation of private contractual services, especially supporting services, in accordance with an agreed plan. (f) Enhancing capacity for strategic planning. A strategic planning cell would be set up in the Department of Health, Medical and Family Welfare to address strategic planning issues in the health sector and provide management with policy options. It would undertake operational and policy related research projects, either independently or through local consultants, and it would organize workshops and seminars. It would monitor and review the Burden of Disease and Cost-Effectiveness study initiated during preparation jointly by the Administrative Staff College of India (ASCI) and the Harvard Center for Population and Development Studies. The study is estimating Disability Adjusted Life Years (DALY) gained in AP as an extension of the analysis of the Global Burden of Disease study undertaken in the WDR (1993). An important finding of this study will be that it will provide an estimate of cost- effectiveness of 30-50 most important health interventions, which would provide important policy options for health sector planning in AP. The study would also provide a strong empirical basis to review identification of low cost-effective mechanisms for which user charges would be appropriate, on the basis of which the AP Government could determine the level and extent of user charges. In addition, the strategic planning cell would undertake analyses of a number of other equally important health issues including: monitoring the role of the private sector and reviewing the suitability of present regulations relating to the quality of private care provision; analyzing the evolving epidemiological profile in AP; and undertaking of periodic review of the health manpower supply situation and training needs in AP. At negotiations, the Government of AP and APVVP provided assurances that the Government of AP would ensure that a strategic planning cell would be set up by June 30, 1995 within the Department of Health, Medical and Family Welfare that would report directly to the Secretary of the Department. (g) Addressing workforce issues. There is currently no acute shortage of professional staff overall, but there is a shortage of some medical specialties and nurses. The first step would be to improve recruitment and prompt filling of job vacancies by improving the main procedures. Although APVVP has the legal authority to recruit staff directly, implementation of this authority has not followed because of Government's overall staffing concern. APVVP would be allowed greater flexibility for recruiting staff. Staff could be recruited either independently by APVVP as specified by the 1986 APVVP Act or by the Government through the Department of Medical, Health and Family Welfare with APVVP acting as the nodal agency for recruitment. At negotiations, GOAP provided assurances that it would implement a program acceptable to IDA for strengthening the management effectiveness of APVVP, including providing APVVP adequate authority to select, employ and transfer APVVP staff. 20 D. Project Description 2.9 In conjunction with the Program for Health Sector Development, the Government would make some specific investments that are consistent with the objectives of the project as stated in paragraph 2.1. These investments would strengthen the organizational structure of health care at the district level by linking preventive and curative health care services and establishing a policy framework for the development of a health sector program in AP. In support of this approach, the project would finance the following investments: (i) strengthening institutions for policy development and implementation capacity; (ii) improving quality, access and effectiveness of health services at district hospitals; (iii) and improving quality, access and effectiveness of health services at area and community hospitals, including referral mechanisms that will strengthen linkages with primary health services. The total number of beds at district, area and community hospitals would increase from the existing number of 9,651 beds to 14,000 beds at project completion, increasing the bed capacity at the secondary level by 45%. The corresponding increase at the district hospital level would be from 4,600 beds to 5,600 beds, an increase of about 22%; while the increase at the area and community hospitals would be from 5,051 beds to 8,400 beds, an increase of about 66%. Institutional Strengthening (US$4. 1 million. 3 % of base costs). 2.10 Improvin2 the Institutional Framework for Policy Development. Sectoral capacity for development of policy would be strengthened through the creation of a planning cell headed by a Joint Secretary who would report directly to the Secretary of Health, Medical and Family Welfare, Government of AP. The planning cell would monitor the critical issues in the health sector in AP by commissioning studies, workshops and seminars and by directly hiring consultants to facilitate these activities. As mentioned earlier, some of the issues would include monitoring the development of the private health sector and reviewing the suitability of present regulations relating to the quality of private care provision, analyzing the evolving epidemiological profile in AP, and evaluating the burden of disease and cost-effectiveness of public health interventions and reviewing medical manpower. In addition, it would review implementation of cost recovery mechanisms and sectoral resource allocation patterns. At negotiations, the Government of AP and APVVP provided assurances that GOAP would carry out by December 31, 1995, a review of the policy framework for private provision of health services in AP and thereafter discuss with the Association recommendations arising from such review. Under this sub-component the project would finance studies, workshops, local consultants, computers, operational expenses and salaries of incremental staff on a decreasing basis. 2.11 Strengthening Institutions and their Implementation Capacity. Four key areas that would be addressed include strengthening structures, systems and procedures; culture of service delivery; resources; and training. At APVVP level, the focus would be on improving management effectiveness, and at community, area and district hospitals emphasis would be on strengthening service delivery management. APVVP will be able to better manage its resources, deliver clinical services effectively, and its hospitals will be able to play a role within the district health systems by taking the following actions. These are: provide greater freedom of action for APVVP with regard to recruitment of staff and raising revenue; establish clarity of goals, objectives and procedures; improve supervision; create opportunities for contracting out services, 21 especially support services; improve medical record-keeping and management information systems; provide management training; and improve capacity for equipment management, especially state-wide maintenance services by enhancing the capacity of the equipment maintenance and training center (EMTC) and establishing 3 zonal workshops. The implementation capacity of AP Health and Medical Housing Infrastructure Development Corporation (APHMHIDC) would also be strengthened to deal with the increased supervision of civil works under the project through appointment of 2 full time architects and procurement of additional vehicles and computers. In addition, monitoring and evaluation capacity would be strengthened including improvement of the hospital management information system. At negotiations, the Government of AP provided assurances that APVVP would engage key additional headquarters personnel and APHMHIDC would engage key additional personnel to be recruited under the project by June 30, 1995. Under this sub-component the project would finance local training, MIS/IEC materials, computers, vehicles, studies, workshops, operational expenses and salaries of incremental staff on a decreasing basis. 2.12 A key component of the project is strengthening the management capacity of APVVP to adequately address its increased responsibilities. The first aspect of strengthening APVVP's management is consolidating the existing institutional and management structure, and evaluating the arrangements from time to time to see whether the management system is producing the best results. APVVP is currently managed by its Governing Council consisting of 5 members of the medical profession and Legislative Assembly nominated by the Government of AP, and 5 ex-officio members that include the Secretaries of Health and Finance Departments, Commissioner Institutional Finance, Vice Chancellor of the University of Health Sciences and the Director of Health. The Governing Council has powers to make regulations, borrow money and to levy fees for services as well as the management of the Commissionerate. The Government has powers to issue directions to the Commissionerate in matters of inspection and control, to make rules and undertake audit of APVVP's accounts. The Commissioner, who is the Chairman of the Governing Council and is the Chief Executive, is appointed by the Government from among the members of the medical profession who have administrative experience. The AP law that established APVVP provides for Government of AP combining operator and regulator functions for secondary hospitals, i.e., the key government officials entrusted with supervisory authority are also members of the Governing Council. As those officials customarily do not participate, but send Departmental representatives, in meetings of the Governing Council, they are however able to adequately regulate the Governing Council and management of APVVP. APVVP is a legal devise to improve disbursements and contracting and increase participation of non-governmental organization, but is administered by GOAP along the same lines as a Government Department. It is therefore subject to audit and supervisory arrangements applicable to government agencies. At negotiations, the Government of AP provided assurances that not later than July 1, 1997, GOAP would carry out, jointly with GOI and IDA, a detailed mid-term review of project progress including a management review of APVVP and thereafter implement its recommendations. 2.13 APVVP's organizational structure and the existing and proposed additional staff are shown in the chart in Annex 5. The second aspect of strengthening management will be achieved by the increased management training for professional cadres and on-going in-service training for clinical and technical cadres. This will facilitate the implementation of the quality improvement strategy of the project, through which new responsibilities are being allocated, and 22 it is hoped that decision making will be decentralized down to the appropriate management level. The third aspect will consist of enhancing staff strength at the Head Office to undertake increased responsibilities and perform some new functions. Headquarters staff will be increased by adding 37 posts plus 3 additional posts will be created at the equipment storage facility at King Koti hospital in Hyderabad. This will provide the required staffing to meet the increased workload and reorient the structure of APVVP to meet its new challenges. Specific areas targeted for strengthening include the training and referral unit (6), the finance and audit unit (16), the Office of the Joint Commissioner, General (12) and the Office of the Joint Commissioner, Service Delivery (3). These changes are in line with the increased responsibilities assigned to APVVP through this project. 2.14 The management information system (MIS) and the health management information system will be strengthened (HMIS). These will facilitate systems improvement, wider access and improved data collection and utilization for planning and policy making, problem solving and monitoring. In AP, at the hospital level, both information collection and management are fairly rudimentary. The project will: (i) enhance and extend the computerized system through the provision of hardware and software, and consultancy support; (ii) establish trained and equipped information cells at HQ and district levels; (iii) train all management staff in appropriate record keeping; and (iv) introduce a completely revised medical record system for Ips and diagnostic services. Improving Service Ouality. Access and Effectiveness at District Hospitals (US$55.1 million. 40% of base costs). 2.15 Renovate/extend 21 District Hospitals. Seventeen existing district hospitals would be renovated and extended, and four others which are currently area hospitals would be upgraded into district hospitals. The four area hospitals that would be upgraded into district hospitals would be in those districts that have district hospitals combined with teaching facilities, and which are not under the jurisdiction of APVVP. Under the project, there would therefore be 21 district hospitals under APVVP. There are 4,600 existing beds at district hospitals under APVVP. The clinical effectiveness and quality of services for the existing beds would be improved as described below. In addition, 1,000 new beds providing improved services would be added at the district hospitals. The total number of beds at district hospitals would total 5,600 at project completion. A limited number of staff quarters would also be built in areas where housing is a problem for staff. Under this sub-component the project would finance civil works, professional services and building maintenance. 2.16 Upgrade Clinical Effectiveness and Ouality of Services at District Hospitals. At the 21 district hospitals, updated norms and standards for clinical and support services would be applied, staffing norms conforming to the services that will be provided at each type of facilities would be adopted, a system for monitoring improvements in the quality of clinical care would be established through the adoption of a quality assurance program and the capacity of support services would be expanded. Staff skills in clinical and technical areas would be enhanced through the provision of training to improve the quality and range of services. At negotiations, the Government of AP provided assurances that APVVP would adopt within six months after upgradation of each facility, staffing and technical norms at its district hospitals as agreed at negotiations to ensure the quality of services. Under this sub-component the project would 23 finance medical and other equipment, medical laboratory and other supplies, medicines, minor civil works, professional services, vehicles, furniture, local consultants, local training, workshops, fellowships, equipment and building maintenance, operational expenses and salaries of additional staff on a decreasing basis. Improving Ouality. Access and Effectiveness at Area and Community Hospitals (US$78.0 million, 57% of base costs). 2.17 Renovate/extend 49 Area and 80 Community Hospitals. All the 49 area hospitals and 80 community hospitals would undergo renovation and extension. There are 5,051 existing beds at these area and community hospitals under APVVP. The clinical effectiveness and quality of services for the existing beds would be improved as described below. In addition, 3,349 new beds providing improved services would be added at area and community hospitals. The total number of beds at area and community beds would total 8,300 at project completion. Staff quarters would be built at a large number of these facilities, especially in the more remote and tribal areas where accommodation for staff is poor. Improved services would be provided at six community hospitals and three area hospitals located in tribal areas which have an existing bed capacity of 270 beds. These nine hospitals would be renovated and extended, and 290 new beds would be added. Because hospital utilization is low in tribal areas, a major effort would be undertaken to encourage tribal populations to make greater use of services offered at community facilities through information, education and commnunication (IEC) efforts, while concurrently improving the quality of service offered to tribal populations. Under this sub-component the project would finance civil works, professional services and building maintenance. 2.18 Upgrade Clinical Effectiveness and Quality at Area and Community Hospitals. At the 49 area and 80 community hospitals, updated norms and standards for clinical and support services would be applied, staffing norms conforming to the services that will be provided at each type of facilities would be adopted, a system for monitoring improvements in the quality of clinical care would be established through the adoption of a quality assurance program and the capacity of support services would be expanded. Staff skills in clinical and technical areas would be enhanced through the provision of training to improve the quality and range of services. At negotiations, the Government of AP provided assurances that APVVP would adopt, within six months after upgradation of each facility, staffing and technical norms at its area and community hospitals as agreed at negotiations to ensure quality of services. Under this sub- component the project would finance medical and other equipment, medical laboratory and other supplies, medicines, vehicles, furniture, local consultants, local training, workshops, fellowships, equipment and building maintenance, operational expenses and salaries of additional staff on a decreasing basis. 2.19 Improve Functioning of Referral. Conceptually a multi-tier health delivery system which combines preventive, curative and specialized care is efficient when it performs adequately. It works best when the lowest tier (the primary care level) is easily accessible to the community and provides the bulk of the preventive care as well as the first line care for common illness conditions. Patients with more complex problems are identified in a timely and systematic fashion, and referred to an appropriate higher level. Each successive level provides services that is technically more complex and therefore more expensive. In such a system the higher tier provides technical leadership and support for the lower tiers, and the community has confidence 24 in the quality of care provided at each tier and patients understand that they will be referred in accordance with their medical needs. In reality, the referral system in AP, as in the rest of India does not function well. The different tiers do not complement each other, the lower tiers are underutilized, institutional and technical linkages between the lower and the higher tiers are weak and each tier operates as an independent entity providing similar levels of care. It is estimated that a third of all cases which are currently treated at tertiary facilities could be treated, and at lower costs, at secondary facilities if those facilities were properly equipped and staffed. 2.20 In order to improve the referral system, the project would implement several measures to strengthen the referral system and improve the quality of care in the secondary hospitals. At negotiations, the Government of AP provided assurances that GOAP and APVVP shall strengthen the referral system between the primary, secondary and tertiary levels by July 1, 1995 by: (i) establishing District Referral Committees in all 23 districts in coordination with the Directorate of Health Services; (ii) issuing appropriate administrative directives to strengthen the management of the referral system; (iii) implementing referral protocols; (iv) implementing clinical management protocols; and (v) establishing an incentive system with differentiated user fees for users and non-users and allowing patients to by-pass waiting lines when they carry a referral slip. Special attention would also be given to establishing mechanisms to improve access for remote and disadvantaged groups and tribal communities. The project would establish linkages and communications between the secondary and primary health care levels. The secondary hospitals would provide clinical and technical support to the PHCs; clinical skills at secondary facilities would be updated and upgraded; technical support for the primary level of care and community hospitals would be strengthened; referral mechanisms between community, area and district hospitals would be strengthened; and mechanisms to provide greater access to secondary and higher levels of health care would be formulated by making the referral system more timely, effective and client-friendly. Under this sub-component the project would finance vehicles, MIS and IEC materials, local training, local consultants and workshops. III. PROJECT COST, FINANCING, IMPLEMENTATION AND DISBURSEMENTS A. Project Costs 3.1 The total cost of the project is estimated at about Rs.6,083.2 million or US$158.9 million equivalent including taxes and duties estimated at US$8.8 million equivalent. IDA would finance about US$133.0 million or about 88.6 percent of total project costs net of taxes; the balance would be financed by the Government of AP. The direct and indirect foreign exchange cost is estimated at US$27.5 million. The project would finance civil works, equipment and furniture, vehicles, medical and laboratory supplies, medicines, other supplies, MIS/IEC supplies, professional services, training, studies and evaluations, and incremental salaries and costs on a declining basis. Cost estimates, the financing plan, procurement arrangements and disbursements plans are attached in Annex 1. 3.2 The breakdown of project costs by component and categories of expenditure for the project is summarized in Tables 3.1 and 3.2 below. 25 Table 3.1: Cost By Component Rs. Million US$ Million % X Total Component Local Foreign Total Local Foreign Total Foreign Base Exchange Costs I Institutional Strengthening la.Improve the Policy Framework 15.93 .67 16.60 .50 .02 .52 4% 0% lb.Strengthen Implementation Capacity 104.21 8.67 112.88 3.26 .27 3.53 8% 3% Subtotal 120.13 9.35 129.48 3.75 .29 4.05 7% 3% nI Improve Service Quality, Access & Effectiveness at District Hospitals 2a.Renovate& Extend District Hospitals 781.68 141.33 923.01 24.43 4.42 28.84 15% 21% 2b.Upgrade Clinical Effectiveness 707.26 131.52 838.78 22.10 4.11 26.21 16% 19% Subtotal 1,488.94 272.85 1,761.79 46.53 8.53 55.06 15% 40% HI Improve Service Quality, Access and Effectiveness at Area & Community Hospitals 3a.Renovate& Extend Area Hospitals& 1,074.00 194.16 1,268.16 33.56 6.07 39.63 15% 29% Community Hospitals 3b.Upgrade Clinical Effectiveness 923.07 238.77 1,161.84 28.85 7.46 36.31 21% 26% 3c.Improve Functioning of Referral 35.01 29.98 64.99 1.09 .94 2.03 46% 1% Subtotal 2,032.08 462.91 2,494.99 63.50 14.47 77.97 19% 57% Toa BASELINE COSTS 3,641.15 745.11 4,386.26 113.79 23.28 137.07 17% 100% Physical Contingencies 315.13 74.30 389.43 9.85 2.32 12.17 19% 9% Price Contingencies 1,090.00 217.52 1,307.52 7.80 1.86 9.66 19% 7% Tota PROJECT COSTS' 5,046.28 1,036.93 6,083.21 131.44 27.46 158.90 17% 116% 'NOTE: Inclusive of taxes and duties estimated at US$8.8 million equivalent. 26 Table 3.2: Cost By Categories of Expenditure Rs.Million US$ Million % % total Component Local Foreign Total Local Foreign Total Foreign Base Exchange Costs Investment Costs Civil Works (Renovation& Extensions) 1,651.14 291.38 1,942.52 51.60 9.11 60.70 15% 44% Professional Services 155.40 38.85 194.25 4.86 1.21 6.07 20% 4% Fumiture 62.19 6.91 69.10 1.94 .22 2.16 10% 2% Equipment (Medical & Other) 153.86 211.40 365.26 4.80 6.51 11.42 57% 8% Vehicles 13.32 39.97 53.29 .42 1.25 1.67 75% 1% Medical Lab & Other Supplies 144.72 8.44 153.16 4.53 .26 4.77 6% 4% Medicines 98.70 98.70 197.40 3.08 3.08 6.17 50% 5% MIS/IEC Materials 22.69 7.56 30.25 .71 .24 .95 25% 1% Local Training 38.09 - 38.09 1.19 - 1.19 - 1% Local Consultants 3.70 - 3.70 .12 - .12 - Studies & Workshops 22.05 - 22.05 .69 - .69 - Fellowships(Foreign& Local) 1.35 4.19 5.53 .04 .13 .18 72% - Total Investment Costs 2,367.20 707.40 3,074.60 73.97 22.11 96.08 23% 70% Recurrent Costs - - - - - - - - Salaries of Additional Staff 934.58 - 934.58 29.21 - 29.21 - 21% Operational Expenses 168.54 18.73 187.27 5.27 .59 5.85 10% 4% Building Maintenance 52.02 5.78 57.80 1.63 .18 1.81 10% 1% Equipment Maintenance 118.81 13.20 132.01 3.71 .41 4.13 10% 3% Total Recurrent Costs 1,273.95 37.71 1,311.66 39.81 1.18 40.99 3% 30% Total BASELINE COSTS 3,641.15 745.11 4,386.26 113.79 23.28 137.07 17% 100% Physical Contingencies 315.13 74.30 389.43 9.85 2.32 12.17 19% 9% Price Contingencies 1,090.00 217.52 1,307.52 7.80 1.86 9.66 19% 7% Total PROJECT COSTS 5,046.28 1,036.93 6,083.21 131.44 27.46 158.90 17% 116% *NOTE: Inclusive of taxes and duties estimated at US$8.8 million equivalent. 27 3.3 Basis of Cost Estimates. Estimated costs for civil works are based on current unit costs for construction which vary from US$110 to US$125 per square meter of gross floor area of construction. These costs are comparable to IDA-assisted construction in India. Costs of professional services for design reflect the scale of fees established for similar services provided by local architectural consulting firms. Costs for supervision of construction reflect the standard establishment charges of the state Public Works Department (PWD). Cost estimates for furniture, medical equipment, vehicles and medical supplies are product of lists developed by APVVP, and include import duties and taxes. Costs of other supplies are based on the state estimates and reflect current prices. Estimated costs for the salaries of additional staff are based on basic pay scales including standard allowances for social and other benefits applicable in the State. 3.4 Customs duties and taxes. All imported goods are subject to customs duties and taxes. The estimated cost of the project includes import duties and taxes estimated at about US$8.8 million equivalent. 3.5 Contingency allowances. Estimated project costs include physical contingencies (US$12.2 million) estimated at 10% of all physical components and at 5% for technical assistance, training and salaries. The estimated costs of the project also include price contingencies (US$9.7 million) to cover expected price escalation at the following rates. For civil works, goods, salaries, technical assistance and operation and maintenance - foreign costs: 2.2% in FY95 through FY2002; local costs: 8.0% in FY95, 7.0% in FY96, and 6.0% in FY97 through FY2002. 3.6 Foreign exchange component. The estimated foreign exchange component of US$ 27.5 million is calculated on the basis of estimated foreign exchange proportions as follows: (a) civil works 15%; (b) professional services 20%; (c) furniture 10%; (d) equipment 60%; (e) locally manufactured vehicles 12%; (f) imported vehicles 90%; (g) medical lab supply 20%; (h) medicine 50%; (i) MIS and IEC materials 25%; (j) foreign fellowships 90%; (k) operation and maintenance, and maintenance for buildings and equipment 10%. B. Financing Plan 3.7 The estimated total project cost of US$158.9 million would be financed by an IDA Credit of US$133.0 million equivalent, which would cover about 88.6 percent of the project costs net of taxes. GOAP would finance the remaining costs of US$17.2 million plus all taxes (US$8.8 million). 3.8 The credit would be made available to GOI on standard terms and conditions and on-lent to GOAP under standard arrangements for development assistance to the states. An understanding was reached that GOI would release about three month's anticipated project expenditures in advance to GOAP (in accordance with the amounts established in the Annual Plans), and that upon receipt of funds from GOI, GOAP would 28 transfer all such funds, together with its quarterly counterpart contributions, immediately to the project accounts of APVVP. C. Procurement Arrangements 3.9 Table 3.3 summarizes the project items, their related cost estimates and proposed methods of procurement. Project-related procurement for goods, works and services would follow procedures acceptable to IDA using ICB and LCB documents acceptable to the Association. Project-financed consultants would be recruited according to Guidelines on the Use of Consultants by World Bank Borrowers. Procurement of equipment, vehicles, and medical lab supplies would be bulked to the extent possible and any individual contract exceeding US$200,000 equivalent would be procured under ICB procedures. This is also true for vehicles, except for those needed for immediate use costing up to an aggregate of US$100,000 only, which may be procured through local shopping or rate contract. Shopping under the project would include international shopping procedures, based on comparing price quotations obtained from at least three suppliers from two eligible countries, or local shopping procedures with solicitation of price quotations from at least three suppliers all in accordance with Bank guidelines. Three Section Officers, part of the Export and Purchase Committees, experienced in procurement are responsible for procurement of goods: one for furniture and other supply materials; one for drugs; and one for surgical and hospital equipment. 3.10 Civil Works (US$70.7 million). The civil works component entails no new hospital construction but does involve large and small scale renovations and extensions to 150 hospitals over the seven year life of the project. Work on 125 sites (costing US$63.59 million) will be carried out through local competitive bidding. These works average about US$500,000 and would not be of any interest to foreign bidders. The remaining works at 25 sites (costing US$4.59 million) scattered and in remote areas would be carried out through a combination of force account and soliciting quotations from at least three contractors. These works individually are estimated to cost US$15,000 or less up to an aggregate amount of US$2.12 million. 3.11 Equipment (US$13.2 million). Procurement of most of the equipment would be phased on an annual basis in accordance with the requirements of the project. Contracts valued at over US$200,000 would be procured through ICB for an amount not exceeding US$6.00 million. Contracts valued at US$200,000 or less would be procured through LCB procedures acceptable to IDA for an amount not exceeding US$4.59 million. Purchases totalling US$50,000 or less, and not exceeding in aggregate US$2.65 million equivalent, may be awarded on the basis of local and international shopping. 29 Table 3.3: Procurement Arrangements (Total Costs in US$ Million) Procurement Method International Local Competitive Competitive Bidding Bidding Other /a N.B.F. Total b/ WORKS Civil Works - 63 59 7.07 70.66 (54 05) (6.01) (60.06) GOODS Vehicles 1 82 - 010 - 1.92 (1.60) (0.08) (1.69) Furniture - 1 88 0 63 - 2 51 (1.69) (0.56) (2.26) Equipment 6.00 4.59 2.65 - 13.23 (5.28) (4 04) (2 33) (11.65) Medical Lab Supplies - 0 77 0 77 - 1.55 (0.70) (0.70) (1.39) Medicines - 5 83 1 46 - 7.29 (5 25) (I 31) (6.56) Other Supplies - 1 62 2.43 - 4.04 (I 46) (2 18) (3.64) MISAEC Materials - 0 85 0.28 - 1.13 (0 76) (0 25) (1.02) CONSULTANCIES Project Prep & Implementation Support - - 1.31 - 1.31 (Includes Local Training Services, Workshops) (1 .31) (1.31) Institutional Development (includes - - 8.00 - 8.00 Local Consultants, Studies) (8.00) (8.00) MISCELLANEOUS Fellowships - - 0.20 - 0.20 (0.20) (0.20) Salaries of Additional Staff - - 33.04 - 33.04 (24 62) (24.62) Operational Expenditures - - 6.95 - 6.95 (5.18) (5.18) Building Maintenance - - 2.18 - 2.18 (1.56) (1.56) Equipment Maintenance - - 4.90 - 4.90 (3.65) (3.65) TOTAL 7.82 79.13 71.95 - 158.90 (6.88) (67 95) (58.17) (133.00) NOTES /a "Other" methods include International Shopping, Local Shopping, Force Account, Consulting Services and such 'non-procurement" funded activities such as salaries of incremental staff covered by the project. lb Firgures in parenthesis are the respective amounts financed by IDA. 30 3.12 Vehicles (US$1.9 Million). The state Health Transport Organization is in charge of the procurement of vehicles on behalf of MOH. Vehicles would be procured during the first two years of the project through ICB for an amount not exceeding US$1.82 million. To facilitate project start-up activities procurement of vehicles up to an aggregate of US$100,000 will be undertaken under local shopping procedures or rate contracts. 3.13 Furniture (US$2.5 million), laboratory supplies (US$1.6 million), MIS/IEC materials (US$1.1 million) and other supplies (US$4.0 million) would be purchased as follows. Contracts estimated to cost less than US$50,000 equivalent up to an aggregate of US$4.16 million may be awarded on the basis of prudent shopping with solicitation of price quotations from at least three suppliers. This is again based on the fact that this amount covers purchases by 150 hospitals over a period of seven years. Contracts valued at US$50,000 equivalent or more would be awarded on the basis of LCB procedures acceptable to IDA for an amount not exceeding US$5.12 million. 3.14 Medicines (US$7.3 million) would be purchased by each of the 150 hospitals as well as by APVVP several times per year over the seven year life of the project. Bulking requirements would not always be feasible due to shelf life of the medicines. As a result the individual purchases would be small and not likely to attract foreign bidders. Accordingly, contracts valued at US$50,000 equivalent or more would be awarded on the basis of LCB procedures acceptable to IDA for an amount not exceeding US$5.83 million. Contracts estimated to cost less than US$50,000 equivalent up to an aggregate of US$1.46 million may be awarded on the basis of local and international shopping. 3.15 Consultancv Contracts (US$8.0 million) and Fellowships (US$0.2 million). Consultants required under the project will be hired following procedures prescribed in "Guidelines: Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency"; August, 1981. Documents used for inviting proposals, terms of reference for all consultancies, fellowships, and single-source contracts will be subject to prior review for all contracts valued at US$100,000 or more awarded to firms and US$50,000 or more to be awarded to individuals (See Annex 8). 3.16 Training and Workshops (US$1.3 million). This category includes expenses related to training of about 3,500 medical professionals over the life of the project in respect of seminars, workshops, travel and subsistence allowances. 3.17 Maintenance Services (US$7.1 million). Maintenance costs for vehicles, medical and other equipment items estimated to cost less than US$25,000 per contract up to an aggregate of US$4.9 million would be procured from local commercial suppliers of such services in accordance with procedures acceptable to IDA. Maintenance of buildings and building equipment (funded by the project) estimated to cost US$2.2 31 million shall be carried out by Force Account where such arrangements already exist or by obtaining three quotations from local contractors in accordance with procedures acceptable to IDA. 3.18 IDA Review. All procurement under ICB would be subject to IDA's prior review; all LCB contracts costing US$300,000 equivalent or more for civil works and US$200,000 equivalent or more for goods would be subject to prior review. All other contracts would be subject to random post review in the field by visiting missions. Other contracts for civil works and goods would be subject to IDA review after contract award. Contracts for the hiring of consulting firm costing US$100,000 equivalent or more and contracts for hiring individual consultant costing US$50,000 equivalent or more, would be subject to prior review and approval by IDA. Approximately 60% of the value of the IDA Credit would require prior review. D. Disbursement Profile 3.19 The proposed IDA credit would be disbursed over seven years, consistent with the standard profile for PHR projects in India. The project is expected to be completed on September 30, 2001 and the credit closed on March 31, 2002. The experience with other PHR projects reinforces the justification for a standard disbursement profile. Table 3.4 below shows forecasts of expenditures and disbursements. Table 3.4: Estimated Expenditures and Disbursements IDA FY FY95 FY96 FY97 FY98 FY99 FY2000 FY01 FY02 Annual 8.5 17.0 28.6 40.3 35.3 16.5 12.7 0.0 Expenditures Annual 4.0 9.3 15.8 21.4 21.2 21.2 31.9 8.2 Disbursement Cumulative 8.5 25.5 54.1 94.4 129.7 146.2 158.9 0.0 Expenditures Cumulative 4.0 13.3 29.1 50.5 71.7 92.9 124.8 133.0 Disbursement 3.20 Disbursement percentages and required documentation. The IDA credit would be disbursed against 85% of expenditures on civil works: 100% on professional services, consultants and fellowships; 100 percent of CIF and ex-factory costs or 80% of other local expenditure on furniture, equipment, vehicles, medicines and materials, MIS and IEC materials; and 75% of incremental staff salaries and other recurrent costs on a declining basis during the project period starting with 90% in the first three years, declining to 75% for the fourth and fifth year, and 60% thereafter. Disbursements for 32 civil works renovations and extensions estimated to cost below US$300,000 per contract would be made against Statements of Expenditure based on certification of satisfactory completion. The state government would maintain complete records of funds disbursed, including certificates of completion signed by the District Executive Engineer, the Managing Director of APHMHIDC and or the Commissioner of APVVP. Disbursement for procurement of goods (including equipment, furniture, laboratory supplies, medicines, MIS/IEC materials and other supplies) under contract valued at less than US$200,000 and services under contracts valued at less than US$100,000 per firm (US$50,000 per individual contract), maintenance of buildings, equipment and vehicles and incremental staff salaries would also be made against Statements of Expenditure, with supporting documentation retained by the State government for review by IDA during supervision missions. All other disbursements would be made against fully documented withdrawal applications. 3.21 Special Account and central government advance to the state. In order to accelerate disbursements in respect of IDA's share of expenditures prefinanced by the GOI and the state government, and to allow for direct payment of other eligible local and foreign expenditures, a Special Account would be maintained in the Reserve Bank of India in the amount of US$3.0 million equivalent to cover four months of estimated disbursements through the Special Account. 3.22 Retroactive financing. Retroactive financing for project preparation in the amount of US$5.5 million, about 4.1 percent of the proposed credit, is provided to cover eligible expenditures incurred in implementing appraised project activities after April 1, 1994 or a date one year prior to signing of legal agreement for the project, whichever is later. Retroactive financing in support of project preparation would support initial staff appointments for APVVP headquarters, the construction of the extension to APVVP headquarters to locate key additional, technical survey of the existing hospitals under the project and the preparation of designs pertaining to Phase I of the construction program. Procurement arrangements were reviewed and found appropriate. E. Status of Project Preparation 3.23 The Government of AP finalized a project proposal in January 1994 in consultation with several IDA missions and on the basis of a Workshop on service, facilities and equipment norms. A decision has been made to locate a strategic planning cell within the Department of Health, Medical and Family Welfare and report directly to the Secretary of the Department. A Statement of Health Sector Development Policy has been provided by the AP Government and attached as Annex 2. Management structure of APVVP, the implementing agency, is in place and a plan has been drawn up to improve its implementation capacity through management training and enhancement of staff (Annex 5). Clinical, management and equipment training components of the project have been reviewed and agreement has been reached on a strategy for nursing development. Clinical and diagnostic norns have been developed for each of the three 33 types of community, area and district hospitals in a user-responsive manner (Annex 7). Equipment norms for each type of facility have been developed (Annex 9); staffing norms for each type of facility have been developed (Annex 6); inventory of equipment at 150 facilities is complete and a plan has been drawn up for maintenance arrangements (Annex 10). All facilities for upgradation have been identified, technical surveys and designs have been completed for the first phase of construction (Annex 15). APHMHIDC, responsible for civil works construction, has finalized a detailed construction program, related cost estimates, implementation schedule and developed schedules of accommodation for each of the three types of facilities (Annex 17). Procurement packages for civil works, equipment etc. have been completed. A complete list of equipment for all 150 hospitals has been prepared and equipment specifications have been reviewed with IDA (para 3.9 and Annex 16). 3.24 In addition, the following actions have also been undertaken in refining project design, scope and approach: performance indicators which were developed collaboratively with APVVP are provided in Annex 18; findings and recommendations of the beneficiary assessment study, which surveyed a sample of the target population, have been used to refine project design and strategy; an action plan for delivery of services to tribal and remote areas has been prepared based on the sample survey mentioned above (Annex 14); an IEC plan has been developed (Annex 13); the size of the proposed workforce under the project by cadre, compared to current sanctioned workforce has been reviewed and the cost implications included in project costs; and arrangements for supervision, including audit of APVVP and adequacy of reporting and monitoring arrangements by APVVP has been reviewed with IDA (Annex 19). 3.25 An important aspect of project preparation has been the involvement of key stake-holders. Preparation of the project devoted special attention to facilitating a sense of ownership and commitment of those involved in the process. A sample of potential beneficiaries were interviewed at secondary hospitals and primary health centers during field visits. Their views and experiences were considered, and included in refining project design. Several groups of representatives, including managers and clinical care providers from the different levels of APVVP hospitals, participated actively in developing the proposed formal mechanisms for establishing systematic monitoring and progressive improvement of quality of care in the APVVP system. The Corporation responsible for supervising the design of hospital upgradation has also encouraged interaction between the user of facilities and the design architect. A forum has been set up where the views of users are being actively sought by the architects. F. Implementation Plan 3.26 The project would be implemented by GOAP and APVVP within the existing administrative structure. APVVP would play a central role in implementing the project. The Commissioner of APVVP would be the Project Coordinator. The Project Coordinator would ensure that APVVP would interact closely and coordinate its health 34 care delivery with the three major Directorates reporting to the Secretary Medical, Health and Family Welfare Department. The three Directorates are Medical Education, Health Services and the Family Welfare Program. APVVP would also coordinate with the five smaller Directorates that look after the AIDS program, Preventive Medicine, Employees State Insurance, Indian System of Medicine and Drug Control. The organizational chart of APVVP is shown in Annex 5 on Organization and Management System. As the implementing agency, APVVP would be responsible for undertaking overall management of all aspects of the project including executing, procuring works and goods, supervising and monitoring and reporting. 3.27 The initial phase of project implementation will focus on developmental activities including project launch, monitoring mechanisms and performance indicators, strengthening health MIS system, initiating in-service training of staff in clinical, management and equipment matters, strengthening the functions and appointing staff at the head office and supplying equipment to existing hospitals to improve the quality of service to existing hospital facilities. The first phase of the implementation plan for the civil works program will consist of completing the renovation and extension of APVVP headquarters and the first phase of the hospital upgradation program consisting of 25 hospitals. During the initial phase the implementation plan would be to: complete topographical site surveys and soil tests; finalize and complete all drawings including site development plans, invite bids and commence construction for 150 hospitals under the four planned phases (see Annex 17); and complete over 50 percent of phase I and phase II and about 25% of phase III and phase IV; and prepare and complete all drawings including site development plans, launch bids and sign contracts of all 150 hospitals requiring upgradation. About 30 percent of total construction is expected to be completed by the end of the second year. At negotiations, the Government of AP provided assurances that it would review with IDA annually by April 30 of each year the progress of project implementation over the preceding twelve months and prepare an annual work plan for the following twelve months acceptable to IDA. G. Recurrent Cost and Sustainabilitv 3.28 This section analyzes recurrent cost and sustainability on the basis of the following questions: (i) what will be the incremental recurrent costs of the project as a percentage of current recurrent costs of APVVP; (ii) what will be the size of the incremental recurrent costs as a percentage of the state's plan and non-plan current budget; (iii) what will be size of the incremental recurrent costs as a percentage of the state's health and FW current budget; (iv) what will be the likely share of APVVP as a percentage of the health and FW budget at project completion; and (v) how much funds can user charges reasonably generate at project completion. 3.29 Incremental recurrent costs including contingencies at project completion would be about Rs. 300 million (US$9.6 million at current exchange rates) annually. This is a 38% increase in recurrent costs from current levels. APVVP's grant receipts 35 in FY94 were about Rs. 480 million, which comprised of about Rs. 370 million for salaries and Rs. 110 million for non-salary costs (Annex 3: Public Expenditures on the Health Sector in AP). As a percentage of the state's overall current budget, these incremental recurrent costs at project completion amount to only 0.3%. As a percentage of the state's current health and FW budget, the incremental recurrent costs at project completion will be about 5.6%. In FY94, health and FW allocations comprised about 5.8% of the state's total public spending. Of the state's total health and FW budget, allocations to APVVP amounted to about 13%. Assuming current allocation pattern between the three levels of health care were to remain the same, at project completion expenditures allocated to APVVP would have to increase by 7 percentage points to about 20% of the total health and FW budget of the state. 3.30 These increments should not be a problem for the state to provide. The AP Government would meet the incremental recurrent cost needs by increasing the size of the health budget and by reallocating incremental resources from the tertiary to the secondary level of health care. The AP Government has provided assurances that the required resources will be made available. A commitment to this effect is being sought in the statement on Health Sector Development Policy. At negotiations, the Government of AP and APVVP provided assurances that they would ensure that allocation of project funds each year for APVVP would be fully additional to that in FY95, and that APVVP shall be provided resources for recurrent expenditures on a timely basis adequate to meet its resource requirement under its annual operating plan for each year. 3.31 Analysis also shows that when 15-20% of beds are delineated as private paying wards in addition to some other user charges, APVVP would be able to recover between Rs. 45 to 55 million annually at project completion (Annex 4: Cost Recovery). This would reduce the recurrent cost burden by an estimated 15-18%. As a percentage of non-salary recurrent costs which would be financed in part by user charges, these estimates reflect a considerably greater share and would provide much needed funds for purchasing drugs and essential supplies. To this effect, the Government has reiterated that it is committed to introducing user charges while protecting the health care needs of the poorest segments of society. A commitment to introducing user charges has been included in the Letter on Health Sector Policy, as noted previously. H. Indigenous Populations 3.32 A beneficiary assessment study undertaken during project preparation has: (i) identified through informed participation the health care needs of tribal communities and constraints in provision of these needs; and (ii) recommended plans for delivering adequate and quality health care for members of these communities. An important finding is the low hospital utilization rates of tribal population. The project's tribal strategy is aimed at increasing the demand and seeking timely care by improving the quality of services and providing effective IEC to better inform tribal populations of the benefits of using first referral facilities. Tribal peoples would be a substantial project beneficiary 36 group. The number of beds at area and community hospitals located in tribal areas will be increased from 270 beds to 560 beds, reflecting a share of beds at secondary hospitals that is much more commensurate with their proportion in the overall population of AP. In addition, to increasing the bed strength in tribal hospitals, the project would: (a) strengthen linkages between primary and secondary health care services; (b) provide an incentive package to doctors and other medical staff in tribal areas to encourage them to accept assignment in these areas; (c) increase the appropriate utilization of non-tribal medical system by tribal population and reduce the cost to tribals of utilizing the system. At negotiations, the Government of AP and APVVP provided assurances that the Government of AP and APVVP would carry out the project in tribal blocks in accordance with the strategy agreed with IDA (Annex 14). Understanding was reached that children of doctors resident in tribal areas would be given preference in admission at Government-run residential schools and places in schools for scheduled tribes and scheduled castes; other incentives such as provision of housing, enhanced training opportunities and transfer to an urban area for 4-5 years of service would also be provided. The Tribal Service in AP (created in 1994) already provides for doctors recruited into this service to be formalized into regular service after 4-5 years in tribal areas. 1. Envirommental Aspects 3.33 The proposed project would not raise any environmental concerns. Much of the construction will be upgradation at existing sites and only three new construction sites have been planned for. The project would, however, improve the present status of medical waste disposal through appropriate disposal methods. J. Land Acquisition 3.34 The process of additional land, where required, for the extension of existing hospitals has been initiated and most sites have been made available. IDA has been assured that none of the sites for hospital upgradation would entail involuntary resettlement of any persons. K. Accounting and Auditing 3.35 The project would be subject to normal GOAP accounting and auditing procedures which are considered acceptable to IDA. At negotiations, the Government of AP and APVVP provided assurances that: (i) project accounts would be maintained and audited annually in accordance with sound auditing standards consistently applied by independent and qualified auditors acceptable to IDA; and (ii) certified copies of the annual SOEs together with the auditor's report, which would comment separately on the SOEs, would be submitted to IDA no later than nine months after the close of each fiscal year. 37 IV. PROJECT BENEFITS A. Benefits 4.1 The policy reforms envisaged under the project would improve the efficiency and effectiveness of health care services at the community, block and district levels. By strengthening AP's first referral health systems the project would optimize resource use, especially medical manpower and diagnostic equipment, avoid duplication and wastage, and reduce overcrowding at tertiary health care institutions. Analysis of utilization of medical services suggests that at least a third of the all cases that are currently treated at tertiary facilities could be treated, and at a lower cost, at secondary facilities when these are properly staffed and equipped. In addition, the project would provide a sustainable and replicative framework that could be subsequently used to reorient the health systems in other states of India. 4.2 In terms of investments, the project would have the following benefits. First, the proposed project would have a direct impact on improving the health status of the people in AP, especially the poor in the rural areas. It would reduce mortality, morbidity and disability and thereby increase the potential earning capacity of the poor. Second, strengthening the first line referral facilities and making them more client friendly would also encourage patients to seek timely care resulting in higher cure rates at lower costs. Third, the proposed project should also help regulate and, in substantial measure, reduce patient flow to the tertiary hospitals, where treatment per patient is more expensive. Fourth, the strengthening and upgrading of secondary level facilities would lend credibility and vital support to the primary health care system for implementing the various national and vertical health programs, and providing basic health care in rural areas. Finally, an adequately functioning health system at the block and district levels would encourage a greater participation of the private sector in health care through improved functioning of referral mechanisms. B. Program Objective Categories 4.3 Poverty Aspects. The project is directly relevant to the Bank's anti-poverty strategy. The project would provide better quality of health care services to all 23 districts in the state. Preliminary estimates suggests that the potential beneficiaries are expected to increase from its level of 9 million outpatients who were treated at APVVP hospitals during the past year to about 13 million at project completion. The number of inpatients is similarly expected to increase from its current level of 0.6 million to about 1 million at project completion. About two-thirds of the beneficiaries using APVVP services currently belong to the lower four strata of the decile groups and this proportion is expected to remain much the same. Therefore, a large proportion of the beneficiaries will be poor and underprivileged segments of the state's population. By improving the health status of poor people through reductions in mortality and morbidity, the project 38 would increase their earning potential and assist in making them more productive members of society. 4.4 Gender Issues. In general, the project would provide much greater access to women, especially rural women, for receiving health care and hospital services by increasing access to facilities in remote areas. It would also improve the quality of services that women receive at existing facilities by improving and upgrading clinical effectiveness at these facilities. More specifically, the project would reduce maternal mortality by addressing the most critical gaps for an effective safe motherhood program. Essential obstetrics care is already being provided under the CSSM project but the provision of emergency obstetrics care is lacking. This project would fill that gap by strengthening the referral system from the community to the community hospital level where emergency obstetrics care is provided. The improvements in the referral system and the strengthening of links between PHCs and community hospitals will assist in providing timely access to emergency obstetrics care, and shorten the waiting and transportation time for those most critically in need of emergency care. There will be 80 community hospitals in the state, in addition to the area and district hospitals, that will be properly staffed and equipped to deliver emergency obstetrics care. In addition, bed strength at 2 district and 3 area maternity hospitals under the APVVP system will be increased from 266 beds to 450 beds. C. Risks 4.5 The project carries several risks that are associated with PHN projects in general in India. These include basic implementation problems such as slow start-up, poor procurement, slow disbursement, frequent management turnovers, untimely and inadequate flow of funds and poor maintenance of buildings and equipment. Most of these risks can be substantially reduced through careful project design. Measures have been incorporated in the project to minimize these risks, several of which are laid out in Table 1.1. 4.6 There are two additional risks associated with this project. Institutional. Since this would be the first project to reorient the health system of a state in India, the capacity of existing institutions to undertake systemic improvements and to establish a more rational health delivery system has not been tested in India. The institutional strengthening aspects that are in-built in the project are expected to address this risk. These institutional aspects include: strengthening the strategic planning capacity in the Department of Health, Medical and Family Welfare; enhancing APVVP's implementation capacity through strengthening its organizational structure, systems and procedures, culture of service delivery, resources and training; and enhancing the Infrastructure Development Corporation's capacity to undertake supervision monitoring of the construction program. Financial: Another risk would be the potential hurdles faced by the state government to instituting user charges because of the politically sensitive nature of this issue. The AP Government has reaffirmed its commitment to institute user charges 39 while protecting those who cannot afford to pay. The on-going study on the burden of disease and cost-effectiveness would provide greater information about cost of specific public health interventions. By providing estimates of cost-effectiveness in terms of costs per DALY gained of selected public health interventions, it would provide an empirical basis to set user charges. These results could thus provide the Government with greater flexibility in charging user fees. Yet another financial risk is the overall financial status of the state. This is a risk associated with projects in all other sectors in India. The states will eventually need to adjust and reduce their fiscal deficits. The overall difficult fiscal situation of the state is a risk in terms of the adequacy of funds allocated to the health sector, especially the secondary level of health care. The Government of AP has provided assurances in a statement on Health Sector Development Policy that it will provide sufficient resources to meet the financial needs and adopt key policies that will assist APVVP generate additional funds. Specifically, the cost recovery mechanisms proposed under the project will relieve some of the recurrent cost burden faced by the AP Government. V. AGREEMENTS REACHED AND RECOMMENDATION 5.1 The Government of AP has furnished a Health Sector Development Policy Program (Annex 2). Availability of IDA assistance for the project would be subject to the implementation of actions set out in the Reform Program (para 2.8). 5.2 At negotiations, the Government of AP and APVVP provided assurances that: (a) The Government of AP shall carry out the Reform Program including: resource enhancement for the secondary and primary levels of health care; safeguard of resource allocations for operations and maintenance purposes to provide for adequate amounts of drugs and essential supplies, and maintenance of equipment and buildings at secondary hospitals under APVVP; selection, employment and transfer of staff; implementation of service improvements and user charges in accordance with an agreed program and time schedule; and retention of a third or more of user charges by collecting hospitals (para 2.8); (b) The Government of AP would ensure that a strategic planning cell would be set up by June 30, 1995 within the Department of Health, Medical and Family Welfare that would report directly to the Secretary of the Department (para 2.8(f)); (c) GOAP would carry out by December 31, 1995, a review of the policy framework for private provision of health services in AP; and thereafter 40 discuss with the Association recommendations arising from such review (para 2.10); (d) APVVP would engage key additional headquarters personnel and APHMHIDC would engage key additional personnel to be recruited under the project by June 30, 1995 (para 2.11); (e) not later than July 1, 1997, GOAP would carry out, jointly with GOI and IDA, a detailed mid-term review of project progress including a management review of APVVP and thereafter implement its recommendations (para 2.12); (f) APVVP would adopt within six months after upgradations of each facility staffing and technical norms at its district, area and community hospitals as agreed at negotiations to ensure the quality of services (paras 2.16 and 2.18); (g) GOAP and APVVP shall strengthen the referral system between the primary, secondary and tertiary levels by July 1, 1995 by: (i) establishing District Referral Committees in all 23 districts in coordination with the Directorate of Health Services; (ii) issuing appropriate administrative directives to strengthen the management of the referral system; (iii) implementing referral protocols; (iv) implementing clinical management protocols; and (v) establishing an incentive system with differentiated user fees for users and non-users and allowing patients to by-pass waiting lines when they carry a referral slip (para 2.20); (h) GOAP and APVVP would review with IDA by April 30 of each year the progress of project implementation over the preceding twelve months and prepare an annual work plan for the following twelve months acceptable to IDA (para 3.27); (i) Government of AP would ensure that allocation of project funds each year for APVVP would be fully additional to that in FY95, and that APVVP shall be provided resources for recurrent expenditures on a timely basis adequate to meet its resource requirement under its annual operating plan for each year (para 3.30); (j) Government of AP and APVVP would carry out the project in tribal blocks in accordance with the strategy agreed with IDA (para 3.32), (Annex 14) and (k) (i) a project account would be maintained and audited annually in accordance with sound auditing standards consistently applied by independent and qualified auditors acceptable to IDA; and (ii) certified copies of the annual 41 SOEs together with the auditors' report, which would comment separately on the SOEs, would be submitted to IDA no later than nine months after the close of each fiscal year (para 3.35). 5.3 With the above assurances and agreement, the proposed project would be suitable for an IDA Credit of SDR 90.7 million (US$133.0 million equivalent) on standard IDA terms with 35 years maturity. - 42 - Annex 1 Page 1 of 8 Project Costs Cost By Component fTR_u U eAil MIIU_e S % Tam c_m r_ mm I-. TrFoui Toeu Lo Fors'm Tol Exc.m Co I 1S Iasl n_.ps n dll Pnuw 15.93 .67 16.60 5 .0 5 4% 0% Ib-Stiq_..Lm uinCAflv 1N 2 1 UZ 112.1t Li 1 Li LAl II Sub$" 120.13 935 129.48 3.3 3 40 7% 3% 11vm S_'i QWi", A_ & EffedhN DaOe,4m HPa. Ua1. A EaumiDiammHcipm 7t1.61 141.33 923.01 24.4 4.4 23.1 15% 21% is - Uu CJicI EfFawum m S _ p 7 1 1 13a.3 ZL42 UL2 L1 2 41 Z2 I" in Sb 1,4U8.94 272.93 1,761.79 46.5 8.5 55.1 15% 40S Ml Upsw ieA,I QinIMt, Am mi EIIbdhim Ft Ana & rC-In Hhspkub 3a. -sb m A Eu.Am Au C _oMuI¶ HOWIMl 1,074.00 194.16 1,268.16 33.6 6.1 39.6 15% 29% 3b Upgisawuai Mlft uAmja-aA iCo m ia 923.07 233.77 1,161.S4 21.3 7.5 36.3 21% 26% kc - I s Fu g d1 31111i 22L I= 6f Li i.2 La 4A1 LI S _umI 2.032.08 462.91 2.494." 63.5 14.5 78.0 19% 57% Tow ASLuum COS1 3,641.15 745.11 4,336.26 113.8 23.3 137.1 17% 100% Phviui COWM _. 315.13 74.30 389.43 9.8 2.3 12.2 19% 9% Pr" Caauoqmu 1,090.00 217.52 1,307.52 7.8 1.9 9.7 19% 7% TitoePRW3CCOSIS 5,066.28 1.036.93 6,083.21 131.4 27.5 158.9 17% 116% - 43 - Annex I Page 2 of 8 Cost by Categories of Expenditure (Rupe MiPllonl (usS Mill") s T1 Liocl Forein Todnl Lcei Forelm Tota Fldimge Co 1neum Coat Civi Works(Renovauoo&Exteaszou) 1.651.14 291.38 1,942.52 51.6 9.1 60.7 15% 44S Profnoai Services 155.40 38.85 194.25 4.9 1.2 6.1 20% 4% Furcine 62.19 , 6.91 69.10 1.9 .2 2.2 10% 2% EquWmen (Medical) 13S.36 207.53 345.89 4.3 6.5 10.8 60% 8% Eqfimn (Other) 15.50 3.87 19.37 .5 .1 .6 20% - Vehices 13.32 39.97 53.29 .4 1.2 1.7 75% 1% Medical Lab Stpplies 33.76 ."44 42.20 1.1 .3 1.3 20% 1% Medicines 98.70 98,70 197.40 3.1 3.1 6.2 50% 5% Od.b Supplies 110.96 110.96 3.5 - 3.5 - 3% MiS/lEC Matenals 22.69 7 56 30.25 7 2 9 25% 1 % LocalTranin 3t.09 - 38.09 1.2 * 1.2 I% Lal Coasultants 3.70 - 3.70 . I . I - Soies 20.10 - 20.10 .6 - .6 Worbbops 1.95 - .95 .1 - . I Fiilowsups (Forcipn) .47 4.19 4.65 .0 .I .1 90% Felowwhips( lical) .8 - .8t .0 .0 TOW lnveelncoals 2,367.20 707.40 3,074.60 74.0 22.1 96.1 23% 70% Reewima CoaS Salries of Addidoal Staff 934.58 - 934.58 29.2 29.2 21% Opeional Expem 168.54 18.73 187.27 5.3 .6 5.9 10% 4% Building M inenance 52.02 5.78 57.80 1.6 .2 1.5 10% I % 11ipeaW Mainnce I18.81 13.20 132.01 3.7 .4 4.1 10% 3% Total Recurres,Costs 1,273.95 3771 1.311.66 39.8 1.2 41.0 3% 30% Total BASELDIE COM 3,641.15 745.11 4,386.26 113.8 23.3 137.1 17% 100% Physical ConOtgences 315.13 74.30 389.43 9.8 2.3 12.2 19% 9% Price Contingencies 1,090.00 217,52 1.307.52 7.8 1.9 9.7 19% 7% Total PROJECT COSMS 5,046.28 1,036.93 6,083.21 131.4 27.5 158.9 17% 116% - 44 - Annex 1 Page 3 of 8 Expenditure Accounts by Years - Base Costs (Costs in Rs. Millions) Fardgm Ban Cost Exchap 195 1996 1997 199 1999 2000 2001 Tota A _neu hnvuiuie Cams CivilWorks(Renovauon&Ex iaons) 97.1 194.3 388.5 679.9 485.6 97.1 - 1.942.5 15% 291.4 Professioal Senncc 9.7 19.4 38.9 68.0 48.6 9.7 - 194.3 20% 38.9 Funtire 3.5 6.9 13.t 24.2 17.3 3.5 - 69.1 10% 6.9 Equipnem (Medical) 34.6 69.2 103.8 69.2 69.2 - * 345.9 60% 207.5 Eqt.iem (Other) 1.9 3.9 5.8 3.9 3.9 - - 19.4 20% 3.9 Vehicles 2.7 16.0 26.6 8.0 - - 53.3 75% 40.0 Medical Lab Supplies 4.2 6.3 6.3 6.3 6.3 6.3 6.3 42.2 20% 8.4 Medicines 19.7 29.6 29.6 29.6 29.6 29.6 29.6 197.4 50% 98.7 OCher Supplies 11.1 16.6 16.6 16.6 16.6 16.6 16.6 111.0 MISIIEC Macenals 0.6 1.S 3.6 5.1 6.4 6.4 6.4 30.3 25% 7.6 Local Training 3.8 7.6 7.6 7.6 5.7 5.7 - 38.1 - - Local Consulana 0.1 0.2 0.4 0.6 0.3 0.8 0.8 3.7 - Snadia 1.0 3.0 4.0 4.0 4.0 3.0 1.0 20.1 Workshops 0.1 0.3 0.3 0.3 0.4 0.3 0.3 2.0 - Felwshtps (Foreign) 0.1 0.3 0.9 0.9 0.9 0.8 0.7 4.7 90% 4.2 FdewiUps (Local) 0.0 0.1 0.2 0.2 0.2 0.2 0.1 0.9 TtOWlnvesuina Cos 190.2 375.5 647.1 924.5 695.5 180.0 61.8 3074.6 23% 707.4 RdrT1 Cods SalariesofAddiomlStaff 46.7 84.1 112.1 130.8 186.9 186.9 186.9 934.6 Oionai Expat 9.4 16.9 22.5 26.2 37.5 37.5 37.5 187.3 10% 18.7 Building Mai wne - 2.9 5.8 8.7 8.7 11.6 20.2 57.3 10% 5.8 Eqwpmem Mainteance 6.6 11.9 15.3 18.5 26.4 26.4 26.4 132.0 10% 13.2 TotalRecurrentColt 62.7 115.7 156.2 184.2 259.4 262.3 271.0 1.311.7 3% 37.7 TotsABASELflECOS"S 252.9 491.2 803.3 1.108.7 954.9 442.4 332.8 4386.3 17% 745.1 Physical Conutingence 22.8 44.5 74.3 103.8 85.7 34.5 23.8 389.4 19% 74.3 Price Contingercies 12.3 66.3 171.2 322.3 355.2 200.1 179.7 1.307.5 17% 217.5 Total PROJECT COSTS 281.5 602.0 1.048.7 1.534.9 1,395.8 677.0 536.3 6.083.2 17% 1.036.9 Taxes 17.5 37.6 67.3 92.4 77.8 24.3 15.6 333.0 Forein Exchange 61.7 135.7 230.5 268.2 228.0 68.0 44.3 1.036.9 - 45 - Annex 1 Page 4 of 8 Expenditure Accounts by Years - Base Costs (Costs in US$ Millions) F-ON Ba Cost E p 9m 199 1997 1994 199 2000 2001 Total N A _muW Innt C a Civil Works(Ro A &EusavAkm) 3.0 6.1 12.1 21.2 15.2 3.0 60.7 15% 9.1 Profnasioml Suvic 0.3 0.6 1.2 2.1 1.5 0.3 - 6.1 20% 1.2 Furniru 0.1 0.2 0.4 0.8 0.5 0.1 - 2.2 10% 0.2 Eqpit (Medical) 1.1 2.2 3.2 2.2 2.2 - 10.8 60% 6.5 Equimme (Oder) 0.1 0.1 0.2 0.1 0.1 - 0.6 20% 0.1 V d 0.1 0.5 0.8 0.2 - * * 1.7 75% 1.2 Medical LAb Suppliu 0.1 0.2 0.2 0.2 0.2 0.2 0.2 1.3 20% 0.3 Mdi 0.6 0.9 0.9 0.9 0.9 0.9 0.9 6.2 50% 3.1 Otder Supplie 0.3 0.5 0.5 0.5 0.5 0.5 0.5 3.5 - MISAIEC M iea 0.0 0.1 0.1 0.2 0.2 0.2 0.2 0.9 25% 0.2 LoA Trnin4 0.1 0.2 0.2 0.2 0.2 0.2 - 1.2 - Local Consulmm 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 - S.idic 0.0 0.1 0.1 0.1 0.1 0.1 0.0 0.6 Woqfp 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Fei.os (Foteg 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 90% 0.1 Fellowhips (Local) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Tdoa llnves_Ccm 5.9 11.7 20.2 28.9 21.7 5.6 1.9 96.1 23% 22.1 Recre. Ce- - - Salu,ia of AddieonalStaff 1.5 2.6 3.5 4.1 5.8 5.8 5.8 29.2 - Operu ap. 0.3 0.5 0.7 0.8 1.2 1.2 1.2 5.9 10% 0.6 Building Mainenance - 0.1 0.2 0.3 0.3 0.4 0.6 1.8 10% 0.2 Equ4mmMaib 0.2 0.4 0.5 0.6 0.8 0.8 0.8 4.1 10% 0.4 Tota Recwst Cub 2.0 3.6 4.9 5.8 8.1 8.2 8.5 41.0 3% 1.2 TIalBASELI4UCOflI 7.9 15.4 25.1 34.6 29.8 13.8 10.4 137.1 17% 23.3 Pbyl C _ condass 0.7 1.4 2.3 3.2 2.7 1.1 0.7 12.2 19% 2.3 PriceComLtm -0.1 0.3 1.2 2.4 2.8 1.6 1.5 9.7 19% 1.9 Tdol PROJECT COS1S 3.l 17.0 28.6 40.3 35.3 16.5 12.6 158.9 17% 27.5 Turn 0.5 1.1 1.8 2.4 2.0 0.6 0.4 8.8 ForeignExchae 1.3 3.8 6.3 7.0 5.8 1.7 1.1 27.5 - 46 - Annex 1 Page 5 of 8 Disbursement Accounts by Financiers (Total Cost in US$ Million) GOP IIIRD TOW FM. (EKidL Do" A A_ingme C; A A _ % Eic. Ta) Taxi Civil Work 10.60 15% 60.06 85% 70.86 45% 10.77 54.94 4.95 Cowmkamt. Stwis. Wokhops. Proftul Sarvi s 0.00 - 8.0 100% 8.00 5% 1.44 6.57 - FwiOe 0.25 10% 2.26 90% 2.51 2% 0.26 2.06 0.18 Vehicle 0.23 12% 1.69 81% 1.92 1% 1.44 0.25 0.23 Equipm 1.59 12% 11.65 88% 13.23 8% 7.71 3.94 1.59 Mduins. Lab 9Su &Co s 1.29 10% 11.59 90% 12.88 8% 3.99 8.08 0.81 MIS/IECMazais 0.11 10% 1.02 90% 1.13 1% 0.29 0.77 0.08 Local Trni SuCS - 1.31 100% 1.31 1% 1.31 Fellowsuips 0.00 * 0.20 100% 0.20 0% 0.15 0.05 SaJari 8.41 26% 24.62 75% 33.04 21% - 33.04 Opemios E ledigu 1.77 26% 5.18 75% 6.95 4% 0.71 5.76 0.49 iding - 0.62 29% 1.56 72% 2.13 1% 0.22 1.80 0.15 EoPipwew Mwm. 1.25 26% 3.65 75% 4.90 3% 0.50 4.06 0.34 Tota 26.12 16% 132.73 84% 158.0 100% 27.46 122.63 8.81 - 47 - Annex 1 Page 6 of 8 Expenditure Accounts by Project Components (Costs in USS Millions) Inww Se-c Qualia. Improw Savics QmaaeW. Acce. a Aim A Inwartioil Saw,6ienim AM a Dism. Hoopeals Conrw.gy Hem" Cps UPd Inmpov S f UppU AiM AM £ n wo policy nImp_ Dls. m 4 Clilci C _AM Cos_ R84u Fru,wwork Capaday Hospials EfVawus_ _ lIloFpik Ftun T TAL % Am_ Cav Worb (Reooa &Exusainfs - 2-.54 0.09 35.0 -- 60.70 0O% 6.1 Proeaoa Se rv- - 2.55 0.01 3.51 - 6.07 10% 0.6 Fur - - 0.74 - 1.42 - 2.16 10% 0.2 E*6qum (Medical - 2.52 - 8.29 10.81 10% 1.1 Equpmen O r) 0.02 0 32 0 24 - 0.02 - 0 61 10% 0 1 V dlaic 0.01 0 13 - 0.10 0.46 0.96 1 67 t0% 02 MedkalLabSu Sppi N 0.79 013 - 1.32 10% 01 Md'.' - 3.70 2.47 6.17 IOS 0.6 Odw swplum - 1.39 2.05 3.47 10% 0.3 MISIIEC ManI . 0.16 - - - 0.78 0.95 IO% 0.1 LACMITrUWiS 0.6 - 0.19 0.12 0.02 1 19 55 0A1 LaadCosuml 0.10 - 0.0- - 0.02 0.12 1s 0.0 Saws 0.16 0.42 - - . 0.05 063 a 0% 01 W.bhops 0.03 0.01 0.01 - 0.01 0.06 5 % 0.0 Fei.w.hi *Fo,m J, 0.15 0.15 55 0.0 Fedo (Local) OM 0.0 0.01 - 0.03 35 0.0 Tod lowi C_s 0.32 1.91 28.09 9.0 35.56 15.55 1.3 965.O 10% 9 5 Sswm C 0% Saiu dofAddionldiSuff 0.09 096 - 12.67 - 15.4 29.21 51 1.5 Op(um 6_aIzpa 011 066 1.95 - 2.93 0.20 5.a5 10% 06 Uiildq M uAMin -- 0.75 0.01 1.05 1 81 10% 0,2 Equ_p M _ . 1.71 - 2.35 - 4 13 10% 0 4 TWelullln Co 0.20 1.62 0.75 16.41 1.05 20.76 0.20 40.99 6% 2.6 Tld MASEUNE COSTS 0.52 353 25.54 26.21 39.63 36.31 2.03 13707 9% 12.2 PIAC aonmsga 0.04 0.26 2.U1 1.93 3.96 2.54 020 12.17 0% - PrimComa m 0.04 0.25 L." 2.06 2.58 2.73 0. 15 966 S% OS Tuol raomIcr CoSS 0.60 4.04 33.61 30.25 46.17 41.61 2.38 155.90 S% 12.9 TUN 0.01 0.13 2.14 1.22 2." 2.14 0.21 R.51 9% 0.5 FaorgpE-cIp 0.02 0.32 5.23 4.56 7.15 5.76 1.09 27.46 9% 2.5 - 48 - Annex 1 Page 7 of 8 Project Components by Year (Base Costs in Rs. Million) Ban Cost 1995 1996 1997 1998 1999 2000 2001 Totel I Inktdoaal Stregthfeag Is - Improve dfe Policy Framewoet 0.8 1.9 2.6 2.8 3.3 2.9 2.4 16.6 lb- Strenghen implemenaon Capacy LA 1i2 21. MA 1 1 122 1120 Subtol 8.2 17.8 22.9 21.9 23.7 20.5 14.5 129.5 11 lmprove Servce Quality, Acce & Effectiveness at Distrid Hosptal 2a-RRnovateAE.uendDistHosptals 44.9 91.1 182.2 318.2 228.3 49.8 8.4 923.0 2b -Upgrade Clinil Effectiveness an Secondary Hospilals 560 2S 1261 1307 1587 135 133.4 831.1 Subtl 101.0 189.2 308.3 448.9 387.1 185.4 141.9 1,761.8 m iinrve Se vie Quaily, Acm ad Bffectlves at Area & Community Hospials 3a - RonaoehExtendArea &ConumityHospitals 61.7 125.1 250.3 437.2 313.7 68.4 11.7 1.268.2 3b- UpgradeCliicalEffectivenammAreaiCoam Hospital 79.5 147.4 202.1 190.5 223.4 161.0 158.0 1,161.8 3c - Improve Functoaing of Referral Li ILl l 1 Q2l La _ , 61 Subtotal 143.8 284.2 472.0 637.9 544.1 236.4 176.4 2.495.0 Tota BASELINE COsrs 252.9 491.2 803.3 1.108.7 954.9 442.4 332.8 4.386.3 Physical Conungences 22.8 44.5 74.3 103.8 85.7 34.5 23.8 389.4 Price Coningencues Local 8.5 48.0 128.0 259.2 290.9 178.2 163.3 1,076.1 Foreign 0.6 3.9 10.7 16.5 17.2 6.0 4.5 59.5 Subta lInflslio 9.2 51.9 138.7 275.7 308.1 184.1 167.8 1.135.5 Devahaion 3.6 14.4 32.5 46.6 47.1 16.0 11.9 172.0 S_Aa a Prke Codtlagemks 12.S 66.3 171.2 322.3 355.2 200.1 179.7 1,307.5 Total PROJECT COSTS 288.5 602.0 1.048.7 1,534.9 1,395.8 677.0 536.3 6,083.2 Tax= 17.5 37.6 67.3 92.4 77.8 24.8 15.6 333.0 Foreign Exchange 61.7 135.7 230.5 268.2 228.0 68.0 44.8 1,036.9 - 49 - Annex 1 Page 8 of 8 Project Components by Financiers (Total Costs in US$ Million) GO" IBRD TOal FW. (E=L Du Amim S A _Aa" S Am_t S Ezc Taxe TAM I h all Is- heq. de PoCYFn 0.06 10.1% 0.53 89.2% 0.60 0.4% 0.02 0.56 0.01 lb - rl- P C Q_ 1. 311 3 16 862S i. LAI QL Llt UI Suuial 0.62 13.4% 4.01 86.6% 4.63 2.9% 0.34 4.14 0.14 n [mumw. smvim. Q.aiwy, Aceem & Mectivmnew at D Si Hoap 2a.RmvmeA E- DistHapa 4.72 14.0% 28.89 86.0% 33.61 21.1% 5.23 26.24 2.14 2b- Up$rab Clmcal Effctiavne 5£2 198% 422 U).t2 3= 12.Q1 £16 2414 L2Z S=bul 10.69 16.7% 53.14 83.3% 63.83 40.2% 10.09 50.38 3.37 [ Improve So vkm QmW, A=c= md Nh Ulem at A. & C_om y H1slih -a.fm A&EP 4Are&Ca.AC yHo.p-k 6.48 14.0% 39.69 86.0% 46.17 29.1% 7.11 36.05 2.95 3b-UppadsC lnIMIE&vdm1siACOMM Ho_Pfi 8.04 19.2% 33.84 80.3% 41.38 26.4% 8.76 30.96 2.14 3c - improve Fum of Rderrl Q.2-2 . LM 120.0 2.31 LJ 1 Lo Lm 021 S_m1U 14.81 15.1% 75.62 84.9% 90.43 19.0% 17.03 68.10 5.30 TOW DI. _ 26.12 16.4% 132.78 83.6% 158.90 100.0% 27.46 122.63 8.81 -50 Annex- a ge1 of S From Mr. B.V. Rama Rao Special Chief Secretary Medical, Health and Family Welfare Department Government of Andhra Pradesh Hyderabad To Mr. Heinz Vergin Director India Department The World Bank Washington D.C. Subject Andhra Pradesh District Health Systems Project Health Sector Development Policy Government of Andhra Pradesh and Andhra Pradesh Vaidya Vidbana Parisbad have proposed to IDA a project for the development of First Referral Health Systems. I am pleased to send you in this connection the attached Policy Matrix reflecing Government decisions in respect of health policy reform. Special Chief Sec Medical, Hlth and Family Welfare Government of Andhra Pradesh Hyderabad Heatth Sector Develoomont Policy Program in Andhra Pradesh ISSUE EFFECT PROPOSED CHANGE OR ACTION 1. Adequacy of the overall size of Public health expenditure in AP is about 5.8% of Recognising the link between basic public health provision and the health budget to meet public the state budget and 1.3% of GDP. These health poverty alleviation, the Government will maintain the share of health goals expenditures are inadequate to provide essential health sector allocations within the overall budget at least at primary health care together with a basic package the current level. of clinical/curative services. 2. Imbalances in public Primary and secondary level care have been The Project State shall, pursuant to the Reform Program, expenditure between different neglected at the expense of tertiary care. ensure that the share of the primary and secondary levels in levels of the health sector Underfunding of these levels have resulted in the total resources (plan and non-plan) allocated by the shortage of drugs, lack of maintenance of Project State for the health sector shall be increased each facilities, shortage of doctors and other health year until (and including) the Project State's financial year care personnel. Moreover the imbalance has led 2000. to duplication of services and inefficient use of resources. In particular, the current overuse of tertiary facilities means that treatment costs per patient are needlessly high for many ailments. 3. Management Management of public health facilities in AP is District, area and community hospitals will be strengthened by weak which produces low service efficiency and improving their implementation capacity. Four key areas will effectiveness. Moreover lack of appropriate be addressed: strengthening structures, systems and management arrangements and authority to act procedures; culture of service delivery; resources; and means that there are few incentives for hospitals training. At APVVP level the focus would be on improving and their staff to improve hospital operation and management effectiveness; at community, area and district quality of services. hospitals the emphasis would be on strengthening service delivery management. These changes will be facilitated by allowing institutions to retain a third or more of the income generated through user charges (eg. payments for private beds) for use at the point of collection. IA 4. Quality of and access to Quality of medical services is inadequate. In Quality and access will be improved, especially for the poor hospital services addition, access to health care services is limited and underserved, by: i) upgrading and expanding physical especially for populations in the least developed capacity; ii) upgrading clinical effectiveness and quality of areas of the state particularly women and tribal services at area and community hospitals; iii) improving the groups. referral system eg. for essential obstetric care for women with high risk pregnancies; and iv) adopting staffing and technical norms at its community, area and district hospitals in line with those agreed with IDA at negototiations and specified in the SAR. The plan to address the needs of tribal groups will aim to improve the demand for hospital services in their areas both by the above improvements in quality and IEC; and also through the provision of incentives for health personnel stationed there. 5. Strategic planning Inadequate strategic planning capacity in the The capacity for strategic planning will be enhanced through health sector has resulted in sub-optimal use of establishment of a Planning Cell in the Dept. of Health, resources. Decisions on public health spending Medical and Family Welfare. This will, either independently or priorities presently do not take into full through specific research projects: monitor the role of the u, consideration: the size and scope of services private sector; review the suitability of present regulations 9 provided by private-commercial and voluntary relating to the quality of private care provision; analyze the sectors; the health manpower supply situation; evolving epidemiological profile in AP; monitor the burden of and the predicted future epidemiological profile in disease and recommend cost-effective means for achieving AP. best use of limited resources; and undertake periodic review of the health manpower supply situation and training needs in the state. 6. Workforce Improvement of services at APVVP hospitals is APVVP will be given authority to recruit staff. This will significantly restricted by workforce problems, include authority: i) to advertise, appoint, promote and both in terms of quality and quantity. The number transfer staff internally; ii) to post staff as needed especially of staff sanctioned at hospitals does not fit current in tribal areas; iii) to introduce appropriate incentives; and needs; there are many vacancies due to poor iv) to relax service rules if necessary to maintain the provision cumbersome recruitment procedures, lack of of services when appropriately qualified staff are unavailable. incentives for staff and supply side problems in the case of remote rural and tribal areas. o 7. The role of the private sector The health services development strategy of the The role of the private sector would be continuously Government has not taken sufficient account of monitored, the quality of services provided by private care the scope and coverage of non-Governmental practitioners would be assessed and regulations relating to providers and the role of this sector in delivering improvements in service quality would be evaluated (see 5 quality health care is underdeveloped. Therefore above). In addition, referrals between private primary care and the Government is inhibited in prioritising and the public sector secondary level diagnosis, treatment and rationalising its investment in the public health care would be encouraged through District Referral sector. Committees. The government will carry out by December 31, 1995 a review of the policy framework for private provision of health services in AP. 8. User charges Inadequate charging of user fees has resulted in The Government would issue regulations to facilitate APVVP low levels of funds for supplies, operations and to levy charges while protecting the poorest sections of maintenance. society. The guiding principle of user charges would be: to target the receipts particularly on non-salary recurrent costs; to charge for amenities such as private beds; and to charge for procedures that are low in cost-effectiveness in order to pay for those interventions that are high in cost-effectiveness. GOAP and APVVP would ensure that at least 20% of all beds at district and area hospitals would be dedicated as paying wards as soon as basic services are improved at these facilities. Other charges such as a nominal registration fee and for diagnostics and drugs would be phased in as improvements in basic services are provided. (See item No.3 for retaining income from user charges at individual hospitals.) For reasons of poverty alleviation and gender equity, some patients such as children under five years of age and women with high-risk pregnancies will be exempt from user-charges. Other exemption categories will be agreed in consultation with IDA. In addition, adequate administrative and organizational mechanisms for collecting user charges would be put in place. _. 9. Contracting services Contracted service are underutilised and results in APVVP will monitor cost-effectiveness and quality of existing substantial inefficiencies. contracted services. Furthermore the Governing Council will review as appropriate new proposals for contracting-out health services especially support services. 10. Safeguarding the operations The existing secondary hospitals face operational Taking into account budgetary provision, GOAP and APVVP and maintenance component of deficiencies and function poorly due to lack of will maintain sufficient funds in the non-plan health budget for the health budget non-salary recurrent funds. adequate supplies of drugs and other medical supplies at secondary hospitals, and for maintenance of equipment and buildings. 11. Poverty alleviation About 38% of households are below the poverty The investments made in this project will aim to reduce line in AP. In this group, health indicators such as poverty: by increasing the earning potential of workers mortality and morbidity rates, are especially through reduced illness; by increasing the enrolment of adverse. children in school and making them better able to learn; and by avoiding the greater expenditures needed deal with untreated illness. A strengthened referral mechanism will provide greater and more timely access in case of more serious health problems. - l . _~~~~~~~~~~~~~~~i - 55 - Amex3 Page 1 of 9 Public Expenditures on the Health Sector in Andhra Pradesh Share of health sector in public expenditures 1. The public health care system in Andhra Pradesh operates within the confines of a very restricted budget (Table l). Total revenue expenditure on Health and Family Welfare (FW) in 1991/92 was Rs. 375 crores, representing about 5.8% of the total state revenue budget. It rose to Rs. 464 crores in 1993/94 (Revised Estimate) and is budgeted to increase to Rs. 504 crores in the current fiscal year. However, health expenditures' grew more slowly than expenditures on other social sectors, such as education and water and sanitation, and more slowly than total revenue expenditures. As a result, the relative share of the health budget in total revenue expenditures declined to about 5.6% in 1994/95. It share in total (revenue and capital) budget expenditure is currently 5.1%, compared to 5.5% in 1991/92. 2. By all standards, public health expenditures are extremely low in the state. Revenue expenditures on health and FW constituted a mere 1.3% of the state Net Domestic Product in 1990/91 which is the same for India as a whole.2 Per capita annual public health expenditure was about Rs. 51 in 1990/91 or about US$2.5 in 1994/95. 3. The revenue budget accounts for 94 % of the total expenditures of the state government. The bulk of the health and FVW budget also consists of revenue expenditures. There are apparently no other expenditures on health which appear in the budgets of other departments, although certain large public sector undertakings, mainly those owned by the central government, provide health facilities for their employees. The figures mentioned above are, therefore, good indicators of the claims of the health sector on public resources. Structure of revenue receipts and the revenue deficit 4. Table 2 shows the structure of revenue receipts of the state. Currently, about 70% of total revenue receipts consist of the state's own revenues (55% of own tax revenues and 15 % of non-tax revenues). Central taxes comprised 14 % of total receipts and 15 % of receipts accrue as grants from the Centre. These shares have been more or less constant over the last three years. Unles otherwise specified, public health expenditures include expenditures on FW. ' The relatively small size of the health budget can also be gauged by comparing it with the budget of other 'social senrices'. Expenditu on bealth, as a proportion of total revenue expenditure, are lower than expenditures on the 'welfare of scheduled castes and tribes' (about 6.4% of the revenue budget in 1991/92), which consist of various subsidies and incentives for SC/ST. the education budget consties about 18% of revenue expenditures. - 56 - Annex 3 Page 2 of 9 5. Total revenue receipts increased at 9.6 % per annum between 1991/92 and 1994/95, while revenue expenditures rose more rapidly at 11.6% per annum. Consequently, the deficit on the revenue account has increased to Rs. 704 crores in the current fiscal year, representing about 8.5% of revenue receipts. At the beginning of the decade, the state government commanded a small surplus on the revenue account of about Rs. 331 crores. Composition of the health budget by pro2ram/service 6. A large share of public health expenditures in Andhra Pradesh is allocated to the provision of primary health care services, which include expenditures on the FW program and programs for the prevention and eradication of communicable diseases. At the beginning of the decade, the respective shares of these two major public health programs in the revenue budget of the health and FW sector were 20% and 17%. Some primary health care is provided by secondary and tertiary hospitals and hence expenditures on these programs understate the total public expenditure on primary care. Nevertheless, these programs constitute the most important components of primary health care and together accounted for 37% of the total health budget. The share of expenditures on FW has fallen to about 14% of the health budget in the last two years. 7. A recent analysis of the composition of public expenditures on health during the last decade highlights the budgetary emphasis on primary health care.3 The main features of subsectoral allocations during the eighties were: (i) a rising share for primary services; (ii) a declining share for hospital services; and (iii) a modestly rising share for education and training.4 The share of primary services steadily increased from 46% in 1980/81 to a peak of 56% in 1985/86, after which it declined to about 49% in 1989/90. Hospital services exhibited a consistent and significant reduction in their share of expenditures from about 41 % in 1980/81 to about 34% in 1989/90. However, this did not result in a reduction in real terms in resources allocated to hospital services, since the overall health budget grew by about 69% in real terms over the decade, or at an average rate of about 6% (in real terms) per year. 8. This analysis of subsectoral allocations highlighted some important issues. First, the allocation of expenditures to hospital services is relatively low in Andhra Pradesh, compared to both other low-income countries and to other Indian states. Only 4 countries in the 29 countries reviewed by Barnum and Kutzin (1993) spent less than 40% of the health budget on hospital services. An earlier study by ORG (1986) covering health expenditures in different Indian states reported an all-India average share for hospital services of about 45 % of the health budget. 'Mahapatra and Berman (1991). 'Allocation of Government Health Services Expenditures in Andhra Pradesh, India, during the Eighties.' Harvard School of Public Health (Mimeo). 'P rimary services were defined as public health programs and primary institutions and hospital services consisted of both secondary and tertiary hospitals. - 57 - Annex 3 Page 3 of 9 9. Second, allocations to hospital services in Andhra Pradesh have been adversely affected even in years when the overall health budget has grown, whereas allocations to primary health services were vulnerable to reductions only in years when the overall health budget was constrained. The fluctuations in annual Plan allocations for hospital services (see para 11) also seem to indicate that there have been positive efforts at reducing allocations to hospitals in the state. 10. Third, resource allocations within the hospital sector are skewed in favour of tertiary level hospitals (see para 16). Secondary level hospital care has suffered on account of low levels of overall public expenditures and the pattern of subsectoral allocations within the health sector and within the hospital services sector. Allocations of Plan expenditures for the health sector ii. The allocative process in government health expenditures is more clearly indicated by an analysis of Plan expenditures. Non-Plan expenditures tend to be carried over from year to year by default, whereas Plan expenditures are subjected to enhancements and cutbacks from year to year. 12. The annual Plan expenditure (revenue plus capital) for the state was about Rs. 1,489 crores in 1991/92, Rs. 2,206 in 1992/93 and Rs. 2,200 in 1993/94 (revised estimates). Plan expenditures on health and FW consist almost entirely of revenue expenditures and it is therefore more useful to compare plan expenditures on health with the total plan revenue expenditure.5 The plan budget for health and FW in 1991/92 and 1992/93 was Rs. 114 crores; in 1993/94, however, it declined to Rs. 100 crores. The health sector claimed about 10% of the plan revenue budget in 1991/92, 8. 1 % in 1992/93 and 7% in 1993/94. The social services sector, as a whole, received about 50% of annual Plan allocations, of which about half was absorbed by water supply and sanitation and the welfare of SC/ST. 13. Plan funds have been a more important source of finance for the health sector than for all government expenditures. Taking the budget as a whole, Plan funds constituted 20% of the total (revenue and capital) budget in 1991/92 and 25% in 1992/93 and 1993/94. The share of Plan funds in the health budget, by contrast, has generally been higher (30% in 1992/93, 27% in 1992/93 and 21 % in 1993/94). This share exhibits considerable year to year variations which can be attributed to the planning process itself and the greater scrutiny and inter-departmental pulls to which claims on Plan funds are subjected. The dependence on Plan funds for all social services was lower than that of the health sector (23%, 24% and 21% for the three years respectively) largely because of the relatively low share of Plan funds for the education sector.6 The greater dependence of the health sector on Plan funds (when compared to other social I In 1991/92, plan capital expenditure on health and FW was only R3. I crore. 'Plan funds constituted between 8-10% of expenditure on education during these three years. - 58 - Annex 3 Page 4 of 9 sectors) indicates that the sector is more vulnerable to budgetary stringencies and ad hoc allocations. 14. Within the health sector, Plan allocations to hospital services and especially the secondary level hospitals are most susceptible to ad hoc changes. This is because Plan allocations in the health sector have devolved almost entirely on the family welfare program and the various national programs for the prevention and eradication of diseases. The former accounted for 64% of total plan funds for the health sector in 1993/94; the latter accounted for another 17%. Between them, these schemes have accounted for nearly 80% of sectoral Plan expenditures over the last three years. Plan allocations for these programs have been protected because they are funded either entirely by the Central government (Central plan schemes) or have been driven by Central plan allocations in the case of Centrally sponsored schemes, where access to Central Plan resources are contingent on the allocation of state resources. 15. Since plan allocations for Central schemes are relatively protected and annual expenditures tend to be more stable, much of the year to year variation in Plan expenditures result in substantial variations in state plan allocations for other schemes. Plan allocations for hospital services, particularly at the secondary level, are likely to be the most vulnerable expenditures. 16. This general conclusion is reinforced by a recent analysis of plan allocations during the 1980s for the health sector in Andhra Pradesh.7 Between 1980/81 and 1989/90, between 87% and 95 % of plan expenditure for the health sector was absorbed by primary services, the balance being devoted to hospital services. Furthermore, plan allocations to primary services has always been positive, even in years when overall plan allocations for the sector fell. By contrast, the growth of allocations to hospitals fluctuated from year to year. The hospital sector in the state has therefore suffered from consistent underfunding and has had access to very few resources for improving access and enhancing quality. Distribution of public resources for hospitals 17. During the last decade, the allocation of total public resources (plan and non-plan) for the hospital sector to secondary and tertiary level hospitals, respectively, has been in the ratio of 51:49.8 The norm recommended by the Planning Commission is a ratio of 67:33. Analysis of plan allocations for the two levels of hospital services during the same period confirmed that tertiary hospitals claimed a greater share of incremental resources as well. Two-thirds of total plan resources allocated to all hospitals were absorbed by tertiary level institutions. Given the fact that hospitals received a very small share of Plan funds, the absolute levels of plan 'Mahapala and BeTman (1991), Ibid 'Mahaptara nd Berman (1992). 'Sub-allocation of the Firancial outlay for Hospital Services in AndhA Pradesh, India during the Eighties. Has it been appropriate:' Harvard School of Public Health (Mimeo) - 59 - Annex 3 Page 5 of 9 expenditure on secondary level hospitals are very small. Resources for APVVP 18. The Andhra Pradesh Vaidya Vidhana Parishad (APVVP) was established in November 1986 and 141 institutions comprising community, area and district hospitals and dispensaries were transferred to the APVVP with effect from March 1987. The major share of secondary level hospital services is now provided by the institutions under APVVP management. Budgetary allocations to APVVP are therefore an important indicator of public expenditures on secondary level hospital care. 19. Currently, almost the entire expenditure of APVVP is financed by grants-in-aid provided by the state government. These grants amounted to Rs. 390 million in 1991/92, Rs. 450 million in 1992/93 and Rs. 480 million in 1993/94. The projected grant for this year is lower at Rs. 460 million. Of the total non-plan budget for the health sector of Rs. 2.6 billion in 1991/92, APVVP received only 15%; this share fell to about 13% in 1993/94 and to less than 12% in the budget estimates for the current year. 20. Plan funds for APVVP have been negligible (Rs. 9 million in 1991/92 and Rs. 11 million in subsequent years). APVVP gets less than 0.75 % of total Plan resources for the health sector. 21. About three-quarters of APVVP expenditures is absorbed by salaries, a share which has remained more or less constant since the beginning of the decade. Budgetary restraint has therefore been effected by holding constant in nominal terms, expenditures on drugs supplies and consumables. Since price inflation for these commodities has been greater than average, real expenditure on critical inputs other than personnel has declined substantially in recent years. Public Expenditures Issues Arising from the Project 22. The state government is expected to meet about 10% of the total project costs. With a total project cost of U$159 million including price and physical contingencies (Rs. 6.08 billion) distributed over 7 years, the annual average disbursements will be about Rs. 87 million. The state government's annual incremental contribution will need to be about Rs. 8.7 million, which represents a 19% increase over current budgetary allocations to APVVP.9 The state government's enhanced incremental annual allocation to APVVP necessary to cover project costs must be clearly earmarked in the annual Plans and budgets. 23. Expenditures under the project will be fully additional. Additionality will be monitored for total expenditures on the health sector and for APVVP in particular relative to the base year 1994/95. However, only budget estimates are available for the current fiscal year which are Rs. 5.04 billion and Rs. 460 million for the health sector and APVVP, respectively. Assuming an 9 It reprsents an evenmore substantial increase in Plan funds for APVVP (Rs. 87 million compared to the currenm levei of Rs. 11.5 nillion). - 60 - Anne 3 Page 6 of 9 annual inflation rate of 8-10%, nominal expenditures should grow at least these rates. Additionality implies that these allocations by the state government will be fully incremental to the funds provided to APWP through IDA. 24. Annual recurrent expenditures at the end of the project are expected to be about Rs. 300 million (at base prices). Assuming current allocation pattern between the three levels of health care were to remain the same, at project completion budget allocation to APVVP would have to increase by 7 percentage points to about 20 % of the total Health and FW budget of the state. The incremental recurrent costs of the project at Rs 300 million is only about 0.3 % of the state's total public spending and 5.6% of the health and Family Welfare spending, and should not be a problem for the government to provide. Understanding has been reached with the AP government that it would meet the incremental recurrent cost needs by: ensuring that allocation of project funds for APWP would be fully additional to GOAP's fiscal budget of FY95; increasing APWP's recurrent expenditure to fully match its increased capacity; and reallocating incremental resources from the tertiary to the secondary health care level. The governments calculation of recurrent costs as well as the financing proposal for the project do not take into consideration the revenue that would be recovered at project completion through user charges. Analysis shows that when 15-20% of beds are used for private paying care and some other minor user fees are charged, APWP would be easily able to recover between Rs. 45 to Rs. 55 million annually at project completion. The analysis thus suggests that the project would be financially sustainable. - 61 - Annex 3 Page 7 of 9 Table 1: Andra Pradesh: Structure of Government Expenditures (in Rs. crores) (as % of revenue expenditures) 91/92 92/93 93/94 94/95 91/92 92/93 93/94 94/95 ACC ACC R.E. B.E. ACC ACC R.E. B.E. Total Revenue Expenditure 6451 7190 8079 8963 100.00 100.00 100.56 100.01 Geal Services 1829 2112 2545 2865 28.35 29.37 31.50 31.96 Socal Services of which: 2347 2736 2948 3475 36.38 38.05 36.49 38.77 Education 1150 1353 1524 1843 17.83 18.82 18.86 20.56 Health & Family Welfare 375 422 464 504 5.81 5.84 5.74 5.62 (Family Welfare) 74 84 66 68 1.15 1.17 0.82 0.76 (Prevention/Eradication) 65 n.a. 83 n.a. 1.01 0.00 1.03 0.00 Water & Sanitation 186 257 217 274 2.88 3.57 2.69 3.06 Welfre of SC & ST 415 460 470 553 6.43 6.4 5.82 6.17 Othen 82 n.a. 127 n.a. 1.27 0.00 1.57 0.00 Economical Services 2226 2282 2561 2551 34.51 31.74 31.70 28.46 Grants-in-Aid 49 60 70 73 0.76 0.83 0.87 0.81 Total Capital Expenditure 419 803 767 899 6.10 10.05 8.67 9.12 GRAND TOTAL 6870 7993 8846 9862 (as & of total expenditure) Memo Items: Population: 66.5 million (1991) State Net Domestic Product: 1988/89 - Rs. 19,793 crores (est. 1990/91 Rs. 25,489 cr; 1991/92 Rs. 28,349 cr.) Table 2: Andhra Pradesh: Structure of Revenue Receipts (in Rs. crores) (as % of revenue expenditures) 91/92 92/93 93/94 94/95 91/92 92/93 93/94 94/95 ACC ACC R.E. B.E. ACC ACC R.E. B.E. Toal Revenue Receipts 6282 7067 7792 8260 100.00 100.00 100.00 100.00 State's Own Revenue 4455 4965 5385 5783 70.92 70.26 69.11 70.01 Own Tax Revenue 3474 3886 4256 4487 55.30 54.99 54.62 54.32 Non-tax Revenue 981 1079 1129 1296 15.62 15.27 14.49 15.69 Cental taxes 877 1049 1147 1232 13.96 14.84 14.72 14.92 Grants from Centre 950 1053 1260 1245 15.12 14.90 16.17 15.07 - 62 - Annex 3 Page 8 of 9 Table 3: Andhra Pradesh: Plan Expenditures by Sector (in Rs. crores) (as % of plan revenue expenditures) 91/92 92/93 93/94 94/95 91/92 92193 93/94 94/95 ACC ACC R.E. B.E. ACC ACC R.E. B.E. TotalPlanRevenue 1078 1411 1449 1369 100.00 100.00 100.00 100.00 Social Services 539 643 611 819 50.00 45.57 42.17 59.82 Education 72 109 93 156 6.68 7.73 6.42 11.40 Health & Family Welfare 114 114 100 109 10.58 8.08 6.90 7.96 of which: 0.00 0.00 0.00 0.00 Family Welfare 73 83 64 67 6.77 5.88 4.42 4.89 Dissea control 19 n.a. 24 n.a. 1.76 0.00 1.66 0.00 Others 22 22 2.04 0.00 1.52 0.00 Water supply & sanitation 149 189 178 233 13.82 13.39 12.28 17.02 Welfar of SC &ST 150 161 158 210 13.91 11.41 10.90 15.34 Total Plan Capital 411 795 751 871 38.13 56.34 51.83 63.62 GRAND TOTAL PLAN 1489 2206 2200 2240 Table 4: Andhra pradesh: Allocations to APVVP (in Rs. crores) (as % of health budget) 91/92 92193 93/94 94/95 91/92 92/93 93/94 94/95 ACC ACC R.E. B.E. ACC ACC R.E. B.E. Non-Plan Total Health & Family Welfare 264 308 364 395 100.00 100.00 100.00 100.00 of which: Grants to APVVP 39 45 48 46 14.77 14.62 13.27 11.74 ComniSssionente I I I 1 0.38 0.32 0.27 0.25 (Salaries) I I 1 0.00 0.19 0.18 0.16 Hospitals & Dispensaries 38 44 47 46 14.39 14.29 13.03 11.55 (Saries) 34 34 34 10.93 9.47 8.73 (Othe) 10 13 12 0.00 3.25 3.57 3.04 Hospital Equipment Repair Uni 0.08 0.07 0.05 0.05 0.03 0.02 0.01 0.01 (Saaries) 0.04 0.04 0.04 0.01 0.01 0.01 Lumpsum Provision 0.57 0.67 0.22 0.22 0.00 0.00 Plan TotalHealth&Family Welfare 114 114 100 109 100.00 100.00 100.00 100.00 of which: Grants to APVVP 0.87 1.08 1.15 1.15 0.76 0.95 1.15 1.06 Comrnissionerate 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 (Saaries) 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 Hospitals & Dispensaries 0.86 1.07 1.14 1.14 0.75 0.94 1.14 1.05 (Salries) 0.31 0.76 0.80 0.80 0.27 0.67 0.80 0.73 Other 0.55 0.31 0.34 0.34 0.48 0.27 0.34 0.31 - 63 - Anlm Page 9 of 9 Table 5: Structure of APVVP Expenditures (Hospitals & Dispensaries) (in Rs. lakhs) (in %) 91/92 92/93 93/94 94/95 91/92 92/93 93/94 94/95 ACC ACC R.E. B.E. ACC ACC R.E. BE. APWP Hospitals & Dispensaries 3872 4391 4744 4562 100 100 100 100 of which: Pay & Allowances 2580 2987 n.a., n.a. 66.63 68.03 n.a. n.a. Non-salary expenses 1292 1404 t178 1059 33.37 31.97 24.83 23.21 Travel 11.49 11.53 12.50 n.a. 0.30 0.26 0.26 0.00 Wages 5.22 3.87 5.50 n.a. 0.13 0.09 0.12 0.00 Administration 68.53 42.04 49.10 68.00 1.77 0.96 1.03 1.49 Water and Electricity 83.91 103.63 78.00 100.00 2.17 2.36 1.64 2.19 Rents, Rates & Taxes 3.36 5.60 4.50 3.50 0.09 0.13 0.09 0.08 Purniture 5.36 34.48 48.00 0.14 0.79 1.01 0.00 Machinery& Equipment 117.26 116.12 53.00 19.00 3.03 2.64 1.12 0.42 Hospital Consumables 640.98 835.04 671.50 681.70 16.55 19.02 14.15 14.94 Drugs 541.66 708.50 580.00 580.00 13.99 16.14 12.23 12.71 Other Consumables 69.22 105.60 80.50 84.70 1.79 2.40 1.70 1.86 Linen 30.10 20.94 11.00 17.00 0.78 0.48 0.23 0.37 Cleaning materials 8.89 9.74 8.00 9.50 0.23 0.22 0.17 0.21 Diet 99.22 91.28 86.10 100.00 2.56 2.08 1.81 2.19 Maintenance 8.42 18.73 15.99 77.00 0.22 0.43 0.34 1.69 Ambulances 8.42 18.73 15.99 23.40 0.22 0.43 0.34 0.51 Buildings 45.60 0.00 0.00 0.00 1.00 Machinery & Equipment 8.00 0.00 0.00 0.00 0.18 Minor works (buildings) 238.94 130.45 145.65 n.a. 6.17 2.97 3.07 0.00 Memo Items: Number of APWP Beds 9586 9586 9586 9586 Average Annual Expenditure (in Rupees) Hospital Consumables 6687 8711 7005 7111 Drugs 5651 7391 6050 6050 Other Consumables* 722 1102 840 884 Linen 314 218 115 177 Cleaning materials 93 102 83 99 Diet 1035 952 898 1043 Other consumables include needles, syringes, lab materials, X-rays, gauze, surgical cotton, etc. - 64 - Annex 4 Page 1 of 7 Cost Recoverl 1. The Government of Andhra Pradesh has proposed that some charges be levied on users of APVVP facilities. This revenue could be used to finance part of the anticipated incremental recurrent expenditures at the end of the project. 2. Cost recovery in the project has been conceived of as a means of providing a modest supplement to, and not as a substitute for, the APVVP operating budget. This will help to maintain the higher level of quality achieved by the project. The responsibility for meeting the recurrent cost obligations of the project will continue to be met by the government. A substantial cost-recovery ratio is neither feasible nor desirable given the large proportion of poor, of women and tribals among the clientele served by APVVP. Beneficiary assessment studies show that the poor are disproportionately represented among the users of public hospitals in Andhra Pradesh. High levels of user charges could discourage use of APVVP facilities by these sections and deny access to critical hospital services. 3. The guiding principles of user charges would be: (a) to protect the poorest and most vulnerable sections of society; (b) to target recovery on non-salary recurrent costs; (c) to charge for amenities such as private beds; charge for low cost-effectiveness procedures in order to generate and free public resources for higher cost-effectiveness intentions; and (c) to ensure administrative simplicity. User charges will be instituted in a phased manner after improvements in the quality of basic services (such as staffing and technical norms) and infrastructure. In the absence of quality improvements, the levying of a fee can lead to reduced demand for hospital services. 4. Three main types of user charges are proposed: paying wards, outpatient charges and charges for services provided to the private sector (special clinics for paying outpatients and diagnostic services). This Annex examines the potential revenue that can be generated for APVVP by a few simple user charges under alternative assumptions. This is followed by a discussion of possible implementation mechanisms. Projected Revenue from Paving Wards 5. Agreement has been reached to allocate 20 % of all beds at district and area hospitals as paying wards. A total of 14,000 beds are expected to be in place at the end of the project, of which 10,500 will be at district and area hospitals, 2,100 beds would be allocated as paying beds, representing 15 % of the total bed stock at all hospitals. However, this represents over 45 % of the incremental beds that are expected to be added by the project, and nearly 60% of the incremental beds at district and area hospitals. - 65 - AnnexA Page 2 of 7 6. Three types of paying beds will be offered at district and area hospitals. Category A comprises single rooms with attached toilet, Category B shared rooms with or without attached toilet and Category C comprises cubicles in general wards which provide some privacy to patients. Projected revenues calculated below are based on the assumption that 35 % of paying beds are classified as Category A, 45 % as Category B and 20% as Category C. Patients opting for paying wards would have to pay bed charges; those opting for A and B categories would also have to pay for treatment costs for surgery and diagnostics. 7. Revenue collections from bed charges in paying wards under alternative assumptions of bed occupancy rates are presented in Table 1. The annual collection assuming 70% occupancy is expected to be about Rs 17.2 million; assuming 80% occupancy, it is expected to be about Rs. 19.6 million. Table 1: Annual Collections from Paving Beds Bed Charge Number 70% occupancy 80% occupancy (Rupees/day) of beds (Rs. mill.) (Rs. mill.) Category A 50 735 9.39 10.73 Category B 30 945 7.24 8.28 Category C 5 420 0.54 0.61 Total Revenue 2,100 17.17 19.62 8. Patient opting for paying beds in Categories A and B will also be charged for major and minor surgeries. A differential pricing policy for surgical charges which links charges to the type of amenity provided (e.g. higher charges for Category A beds) can lead to excess demand for Category B beds and underutilization of Category A beds, unless there is a substantial difference in quality between the two types of wards. Quality differences of this order are not being planned. It is therefore recommended that uniform surgery charges are levied for both categories of beds. 9. Table 2 presents projected revenues generated by surgery charges for patients in paying wards. The total revenue generated by surgery charges, under the above assumptions, is expected to be Rs. 11.8 million for 70% occupancy and Rs 13.4 million for 80% occupancy. Surgery charges have been assumed to be Rs. 700 for major surgeries and Rs. 200 for minor surgeries (data provided by APVVP) and are inclusive of expenditure on suturing material, anaesthetic drugs and OT charges and routine pathological tests. Drugs, disposables, X-rays and ultrasonography tests are not included in this package offer and are expected to be charged separately. -_----- - 66 - Annex4 Page 3 of 7 10. The rationale for the proposed charges are related to prices being currently charged in other tertiary government hospitals located in Hyderabad. However, the ability to pay at APVVP hospitals, which will cater to large members of poor is not evident. If the paying capacity of the population at the district and sub-district level is lower, lower prices may need to be charged. Prices levied in private hospitals in district and taluk headquarters can provide a benchmark figure, provided the quality of care in APVVP private wards in comparable to that in private hospitals. Table 2: Projected Revenues from Surgical Procedures (Paying Ward Patients only) Occupancy InpatLients Major Revenue Minor surgeries Revenue surgeries (Rs.m) (Rs.m) Category A 70% 18,780 4,695 3.29 9,390 1.90 80% 21,460 5,365 3.76 10,730 2.1 Category B 70% 24,145 6,035 4.22 12,070 2.41 80% 27,590 6,897 4.83 13,795 2.76 Total 70% 42,925 10,730 7.51 21,460 4.31 80% 49,050 12,262 8.59 24,525 4.86 Notes: 1. The number of inpatients has been calculated using a 70% or 80% bed occupancy rate to get total number of bed-days in a year and dividing by an expected average length of stay of 10 days (which is the current average). 2. The number of major and minor surgeries has been calculated by assuming that 25 % and 50 % respectively of inpatienus will undergo each type of surgery. Data provided by APVVP for recent years show that currently about 15 % and 30% of inpatients undergo major and minor surgeries respectively. It can be safely assumed that the proportion of such patients will be higher in paying wards. 11. Additional revenue will be generated by charging for X-rays, ultra-sonography, and consumables. Since data are not available on the per patient use of these services and consumables, a rough estimate of prospective revenues can be made by assuming a flat rate of Rs. 200 per inpatient. A sum of Rs. 8.59 million for 70% occupancy and Rs 9.81 million for 80% occupancy can be generated in this manner. - 67 - Annex 4 Page 4 of 7 12. Table 3 summarizes the recoveries from paying bed patients. Table 3: Revenue Collection from Paving Beds (Rs million) Bed Charges Surgical Drugs and Total procedures consumables 80% 19.6 13.4 9.8 42.8 occupancy 70% 17.2 11.8 8.6 34.5 occupancy _ 13. These preliminary calculations, indicate that between Rs 35 - Rs. 43 million can be recovered through paying room charges. The gross revenue collections must be discounted for additional costs that would be incurred to provide higher quality service in these wards (such as higher nurse to bed ratio, additional attendants and extra amenities such as electricity and water). Assuming that extra costs for providing these services are 20% of gross collections, net revenues generated will be between Rs 2.8 million and Rs. 3.4 million. Distribution of pavinz bed capacity 14. Although it has been assumed that 20% of total bed capacity in area and district hospitals will be designated as paying beds, a uniform proportion cannot be used across rural/urban areas and across districts. Since the paying capacity of the catchment areas of different hospitals varies widely due to differences in the incidence of poverty and in per capita income, a uniform distribution may result in underutilization of bed capacity in poorer regions. More detailed data on socio-economic characteristics would be required to arrive at an optimal distribution of paying bed capacity. 15. The extent of private bed capacity in the different districts and taluks may provide a good indicator of paying capacity. The distribution of public/private beds is markedly different in various districts of Andhra Pradesh, ranging between a 80:20 ratio to a 20:80 ratio. A notable feature of the distribution is that the more backward districts (for example, in drought prone Rayalaseema region and districts with a high proportion of tribals), the private sector beds is relatively low indicating that paying capacity is low. In such districts, the proportion of paying wards in APVVP hospitals should be low, since demand may be too low to generate additional revenues which are sufficient to cover the extra cost of providing the service. 16. A critical assumption in the above exercise is that relatively high bed occupancy rates can be achieved. Sample data from a few district and area hospitals indicate that current - 6s - Annex 4 Page 5 of 7 occupancy rates in paying wards are as low as 25-35 %, because of lack of water in the toilets and lack of nursing care. Paying ward patients have to share the nurse and other attendants with the general ward and hence tend to get less attention. Indifference towards the general conditions in the hospital and towards providing the extra care and amenities demanded by paying inpatients has resulted in very low occupancy rates and recoveries. 17. In order to achieve high utilization rates in the paying wards, APVVP would have to improve the quality of services at secondary hospitals. Paying beds would create some quality competition between the public and private sectors in those limited areas where there is overlap of services and therefore contribute to improving the quality of services provided and reduce inefficiencies at health facilities. Such opportunities, however, would be limited since private facilities are not available everywhere, and some critical services such as the treatment of communicable diseases which affect the poor are not provided by private facilities. 18. Another way of judging paying capacity is to compare the expenditure on one illness episode, based on the charges assumed above, and with the per capita income. Assuming an average length of stay of 10 days, the expected expenditure for different categories of patients is Rs. 1,400 for a patient undergoing a major surgery using a Category A bed and Rs. 50 for a patient using a Category C bed (Table 5). These compare with an estimated per capita GDP of Rs. 5,950 in 1994/95. Direct expenditure on hospitalization (excluding drug charges) is about 25 % and 8 % of per capita GDP for the two types of inpatients respectively. For a family of five with a household income which is 350% of per capita GDP, one case of hospitalization represents about 6.7% of household income for a Category A patient and 02. % for a Category C patient. The level of charges indicated here seem to place only a modest burden on the average household, although the substantial other direct and indirect expenditures, such as foregone earnings, which tend to be higher for poorer patients, should be taken into account when determining the ability to pay. Table 5: Per Patient Direct Expenditure on Hospitalization (in Rupees) Major Surgery Minor Surgery General Category A 1,400 900 700 Category B 1,200 700 500 Category C 50 50 50 Outpatient charges 19. The number of new outpatients is currently about 10 million. Improvements in quality which are envisaged in the project and the normal growth in population would probably result in an annual turnover of about 12.5 million new outpatients after 3 years of project implementation. - 69 - Annex 4 Page 6 of 7 20. One of the important objectives of the project is to enhance access to hospital services of those from low income groups. Outpatient charges, however modest, can negatively influence women's use of hospital services, for instance, in poor households. Poor households often bear a disproportionate share of the total costs in the form of indirect costs (especially foregone earnings, since very few of them enjoy paid medical leave). Any additional user charges would add to the total cost burden of the poor. There is therefore a strong equity argument for exempting the poorest households from all direct charges. Practical considerations, however, prevent the use of income criteria to determine exemption categories among outpatients. Employers' salary certificates can be used only for a minority of patients working in the organized sector in urban areas. Currently, GOAP issues two types of ration cards to distinguish households under the poverty line from those above the poverty line. A number of malpractices have been noted in the administering of the ration card system, which limit their use by hospital managements to determine the income status of patients. This can result in ineligible households benefitting from free hospital services. 21. It is proposed that exemption categories will need to be carefully evaluated. An alternative is to exclude women with high risk pregnancies and children under the age of 5. However, this alternative has its own problem. The proposal is currently to have voluntary payment for out patient services such as through the sale of APVVP seals at the time of outpatient registration. 22. Data on the number of outpatients by gender, age and type of case are not available. However, an estimate of the gross revenues can be made under different assumptions. Assuming an outpatient charge of Rs. 2 and that 30% of outpatients fall in the non-exempted categories, the gross revenue collection is Rs. 7.5 million. On the other hand, if only 50% of the outpatients are exempted, Rs. 12.5 million can be collected annually. In view of administrative convenience, a uniform low rate for each unexempted outpatient is preferable to levying different charges for different services and different types of users. Additional services 23. APVVP proposes to set up special outpatient clinics and offer diagnostic services for the private sector. The market for the latter is estimated to be large. The decision to offer these services would have to follow a more precise estimate of demand. Preliminary estimates indicate that about as much as Rs. 10 million can be raised through the sale of these services. - 70 - Annex 4 Page 7 of 7 Administrative issues 24. Current procedures for collecting revenue from paying beds are rather informal and would prove unsatisfactory when the number of paying beds is expanded. Institution of new collection methods requiring formalizing procedures, appointment of additional staff and training of staff in new procedures is proposed under the project. Monitoring the flow of collected funds and the enforcement of exemption rules will also be required. It has been proposed that approximately one-third of the revenues will beq retained at the point of collection to provide incentives to hospital managers. Centralizing the remaining two-thirds of revenue collections at the APVVP head office is justified in view of APVVP's mandate to ensure equitable access and quality of hospital services across different geographic regions. Summar 25. Annual non-salary recurrent expenditures at the end of the project are expected to be Rs. 262 million (comprising Rs. 156 million for incremental expenditures arising from the project and Rs. 106 million for the existing level of non-salary expenditures). The few simple measures oudlined above can raise revenues to the order to Rs. 45-55 million, representing about 20% of the annual non-salary recurrent costs at the end of the project. The assumptions used in the above calculations are fairly cautious. Different pricing rules, for instance a larger differential between Category a and Category B bed charges, can lead to the generation of additional revenues and also create possibilities for a greater degree of cross-subsidization. An important issue in setting bed charges is that net revenue should be substantially positive. Experience from many countries shows that the net revenue from private wards is often negative because the additional costs of providing the service have not been taken into account. On the other hand, if extra costs are not incurred in raising the quality of the care provided, the private wards may be underutilized. If the net revenue from paying wards is negative, high income patients will actually be subsidized, an unintended equity effect which should be avoided. 26. The simple simulations described in this annex indicate the possible minimum levels of revenue collection. A detailed analysis would involve the effects of prices on efficiency, equity and revenue generation and their effects on the optimal level of user charges. - 71 - Annex 5 Page 1 of 13 Organization and Management of APVVP Current Administrative Structure of APVVP 1. The project will be implemented within the existing administrative structure. The Andhra Pradesh Vaidya Vidhana Parishad (APVVP) will play a central role in implementing the project. It will interact closely and coordinate its health care delivery with the three major Directorates reporting to the Principal Secretary Medical, Health and Family Welfare Department: Medical Education, Health Services and Family Welfare Program. In addition, APVVP will also coordinate with the five smaller Directorates that look after the AIDS Program, Preventive Medicine, Employees State Insurance, Indian System of Medicine and Drug Control. 2. APVVP was established through a Legislative Act in 1986. the result of the Andhra Pradesh Governments' considerable commitment to improving its health system, particularly its secondary hospitals. The APVVP is a Commissionerate set up specifically to improve the functioning of secondary level hospitals. APVVP's objectives are to provide access to adequate patient care in rural areas and support to the primary health care network, reduce pressures on the overstretched tertiary hospitals in the cities and mobilize resources from the market as a supplement to the state budget to improve, upgrade and maintain health care institutions. 3. APVVP is managed by its Governing Council consisting of 5 members of the medical profession and Legislative Assembly nominated by the Government of AP, and 6 ex-officio members that include the Secretaries of Health and Finance Departments, APVVP Secretary, Commissioner Institutional Finance, Vice-Chancellor of the University of Health Sciences and the Director of Health. The Governing Council has powers to make regulations, borrow money and to levy fee for services as well as management of the Commissionerate. The Government has powers to issue directions to the Commissionerate in matters of inspection and control, to make rules and undertake audit of APVVP accounts. The Commissioner, who is the Chairman of the Governing Council and is the Chief Executive of APVVP, is appointed by the Government from among the members of the medical profession who have administrative experience. APVVP is a government agency reporting to the Government through the Secretary, Department of Health, Medical and Family Welfare. While APVVP functions in effect like a Directorate within the Department of Health, Medical and Family Welfare, the use of a corporate vehicle provides significant potential for improved efficiency in contracting, disbursement and management matters as well as in providing non-govemmental participation in the health sector. The flexible organizational structure of APVVP has not been adequately utilized in the past. The proposed project would make it possible to fully use the organizational flexibility assigned to APVVP through investments in first referral facilities. 4. The following section is an exposition of the management and organization issues faced by APVVP, both in structure and in function (see chart for APVVP's organization and management functions and responsibilities). In each case, the section 'Action Taken' refers to - 72 - Annex 5 Page 2 of 13 actions taken during the preparation of the project. The 'Action Required' section refers to issues that are being addressed by the project. Greater freedom of action for APVVP Issues 5. Although the Act setting up APVVP was passed in 1986, not all the implications of the Act have yet been implemented. The two most significant areas in which the freedom envisaged in the Act need to be implemented are: (a) Staff remain government employees on deputation from the Department of Health, Medical and Family Welfare, and are subject to all government regulations and restrictions. Examples of the latter include reliance on the state's recruitment and promotion machinery; restrictions on employing staff from outside the state, and for some cadres, outside the zone; and, with some exceptions, adherence to state wide salaries and benefits. The consequences of these restrictions are explained in Annex 7 on 'Workforce' issues. (b) Despite reference in the Act that APVVP would be permitted to charge fees for services provided, it is not allowed to do so without Government clearance. Charges are being levied for long established services such as medical certification, or for new services, where there is no political sensitivity, such as ultrasound testing (50R). In this respect APVVP is in a similar situation to that of the independent tertiary hospitals such as Osmania, which also need government approval for fee increases. (c) Reasons for the restrictions on workforce matters include concerns about setting precedents for health cadres employed in other government health agencies, and the desirability of retaining sufficient flexibility that staff are able to transfer readily between agencies, without compromising their seniority or pension rights. 6. To meet these objections APVVP has been revising the various sets of regulations which govern employment matters, in order that the government may approve them and delegate responsibility for implementing them. This approval requires referral to various Departments such as Finance, and to the Special Chief Secretary of Health, Medical and Family Welfare, and to the Chief Secretary. The 'General Services Regulations' have already been revised and approved, and have been used as a model for revising those in force within the Directorates of Health Services and Medical Education. - 73 - Annex S Page 3 of 13 7. Specific cadre regulations, which define categories and grades of staff, are being prepared for approval. It is anticipated that approval covering all staff matters will be delegated to the APVVP shortly. 8. The advantages of implementing the Act's provisions for workforce matters can be seen? in the marked improvements regarding the supply of drugs and consumables since APVVP was given greater freedom over purchasing, and in the progress they have been able to make in developing the project proposals by having freedom to contract out work to consultants. Actions Taken and/or Understandings Reached 9. Understanding has been reached with GOAP that APVVP will have access to all deposits of money allocated as part of the project, including unspent funds rolled over into new financial years. 10. APVVP has agreed to engage key additional HQ personnel to be recruited under the project by June 30, 1995. 11. Successful implementation of the project will depend on the removal of restrictions on workforce issues. APVVP will be given authority to recruit staff. This would include authority: - to advertise, appoint, promote, and transfer staff internally; - to post staff as needed in tribal areas; - to introduce appropriate incentives; and - to relax standards where necessary to make use of temporary contracts and deputations as needed to maintain services when appropriately qualified staff are unavailable. 12. As discussed in more detail in the Letter of Health Sector Policy, APVVP is being encouraged to generate income in ways permitted in the 1986 Act. Clearer 2oals. objectives and procedures Issues 13. Clarity about the clinical and managerial goals and objectives of hospitals, services, and constituent managers and departments, should be emphasized throughout the system. The Workshop held in November 1993 clearly delineated the clinical components to be carried out at each level of the system, and the referral mechanisms have now been refined. There is an - 74 - Annex 5 Page 4 of 13 attitude amongst some district level officers that they are deliverers of clinical care, discrete from the other primary health care activities going on around them. Many do not see themselves playing a role in supporting PHC and national/vertical programs. 14. Job descriptions and attitudes to work tend to be process oriented, rather than focused on achieving defined objectives. The assumption is that appointees will naturally understand what is required of them. In practise, district co-ordinators complained that they suddenly found themselves in administrative positions, with little or no idea as to how they should carry out their roles. 15. The current system is highly centralized, with little delegation of authority. Even the appointment of a Class IV worker (i.e. a low level worker earning Rs. 1875 a month) requires the presence of a Joint Commissioner, even though an objective testing procedure has been developed. Under this arrangement, either a Joint Commissioner must make an expensive journey to confirm the appointment, or the hospital is bereft of a cleaner until a Joint Commissioner visits. A number of solutions could be implemented e.g. a temporary appointment for later ratification; delegation of responsibility for such junior posts to the RMO; or confirmation via mail, fax or phone. Action Taken and/or Understandings Reached 16. Missions and goals are being prepared for all hospitals, following a common style, but allowing for local conditions e.g. particular responsibilities for cyclone situations. Within hospitals there is also a similar need to define services more clearly. Clearly delineated objectives will ensure that staff appreciate their wider health role. 17. Regulations and procedures are being reviewed. The manuscript version of a new SOP manual is now being checked within APVVP with a view to its early production and distribution. It was also agreed that the Joint Commissioners of APVVP would undertake production of core job descriptions based on government regulations, and APVVP policies, which could be adapted by local managers. 18. Delegation of responsibility throughout the system, especially to district level is desirable. The revised procedural manual will endeavor to iron out the sorts of problems described above, and there appears to be a willingness at all levels to begin working this way. In particular, APVVP has agreed to pay attention to delegating budgets to district level, and from district to RMO level, in a staged manner through the life of the project. 19. In addition to clearer objectives and procedures, in order to support increased delegation, there will be training to ensure all managers are capable of performing the role required of them (see 'Management Training'), and strengthened supervisory capacity. - 75 - Annex S Page 5 of 13 20. As and when APVVP is permitted to raise significant revenue through income generation and patient charges, a system of business planning will be introduced. For instance, based on local and historical data, the next year's activity level will be estimated, both in terms of clinical activity (number of patients seen etc.) and charges to be made, so that a realistic budget can be agreed. This will focus activity, and allow for closer supervision. The notion of units being able to retain a portion of the income generated has been included in order to maintain motivation. This will not be practicable until the hospital's quality has been raised. Improved Supervision Issues 21. Effective supervision has been lacking for a variety of reasons. As well as making it clearer what people are supposed to do, and training them in supervisory techniques, there is a need for better communications links between units, clearer lines of responsibility, more capacity in the system for monitoring and more transparency of decision-making and action. Action Taken and/or Understandings Reached 22. Clearer links between units is being achieved by ensuring telephone, fax and radio linkages to the maximum extent allowed by the Indian phone system, and by some increase in the availability of transport. NICNET is being used for sending information to HQ from district level. 23. Extra capacity is being addressed by introducing District Co-ordinator offices with additional staff (378 extra posts), and physically separating the District Co-ordinator activities from the person's clinical role as head of the District Hospital. The APVVP HQ is also to have additional staff and a restructuring of functions. Clearly delegated responsibilities will also generate more time to attend to monitoring and supervision. 24. Transparency will be encouraged through several mechanisms. The roles and functioning of the Hospital Development - cum - Advisory Committees are being reconsidered to improve their role in reviewing performance and links with the community. The new District Referral Committees and quality strategy will automatically consider linkages and weak spots. 25. More attention will be paid to ensuring that users understand what they can expect, or not expect, by IEC activities, posting information in Out Patient Areas, advising Panchayat and NGO leaders etc. This will be a local responsibility, with activities monitored by the centre. 26. Adequate fuel, oil and lubrication allowances will be made available. - 76 - Annex 5 Page 6 of 13 Contracting Out Services Issues 27. It is recognised within APVVP that it is often more efficient and/or effective to use private contractor services, instead of direct labor. Several years ago, the state decided to contract out all hospital kitchen services. However, there is political sensitivity about 'privatizing' health, and also some concerns about quality. Within the state there is variability in the availability of private services. In view of the difficulties with employing government staff, such as slow recruitment and poor attendance, and the desirability for managers to focus on performance rather than employer matters, further progress in this area is recommended. 28. The possibility of using private sector suppliers of health, with APVVP playing a 'purchaser' role instead of a 'provider' role, is unlikely to be politically acceptable. In the past the state has employed private doctors as part-time consultants, but this was stopped on the basis that it favored the doctor's reputation more than it improved the government sector's clinical services. Action Taken and/or Understandings Reached 29. APVVP would be given responsibility to monitor the cost-effectiveness and quality of existing contracted services. The Governing Council of APVVP would therefore review and propose implementation of private contractual services, especially supporting services in accordance with an agreed plan. District Co-ordinators will keep APVVP management advised about local problems, the availability of local private services and any desire to extend contracting in their units. Management Training Issues 30. This project is designed to improve the quality of health services delivered by APVVP, and to this end there is to be a major increase in the facilities, equipment and consumables available. In addition, there will be a major increase in the number of new staff appointed. At the same time, all systems and procedures are undergoing review and a new medical records system is to be introduced. A quality improvement strategy is being implemented, new responsibilities are being allocated, and it is hoped that decision making will be decentralized down to the appropriate management level. This would require a major training program in any system, and in one where basic training even for professional cadres has been of limited quality, and where inservice training has been negligible up until now, this is a major challenge. - 77 - Annex 5 Page 7 of 13 31. With many hospitals being renovated, extended or built over such a large area, and with no in-house training capacity, careful consideration is required about what training to offer; how it is best delivered so as not to disrupt operational services; where it is best provided and by whom; how it should be scheduled; and how it should be evaluated, when and by whom. Each cadre and level needs to be considered separately, and priorities identified. 32. There is an inevitable overlap between clinical, technical and management training, and care will be needed to ensure that the programs developed are compatible. Experience at the SIHFW suggested that where it was attempted to teach management alongside clinical material, the latter received much more attention. It was felt that it would be better to develop discrete management modules for doctors. 33. Despite discussing the possible advantages of developing a cadre of professional health managers to support medical officers, there has been widespread consensus that training for such a cadre is not yet appropriate. Action Taken and/or Understandings Reached 34. A committee was established to follow-up specific issues. The committee is chaired by the Joint Commissioner (Zonal), and includes a tertiary care clinician with a PG Diploma in Healthcare Administration, a medical educator from the Institute of Health and Family Welfare, and two District Co-ordinators. 35. The committee has reviewed the costs for management training given in the project proposal. Items for which costs have been estimated include the cost of initial TNA if outside help is required; buying or hiring equipment for district hospital post graduate training centers; transport costs for attendees (TA/DA, or travel allowance and day allocation); renting accommodation if institutions running courses do not use their own; contracting out training (see below); preparing and printing training material; consumables such as OHP slides and stationery; teaching aides; books and journals; and possible visits to other countries, or fellowships and scholarships for selected personnel to study health care management and/or its teaching elsewhere. People so trained would be additional resources to assist with teaching. 36. The committee has also carried out a questionnaire based assessment of management training needs. On this basis, they have planned to train, at the district level, the top 5 staff (115 people) in each district in multi-disciplinary courses during Year 1. This will be done in 4-5 blocks with staff from different districts so as not to denude districts at any one time. Thereafter, similar courses will be held once a year in order to cope with promotions etc. Priority will be given to post-holders, not deputies or people close to retirement. Below this level, APVVP plans to use the district staff, who have been trained as described, to teach the hospital level staff at district centers. - 78 Annex 5 Page 8 of 13 37. The courses will be contracted out, probably inviting ASCI, the state's Institute of Administration, and NIMS Departmant of Health Administration to bid for the job. All these institutions are able to sub-contract specialist faculty. It has been costed approximately, and choice of center will be on the basis of cost, capacity to meet the targets and the learning approach. 38. The committee has included the following suggestions in the project proposal. (i) People at all levels will have a clearer idea of their role and how it impinges on others. For technical staff, pharmacists etc., this should be included in their technical training. (ii) Staff will work together in teams. Some of the training of, for example, the RMO, Head Nurse, and Pharmacist, will be given to them in teams. Similarly, to improve understanding and co-operation between District Health & Medical Officers and District Co-ordinators, they will be given joint training. (iii) A third area addressed is the familiarization with APVVP and government rules and procedures. especially regarding personnel and financial matters. (iv) Specific aims of the project, such as quality improvement, communications with tribal groups, medical records etc. have also been covered.(v) General managerial topics designed to improve performance e.g. communications, problem solving, supervision and so on are also being considered. 39. The committee has analyzed numbers, reviewed course content elsewhere in order to develop appropriate curricula, identified and screened possible contractor institutions etc. It is in a position to let contracts and develop an assessment methodology so that training can start by the end of 1994. There is a clear agreement that curricula and delivery system should emphasize practical understanding and skills enhancement. Hence they should be participative and experiential rather than didactic. 40. It was decided that generally district level staff should receive training organized centrally, and that staff from community and area levels should be trained at the district levels. Strengthening Management 41. A key component of the project is institutional strengthening of APVVP. One aspect of this will be accomplished by the increased management training already discussed in the previous section. The second aspect will consist of both enhancing staffing and providing key services to facilitate project activities. 42. The new secretary is clearly a major contribution to the system, and measures are being taken to encourage delegation of authority. The manual of procedures has been published, and will provide the basis for a better understanding of what is expected of managers at all levels. 43. The proposal is to increase staff strength at the Head office from 103 to 143 i.e. an addition of 40 posts including 3 additional posts at the equipment storage facility at King Koti - 79 - Annex 5 Page 9 of 13 Hospital in Hyderabad. This will provide the required staffing to meet the increased workload and reorient the structure of APVVP to meet its new challenges. 44. Specific areas targeted and posts proposed are: 45. Training and Referral Unit. One new post of Joint Commissioner, Training, Referral, M&E and IEC has been created. Under this Joint Commissioner, two new posts of Deputy Commissioner have been added. The first will be in charge of Nursing, Training and Referral. Training will consist of both management and clinical training (see Annex 11). In addition, referral and support for PHC will be provided by co-ordinating with the Directorate of Health under the District Referral Committee. The Deputy Commissioner assigned to this task will be assisted by a Junior Assistant. A second Deputy Commissioner will deal with Monitoring and Evaluation and IEC (Information, Education and Communication, with special emphasis on tribal areas). The Deputy Commissioner will be assisted by two Senior Assistant Programmers. A Deputy Statistical Officer and Statistician who are already employed by APVVP will be re- assigned to this unit. 46. Finance and Audit Unit. Due to the increased demands on expenditure controls and auditing requirements, this unit will also be expanded. On the Auditing side, a new Deputy Audit Officer, 2 additional Assistant Audit Officers, 2 Section Officers and 2 Senior Accountants will be appointed. On the Finance side, an additional Finance Officer, 2 Section Officers, 2 Senior Assistants and 2 Junior Assistants will be appointed to meet the increased workload. 47. In addition, the Office of the Joint Commissioner (General) will also be strengthened by adding a Biomedical Engineer to help with equipment procurement and 2 draftsmen to help with civil works. The Equipment Maintenance and Training component under this Commissioner will also be strengthened as described in Annex 10 (Equipment Maintenance and Training in APVVP Hospitals). 48. Finally, the Office of the Joint Commissioner (Service Delivery) will be strengthened by the addition of a new Section Officer for general procurement, 2 Senior Assistants, and 1 Pharmacist for general procurement of drugs and medical supplies. 49. The attached chart shows the existing and proposed additional staff of APVVP and its organizational structure. Medical Records and Management Information Systems Issues 50. The strengthening of MIS and HMIS is intended to facilitate systems improvement, wider access and improved data collection and utilization for planning, policy making, problem solving - 80 - Annex 5 Page 10 of 13 and monitoring. Specifically, the objectives of the MIS and HMIS in the project are to: assist improvement of the institutional framework for policy development by improving the information available for sectoral review and policy development; strengthen APVVP institutions and their implementation capacity facilitating rational planning and resource allocation, and more focussed problem solving at all levels; and upgrade clinical effectiveness and quality of services at all hospitals by better supervision, patient management and resource utilization. Current Situation 51. Up-to-date, accurate information is required at all levels of the health care system, from clinical decisions in hospitals upto policy making in the secretariat. Planning and resource allocation, research and problem solving, supervision, monitoring and evaluation all require underpinning with an adequate information system. 52. In AP, at the hospital level, information collection in departments is fairly rudimentary, consisting of ledgers recording basic registration details such as patient name, sex, village etc. Some activity records (e.g. operations carried out) are available; basic accounts are kept; and ledgers and bin cards for stock control are available. Management itself is fairly rudimentary at this level, being basically day-to-day administration and response to problems as they arise by the senior doctor. 53. There are no medical records for out-patients, and for in-patients records are variable and sometimes difficult to retrieve. This situation is the result of various factors, including lack of stationery, lack of diagnostic services so there are few results to record, lack of incentive and lack of training. 54. The District Co-ordinator (the senior hospital doctor at the district hospital who is overall responsible for the management of the hospitals in the district) collects information for reporting to APVVP HQ. Many of the statistics collected are those developed under IPP II and IV, or for reporting to the Health Intelligence Bureau of the national MoH on morbidity, mortality and communicable diseases, in order to generate national statistics and reports. Until recently the NICNET system was not being used by the APVVP districts to report these statistics, and there is no in-house computerization at this level. It has now been agreed to use NICNET. 55. At APVVP level, there is a computerized information system which is able to generate information about a number of fields, by zone, district and hospital. Compliance with existing report formats was implemented early, and a computerized system was developed to facilitate generation of hospital activity indicators. For example, it is possible to show how the system can compare hospitals and districts by average length of stay; bed occupancy; turnover intervals; cumulative IP days; ratio of OP:IP days; as well as the basic information on numbers of beds, EPs, OPs, deaths and discharges. - 81 - Annex 5 Page 11 of 13 56. Similarly, during project preparation, it was evident that the manpower information system is effective. It is comparatively easy to obtain reports by cadre, hospital, district and zone on posts sanctioned, revised norms and vacancies, as well as the basic salary ranges by cadre. With greater responsibility for recruiting all cadres, there will be greater need for accurate manpower information, and also greater opportunity to confirm its accuracy and comprehensiveness. Actions Taken and/or Understandings Reached 57. There are four broad elements to the proposal: (i) enhancing and extending the computerized system through provision of hardware and software, and consultancy support; (ii) establishing trained and equipped informatin cells at HQ and district levels; (iii) training all management staff in the importance and use of information and ensuring SOPs and procedures include appropriate record keeping; and (iv) the introduction of a completely revized medical record system for IPs and diagnostic services. 58. The proposed equipment and software requirements, divided between HQ and district allocations, are shown in Figure 1. The computer service at district level will be part of the District Co-ordinator's implementation cell, based at the district hospital, but with the responsibilities over the whole district. A bio-statistician, an office superintendent and an accountant, as well as clerical support will be recruited for each district. They will receive in- service training. Workshops, studies, and consultancy allocations to develop training packages will be developed as necessary. 59. APVVP will want to consider their own monitoring indicators and the Bank's performance indicators (Annex 18) for various aspects of resource control, activity analysis, and quality. Their existing systems will not necessarily be able to readily extend to cover all the new requirements, so consultancy assistance has also been included to enable review and enhancement of the existing hospital activity and manpower systems already in place. 60. In terms of implementation, the intention is to ensure that the new systems, personnel and equipment, with initial training in the use of the hardware and software are available during the first year of the project. All the top five managers in each district will receive management training, including training in information, record keeping and supervision during the first year, and an increase in the allocation for stationery has been included in the project, so that managers and departmental staff should be able to collect and submit the raw data required. 61. The medical records system needs a thorough review and the format to be used needs to be developed and and agreed upon. Essential data needs to be recorded and a plan needs to be devised on records to be stored and analyzed. APVVP plans to deal with this later in 1994 when the relevant extra staff have been appointed. It will need clinical and quality assurance inputs. Centers in AP, such as Osmania Medical Center, are reported to have good systems which 82 Annex 5 Page 12 of 13 provide a model. A seperate allocation has been included in the project, Rs. 750,000 a year, to permit the printing of new records, including registration cards, I/P case notes, departmental report forms and test requests. 62. It is proposed to maintain records for O/P within hospitals, so storage space is being designed and equipped for I/P records only. An additional 91 records clerks will also be recruited, and training will be provided for them. These records will begin to provide a source of information for better planning, epidemiological surveys, assessment of case mix, and quality review through clinical audit. Understandings Reached 63. Although no O/P records will be stored at the hospital, it is desirable that O/P are given some sort of registration record, to reduce duplication of tests and examinations, ensure recognition of previously identified drug reactions, and to alert the doctor of underlying chronic disease such as diabetes. It would also be very helpful in supporting the referral system being established. Various records have been issued under maternal and child health and vertical programs, but there is nothing from the secondary hospitals. Currently, patients are merely given a flimsy chit showing what drugs or tests are needed, which they take to the pharmacy or diagnostic department. No permanent record is then kept. 64. Evidence from elsewhere suggests that patients are able to safely keep such cards, especially if a small charge is made for them. It is recommended that a suitable record be designed, perhaps a more resilient plastic laminated card, which could have basic information punched on it e.g. date of birth, blood group, penicillin allergy, tetanus immunization, diabetic; for women, the number of births etc. The cost of doing this, however, has to be considered against other options. Alternatively, a small booklet could allow the doctor to record a short note of any preliminary diagnosis, and if the patient is being referred to another level, s/he could carry this note with them. 65. The numbers of patients seen in clinics is very high, and some clinicians fear that taking time to write notes would merely clog the clinics further. However, until recently, they had artificially shortened clinic hours which made for unnecessary time constraints. A recent decision to lengthen clinic hours throughout the morning, and the additional medical staff proposed, should greatly relieve the time pressure, and permit at least basic notes to be recorded. A.P. Vaidya Vidhana Parishad (APWP) LEGEND Organizational Chart * Sanctioned Post already Exists Commissioner 0 New Post Created by this Project APVVP General Support Services Training & Referral Service Delivery I I~~~~~~~~ I -l 0 Joint J_ls_t * Jouit Commissioner oi C_E C_ IEC tt;_ (Nws S __________________ _____;---------;-- -------------------__ ( =.. r - _e~ _ ,,__ tw 0 WSerno *~~~~~~~~~~~~~~~~~~~ LS | _ I tdl 1S N_^ Ul _ P ~~~~~~~r_ddU| Tr-w ItME ad IEC I- 0 huiPhal 0. Weoa tmm Nu,hg U. w .,udk Usk a ReferA) Fert.wmo tELm Pr~.fme. thwl Pn_ri Utk C _wmbI tUak 00 Sr ASH Prrnp |f bfr mpi | tor Drop * le Eqe 0 Son osr, * se.. Ofl1w 0 Jr Aso 0 Dy Staite Ofl, Eq M E *SwSK EWcr * Sr Aek O* St Acs-wou c St Aenis 0 sawd * Srn_ 0Iot -F O @0 Sal"ior a.. , o ImodEa 0, *r Aus, a. 0 Dp a F * Ty.a 0 Ir A__ I O|C Sr ASheaN 00 Si A/tt .w * steih.OWe 0 E Aonm 0 Fg * Tyrp T S kr. Aaan 0 kr An.m .S As,. n S Typir *000 D.nMI . Typiss 0 tw ti *0 Tyt 0 TYp| Equip Mais & Tralig SceayOfc I Cr"-u |Vigilance Ofrice Secretary Ofrice (Hyderbd) j - Ll | P ~~~~~~~~Vrnguiiice * Secrelary * r. EgraneI Officer 00 TlMue Sq|NVis. 0000 1u. S r |i | Sm Offlr I 0 LDS_ | | 0 Ir. St ry Wmhr|S Sr Aita|l | * Typiu | A| serid SWscnuy 1 411114-1111 | Finance & Audit 0 s| | | JO Ir A-Uffi ypa. | r * 5 TYr P- ||O k SrAy Wrare F~ otrwr I |e Tt Op-rra C.2mg.* 0~~~I rylimf *o Dy F' . Otletirer ......... | * Terrl A Oer, | | * aAe re O , 00 oSpa"y FO orr, Anmr Aedw Offmrr, S RDrd t 0 h. Eftima ~~~~~~~~~~0 Opn Ene k Offeon J rts ActsO5rer SODpeaeto (Reeon Cotloninti 0 Srry o r0 | 0 | edwlma ZONE ~ P" i 00 ke Aenu/Typi 11 |LDO S| A 00000 Er EST 000 S ED Seaii 0 EI A |n/IytD 00 Er. Srmy W Ie such ZONEI LS Ji - 84 - - Annex 6 Page 1 of 26 Workforce Issues Issues 1. A significant restriction on improving services in APVVP hospitals is the workforce, both in terms of quality and quantity (see attached tables on medical vacancies). 'Yardsticks' defining the sanctioned staff at hospitals of different sizes were agreed in 1977, and no longer fit current needs; there are many vacancies, some of which are a consequence of poor management practice (Annex 5), and some of which are a consequence of inadequate salaries, or of supply side problems. t 2. As an example of poor practice, the last medical and nursing recruitment took place in 1991/92, although it was supposed to occur annually. For 787 posts advertised, 4,666 doctors applied, 769 were offered posts, and several hundred failed to take up their post. The failure to take up posts is particularly a problem for postings to remote and tribal areas. In other words, there is not an absolute shortage of staff, but there is a shortage of staff available for deployment in all areas. 3. The evidence, from APVVP and other local respondents, and the report of the Indian Society of Health Administrators (ISHA) on manpower in India, suggests that there is not an extreme shortage of professional staff overall. Pharmacists, technicians, and MBBS grade doctors are available in the state, but there is a shortage of some medical specialities and of nurses. There has been a recent advertisement by the Director of Health on behalf of the APVVP to recruit 381 doctors, and there are 4,746 applications awaiting processing. Government posts are preferred because of the overall higher benefits compared to the corporate sector, where only very senior doctors can charge consultation fees, and the rest are paid a set rate for the job. 4. Some current employment practices exacerbate supply problems by unnecessarily restricting posts to holders of higher academic or professional qualifications, a situation supported by local professional interests. Motivation of otherwise able people suffers, and employment costs are raised. Costs are also raised by the practice of employing a number of specifically named cadres instead of having a pool of workers who can cover several related jobs. Employing several similar workers also overcomes the problems which result from high absenteeism. 5. The productivity of staff is low, with poor attendance, and inefficient procedures. There is little in-service training, and professional staff are not up to date in their clinical and management skills. Incentives to motivate staff to achieve are few. Indeed many practices inhibit motivation e.g restricting senior posts to staff holding academic or professional qualifications, rather than allowing competition from experienced individuals who have demonstrated their managerial ability. - 85 - Annex 6 Page 2 of 26 6. The increase in staff as a result of the project, particularly doctors, will be sizeable. Workforce MIS at APVVP is difficult to compare with what is being proposed in the project. Details of Workforce MIS are in Annex 5 (Organization and Management of APVVP). Action required and/or taken 7. Workforce problems are being addressed by the Government, and through the proposed project. Recruitment procedures used by APVVP are being reviewed to reflect the more independent role discussed in the Annex on Organization and Management of APVVP (Annex 5) in the section on "Greater Freedom of Action in APVVP". All procedures, including those pertaining to recruitment, are being reviewed currently. The aim is to streamline decision making by relying on clear criteria and delegation of responsibility, rather than bureaucratic centralisation. 8. The size of the total proposed size of the workforce by cadre, compared to current total sanctioned workforce has been reviewed and are shown in the attached tables. Cost implications of this workforce have also been taken into account in project cost analysis. 9. The project proposal includes a manpower inventory at the start of the project, and a close monitoring of the workforce situation throughout the life of the project. This includes vacancies, speed of appointment, numbers taking up posts, attrition rates, etc, to permit on going review of the situation, and the implementation of appropriate action to rectify any shortcomings. Current MIS facilities are good, but, as indicated in the proposal, will need to be refined to enable this to occur, and to permit better understanding of the cost implications for the project. Restructuring of the APVVP HQ as planned should aid co-ordinated attention to personnel matters. 10. Since there appears to be no supply side problem, there is no need to develop widespread additional incentive packages at this stage, and the first strategy is to improve recruitment practices. At the moment, the situation is being addressed through provision of improved facilities and accommodation, and when APVVP handles its own recruitment activities it will be far more flexible in matching applicants' needs and interests with postings. 11. However, it is likely that there will continue to be problems in recruiting staff for rural and tribal areas. The project will address this situation with the construction of an additional 42 Type II, 31 Type III and 23 Type IV new staff quarters for all medical staff in tribal areas. Moreover, APVVP has agreed to offer other benefits to medical staff to increase their committment to tribal postings, such as: a bonus at the end of a specified period of posting; educational allowance for their children; additional leave eligibility; and extra weightage for doctors and other staff for PG qualification admission and for fellowships. 12. A Workforce Review Team has been set up at APVVP to appraise these packages of benefits and incentives for effectiveness and cost. Their terms of reference have been - 86 - A-nnex 6 Page 3 of 26 expanded to review the effectiveness of the new recruitment procedures, once they are implemented. They will also consider the implications of supply side changes, such as a change of 'corporate' hospital benefits, or increased foreign demand. This team would also sponsor ongoing studies to identify exactly what the position is regarding, for example, the supply of anaesthetists or other suspected shortages, where current evidence is contradictory. 13. In addition, the new Strategic Planning Cell in the Department of Health, Medical and Family Welfare would monitor the overall situation regarding supply side and inter- governmental matters. 14. More effective use of the workforce will generally be aided by the training being provided (see Annex 5, section on 'Management Training'), which will include supervision and leadership skills as well as rewards for good practice. These would include bonus incentives, preferential treatment for training and/or promotion, or simply some sort of "public" recognition. Attention is being given to revising job descriptions and to setting out clearer goals and objectives, which will make it more obvious what people are supposed to achieve (see Annex 5, section on 'goals and objectives.') 15. In order to encourage higher standards of performance there also needs to be more empowerment of users, for example, by better publicity about the services they can expect (see Annex 13, IEC Strategy), and stronger monitoring by Hospital Development Committees, etc. This will focus attention on poor attenders, or low performance standards. Strengthening the Vigilance section of the APWP HQ would also help to overcome absenteeism and the consequent non-availability of services. 16. The project proposal already shows a general move to multi-skilling/multi-tasking, and the proposed yardsticks and the clinical referral system developments seek to encourage this. In particular, there has been a marked drop in the number of specialists earmarked for many posts, especially at community hospital level. It is also proposed to employ ANM/MPW(F)s to cover about 25 % of the nursing posts in maternity areas, on a temporary basis, although this will require training for the MPWs. The current yardsticks for nurses have been confirmed by local nurse managers as permitting adequate 24 hour coverage of the facilities planned. Similarly, it is proposed to convert the various thotis, stretcher bearers, etc, into one grade and designate them as general worker. -87 - Annex 6 Page 4 of 26 APVVP Medical Workforce S.No. Category Sanct- Revised ioned total total (APVVP NORMS) 1. C.8.S. 242 369 (Ra .5390-8980) 2. C.S.R.M.O. 21 68 (Rt .5390-8980) 3. DY.C.S. 152 259 (RI .4400-8700) 4. DY.DENTAL SURG. 16 21 (Rs.4400-8700) 5. C.A.S. 704 1402 (Rs .3640-7580) 6. D.A.S. 98 123 (Rs .3640-7580) _____________________________ GRAND TOTAL 1233 2242 …-- - - - - - - -._ _ _ _ _ _ _ _ _ _ _ _ _ _ -- - -l - - - - - - - - - - - - - - - - - - - - - - - - - - 88 - - Annex 6 Page 5 of 26 S.No. Category Sanct- Revised ioned total total (APVVP NORMS) 1. Occupational 1 0 Therapist (Rs.2750-5960) 2. Physiotherapist 0 01 (Rs.3640-7580) 3. Nursg.Bupdt.Gr.I 3 7 (Rs.3310-6840) 4. Nurig.Supdt.Gr.II 23 68 (Ri.2930-5960) 5. Head Nurse 316 488 (Rs.2525-5390) 6. Staff Nurse 1818 3185 (Rt.2315-4880) 7. Nursing Orderly/ 1200 1316 (Rs.1375-2375) 8. A.N.M/M.P.W 319 470 (Rs.1873-3750) 9. Med.Sl.Wr.Gr.I 6 O (Rs.2375-5040) l0.Med.Sl.Wr.Gr.II 11 0 (Rs.2075-4270) 1.Lady H.V. 4 7 (Rs.2075-4270) 12.Health Inspector 10 68 (Rs.2075-4270) 13.Health Suprvr. I _ (Rs.2315-4880) 1A.Pharmacist Suprvr. 0 42 tRs.2600-5580) 15.Pharmacist Gr.I 6 68 (Rs.2195-4560) 16.Bio-Chemist 0 2 (Rs.3310-6840) 17.Pharmacist Gr.II 428 442 (Re.1975-4010) 18.Radiographer 171 192 (Rs.2075-4270) _ 89 _ Annex 6 Page 6 of 26 S.No. Category Sanct- Revised ioned total total CAPVVP NORMS) 19.Lab Technician 223 289 (fSn. 1875-3750) 20.Lab Attendant 115 164 (Ri.1535-2840) 21.ECG Technician 2 0 (Rs.2075-4270) 22.Dark Room Aset. 163 192 (Rs.1665-3200) 23.Refractionist 20 21 (Rs.2075-4270) 24.Optometerist/ 2 0 Ophth.Aset. CR,.2195-4560) 25.Theatre Agst. 79 168 (Rs.1535-2840) 26.Electrician 26 70 (R*.1875-3750) 27.Lay Secy.Gr.I - 21 (R%.3640-7580) 28.Lay Secy.Gr.II 19 68 (Rs.3110-6380) 29.Off. Supdt/ 22 42 Aecountant (Rs.2600-5580) 30.Bio-Statistician 0 21 (Rs.2600-5580) 31.Sr.A,iistant 131 259 (Rs.2195-4560) 32.Jun.Assistant 323 580 rRi.1745-3420) 33.Junior Analyst 6 42 (R .2375-5040) 34.Typist 47 117 (Re.1745 - 3420) 35.Data Processing Officers 0 21 (Ro.2600 - 0580) - 90 - Annex 6 Page 7 of 26 …-- - - - - - - ----- -- - ---- - - ----- --- -- --- -- ------- ---- --- -- -- S.No. Category Sanct- Revised ioned tota. total (APVVP NORMS) 36.Telephone Opr. 3 133 Reception. (Rs.1745 - 3420) 37.Record Asst. 35 91 (Rs.1535 - 2840) 38.0ff.Attdt./Peon 165 184 (Rs.1375 - 2375) 39.Dhobis 229 0 (Rs.1375 - 2375) 40.Mali 148 42 (Rs.1375 - 2375) 41.Driver (Amb.) 98 239 (Rs.1595 - 3020) 42.Cleaner/Amb.Attn. 24 150 (Rs.1375 - 2375) 43.Mechanic 20 0 CRs.1375 - 2375) 44.Plumber 26 68 (Rs.1375 - 2375) 45.Carpenter 19 0 (Rs.1375 - 2375) 46.Barber 39 0 (Rs.1375 - 2375) 47.Tailor 18 21 (Rs.1375 - 2375) 48.Thoties/Sweepers/ 1499 2403 JSWs. (Ri.1375 - 2375) 49.Watchman/Waterman 224 382 (Rs.1375 - 2375) GRAND TOTAL 8042 12164 --- - --- ---- --- ---- - -- -- - - --- -- -- -- - -- -- - -- -- - - 91 - Annex 6 Page 8 of 26 Yardsticks of Staffing Pattern of Community Hospitals Existing Government Norms and APVVP Norms (30 and 50 Bedded Hospitals) S.NO. NAME OF THE 30 BEDDED HL. 50 BEDDED HL. POST --------------- ------------------ 1977 Y/S. APVVP 1977 Y/S. APVVP + LATEST PROPOSED - LATEST PROPOSED ADDN. Y/S. ADDN. Y/S. -------------------------------------------------------------- 1 2 3 q 4 5 6 1.CL.SURG.SPL. 1 - l (Rs.5390-8990) (O&G/GM/ GS/PAED.) 2.DY.CL.SURGEON 1 1 I (Rs.4400-8700) 3.CIV.ASST.SURG. 3 '4 4 5 (Rs.3640-7580) 4.DENTAL ASST.SURG. 1 1 1 (Rs.3640-7580) 5.HEAD NURSE 1 1 1 1 (Rs.2525-5390) 6.STAFF NURSE 6 6 10 10 (Rs.2315-4880) 7.A.N.M. 1 Z Z (Rs.1875-3750) B.NURSING ORDERLY 3 3 5 5 (Rs.1375-2375) (M-Z; (M-3;F--P) F-1) 9.PHARMACIST GR.II 1 z 2 (Rs.1975-4010) 10.LAB TECHNICIAN -1 1 1 1 (Rs. 1875-3750) 11.RADIOGRAPHER 1 I 1 1 (Rs.2075--4270) 12.DARK ROOM ASST. l 1 1 1 (Rs.1665-3200) 13.SR.ASST. - - I I (Rs.2195-4560) 14.JR.ASST. 1 l 1 1 (Rs.1745--3420) - 92 - Annex 6 Page 9 of 26 Yardsticks of Staffing Pattern of Community Hospitals Existing Government Norms and APVVP Norms (30 and 50 Bedded Hospitals) (cont'd) 1 2 3 4 5 6 15.COOKS 1 - 2 (Rs. 1375-2375) 16.DHOBI(CONTINGENCY/ 1 - 2 CONTRACT) 17.MALI(CONTINGENCY) 1 - I - (Rs.1375-2373) 18.THOTIES/SWEEPERS 5 5(JSW) 7 7 (JSW) (Rs.1375-2375) 19.DRIVER tAMB.) - 1 - 1 (Rs.1595-3020) 20.AMB.ATTENDER/ - 1 I CLEANER(Rs..1375-2375) 21.WATERMAN/WATCHMAN I 1 2 2 (Rs. 1375-2375) (WATCHMAN) T O T O L 31 31 46 43 COST 9.92 9.80 13.80 13.96 (Rs.in lakhs) - 93 - Annex 6 Page 10 of 26 Yardsticks of Staffing Pattern of Area Hospitals Existing Government Norms and APVVP Norms (100 Bedded Hospitals) S.NO. NAME OF THE 100 BEDDED HOSPITAL POST ----------------…---------- 1977 Y/S. APVVP + LATEST PROPOSED ADDN. Y/S. 1 2 3 4 1.CIVIL SURGEON SPECIALISTS 4 4 (Rs.5390-8990) 2.CIVIL SURGEON R.M.O. 1 1 (Rs.5390-8990) 3.DY.CIVIL SURGEONS - 2 (Rs.4400-8700) 4.CIVIL ASST.SURGEONS 16+4 12* (Rs.3640-7580) 5.DENTAL ASST.SURGEON 1 1 (Rs.3640-7580) 6.NURSING SUPDT. I I GR.II (Rs.2930-5960) 7.HEAD NURSE 4 4 (Rs.Z525-5390) 8.STAF, NURSES Z4 24 (Rs.E315-4880) 9.NURSING ORDERLY 10 a (Rs.1375-2375) 10.A.N.M. 3 3 (Rs.1875-3750) 11.HEALTH INSPECTOR - 1 (R5.2075-4270) 12.PHARMACIST GRADE I 1 1 (Rs .2195-4560) 13.PHARMACIST GRADE II 4 3 (Rs.1975-4010) 14.REFRACTIONIST 1 - (Rs.2075-4270) 15.LAB-TECHNICIAN 3 3 (Rs.1875-3750) - 94 - Annex 6 Page 11 of 26 Yardsticks of Staffing Pattern of Area Hospitals Existing Government Norms and APVVP Norms (100 Bedded Hospitals) (cont'd) 1 2 3 4 16.LAB ATTENDANTS 2 (Rs.1535-2840) 17.RADIOGRAPHER l1 (Rs.2075-4270) 18.DARK ROOM ASST. 1 1 (Rs.1665-3200) 19.STRETCHER BEARER 2 _ (Rs.1375-2375) 2O.THEATRE ASSISTANT 2 2 (Rs.1535-2840) 21.ELECTRICIAN l 1 (Rs. 1875-3750) 22.LAY SECY & TR.GR.II 1 1 (Rs.3110-6380) 23.ACCOUNTANT 1 _ (Rs.2600-5580) 24.SENIOR ASSISTANTS 3 2 (Rs.2195-4560) 25.JUNIOR ASSISTANTS/TYPISTS 6 6 (Rs.1745-3420) 26.TYPIST 1 1 (Rs. 1745-3420) 27.TELEP,HONE OPERATOR- - CUM-RECEPTIONIST (Rs. 1745-3420) 28.MEDICAL RECORD ASSISTANT 1 1 (Rs. 1535-2840) 29.OFF.ATTENDER 2 2 (Ri.1375-2375) 30.CARPENTER 1 (Rs.1375-2375) 31.TAILOR 1 (Rs.1375-2375) 32.COOKS 2 (Rs. 1375-2375) 33.DHOBI (ON CONTRACT) 2 34.MALI (CONTINGENCY) 2 (Rs.1375-2375) - 95 - - Annex 6 Page 12 of 26 Yardsticks of Staffing Pattern of Area Hospitals Existing Government Norms and APVVP Norms (100 Bedded Hospitals) (cont'd) 1 2 3 4 35.DRIVER (AMBULANCE) 2 2 (Rs.1595-3020) 36.CLEANER/AMB. 1 ATTENDER (Rs.1375-2375) 37.MECHANIC (Rs.1375-2375) 38.PLUMBER (Rs. 1375-2375) 39.BARBER (CONTRACT) 1 _ 40.THOTIES/SWEEPERS 15 24 (J.S.W.) (Rs. 1375-2375) 41.WATCHMAN 2 2+1 (Rs.1375-2375) 42.WATERMAN l (Rs.1375-2375) 134 122 COST 47.26 38.81 (RS. IN LAKHS) Earmarking of Specialists: CIVIL SURGEON SPECIALISTS _ (SR. CONSULTANTS) MD. GENERAL MEDICINE .... 1 MS. GENERAL SURGERY .... MD. OBST.& GYNAECOLOGY .... MD. PAEDIATRICS .... 1 * CIVIL ASSISTANT SURGEONS ... 12 (JR. CONSULTANTS) MD. GENERAL MEDICINE .... MS. GENERAL SURGERY .... I MD. OBST.& GYNAECOLOGY .... I MD. PAEDIATRICS .... 1 DA/MD. ANAESTHESIA .... 2 DCP/MD. PATHOLOGY .... 1 RADIOLOGIST .... 1 REST .... OPEN - 96 - Annex 6 Page 13 of 26 Yardsticks of Staffing Pattern of District Hospitals Existing Government Norms and APVVP Norms (200, 250 and 300+ Beds) S.NO. NAME OF THE POST 200 BEDDED HL. 250 BEDDED HL. 300 + BEDDED HL. GOVT.EXIST. APVVP GOVT.EXIST. APVVP GOyT.EXT. APVVP NORMS NORMS NORMS NORMS NORMS NORMS 2 3 4 5 6 7 a 1.CIVIL SURGEON SPECIALISTS 7 8 7 8 7 a (Rs.5390-8980) 2.CIVIL SURGEON R.M.O. 1 1 1 1 1 1 (Rs.5390-8980) 3.DEPUTY CIVIL SURGEONS 3 3 3 3 3 3 (Rs.4400-8700) (1 RMO) (1 RMO) (1 RMO) 4.DEPUTY DENTAL SURGEON 1 1 1 1 1 1 (Rs.4400-8700) 3.CIVIL ASSISTANT SURGEONS/DY. 18 18 20 20 21 21 (Rs.3640-7580) 6.PHYSIO-THERAPIST - 1 - 1 - I (Rs.3640-7580) 7.NURSING SUPDT. GRADE I - - _ _ (R,.3310-6840) B. NURSING SUPOT. GRADE II 1 1 1 l 1 1 (Rs.2930-5960) 9. HEAD NURSE a B 10 10 12 12 (Rs.2525-5390) *** 10.STAFF NURSE 48 48 60 60 78 78 (Rs.2315-4880) 11.NURSING ORDERLY 20 20 25 25 30 30 (Rs.1375-2375) 12.A.N.M. 5 5 6 6 6 6 (Rs.1875-3750) 13.HEALTH INSPECTOR - 1 - 1 (Rs.2075-4270) 14.PHARMACIST SUPERVISOR - -1 - 1 (Rs.2600-5580) 15.PHARMACIST GRADE I 1 1 1 l 1 1 (Rs.2195-4560) 16.PHARMACIST GRADE II 7 5 9 7 .11 7 (Rs. 1975-4900) 17. DENTAL LAO TECHNICIAN 0 1 0 1 0 1 (Rs.1875 - 3750) - 97 - Annex 6 Page 14 of 26 Yardsticks of Staffing Pattern of District Hospitals Existing Govermnent Norms and APVVP Norms (200, 250 and 300+ Beds) (cont'd) 1 2 3 4 5 6 7 8 18.RADIOGRAPHER 3 3 3 3 3 3 (Rs.2075-4270) 19.JR.ANALYST/(8IO-CHEMIST) - 1 - 1 - I (Rs.2375-5040) 20. JR.ANALYST/(MICRO BIOLOGIST) - l - 1 _ (Rs.2375-5040) 21.LAB-TECHNICIAN 3 3 3 3 3 3 (Rs.187S-3750) 22.LAB ATTENDANTS 3 3 3 3 3 3 (Rs.1535-2840) 23.DARK ROOM ASSISTANTS 3 3 3 3 3 3 Rs.1665-3200) 24.REFRACTIONIST I 1 1 1 1 1 (Rs.2075-4270) 25.THEATRE ASSISTANT 3 3 3 3 4 4 (Rs.1535-2840) 26.STRECHER BEARER 2 - 2 - 2 - (Rs.1375-2375) *27.ELECTRICIAN 1 1 1 1 1 1 (Rs.1875-3750) 28.LAY SECRETARY & TR. GR.II 1 1 l I1 1 CRs.3110-6380) 29.OFFICE SUPDT (ACCOUNTANT) 1 1 1 1 1 1 (Rs.2600-5580) 30.BIO-STATISTICIAN - *1 - 1 - I (Rs.2600-5580) 31.SR.ASSISTANTS 4 3 5 4 6 5 (Rs.2195-4560) 32.4R.ASSISTANTS 8 6 10 8 12 10 (Rs.1745-3420) 33.TYPL1TS 2 2 2 2 3 3 (Rs.1745-3420) 34.DATA PROCESSING OFFICER - 1 I - 1 (Rs.2600-5580) 35.TELEPHONE OPERATOR- - 4 _ 4 - 4 CUM-RECEPTIONIST (Rs.1745-3420) 36.RECORD ASSISTANT 2 2 2 2 2 2 (Rs.1535-2840) - 98 - Annex 6 Page 15 of 26 Yardsticks of Staffing Pattern of District Hospitals Existing Govermment Norms and APVVP Norms (200, 250 and 300+ Beds) (cont'd) …-- -__- - --__ __ ____-_-__-_ - _ - _- _ l1 2 3 4 5 6 7 8 …__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 37.OFFICE ATTENDER 3 3 4 4 5 5 (Rs.1375-2375) 38.COOKS 4 - 4 - (Rs.1375-2375) 39;DHOBI. 3 - 4 - 4 _ (Rs.1375-2375) 40.MALI (CONTINGENCY) 2 2 2 2 2 (Rs.1373-2375) REGULAR REGULAR REGULAR 41.DRIVER (AMBULANCE) 3 3 3 3 3 3 (Rs.1595-3020) 42.CLEANER/AhB.ATTENDANT I 1 1 1 1 1 (Rs.1375-2375) 43.CARPENTER I - I - 1 - (Rs.137S-2375) 44.MECHANIC 1 - I - I - (Ri.1375-2375) 45.PLUMBER 1 1 1 1 1 (Rs.i375-2375) *46.BARBER 2 - 2 - 2 - (Rs.1375-2375) 47.TAILOR (CONTRACT/CONTING.) 1 1 1 1 l 1 (Rs.1375-237S) REGULAR REGULAR REGULAR 48.THOTIES/SWEEPERS 25 25 30 30 40 40 (Rs.1375-2375) 49.WATCHMAN 4 4 4 4 4 4 (Rs.1375-2375) T O T A L 208 211 243 239 267 293 COST (Rs. in lakhs) 67.04 67.60 77.77 78.28 90.24 91.83 …__ _ _ _ _ _ _ _- - -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _. - 99 - Annex 6 Page 16 of 26 Earmarking of Specialists C.S.S. (SR. CONSULTANTS) 1. MD. GENERAL MEDICINE 1 2. MS. GENERAL SURGERY 1 3. MD. OBSTETRICS & GYNAECOLOGY . 4. MD. PAEDIATRICS 1 5. MD. ANAESTHESIA 1 6. MS. ORTHOPAEDICS 7. MS. OPHTHALMOLOGY S. OPEN : FORENSIC SPECIALIST/ CARDIOLOGY/RADIOLOGY/ PATHOLOGY C.A.S. (JR. CONSULTANTS) SPECIALITY 1. MD. GENERAL MEDICINE 1 2. MS. GENERAL SURGERY 1 3. MD. OBSTETRICS & GYNAECOLOGY 2 4. MD. PAEDIATRICS 1 5. DA/MD. ANAESTHESIA 2 6. MS. ORTHOPAEDICS 1 7. MS. OPHTHALMOLOGY 1 B. DCP/MD CLINICAL PATHOLOGY 1 9. MD. RADIOLOGY 1 10. rS. E.N.T. I 11. REST OPEN STAFF NURSES : The norms have been based on 325 beds i.e., one itaff nuirse for 5 beds + 20% of the total strength. - 100 - Annex 6 Page 17 of 26 Yardsticks of Staffing Pattern of M.CH. Hospitals (50 and 100 Bedded) ----------------------------------------------------------------- S.NO. NAME OF THE POST 50 BED HL. 100 BED HL. ----------------------------------------------------------------- 1.CL.SURG.SPL. 1 3 (Rs.5390-8990) 2.DY.CIVIL SURGEON 1 (Rs.4400-8700) R.M.O. R.M.O. ** 3.CIVIL ASSISTANT SURG. 6 10 (Rs.3640-7580) 4.PATHOLOGIST - 1 (Rs.3310-6840)(CLINICAL) 5.HEAD NURSE 1 2+2 (Rs.2525-5390) 6.STAFF NURSE 8 16 (RS.2315-4880) 7.A.N.M. 4 8 (Rs.1875-3750) 8.LADY H/V. 1 (Rs.2075-4270) 9.NURSING ORDERLY 5 8 (Rs. 1375-2375) (100% FEMALE) 9.PHARMACIST GR.II 2 4 (Rs.1975-4010) 11.LAB tECHNICIAN l1 2 (Rs.1875-3750) 12.RADIOGRAPHER I 1 (Rs.2075-4270) 13.DARK ROOM ASST. 1 1 (Rs.1665-3200) 14.THEATRE ASST. - 2 (rs.1535-2840) 15.ELECTRICIAN - I (Rs. 1875-3750) 16.LAB ATTENDER 1 l (Rs.1535-2840) 17.SR.ASST. 1 2 (Rs.2195-4560) 18.JR.ASST/TYPIST 1 3 (Ru.1745-3420) - 101 - Annex 6 Page 18 of 26 Yardsticks of Staffing Pattern of M.CH. Hospitals (50 and 100 Bedded) (cont'd) …____________________________________________________.___________ S.NO. N,AME OF THE POST 50 BED HL. 100 BED HL. …________________________________________________________________ 19.TELEPHONE OPERATOR - 1 (Rs.1745-3420) 20.RECORD ASSISTANT 1 (Rs.1535-2840) 21.ATTENDER 2 (Rs.1375-2375) 22.DRIVER (AMB.) 1 1 (Rs. 1595-3020) 23.AMB.ATTENDER/ 1 1 CLEANER (Rs. 1375-2375) 24.JR.SANITARY WORKERS 10 18 (Rs. 1375-2375) (100% FEMALE) 25.WATCHMAN 1 3 (Rs.1375-2375) T O T A L 48 95 COST (Rs.in lakhs) 14.36 29.51 Earmarking of Civil Surgeon Specialists and C.A.S. CL2.. S(SR.CONSULTANTS) 50 BEDS 100 BEDS SPECIALITY : MD. OBSTETRICS & GYNAECOLOGY 1 2 MD. PAEDIAATRICS 1 ** C.A.6. (JR.CONSULTANTS) SPECIALITY : MD. OBSTETRICS & GYNAECOLOGY 4 7 MD. PAEDIATRICS 1 2 MD. ANAESTHESIA 1 1 - 102 - Annex 6 Page 19 of 26 APVVP Yardsticks for Staffing Pattern of 50 Bedded Paediatric Hospital S.NO. NAME OF THE 50 BEDDED HL. POST APVVP NORMS. 1 2 3 1.CL.SURG.SPL. 1 (Rs.5390-8990) 2.CIV.ASST.SURG. 4 (Rs.3640-7580) 3.DENTAL ASST.SURG. 1 (Rs.3640-7580) 5.HEAD NURSE 1 (Rs.2525-5390) 6.STAFF NURSE 8 (Rs.2315-4880) 7.A.N.M. 2+2 (Rs.1875-3750) 8.NURSING ORDERLY 5 (Rs.1375-2375) 9.PHARMACIST GR.I1 2 (Rs.1975-4010) 10.LAB TECHNICIAN 1 (Rs.1875-3750) 11.RADIOGRAPHER (Rs.2071-4270) 12.DARK ROOM ASST. (Rs.1665-3200) 13.SR.ASST. 1 (Rs.2195-4560) 14.JR.ASST. (Rs.1745-3420) 15.JLJNIOR SANITARY WORkERS 7 (Rs.1375-2375) 16.DRIVER (AMB.) 1 (Rs.1595-3020) 17.AMB.ATTENDER/ 1 CLEANER(Rs.1375-2375) 18.WATCHMAN 2 (Rs.1375-2375) T O T A L 42 COST (Rupees in lakhu) : Rs. 13.25 - 103 - Page 20 of 26 APVVP Yardsticks for Staffing Pattern of City dispensaries (21) S.NO. NAME OF THE POST UNIT 1977 APVVP COST GOVT NORMS YARD- STICKS+ ADDITION 1. bY.CIVIL SURGEON 0.69 1 1 (Rs.4400 - 8700) 2. CIVIL ASST. SURGEON 0.56 1 l (Rs.3640-7580) 3. STAFF NURSE 0.35 1 1 (Rs.2315 - 4880) 4. PHARMACIST GR.II 0.30 1 l (Rs.1975 - 4010) 5. A.N.M. 0.29 1 1 (Rs.1875 - 3750) 6. LAB-TECHNICIAN 0.29 1 - (Rs.1875 - 3750) 7. NURSING ORDERLY 0.21 2 2 M.N.0(1)/F.N.0(1) (Rs.1375 - 2375) 8. WATERMAN/WATCHMAN 0.21 1 1 (Rs.1375 - 2375) 9. THOTIES 0.21 2 2 (RS.1375 - 2375) ____________________ T OT TA L 11 10 COST (RUPEES IN LAKHS) 3.53 3.24 ----------------------------------------------------------------- - 104 - Annex 6 Page 21 of 26 APVVP Yardsticks for Staffing Pattern of Secretariat Dispensary --------------------------------------------------------------- S.NO. NAME OF THE POST UNIT 1997 GOVT APVVP COST YARDSTICKS+ NORMS ADDITION 1. CIVIL SURGEON SPL. 0.84 1 1 (Rs.5390 - 8980 2. CIVIL ASST. SURGEON 0.56 2 3 (Rs.3640-7580) 3. DENTAL ASST.SURGEON 0.56 - 1 (Rs.3640 - 7580) 4. STAFF NURSE 0.35 2 2 (Rs.2315 - 4880) 5. PHARMACIST GR.II 0.30 2 2 (Rs.1975 - 4010) 6. LAB-TECHNICIAN 0.29 1 1 (Ri.1875 3750) 7. NURSING ORDERLY 0.21 2 2 M.N.0(1)/F.N.0(1) (Rs.1375 - 2375) 8. ATTENDER 0.21 1 1 (Rs.1375 - 2375) 13.SWEEPERS 0.21 2 2 (Rs.1375 --2375) T O T A L ;2 14 COST (RUPEES IN LAKHS) 4.60 5.72 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 105 - Annex 6 Page 22 of 26 District Coordinator Office Category - B District (Less than 500 Beds) (RUPEES IN LAKHS) S;No. Category of Post No.of posts 1. a) LAY SECY. GR.I / A.O. 1 (Rs.3640 - 7580) b) A.F.O/A.A.0 l (Rs.3110 - 6380) c) ACCOUNTANT (R%.2600 - 5580) d) SR. ASST. 1 (Rs.2195 - 4560) c) JR. ASST. 2 (Rs.1745 - 3420) d) JR. STENO l1 (Rs.1745 - 3420) c) TYPIST-CUM-TELEX OPERATOR 1 2. a) PHARMACIST SUPERVISOR 1 (Rs.26D0 - 5580) 1. b) 9EDL.STORES ATTENDENT 1 (Rs.1375 - 2375) c) CLASS IV (WORKERS) 2 (Rs.1375 - 2375) T O T A L 2 12 COST 5 3.85 ( RS. IN LAKHS ) FOR 21 D.C.H.S OFFICES IN THE STATE COST I 21 X 3.85 - 80.85 - 106 - Annex 6 Page .3 of 26 APVVP Head Office Costing ----------__-__----------------------------------------------__----- NAME OF THE POST POSTS TOTAL ADDL. ANNUAL TOTAL ADDL. SANC. POSTS POSTS. UNIT COST COST PROPOSED COST HEAD OFFICE Commisssioner 1 1 0 1.97 1.97 (Ri.7580-10100) Jt.Commissioner 3 3w 0 1.42 4.26 - (Rs.6150 - 9820) Vigilance Officer 1 1 0 1.42 1.42 0.52 CRs.6150 - 9820) (inc.in scale) Dy.Commissioner 0 2 2 0.95 1.90 1.90 (Rs.5770 - 9260) Asst. Commissioner 0 2 2 0.90 18o 1.80 (Rs.5390 - 8980) Secretary 1 1 - 0.95 0.95 (Rs.5770 - 9260) Jt. Secretary 2 2 - 1.80 1.80 - (Rs.5390 - 8980) (the post of Addl.Secy changed to Jt.Secy-) Asst. Secretary 1 2 1 0.51 1.02 0.51 (Rs.3110 - 6380) Section Off'icer 20 23 3 0.43 5.59 1.29 (Ru.26db0 - 5580) Sr. Assistants 14 27 13 0.36 9.72 4.68 (Rs.2195 - 4560) Jr.Asst.-cum-typist 13 14 1 0.29 4.06 0.29 (Rs.1745 - 3420) Steno 7 9 2 0.29 2.61 0.58 (Rs,t745 - 3420) U.D.Steno 1 1 - 0.36 0.36 - (Rs.2195 - 4560) Executive Engineer 1 l - 0.73 0.73 _ (Rs.4400 - 8700) Equipment Engineer 1 1 - 0.73 0.73 - (Rs.4400 - 8700) Dy.E.E.(Bio-Medl) 0 1 1 0.60 0.60 0.60 (Rs.3640 - 7580) Senior Architect I 1 - 0.73 0.73 - (Rs.4400 - 8700) - 107 - Annex 6 Page 24 of 26 APVVP Head Office Costing (cont'd) NAME OF THE POST POSTS TOTAL ADDL. ANNUAL TOTAL ADDL. SANC. POSTS POSTS. UNIT COST COST PROPOSED COST Draughtsman -1 3 2 0.43 1.29 0.86. (Rs.2600 - 5580) Finance Officer I r - 1.42 1.42 - (Rs.6150 - 9820) Dy. Fih. Officer 2 1 0.90 1.80 0.90 (Rt.5390 - 8980) Internal Audit Offr. 1 1 - 0.95 0.95 - (Rs.5770 - 9260) Asst.Fin.Officer 2 ,Z - 0.51 1.02 - (Rs.3110 - 6380) Dy.I.A.O. 0 1 1 0.90 0.90 0.90 (Rs4.5390 - 8980) Asst. Audit Officer 4 5 1 0.60 3.00 0.60 (Rs.3640 - 7580) Asst.Accounts Offr. 4 5 1 0.51 2.55 0.51 (Rs.3110 - 6380) Sr. Accountants 22 23 1 0.36 8.28 0.36 (Rs.2195 - 4560) Jr. Accountants 5 11 6 0.29 3.19 1.74 (Rs.1745' - 3420) Shroff 1 1 0 0.26 0.26 - (Rs.1595 - 3020) Dy.Statistical Offr. 1 1 - 0.43 0.43 - (Rs.2600 - 5580) Statistician 1 1 - 0.36 0.36 - (Rs.2195 - 4560) TElephone Operator 1 1 - 0.29 0.29 - (Rs.1745 - 3420) Record Acsts. 2 2 - 0.25 0.50 - (Rs.1535 - 2840) Roneo Operator 1 1 - 0.25 0.25 - (Rs.1535 - 2840) Dispatchers (R.A.) 2 2 - 0.25 0.50 - (Rs.1535 - 2840) Pharmacist Gr.II - 1 -1 0.32 0.32 0.32 (Rs.1975 - 4010) - 108 - Annex 6 Page 25 of 26 APVVP Head Office Costing (cont'd) NAME OF THE POST POSTS TOTAL ADDL. ANNUAL TOTAL ADDL. SANC. POSTS POSTS. UNIT COST COST PROPOSED COST Systems Analyst - 1 1 0.90 0.90 0.90 (Rs.5390 - 8980) Computer Programmer - 2 Z 0.5 1.02 1.02 (Rs.3110 - 6380) Data Procesg.Offr. 2 2 - 0.43 0.86 - (Rs.2600 - 5580 ) Driver 4 6 2 0.26 1.56 0.52 (Rs.1595 - 3020) Peons/Sweeper/Jsw 23 29 6 0.22 6.38 1.32 (Rs.1375 - 2375) Watchman 3 4 1 0.22 0.88 0.22 (Rs.1375 - 2375) …------------------------------------------------ SUB TOTAL 149 200 51 79.16 22.34 ------------------------------------------------- …-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 109 - Annex 6 Page 26 of 26 Costing of Bio-vMedical Workshop-Cum-Training Center and Civil Engineering Department NAME OF TIIE POST POSTS TOTAL ADDL. ANNUAL TOTAL ADDL. SANC. POSTS POSTS. UNIT COST COST PROPOSED COST …__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _--…-_ - _ _- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ BID MEDICAL WORKSHOP CUM TRAINING CENTRE ZONAL (4) Asst.E.E.(Bio-medl.) 1 4 3 0.51 2.04 1.53 (Jr.Engr)(Rs.3110 - 6380) Techinical Instru-- 0 8 8 0.43 3.44 3.44 ment Supervisor (Rs.2600 - 5580) Biornedl.Technician 0 16 16 0.29 4.64 4.64 (Rs.1875 - 3750) J S Ws 1 8 7 0.22 1.76 1.54 (Rs.1375 - 2375) …----------------------------------------------- SUB TOTAL 2 37 35 11.88 11.15 …----------------------------------------------- CIVIL ENGINEERING DEPARTMENT Dy. Exec. Engineer 6 6 - 0.60 3.60 - (Rs.3640 - 7580) Asst.E;(ec.Engineer 11 23 12 0.51 11.73 6.12 (Rs.3110 - 6380) SUB TOTAL 17 29 12 15.13 6.12 Abstract POSTS TOTAL ADDL. TOTAL ADDL. SANC. POSTS POSTS. COST COST PROPOSED HEAD OFFICE 149 200 51 79.16 22.34 BIO MEDICAL 2 37 35 11.88 11.15 WORKSHOP/TRAINIG ENGINEERING DEPT. 17 29 12 15.13 6.12 GRAND TOTAL 168 266 98 106.17 39.61 - 110 - Annex 7 Page 1 of 13 Clinical and Diagnostic Norms at APVVP Hospitals 1. During the preparation of the AP District Health Systems Project, the Andhra Pradesh Vaidya Vidhana Parishad (APVVP) organized a workshop to review the norms for clinical services and equipment for each of the three levels of hospitals within the APVVP system i.e. the Community Hospitals (30-50 beds), the Area Hospitals (75-100 beds) and the District Hospitals (250-350 beds). The workshop brought together 35 participants including senior clinicians; nursing and other technical staff with work experience in the different levels of the health care system; and senior planners, hospital managers and program managers from the Directorate of Health. 2. The workshop served as a vehicle to mobilize their experience and expertise in refining the details of the proposed project. While serving to broaden the participation of several key persons in project preparation, it was expected that these key persons would subsequently form nuclei around which several further working groups and committees would be formed. These would contribute to the development of further components of the project such as the referral system, review of hospital formularies and drug lists, training component etc. This user- responsive workshop will serve as a springboard for the involvement of increasingly large numbers of persons in the preparation and subsequent implementation of the project. This should contribute towards a substantial sense of 'ownership' of the project in Andhra Pradesh. Objectives 3. The objectives of the. workshop were to: (a) Review and recommend the range of clinical, technical, administrative and dnsic services that should be available in the three defined types of hospitals in the APVVP, in particular distinguishing them from the services available at the primary and tertiary levels of care. (b) Based on the proposed range of services, to recommend the norms for physical assets, equipment, instruments, furnishings, materials etc. that would be needed to provide services of adequate quality. 4. Decisions on the norms for the clinical and diagnostic services that should be available at each level of hospital are influenced by: (a) the epidemiological pattern of health problems; (b) the administrative feasibility and the political and cultural acceptability of providing appropriate human, physical and technological resources at a particular level of hospital; and - 111 - - Amex 7 Page 2 of 13 (c) particular characteristics such as the availability and accessibility of alternate sources of equivalent services. 5. Once the norms for clinical and diagnostic services have been established, these norms, in turn, will form the basis for developing some of the other components of the project e.g. referral system, training etc. These interrelationships are shown in Figure 1. Figure 1- Rationale for Clinical Service Norms at Various Facities Levels of clinical care Sonia of the Components of the Project _D Dm t Some ofAC Cmoenu of the Project' - - - - - - - - - - - - - ---- ,- -- - - -- - - -- - - - | Mau | | 5 Mun cli- Sudaa i __b _, |Ti M=MWu A = ----- - 112 - Annex 7 Page 3 of 13 6. Using a worksheet of a tentative list of common health problems, and taking into consideration the tentative staffing patterns proposed for each level of care, the participants worked in three subgroups to consider the level of clinical care that should be available at the primary care level and at each type of secondary care hospital. The subgroups focussed on surgical and obstetric problems, internal medicine and paediatrics, and diagnostic services respectively. It was agreed that the level of care that is being defined is the minimum that should be available at each type of facility. In general, it was agreed that in the absence of a specialist at the Community Hospital, the level of care at this level would be to treat a list of identified, relatively minor conditions, and refer most of the 'erious conditions, including resuscitation and stabilization of emergencies and trauma before referral. 7. For a few selected life threatening conditions which require immediate intervention, it was agreed that general duty medical officers would be trained to provide adequate care at the Community Hospital level. Doctors working at this level who had specialist qualifications but were functioning as general duty medical officers would be required to acquire the skills in clinical disciplines other than their own so as to provide the requisite level of care, particularly in anaesthesia and obstetric and surgical problems. It was recommended that the Area Hospitals should have almost the same level of care as the District Hospitals except that they would provide a more limited range of specialties. 8. Based on the output of this working session, each group proceeded to consider the physical facilities and equipment that would be needed to provide the level of care that was envisaged for each level. The detailed outputs of these sessions together with some more general recommendations that arose from the group discussions are shown in the matrix attached. Among the more prominent decisions were the recommendations not to provide dietary and laundry services in the hospitals. SURGICAL: SERVICES RECOMMENDED FOR EACH LEVEL SECONDARY Condition / Procedure Primary Health Care Tertiary level facilities Community Hospital Area Hospital District Hospital 1. Basic techniques Incision & Drainage Incision & drainage Same as CH Split skin graft N/A Wound debridement Biopsy of skin 2. Trauma & Life Resuscitate, stabilise and Same as PHC + securing Same as CH + Same as CH + follow up Severe head injuries & Support refer airway; circulatory Investigate & manage management, specialist injuries of spinal cord support, **Exploratory laporatomy ornhopaedician stabilisation of fractures 3. Eye Infections Removal of foreign Same as CH Management of corneal Corneal grafting Community eye care bodies abrasion, ulcer; * Retinal diseases programme cataract & glaucoma Vitreous surgery surgery Intra-ocular foreign bodies 4. Ear Nose & Throat Removal of foreign I & D of peritonsillar & As AH + Laryngoscopic All requiring bodies retropharyngeal removal of FB & microsurgery Epistaxis control abscesses, tonsillectomy drainage of mastoid abscess. 5. Teeth & Jaw NA Conservative dentistry same as CH As AH + management N/A Tooth extraction of jaw fractures 6. Chest Resuscitate Rib fracture Same as CH + stabilise Same as AH Mediastinal injuries and & refer Breast abscess & tumours. Heart & lung refer mediastinal injuries surgery Tracheostomy, Thoracocentesis x W SECONDARY Condition / Procedure Primary Health Care Tertiary level racilities Community Hospital Area Hospital District Hospital 7. Gastrointestinal N/A All surgical procedures Same as AH Abdominal malignancies. listed Hepatic surgery (incl. *appendectomy) 8. Genito-urinary Acute urinary retention Same as PHC + Same as CH + urethral Same as CH + GU malignancies cystotomy, hydrocele, dilitation management of ruptured circumcision, vasectomy bladder & urethra. Urolithiasis, prostatectomy 9. Musculoskeletal N/A Closed reduction of Same as CH Open reduction of Spinal fractures uncomplicated fractures, fractures Joint reconstruct ions POP, traction * If possible ** Training to be provided to general duty medical officers LaT OBSTETRICS AND GYNAECOLOGY: SERVICES RECOMMENDED FOR EACH LEVEL SECONDARY Condition / Primary Health Care Tertiary level facilities Procedure Community Hospital Area Hospital District Hospital 1. Complicated deliveries Refer Forceps, vacuum extraction, evacuation of retained products, * Caesarean 2. Threatened or Refer Conservative incomplete abortion management D & C 3. Family planning Tubectomy Same as PHC + IUD laprascopic tubectomy ._ _ 4. Lower abdomenal pain Refer Stabilise & refer Exploratory laparotomy & ectopic pregnancy . . 5. Vaginal diseases Refer Diagnosis & Exam under anaeshesia management 6. High risk pregnancy Early diagnosis & Same as PHC Investigate timely referrral initiate management 7. PID Refer Diagnosis & therapy 8. Menstrual irregularities Refer Refer Diagnosis & management 9. Infertility Refer Refer Diagnosis & management . 10. Cervical erosion Refer Refer PAP smear & * biopsy As AH + biopsy Cancer surgery I1. Malignancies Refer Refer Diagnosis Surgery radiotherapy i A ANASTHESEA SERVICES FOR EACH LEVEL SECONDARY Condition / Procedure Primary Health Care Tertiary level facilities Community Hospital Area Hospital District Hospital 1. Basic technique *Care of airway Intubation Equipment handling 2. General & regional Management anaesthesia * If possible ** Training to be provided to general duty medical officers w -4 MEDICAL: CLINICAL SERVICES RECOMMENDED FOR EACH LEVEL PRIMARY SECONDARY HEALTH CARE HOSPITALS TERTIARY CONDITION HEALTH HEALTH CARE CARE FACILITIES CH AH DH I. Convulsions Symptomatic & refer Symptomatic treatment & Investigate, initiate, L.P_, Advanced investigation, CT scan, advanced refer refer manage, L.P., refer neurological treatment 2. Loss of consciousness / Symptomatic & supportive Initiate treatment, manage, Initiate treatment, CT Scan advanced coma refer manage,refer neurological treatment 3. Encephalities, Symptomatic treatment, Symptomatic treatment & Manage, refer Manage, support CT Scan, advanced meningities, CNS refer refer neurological treatment infections 4. Head injuries First Aid, refer Initiate, observe, refer Manage, stabilise, refer for Manage, stabilise, refer for Advanced management advanced management advanced management with altered sawrsoium with fracture 5. Respiratory infections Initiate, manage & refer Investigate, manage pH change, severe distress pH change, severe distress complications 6. Asthma Symptomatic, refer Manage Severe condition (status) Severe condition (status) 7. C.O. P. D. Supportive, symptomatic Symptomatic treatment & Investigate, manage, follow Investigate, manage, follow refer up up 8. Ear infection Manage Manage 9. Cardio-vascular Mild moderate: manage Mild moderate: manage, Accelerated and severe Accelerated and severe problems, hypertension follow up conditions 10 C.V.A. Symptomatic management, Symptomatic management, Manage, follow up Manage, follow up refer . refer w -4 PRIMARY SECONDARY HEALTH CARE HOSPITALS TERTIARY CONDITION HEALTH HEALTH CARE CARE FACILITIES CH AHl DH II Angina, infarctions Symptomatic management, Investigation, management, Investigate" manage, refer, Investigate, manage, refer, Complications refer refer follow up follow up 12 C.H.F. Symptomatic management, Initiate, manage, refer Complicated, follow up Complicated: follow up refer 13 Rheumatic fever and Symptomatic management, Symptomatic ,management, Investigate, manage, refer, Investigate, manage Complications rheumatic heart refer refer, follow up follow up 14 GI bleeding, ulcers, Symptomatic Symptomatic Endoscopic investigation, Endoscopic investigation, Complications Diseases treatment manage 15 G.E. Manage mild, moderate Manage mild, moderate Severe Severe refer refer 16 Hepatitis Symptomatic treatment Initiate management, refer Confirm diagnosis, manage Confirm diagnosis, manage 17 Cirrhosis Symptomatic Symptomatic Investigate, manage, follow Investigate, manage, follow Complications up up 18 Renal UTI Symptomatic, refer Symptomatic, refer Diagnosis, manage Diagnosis, manage 19 Acute Renal failure Symptomatic, refer Initiate, refer Investigate, management, Investigate, management Dialysis and advanced refer management 20 Musculoskeletal Symptomatic, refer Symptomatic, refer Manage Manage Recurrent: further evaluation,complications 21 Anaemia Preventive and primary Manage moderate Manage severe Manage severe _ . z~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~- PRIMARY SECONDARY HEALTH CARE HOSPITALS TERTIARY CONDITION HEALTH HEALTH CARE CARE FACtLITIES CH AH DH 22 Tetanus Symptomatic, initiate Symptomatic, Initiate Manage Manage 23 Malaria Manage Manage Severe Severe 24 AIDS Diagnosis, initiate Diagnosis, initiate, Diagnose and manage management management 25 Psychiatric Symptomatic management Symptomatic managemcnt Severe 26 Psychiatric disorder Manage mild, moderate Manage mild; moderate Severe refer I 27 Poisoning Initiate, manage, refer Initiate and manage, refer Investigate, manage Investigate, manage , 28 Neonatal rescuscitation Initiate and refer Initiate, refer Manage Manage 29 Neonatal cardio- Initiate and refer Initiate, refer Investigate, manage, follow Investigate, manage, follow Complications pulmonary defects up up 30 Diabetes Diagnosis, initiate Diagnosis, initiate Complications Complications - 31 Snake bite & dog bite Manage Manage Complications Complications - 32 Skin disorders Refer Refer Symptomatic, refer Manage 33 S.T.D.s Manage Manage Diagnose Manage ; C lb - 120 - 7 Pgl 11 d 13 DIAGNOSTIC SERVICES RECOMMENDED FOR EACH LEVEL. X.RAY INVEST1GATIONS CH AH ON PLAIN X-RAYS, I Chest Yes Yes Ys 2 Skul Ye Ye Ye 3 Post Nasal Space (sinus *tc) Yes Yes yes 4 Bones Yes Ye Yes 5 Spines Yes Ye Yu 8 Kidney, Ureter & Bladder Yes Yes Yes 7 Abdomen Yes Y Y" CONTRAST: 8 Barium swalow No Yes Yes 9 Barium meal series No Yes Ye 10 Barium enema No Yea Ye iI Choecystogramme No Yes Ye 12 Intra-Venous Pyelography No Yes Ye 13 Retrograde pyelography No Yes Yes 14 Hystero-salpingography No Yes Yes 15 Sialogramme (sinus etc) No Yes Yes 16 Myeobgraphy No No Ys ULTRASONOGRAPHY CH AH OH I Linear scanning: (with softwas) No No Ye Ob/Gy., abdomen 2 Linear sector scanning (with software) No Yes No Ob/Gy., abdomen 3 Linear sector scanning: (with software) No No Ye Ob/Gy., abdomen & cardiac - 121 - Annex 7 Page 12 of 13 IMAGING STAFF REQUIRED CH AH DH 1 Radiographer 1 2 3 2 Darkroom Assistant 1 2 3 SPACE REQUIRED: 1 X-Ray room 1 1 2 2 Darkroom 1 1 1 3 Changing room with W.C. 1 2 2 4 Office No 1 1 5 Drying room / stores No 1 1 LAB INVESTIGATIONS CH AH DH 1 Malaria parasite Yes Yes Yes 2 Common parasites. Yes Yes Yes ind. eggs, large cysts etc 3 Common bacteriology Yes Yes Yes (stool examination) 4 Protein & glucose in unne Yes Yes Yes 5 Urine deposits. crystals, casts Yes Yes Yes & bactena cells 6 Haemoglobin concentration Yes Yes Yes 7 Erythrocyte Sedimentation Rate. Yes Yes Yes 8 a) Differentiai count Yes Yes Yes (WBC & RBC) b) Red cell morphology No Yes Yes 9 a) Platelet count No Yes Yes b) Total WBC Yes Yes Yes c) Prothrombin No No Yes 10 Retfulocyte count No No Yes 11 Packed Cell Volume No Yes Yes 12 Blood grouping & cross Yes Yes Yes matching 13 Blood glucose & urea Yes Yes Yes 14 Mantoux reaction (TB test) Yes Yes Yes - 122 - Annex 7 Page 13 of 13 Lab tests (cont'd) CH AH OH 15 Pulmonary T.B. (Ziehl-Neelsen method) Yes Yes Yes 16 Leprosy(separate vertical programme) No No No 17 V.D.R.L. (syphilis) No Yes Yes 18 Sickle cell No No Yes 19 Leukemia No No Yes 20 H.I.V. (AIDS - separate national programme) No No Yes 21 C.S.F. (glucose & urea) No Yes Yes 22 Blood-gas analysis No No Yes 23 Blood cholestrol & creatinine No Yes Yes 24 Liver Function Tests (enzyme levels) No Yes Yes 25 Lipid profile No No Yes 26 Electrotyte analyses No Yes Yes 27 A.S.O. titre (antibody to strept. 0) No Yes Yes 28 Rosewaaler test (for rheumatoid factor) No No Yes 29 Widal's reaction (test for typhoid fever) No Yes Yes 30 Australian antigen (hepatitis B) No No Yes 31 Specific gravdy of urine Yes Yes Yes 32 pH of urine No Yes Yes 33 CeOl culture tests - ID & sensitivity No No Yes (eg. bacteria, fungi) 34 Skin allergy (patch testng - tertiary level only) No No No 35 Serum electrophoresis (tertiary level only) No No No 36 Hormonal estimation (Pap smear) No No Yes 37 Sperm count No No Yes 38 Lithium carbonate test (tertiary level only) No No No 39 Blood alcohol concentration No No No (by forensic labs) 40 Serum bilurubin No Yes Yes 41 Histopathology (general) No No Yes eg. carcinoma biopsies - 123 - Annex 8 Page 1 of 7 Clinical Training: Improving Ouality and Effectiveness In-service Clinical Training: Policy and Strategy 1. In order to improve the quality and effectiveness of clinical services in the APWP hospitals, APVVP will establish a system of regular periodic in-service training for all categories of staff who provide clinical and diagnostic services. Training will be aimed at upgrading clinical knowledge and practical clinical skills so as to enable staff to provide good quality care in the range of services that have been defined as the norm for each type of hospital. In addition to clinical skills, training will include user skills for maintenance of the equipment that will be provided at the hospitals. Training will also aim to broaden the perspectives of hospital doctors to recognise the health care needs of the community. This will strengthen the ability of secondary level hospitals to support the primary level. 2. The bulk of this training will be conducted at the upgraded District Hospitals within the APWP system. This will be supplemented by specific training attachments at teaching hospitals and other specialized institutions. Each District Hospital will have a conference room, suitable teaching equipment and library facilities. For the in-service training of doctors, most of the training will be done by senior clinicians in the APVVP hospitals who have had previous experience as teaching staff in medical colleges in the State, with some input from selected consultants from teaching hospitals. For the training of nurses, the APVVP is recruiting a core group of nursing staff who will be full time trainers. For the training of other categories of staff, the details of teaching faculty are being developed. 3. For certain types of specialized training and for updating of the skills of specialists, provision will be made for fellowships and clinical attachments in specialised insitutions in other states or in foreign institutions. Trainine needs assessment and the development of curricula. 4. The following categories of staff will need in-service clinical training that will be organized at the APVVP hospitals: 1. MBBS doctors (no Post Graduate qualification) working in community hospitals; 2. Staff nurses and auxiliary nurses; 3. Radiographers; 4. Laboratory Technicians; 5. Pharmacists; 6. Dentists; and 7. Doctors with a post-graduate qualification who may be expected to manage conditions in a sister discipline at Community or Area Hospitals if there is no - 124 - Annex 8 Page 2 of 7 specialist available in that discipline. The disciplines that are involved are obstetrics and gynecology, general medicine and psychiatry, paediatrics, surgical specialties and anaesthesia, and diagnostic specialties that are expected to be available at the relevant type of hospital. 5. Requisite competencies and related knowledge. skills and attitudes: all categories except nurses. During the project preparation period, APVVP established thirteen (13) curriculum development Working Groups to conduct rapid training needs assessment and prepare appropriate curricula for each of the categories of clinical staff in the hospitals. These working groups are composed of experienced clinicians who are competent in technical (clinical) areas. Many of them had participated in the earlier workshop that defined the norms for clinical and diagnostic services that should be available in each type of hospital in the APVVP system. The working groups used the norms specified at that workshop to identify the required competencies and the desirable knowledge and skills for staff at each type of hospital. 6. Recognizing that the members of these Working Groups have no training or experience in developing training courses i.e. they know what to teach, but are not experienced in designing modem approaches on how to teach, a Training Consultant was hired to guide the work of these Groups. 7. The Working Groups are in the process of working through the following stages of curriculum development: 8. Rapid Training Needs Assessment. A 3 day workshop was conducted by the consultant for the (approximately) 35 members of the Working Groups to provide guidance in TRAINING NEEDS ASSESSMENT in July, 1994. During the workshop, the working groups were taught to identify and analyze the training needs for their target groups by comparing: a) expected competencies; b) gaps in competencies as perceived by experienced senior clinicians; and c) gaps in competencies as perceived by a sample of the target group. It was agreed that, based on this excercise, an Action Plan for training would be prepared by working groups. 9. In a follow-up meeting held on August 30-31, 1994, the steps outlined in the Action Plan were reviewed and found to have been completed on schedule. Training lists for community hospital doctors, specialists and laboratory personnel were ready. A priority list of clinical skills for community hospital doctors, grouped by speciality, and a plan outlining the clinical updating of skills were prepared in order to facilitate the preparation of training manuals and planning the next workshop on curriculum development. Groups of related skills were put together to facilitate designing of training modules/courses. Three sessions were organized for participants to get familiar with clinical skills training using competency based and humanistic training techniques. Steps in skills training viz.: demonstration, practice, feedback and assessment of minimum level of competence were stressed. The expected outcomes of training would be the acquisition of specific abilities vital to the performance of their jobs, improved communication and support supervisory skills. 125 - Annex 8 Page 3 of 7 10. Curriculum development. A 4 day workshop will be conducted by the consultant for the working groups to provide guidance in CURRICULUM DEVELOPMENT and TOT (Training of Trainers). During this workshop, the working groups will be familiarized with the methodology of developing curricula, and will develop samples of curricula for their target groups. By October 1994, each group will submit a sample of the curricula developed by them for review and comment by the consultant. The workshop would also identify a core group of trainers derived from the specialist cadre working in district hospitals; designate six district hospitals as training centers; and designate one of the specialists in each district hospital as coordinator of training. While training for the core group of trainers would emphasize training techniques, for coordinator training, the emphasis would be on planning and coordination of district level training programs. 11. The curricula will use a wide range of teaching packages and teaching aids such as videos, clinical teaching mannequins etc. The emphasis will be on acquiring competence in practical clinical skills. The curriculum will also integrate components of equipment maintenance that are appropriate for equipment users. Training will focus on practical hands-on training using prototypes of equipment and materials that will be available according to the norms for each type of hospital. The curricula will include criteria and methods for verifying that trainees have acquired the desired level of competency at the end of the training period. APVVP will prepare an inventory of training manuals, trainer guides and teaching aids already available or to be developed by other agencies. 12. Designing the Training Approaches. Curricula will be designed for a combination of one or more of the following three modalities: (i) short courses - i.e. week-end courses and courses of 1-2 week duration. (ii) placements at hospitals for practical training of a few weeks' duration. (iii) distance learning packages. 13. Distance Learning Packages (DLP) and Short Courses may be linked so that trainees who have completed some components of DLP would then attend the short course so as to have the opportunity for direct interaction, evaluation and reinforcement. Placements in hospitals for practical training should be timed so that trainees who have attended short courses or completed segments of the DLPs have the opportunity for upgrading the related practical skills. 14. For practical clinical training, most of which will be done at district hospitals, the curriculum will define competencies that have to be acquired in specified skills and procedures. Trainees will be required to observe and practice these pre-defined skills, and their competency will be verified and documented. For some procedures, it may be specified that they will subsequently repeat the procedure at an area hospital under the observation of a specialist until that specialist verifies that the desired level of competency has been acquired. 15. Certification. APVVP will consider awarding a certificate to trainees who successfully complete specified training programs. This certificate may be used as a pre- - 126 - Annex 8 Page 4 of 7 requisite for career development. 16. Training of Trainers. Trainers who provide clinical training in APVVP hospitals need to be updated in terms of training technology and become familiar with the specific curriculum and distance learning packages of APVVP. Training technology that they would have to acquire would include: selection and use of appropriate teaching methods for development of psychomotor skills (i.e. patient management procedures), small group teaching methods, acquisition of desirable attitudes, and methods of assessment for evaluation of learning outcomes. For this purpose APVVP will organize appropriate short courses for staff of district hospitals and medical colleges who will be serving as trainers in APVVP training programs. Input for such training of trainers will be obtained from institutions such as the National Teacher Training Centers for Medical Education and Research (e.g. JIPMER in Pondicherry, PGIER in Chandigarh, etc.). Funds for such consultant support will be available under the Project. 17. Distance learning packages. There is no experience in the use of distance learning packages in the health sector in Andhra Pradesh. However, the distance learning approach, if well managed, is known to be effective and efficient in upgrading and updating knowledge in clinical areas. This project provides the opportunity to develop suitable distance learning packages, for example for medical officers at community hospitals and area hospitals. It will also provide the opportunity to test the feasibility and effectiveness of adopting this as one of the approaches for in-service training. 18. In order to develop this approach, it will be necessary to: (a) develop the learning package; (b) coordinate the learning package with the other training courses that are to be implemented; (c) establish the administrative mechanism for implementing the distance learning program; and (d) conduct a pilot program and evaluate it before extending it throughout the state. During the Project, APVVP will employ suitable short term consultants to assist in developing and testing this approach. 19. Monitoring, evaluation and updating of training programs. The Joint Commissioner, Training in APVVP will be responsible for ensuring the development and implementation of a system for monitoring and evaluation of the training program. Such a system will include: (a) continuous monitoring of the training program; (b) periodic evaluations of the training programs including concurrent and end-of-course evaluations and assessment of the performance of those who have been trained; (c) feedback and utilization of the results of evaluation and (d) ensuring the optimal utilization of trained personnel. A computerised information system in the format of a wide area network (WAN) is under consideration. This network could also be utilized for Health Management Information System (HMIS). APVVP has held discussions with the National Informatics Center (NIC), Hyderabad, on the possibility of utilising the existing district level network of NIC to convey APVVP HMIS data. 20. Management of clinical training. A Joint Secretary at APVVP will be responsible for management of clinical training. In each district, the District Coordinator will also serve - 127 - Annex 8 Page 5 of 7 as the District Training Coordinator. APVVP is considering incentives, as well as the office space and materials needed for this function. All District Training Coordinators will have a joint meeting once in three months with the Joint Commissioner responsible for Training. Training Coordinators will be responsible for preparing the Annual District Training Plans and for coordinating the implementation of the plans. 21. Estimated number of participants and courses. For in-service clinical training, five types of training are envisaged: (1) formal short courses; (2) informal week-end courses; (3) attachments for practical clinical training; (4) distance learning; and (5) fellowships. 22. Details of the numbers and types of clinical training that will be provided under this project is given in Tables 1 and 2. Nursing Training 23. Nursing: Problems. APVVP hospitals have an inadequate numbers of nurses, and those nurses that are available have inadequate skills and motivation and are not adequately supervised. 24. Strategy. This project will: (a) increase the staffing norms for general nurses and auxiliary nurse-midwives (ANMs); (b) extend the use of auxiliary nurse mid-wives to areas such as the outpatient department; (c) establish a systematic in-service training program for APVVP nurses for technical clinical areas and in management and communication skills; and (d) strengthen nursing management by establishing a nursing manager's post at APVVP, and including supervisory nursing personnel in the management teams in each hospital. 25. Nursing Manpower. The current production capacity of the existing nursing schools is adequate to meet the needs of APVVP. For remote and tribal areas, it is expected that recruitment and incentive policies to be adopted by APPVP will be effective for nurses. Clinical Training 26. General nurses. Training will aim at updating knowledge and skills in keeping with the expected functions in District, Area and Community hospitals. This will be done through a full time 2-month course in which morning hours will be used for practical skill training in selected District hospitals while afternoon hours will be used for classroom work for updating knowledge. 27. Three training centers will be established; one in Hyderabad, during year 1, will train 4 batches with 40 nurses per batch (total 160 per year), and in year 3, two further centers will be established in selected zones, increasing the training output to 480 per year. It is expected that during the life of the Project 1760 (60%) of the 2782 nurses will have been - 128 - Annex 8 Page 6 of 7 covered. Of these approximately 50% will be from district hospitals while the remainder will be from area and community hospitals. 28. In each center, 10 BSc nurses who are currently under the Directorate of Medical Education will be recruited by APVVP and serve as APVVP Trainers. Each batch of 40 participants will be trained in 2 courses of 20 participants each. For practical training, 4 participants will be attached to each Trainer. 29. ANM's. Training will aim at upgrading as well as updating knowledge and skills to enable ANMs to perform the additional functions expected of them and improve their performance of current functions. Budgetary provision has been made for training to consist of 1 week courses of mainly classroom- type of learning together with 1 week of practical clinical attachments. Details of this training (training needs analysis, curriculum development, orientation of trainers) needs to be developed. 30. Special nursing areas. It is estimated that a combined total of approximately 100 nurses will have to be trained in the special nursing areas of: (a) operation theater/central sterilization; (b) emergency; (c) obstetrics & neonatal paediatrics; (d) blood bank; and (e) intensive care units. It is not realistic to establish in-house training within APVVP for this purpose, and therefore selected nurses will have to be sent to institutions within the country that are providing such training. Budgetary provision has been made for this purpose. During Year 1 of the project, it will be necessary to identify suitable training locations, and establish a systematic program for this training. 31. Curriculum develoDment and Training of Trainers. A preliminary review of training needs for general nurses has been done by APVVP. The BSc nurses who will be recruited as Trainers have had training in educational technology during their own basic training. 32. APVVP will need to involve the prospective Trainers in conducting a more comprehensive training needs assessment and curriculum development exercise. Since the prospective nursing Trainers will be recruited only during year 1 of the Project, a core group of 2-3 selected individuals, will be invited to participate as observers in the exercise, and be subsequently required to replicate the process with their own colleagues. As soon as the Nursing Trainers are recruited, they will rapidly complete the exercise, and also undergo an orientation process to update and standardize the training approaches that will be utilized. The Nursing college in Hyderabad will be invited to coordinate and facilitate this process. 33. Nursing Training Centers. The implication of the establishment of in-house capacity for in-service training of nurses is that teaching facilities and residential hostel facilities will be needed. It is estimated that the teaching facilities that will be created at district hospitals under this project will be sufficient to accommodate the Nursing component. For hostel facilities, it is proposed that in year 1, a hostel will be added to a commercial complex that is being developed by APVVP in Hyderabad, and is nearing completion. A third floor will be added to - 129 - Annex 8 Page 7 of 7 the two storey building which has an engineering design capable of taking 4 storeys. It is proposed that the catering and housekeeping for this hostel will be done through contracted services through the private sector. 2 Mini-vans will be hired on a contract basis for the training center. Training equipment and materials will be provided through this project. Management Trainine 34. Two types of training will be conducted: (i) training of nursing managers as part of the management teams of hospitals. This is described elsewhere. (ii) training in Ward Management. This will be done in the in-house training centers of APVVP as 1 week courses for all head nurses and nursing superintendents. The training needs assessment, curriculum development, and orientation of Trainers will have to be done in conjunction with the development of Clinical Training as described in earlier paragraphs. 35. Formal short courses for medical officers and nurses are estimated to need two week durations while for other categories the courses are estimated as one week duration. Targets for numbers to be trained are given in Table 1. 36. Informal week-end courses are estimated to be conducted once a month at each district hospital from the second half of year 1 for the entire duration of the project. - 130 - Annex 9 Page I of 6 Equipment Norms for APVVP Hospitals GROUP SERIAL NO. ITEM Rs CH DH AH I I IMAGING EOUIPMENT I 1 500mA X-ray system (incl. installation) 850 0 0 1 1 2 300mA X-ray system (incl. installation) 700 0 1 0 1 3 lOOmA X-ray system (incl. installation) 330 1 0 1 I 4 6OmA mobile X-ray system 150 0 1 1 I 5 Dental X-ray system (NB. at CH only if dentist there) 60 1 1 1 I 6 Ultrasonic scanner, linear 300 0 0 1 1 7 Ultrasonic scanner, linear sector 700 0 1 0 I 8 Ultrasonic scanner, linear sector, upgrade 900 0 0 1 11 ELECTRO-MEDICAL EOUIPMENT II I ECG machine (12-lead) 17 1 2 3 II 2 Cardiac monitor 25 0 1 2 II 3 Defibrillator (with recorder) 65 0 1 2 II 4 Audiometer 50 0 0 1 11 5 Phototherapy unit 6 0 1 2 11 6 Radiant heater, 4KW 6 0 1 1 11 7 Endoscope, fibre-optic 200 0 0 1 II 8 Operating microscope 65 0 0 1 II 9 Cryo Surgery, basic (direct attachment) 5 0 0 1 !1 10 Cryo Surgery, de-luxe 8 0 1 1 11 11 Short-wave electro-physiotherapy unit 20 0 1 1 11 12 Ventilator, adult 75 0 0 1 II 13 Anaesthetic m/c (Boyles with FloTec) 125 0 1 2 11 14 Anaesthetic m/c (Boyles without FloTec) 60 1 1 2 II 15 Pulse Oximeter 100 0 1 1 II 16 Opthlamoscope 5 0 1 3 11 17 Slitlamp with table 21 0 1 1 11 18 Retinoscope 3 0 1 1 11 19 Perimeter 6 0 i I II 20 Emergency resuscitation kit 20 1 2 3 11 21 Sigmoidoscope, rigid, adult 2 0 1 1 11 22 Head light (ENT surgeon) 1 0 1 1 11 23 Pulse air tonometer 5 0 1 1 11 24 Acute Medical Care equipment (for 7 DHs only) 250 0 0 1 111 PNEUMATIC. HYDRAULIC & STERILISATION EOUIPMENT 111 I Dental unit 14 1 1 1 III 2 Dental Chair 14 1 1 1 III 3 Aerotor (turbine & compressor) 21 0 1 1 III 4 Ultrasonic dental scaler 21 0 1 1 111 5 Dental lab. items eg. bath, motor, lathe etc 20 0 0 1 111 6 Operating table, ordinary 8 1 2 3 111 7 Operating table, hydraulic 35 1 2 3 III 8 Autoclave, HP, horizontal 120 0 2 3 - 131 - Annex 9 Page 2 of 6 GROUP SERIAL NO. ITEM Rs CH DH AH III 9 Autoclave, HP, vertical 30 1 1 2 III 10 Autoclave, electrical, with burners, 2-bin 6 1 1 0 III 11 Shadowless lamp, OT, mobile 8 2 3 4 III 12 OT lights, ceiling (shadowless) 45 1 2 3 III 13 Focusing lights, OT (mobile) I 1 2 2 III 14 Suction apparatus (high vacuum MTP) 8 1 2 2 III 15 Suction apparatus, electrical 5 2 4 15 III 16 Foot suction apparatus I I 1 2 III 17 Vacuum extractor 2 1 1 2 III 18 Steriliser, instrument 3 5 10 25 III 19 Diathermy machine (electro-surgery) 12 0 1 2 III 20 Cautery set, electric (Gynae) I 1 2 2 III 21 Automist (OT fumigator) 5 1 2 3 IV LABORATORY EOUIPMENT IV I Microscope, binocular with lamp 9 1 3 5 IV 2 Chemical balance, analytical/optical 6 0 1 1 IV 3 Simple balance 1 1 1 1 IV 4 Photo-electric colorimeter 8 1 1 2 IV 5 Flame photometer 18 0 1 1 IV 6 Spectrophotometer 22 0 0 1 IV 7 Micro Pippette 5 0 1 1 IV 9 Water bath 3 1 1 2 IV 10 Hot air oven, 2 levels 8 1 1 1 IV 11 Incubator, laboratory 8 0 1 1 IV 12 Water still, 4 litres 3 0 1 1 IV 13 Centrifuge (electrical) 4 1 2 3 IV 14 Centrifuge (haematocrit) 8 0 1 2 IV 15 Hot plate, laboratory 2 0 1 1 IV 16 Rotor/shaker (laboratory) 2 0 1 1 IV 17 Counting chamber (haemocytometer) etc I 1 2 3 IV 18 pH meter 15 0 1 1 IV 19 Glucometer (in OPD) 6 1 1 2 IV 20 Haemoglobin meter 1 1 2 3 IV 21 Microtome 12 0 0 1 IV 22 Oven, wax-embedding 8 0 0 1 IV 23 Tissue Processor 65 0 0 1 IV 24 Blood-gas analyser (for 7 DHs only) 450 0 0 1 IV 25 Lovibond comparator 1 0 1 1 IV 26 Timer stopwatch 0.7 1 1 2 IV 27 Alarm clock (timer) 0.4 1 1 2 T TRANSPORT T I Ambulance 350 1 1 2 T 2 Pick-up 300 0 1 1 - 132 Annex 9 Page 3 of 6 GROUP SERIAL NO. ITEM Rs CH DH AH REFRIGERTION & A/C. V I Refrigerator, 165 litres 10 2 5 8 V 2 Refrigerator, 300 litres 20 0 1 2 V 3 Air conditioner, with stabiliser 28 1 5 8 V 4 Water cooler, 60/120 litres 15 1 2 3 V 5 2-body mortuary (cold store) 130 1 2 3 VI HOSPITAL PLANT VI I Generator, 15 KVA (incl. installation) 150 1 0 0 VI 2 Generator, 50 KVA (incl. installation) 200 0 1 0 VI 3 Generator, 62.5 KVA (incl. installation) 250 0 0 1 VI 4 Incinerator, 3KW 50 0 1 0 VI 5 Incinerator, 5KW 70 0 0 1 VI 6 Hot water system (solar units, 100 litres) 20 1 1 3 V'l ADMINISTRATION VII I Typewriter 5 1 3 4 VII 2 Photocopier 80 0 0 1 Vil 3 Roneo mi/c 20 0 0 1 ViI 4 Intercom (15 lines) 80 0 1 0 VII 5 Intercom (40 lines) 200 0 0 1 VII 6 Fax machine 30 0 0 1 VII 7 Telephone (external lines incl. quarters) 11 2 6 12 vII 8 Library facilities 5 0 0 1 1 FURNISHINGS IL. CH DH AH I I Examination table 1400 5 15 30 1 2 Labour table 1250 2 4 6 1 3 Foot steps 600 5 15 30 1 4 Beside screen with curtains 500 10 20 40 1 5 Revolving stool 250 6 20 40 1 6 Saline stand 850 10 25 50 1 7 Wheel chair 1500 2 4 12 1 8 Emergency/recovery trolley 5500 1 2 4 1 9 Stretcher on trolley 2900 2 4 12 1 10 Oxygen cylinder stand/trolley 300 3 8 16 I 111 Height measuring stand 600 1 2 4 1 12 Arm board, child & adult 200 20 40 60 1 13 Jar, Cheatle forceps 300 4 10 20 1 14 Patella hammer 100 2 4 8 1 15 Tongue depressor 30 6 12 20 1 16 Oxygen masks, with regulator 130 2 4 8 1 17 Torch light 50 2 8 12 1 18 Fowler's cot 5200 0 2 4 1 19 Iron cot 1250 30 100 250 1 20 Side rails 300 2 4 10 - 133 - Annex 9 Page 4 of 6 GROUP SERIAL NO. ITEM Rs CH DH AH 1 21 Baby cot 1800 4 6 12 1 22 Beside locker 1250 30 100 250 1 23 Dressing trolley 1650 2 4 12 1 24 Mayo's trolley 900 1 2 4 1 25 Surgical instrument cabinet 4250 2 4 8 1 26 Medicine cabinet 2000 1 4 10 1 27 Instrument trolley 1600 2 4 8 1 28 Linen trolley 1100 2 4 8 1 29 Kick bucket 550 4 8 16 1 30 Bucket, galvanised 120 4 8 20 1 31 Bed pans & urinals 150 4 8 20 1 32 Attendent stool 250 30 100 250 1 33 Traction system, Bohler-Braun 500 1 4 8 1 34 Post-mortem table 4000 1 1 1 1 35 Wash basin 400 10 20 40 1 36 Instrument/Medicine tray with cover 500 4 12 24 1 37 Bowls, various 100 24 48 100 1 38 Kidney dishes, various 80 8 20 40 1 39 Chair (doctors, nurses etc) 450 12 24 50 1 40 Racks, various (patient charts, records etc) 250 6 24 48 1 41 Table, wooden 1600 10 20 40 42 Steel cupboard 2000 4 12 36 1 43 Swab rack (OT) 800 1 2 4 1 44 Fracture table (POP) 6600 0 1 2 1 45 Table, blood donor, 6'x6'x6', wooden 4000 1 2 4 1 46 Mattress 1200 30 100 250 47 Pillow 100 30 100 250 1 48 Wooden bench 2500 10 40 100 2 SURGICAL INSTRUMENT PACKS ,L CH DH AH 2 1 Dilitation & Curettage 1200 3 6 6 2 2 Medical Termination of Pregnancy 1100 1 2 4 2 3 Cervical biopsy 700 1 2 4 2 4 Evacuation 550 2 4 8 2 5 Delivery 1000 4 6 10 2 6 Post natal sterilisaiton 1000 10 12 24 2 7 Episiotomy 700 3 6 10 2 8 Venesection 800 3 6 12 2 9 Copper coil (IUD) insertion 400 2 4 6 2 10 General anaesthesia kit (adult & child) 4000 2 4 6 2 11 Caesarean section 2000 2 4 8 2 12 Incision & drainage 1000 2 4 6 2 13 Vaginal hysterectomy 3000 1 2 4 2 14 Abdominal hysterectomy 5000 1 3 6 2 15 Vagotomy 2500 0 1 1 2 16 Appendicectomy 2500 1 2 2 - 134 - Annex 9 Page 5 of 6 GROUP SERIAL NO. ITEM Rs CH DH AH 2 17 Hydrocele 1200 1 2 2 2 18 Gastro-Jejunal operations 2500 1 2 2 2 19 Haemorrhoidectomy 2700 1 1 1 2 20 Suture removal 400 3 6 12 2 21 Suturing tray 900 2 4 6 2 22 Lumbar Puncture tray 450 1 2 2 2 23 Cholecystectomy 800 0 1 2 2 24 Thyroid 3000 0 1 1 2 25 Catheterisation tray 100 3 6 6 2 26 Orthopaedic set, general 20000 0 0 1 2 27 Inter-Medullary nailing 1000 0 0 2 2 28 Sterling Punch nailing 1500 0 0 2 2 29 Dynamic compression plating 3500 0 0 1 2 30 Amputation set 1500 0 0 1 2 31 Dynamic Hip screw fixation 10500 0 0 1 2 32 Fixation of radius & ulna 250 0 0 1 2 33 Cataract operation 5800 0 4 8 2 34 Needling & cataract evacuation 6000 0 1 2 2 35 Iridectomy 1000 0 1 4 2 36 Iridenclisis 2000 0 1 2 2 37 Extra-capslar operation 2250 0 0 2 2 38 Chalazaon 670 0 5 10 2 39 Tarsorraphy (medial or lateral) 860 0 2 4 2 40 Enucleation (removal of eye ball) 1000 0 2 4 2 41 Probing of lacrymal passages 200 0 2 4 2 42 Dacryo-Cysto-Rhinostomy 350 0 0 2 2 43 Lachcymal sac excision 350 0 2 4 2 44 Trabeculectomy (anti-glaucoma op.) 3300 0 2 4 2 45 Pterygium excision 860 0 2 4 2 46 Entropion correction 1250 0 2 4 2 47 Foreign body in cornea 550 0 4 8 2 48 Foreign body in Anterior Chamber (eye) 1350 0 1 2 2 49 Conjunctival cyst excision 900 0 2 4 2 50 Ear examination 1700 0 1 2 2 51 Mastoidectomy 10000 0 0 2 2 52 Micro Ear set eg.Myringo-, Tympano-plasty 23000 0 0 1 2 53 Nasal set eg. SMR, Septo-polype- etc 9800 0 0 1 2 54 Deflected Nasal Septum 7000 0 0 1 2 55 Rhinoplasty 6800 0 0 1 2 56 Adeno-tonsillectomy 7500 0 2 4 2 57 Tracheostomy 400 5 10 20 2 58 ENT, general 1600 0 4 8 2 59 Endo-laryngeal microsurgery 16500 0 0 1 2 60 Dental instruments kit 5000 1 1 2 - 135 - Annex 9 Page 6 of 6 GROUP SERIAL NO. ITEM Rs CH DH AH L0) 3 MINOR EOUIPMENT R.¶ CH DH AH 3 1 X-ray viewing box, (av.Rs.1,2 & 4 films) 1500 2 6 10 3 2 Developing tanks (X-ray), various sizes 750 1 2 3 3 3 Safelight, X-ray darkroom 250 1 2 3 3 4 Cassettes, X-ray, various 400 4 12 32 3 5 Intensifying screen, various 2000 4 12 32 3 6 Lead apron 2600 1 2 4 3 7 Lead protection screen 7500 1 1 2 3 8 Chest stand, X-ray 900 1 1 2 3 9 B.P. machine , 500 6 12 24 3 10 Weighing scale, adult 600 2 4 12 3 11 Weighing scale, infant 600 1 2 4 3 12 Infra-red lamp (Physiotherapy) 400 2 4 6 3 13 Oxygen cylinder 2800 10 20 40 3 14 Nitrous oxide cylinder 2800 5 20 40 3 15 Regulator & flowmeter for medical gas 1500 3 8 16 3 16 Ambu-bag 600 4 8 16 3 17 Angle-poise lamp 500 0 2 4 3 18 Hot plate, domestic 1200 1 3 6 3 19 Emergency lamp 1000 4 8 16 3 20 Sewing machine 1300 0 0 2 3 21 Fire extinguishers (various types) 1500 2 4 8 3 22 Laryngoscope (adult & paediatric) 600 2 2 4 3 23 Otoscope 400 0 1 2 3 24 Universal bone drill 1200 0 1 2 - 136 - Annex 10 Page 1 of 12 Eguipment Maintenance & Training Services at APVVP Hospitals General Policy 1 . APVVP has adopted a policy for development and provision of equipment technical support services, particularly those addressing the widespread problem of lack of adequate maintenance and repair (M&R). The approach proposed is realistic and practical, and aims to provide the basic services required mainly through in-house resources. This will involve active participation by equipment users as well as trained maintenance staff. Explicitly it is stated that "The primary responsibility for preventive and routine maintenance and fault localization shall be with the concerned hospital employee operating the equipment and/or in charge of the same". 2. A start has already been made by setting up the 'Equipment Maintenance & Training Centre' (EMTC) based at King Koti Hospital in Hyderabad as a focal point for such activities. The EMTC is charged with several training responsibilities viz. "to impart initial, follow up and refresher training programmes to various hospital employees in preventive and routine maintenance of hospital equipment" 3. Considering the equipment maintenance policy adopted by APVVP and the revised equipping norms for the Community, Area and District hospitals, the broad guidelines given in Table 1 indicate what technologies might be serviced by the different options open to APVVP. These options include full in-house coverage, first line maintenance only by in-house staff, and frully contracted out services. More sophisticated technical services will continue to be purchased from equipment manufacturers and suppliers, or from private sector providers, although the need for such services will be subject to on-going review as in-house capabilities grow. It should be borne in mind that any contracted work also has to be 'managed' effectively and often this requires good technical knowledge on the part of the in-house manager to ensure quality and value for money from contractors. 4. Clearly the outreach technical support which can be provided from EMI'C in Hyderabad to hospitals throughout the State is limited, and therefore the concept of a regional and district network of maintenance resources has been developed. An analysis on how this might be best achieved (bearing in mind cost-effectiveness and efficiency ) has been undertaken with the responsible APVVP bio-engineer and his group. The plan in the current Project Proposal is to strengthen EMTC in all its roles (service, training and advice), and to create two additional 'zonal' workshops in other parts of the State. The two locations suggested are: at Eluru District Hospital in West Godavari to cover the east and north-east of the State; and at Cuddapah District Hospital in Cuddapah to cover the south. (See 'Organisational Chart of APVVP State-Wide Hospital Equipment Maintenance Service' below). - 137 - Annex 10 Page 2 of 12 ORGANIZATIONAL CHART OF APVVP STATE-WIDE HOSPITAL EQUIPMENT MAINTENANCE SERVICE APVVP rL- -___ - -------- EMTC 1 -___----------r - ------- r-------- 1 _ : DCHS (Zone A) DCHS (ZoneB) : DCHS (Zone C) L-- -- -T--- - --------- - -T - ---- -- - ----T- - --- ZONE A ZONE B ZONE C WORKSHOP WORKSHOP WORKSHOP Note 1: The District Coordinators of Hospital Services (DCHS) deal with general management, administration, financial control and coordination of M&R services in their respective zones under overall direction of APVVP/HQ. (Dotted lines above indicate general management) Note 2: EMTC will be a maintenance resource centre providing technical back up services to the other zonal workshops in addition to its parallel role in developing and providing technical training for M&R personnel and equipment user cadres. - 138 - Annex 10 Page 3 of 12 Table 1: Maintenance Arranzements First-line maintenance by in-house technical staff Minor attention by in-house staff (contract-out locally) 500 mA X-ray system Tables (various) 300 mA X-ray system Beds (various) 100 mA X-ray system Foot steps Chest stand, X-ray Beside screen 60mA mobile X-ray system ,Stools (various) Dental X-ray system Saline stand Ultrasonic scanner, linear Wheel chair U/sonic scanner, linear sector Emergency/recovery trolley Defibrillator (with recorder) Stretcher on trolley Endoscope, fibre-optic Oxygen cylinder stand/trolley Operating microscope Height measuring stand Ventilator, adult Cots (various) Emergency resuscitation kit Bedside locker acute Medical Care system Trolleys (various) Dental Chair Cabinets (various) Aerotor (turbine & compressor) Traction system Ultrasonic dental scaler Chairs (various) Dental lab.: bath, motor etc Racks (various) Operating table, hydraulic Steel cupboard pH meter Wooden bench Glucometer Blood-gas analyser Generators (various) Incinerators Hot water systems (solar) Gas regulators & flowmeters Sewing machine Fully contracted out services Anaes. m/c (with FloTec) Anaes. mlc (without FloTec) Pulse Oximeter Oxygen cylinder Nitrous oxide cylinder Ambulance Hearse Pick-up Typewriter Photocopier Roneo m/c Intercoms Fax machine Telephones Fire extinguishers - 139 - Annex 10 Page 4 of 12 Table 1 (cont'd) Full maintenance and repair by in-house technical staff ECG machine (12-lead) Incubator, laboratory Cardiac monitor Water still Audiometer Centrifuge (electrical) Phototherapy unit Centrifuge (haematocrit) Radiant heater Hot plate, laboratory Cryo Surgery systems Rotor/shaker (laboratory) S-W electro-physio unit Haemocytometer Opthlamoscope Haemoglobin meter Slitlamp with table Microtome Retinoscope Oven, wax-embedding Perimeter Tissue Processor Sigmoidoscope, rigid, adult Lovibond comparator Pulse air tonometer Refrigerators (various) Dental unit Air conditioner w/stabilizer Operating table, ordinary Water cooler, 60/120 litres Autoclave HP (various) 2-body mortuary (cold store) Shadowless lamp, OT, mobile Oxygen masks, with regulator OT lights, ceiling (shadowless) Torch light Focusing lights, OT (mobile) Surgical instruments Suction m/c (high vacuum MTP) X-ray viewing box Suction appararus, electrical Developing tanks (various) Foot suction apparatus Safelight, X-ray darkroom Vacuum extractor Cassettes, X-ray, various Steriliser, instrument Intensifying screen, various Electro-surgery machine Lead protection screen Cautery set, electric (Gynae) B.P. machine Automist (OT fumigator) Weighing scale, adult Microscope, binocular Weighing scale, infant Chemical balance, analytical Infra-red lamp (Physiotherapy) Simple balance Ambu-bag Photo-electric colorimeter Angle-poise lamp Flame photometer Hot plate, domestic Spectrophotometer Emergency lamp Micro Pippette Laryngoscope (adult & child) Water bath Otoscope Hot air ovens Universal bone drill - 14,0 - Annex 10 Page 5 of 12 5. There is justifiable concern about the capacity of EMTC in Hyderabad to provide good coverage in the north-west since travelling times (by road) from Hyderabad can be up to ten hours to some locations. For this reason it is now recommended that a third 'zonal workshop' be established at the District Hospital in Karimnagar. Table 2 indicates how responsibilities for general M&R service coverage might be shared. Table 2: Proposed Responsibilities for M&R Services M&R SERVICE WORKSHOP * DISTRICTS SERVED EMTC, at Hyderabad Hyderabad Ranga Reddy Medak Nalgonda Mahboobnagar Guntur Zone A: at Eluru District Hospital Srikakulum Vizianagaram Visakapatnam East Godavari West Godavari Krishna Zone B at Cuddapah District Hospital Prakasham Nellore Cuddapah Chittoor Anantapur Kurnool Zone C at Karimnagar District Hospital Nizamabad Warangal Karimnagar Adilabad Khamman 6. Most of the skill development for maintenance personnel will be acquired by on-the- job methods under good technical supervision in an appropriately equipped workshop facility such as EMTC and the proposed Zonal M&R units which will be strengthened and established under the Secondary Health Care Development Program. The detailed requirements for these facilities are attached and the associated costs have been incorporated into the project budget proposed for IDA support. 7. In addition to training of maintenance personnel EMTC can play a significant role in the training of equipment users and in orienting health service managers to their responsibilities for looking after the systems in their charge. There is much scope for improving training of both maintenance personnel and equipment users and a start has already been made in this area by EMTC as shown in Table 3 below. In addition, higher level technical training where appropriate and specialized M&R services can be provided under contract from the manufacturers or their agents and perhaps also from suitable educational or training institutions in the State (or country) such as the Bio-engineering Department at Osmania University in Hyderabad. - 141 - Annex 10 Page 6 of 12 Table 3: Training Program TRAINING PROGRAM BATCHES PARTICIPANTS Radiographers 5 77 Electrician / Mechanics 1 18 Dietitians / MSWs 1 18 UNICEF: Training on stabiliser Repairs 3 38 Background of EMTC 8. Prior to 1987, equipment maintenance services for hospitals throughout the State were provided by the 'Health Equipment Repairs Organization' of the AP State Medical & Health Department. This organization operated a Regional Workshop at Nacharam in Hyderabad and had eight mobile workshop units based at Hyderabad, Warangal, Cuddapah, Guntur, Rajahmundry and Visakhapatnam. 9. After the formation of APVVP in 1987, the Regional Workshop at Nacharam was brought under the control of APVVP. This workshop was staffed by an assistant engineer along with three helpers, one office superintendent, one LDC, two sweepers and one watchman. The mobile workshops remained part of the Directorate of Medical & Health Services since they were involved primarily in supporting EPI cold-chain equipment used in PHC facilities. These latter resources, which include 7 sanctioned posts of junior engineer, are not used very effectively. 10. The staff initially available in the Hyderabad workshop were not sufficient in number nor in some cases competent to cope with the demands of up-keep and repairs of the large amount of medical equipment in the hospitals served. The Assistant Engineer employed was engaged only in the maintenance of plant and buildings. APVVP decided to establish an in-house repair workshop for biomedical equipment which would also serve as a Training Centre and develop programmes suitable for technicians and equipment users in order to improve their skills in operation and maintenance. In line with this equipment maintenance policy adopted by the APVVP Governing Council, EMTC was established in July 1989 and located in the old kitchen block of King Koti Hospital. The following staff have been appointed to the workshop: * Equipment Maintenance Engineer 1 * Junior Engineer (Bio-Medical) 1 * Foreman (promoted electrician) 1 (added in May 1990) * Helpers 2 * Sweeper 1 * Watchman 1 - 142 - Annex 10 Page 7 of 12 The estimated annual expenditure on salaries for these staff for 1992 was Rs 215,000.00 Objectives and Functions of EMTC 11. Training. EMTC, as part of the APVVP Head Office Organization, provides initial follow up when equipment is supplied and also refresher training programmes to various cadres of hospital employees to improve and update their skills in routine operation and care of various hospital equipment, and its preventive maintenance. The Centre also strives to impart necessary skills and knowledge to hospital administrators in the better management of equipment under their charge. 12. Procurement of hospital equipment. The Centre is responsible for technical aspects of procurement and subsequent commissioning of new and modem equipment. This commences with the identification of requirements, giving advice on and evaluating the specifications and performance characteristics, spares, operation instructions, maintenance and repairs manuals, terms of contracts etc. 13. Maintenance & Repair (M&R) services. The Centre tackles all major and minor repairs of the following types of equipments: UCommon ward equipment X Electro-medical equipment *Sterilization equipment *Analytical equipment * Surgical equipment H Electrical equipment In addition, the Centre also undertakes the minor repairs of Imaging and other sophisticated equipment and/or arranges for the major repairs through the authorized service stations of the manufacturers. (See Appendix 1 of this Annex 'Facilities Required for Maintenance Developments). 14. Liaison between APVVP & Equipment Suppliers. The Centre liaises between APVVP and the suppliers at the time of purchase of new equipment and gives technical advice concerning technical specifications, performance characteristics of the equipment and terms and conditions of supply etc. Workshop staff are the members of Expert Committees appointed for procurement activities. They also contact the servicing firms in connection with urgent and major repairs as and when required by APVVP hospitals. De facto, EMTC manages the implementation of equipment supply and service contracts with companies selling such goods and related technical service to APVVP. 15. Condemnation of obsolete and unserviceable equipment. The Centre assesses the life, utility and reparability or otherwise of all old and troublesome equipment. When necessary, it recommends condemnation of any unserviceable or obsolete equipment. For this purpose, a 'Condemnation Committee' has been formed which issues condemnation notes to the hospitals enabling them to buy - 143 - Annex 10 Page 8 of 12 replacements. Useful components from condemned equipment are used for other similar equipment repairs. Present Facilities at EMTC 16. The Centre operates from premises in King Koti Hospital, Hyderabad, comprising: * Workshop for common ward equipment. * Demonstration room with equipment models. * Lecture Hall with audio-visual aids.,(CTV with VCP, OH & projectors etc). * Workshop for electro-medical equipment. * Dormitory for 20 participants. * Indoor recreation facilities for trainees. * Course materials (as developed for programmes noted in Table 3) Past Performance of EMTC 17. From the start of servicing activities in July 1989 until the end of 1992, EMTC records show that it directly undertook the following work: Table 4: Work ComDleted by EMTC Type of work Nos. of jobs Contract estimate (Rs) EMTC actuals (Rs) Major repairs 412 247,200 82,400 Medium repairs 376 75,200 18,800 Minor repairs 480 48,000 12,000 Condemnation 170 n/a n/a TOTALS: 1438 370,400 113,200 18. During the same periods, EMTC has provided outreach services to other districts: *Districts coveredlO *Repairs on spot86 *Repairs at EMTC93 (equipment transported to EMTC) ECondemned on spotl56 - 144 - Amex 10 Page 9 of 12 Proposed Development Plan Under A.P. Health Systems Project 19. The aim of the Equipment M&R sub-component of the Project is to provide a fully integrated service with professional Biomedical engineers and technicians for maintenance and repairs of medical systems. Given the availability of medical facilities, transportation, distribution of population, etc, the services will be organized as a three tier system with APWP Headquarters and EMTC Central Workshop at Hyderabad and a biomedical engineering division based in an appropriately selected workshop location in each of three geographically zones. All these divisions ('zonal workshops') will be linked to and supervised by APVVP/HQ and EMTC. The proposed staffing patterns of the different facilities and the organizatlonal and managerial structure is shown below. Table 5: Proposed Staffing Pattern of EMTC Title APWP EMTC Each Zone Total | __________________ _ | (HQ) (KKH H) (3 total) Dy. Exec. Engineer 1(-) | 1 (-) (Bio-med.) _ _ _ Junior Engineer 1(1) 1(-) 4 (1) (Bio-med.) Technical Instruments 2 (-) 2 (-) 8 (-) Supervisor Technicians (BME) 4(-) 4(-) 16 (-) Junior Sanitary Worker 2 (1) 2(-) 8 (1) Note: the numbers in brackets indicate the existing filled posts 20. All the service workshops should have a specific allocation of funds and functional autonomy. For transportation and mobile workshop facilities, this network should be independent of Health Transport unit of Directorate of Health. Undertaking planned preventive maintenance (PPM) as well as responding to requests for services such as repairs have operating costs which need planned and secure budgets. Capital provision should also be made in the initial stage for setting up test facilities and repair facilities for equipment, mobile workshops. The physical facilities required are summarized in the attached Appendix. -145 - Annex 10 Page 10 of 12 Trainin2 in Facilities Mana2ement for Senior Administrators 21. The proper management of health care facilities is critical to good clinical practice and the safety of patients and staff. They could also otherwise become an administrative and financial burden to the health care organization which owns them. Physical assets such as buildings, plant and equipment represent valuable capital investments. If the right decisions and actions are not taken at key times in the life-cycle of assets, then opportunities can be lost to provide, improve and extend the essential health care service to the communities that they serve. 22. The training programme will address the key issues relating to the management of physical assets. The trainees will consider the following issues: * Where are we now in terms of improving the use of physical assets in the lbkh services? * Where do we wish to be, and what are the areas of improvement and potential benefit? * How do we intend getting there, and what are the most effective means of nig the desired improvements? At all times priority will be given to ways of achieving the service improvements which are at the core of the secondary health care development program. 23. A total of fifteen hours of tuition will take the trainees from basic concepts in inventory and asset management, through the appraisal of the needs of their own estate for action on maintenance, to decision-making concerning implementation of an asset management and maintenance programme. The following modular structure is proposed: - Facilities Management: An Overview - Inventory and Asset Management Concepts - Asset Management and Maintenance - Planning and Costing of Maintenance - Implementing a Maintenance Programme - Trends in Estate and Asset Management 24. The training will have a distinctive interactive format and consider the underlyiig need for structured analysis of existing situations leading to reasoned problem-definition, objectives-setting, options-appraisal and decision-making. The sustained practice in decision analysis which this approach will provide for trainees will form a continuing element in the future management of M&R activities. Case studies based on local situations and circumstances will feature wherever possible. - 146 - Annex 10 Page 11 of 12 Training Programmes for Different Cadres 25. Following the November 1993 Workshop which revised the equipment norms for APVVP Community (30-50 bed), Area (75-100 bed) and District (200-350 bed) hospitals, it has been ensured that all users of technology and plant installed in APVVP facilities will meet their obligations as spelt out in the policy paper. 26. This will be accomplished within the project by incorporating appropriate 'technology modules' into the clinical training programmes being planned. A list of what will be covered by the different cadres is given in Table 6 below. Advisory Role & Services 27. Expertise of the equipment management and maintenance department(s) should be used in planning, extension or renovation of facilities or installation of new plant facilities. This type of liaison will prevent minor disasters such as procuring obsolete or out-dated systems which are not serviceable or uneconomic systems which involve high operating cost etc. Similarly faults due to inadequate radiation protection, load distribution, noise levels of equipment, electrical supply system stability, non-interrupted power systems, leakage and subsequent patient safety problems, explosion hazards due to gases etc., could be avoided if taken care of initially. 28. The involvement of engineering personnel in the inspection of incoming equipment may free the health care systems from unnecessary trouble. If the inspection is not an automatic procedure, short shipments transport damages, insurance claims, or facility performance cannot be taken care of. Even warranty claims cannot be exploited properly. Long delays in putting the system into operation may also be difficult to avoid. Administration & Records 29. Administrative duties will include maintenance of records on all hospital equipment from the time of purchase until its ultirnate disposal. The organization should include a library of technical information manufacturers, literature, users manuals, copies of safety performance standards, books and periodicals of related interest. The library should have photocopying facilities. Stores and accounting facilities should be adequate. The stores at the Headquarters and divisions are to store necessary electronic and electrical spares as well as required hardware. - 147 - Annex 10 Page 12 of 12 Appendix: Facilities Required for Maintenance Development I. Eauipment EMTC/HO Workshop For 3 Zonal Unuts 1. Electrical tool kits 4 6 2. Mechanic's supplementary kits 4 6 3. Electronic Workshop 1 3 4. General Workshop 1 3 5. Materials & components 1 3 6. Refrigeration Service Kit 1 3 7. Technical Literature 2 3 II. Furniture 1 3 E[I. Service Vehicle 2 3 IV. Space Reouirements for Zonal Workshops Area (m2) 1. Electro-medical equipment workshop with power, water & workbenches 30 2. Heavy/dirty equipment repair shop with 3-phase power, water/sink & workbenches 30 3. Engineer office/library/records 4. Secure store for workshop tools, equipment, parts 12 5. Engineer & 'junk' storeroom/area (jobs awaiting completion & cannibalisation 12 for parts) 30 6. Covered 'lean-to' (outside) 7. Corridor/circulation space 12 30 - 148 - Aimex 11 Page 1 of 6 Stren2thening Referral and Support for Primarv Care Improving Functioning of Referral 1. A credible referral system provides patients access to levels of care that are appropriate to their health needs with a minimum of inconvenience and delay. It also ensures continuity of care including follow-up and longer term therapy and rehabilitation. Moreover, it minimizes the use of higher-level facilities when lower level facilities can provide appropriate care at lower cost. Improving the effectiveness and quality of clinical care in hospitals is an essential adjunct to a credible referral system. This project will implement several measures to strengthen the referral system and improve the quality of care in the hospitals. Special attention will be given to establishing mechanisms to improve access for remote and disadvantaged groups and tribal communities. 2. An effective referral system which minimizes by-passing of lower levels of health care has several features. First, services provided at each level need to be clearly defined. Second, services have to be of adequate quality to inspire confidence that patients will be treated in an acceptable, effective and appropriate manner at that level. And third, patients and the community must have confidence that the need for higher levels of care will be recognized promptly and provided for efficiently. 3. In this Project, as described in Annex 4, norms for the range and complexity of services that will be provided at each tier in the health care system have been clearly defined. Clinical skills, equipment and support services at each type of second level hospital will be upgraded and updated in accordance with those norms. The referral system will be improved by (a) strengthening the management of the referral system; (b) implementing referral protocols that specify the "what", "when" and "how" of referrals; (c) clinical management protocols that specify the essential processes of clinical management that should be implemented by staff who manage common conditions without the direct supervision of relevant specialists; and (d) establishing an incentive system for users and staff. 4. Management of the referral system. Agreement has been reached with APVVP on the activities that will be implemented by APVVP during the first year of the project to strengthen the management of the referral system. These activities are: a. New administrative directives b. Systematic dissemination of information about the referral system. 5. New administrative directives will be issued to all APVVP hospitals that will specify procedures to be followed in order to make the referral system effective and acceptable to the community. The directives will provide guidelines for: - 149 - Annex 11 Page 2 of 6 a. transportation facilities for the referral of critically ill patients, for transmitting the results of laboratory investigation results, and for the referral of poor and disadvantaged patients in remote areas; b. avoiding unnecessary delays in the receiving hospital by, for example, publicizing information on clinic hours, laboratory hours, x-ray hours, giving priority to referred cases, simplifying admissions procedures etc.; c. avoiding unnecessary duplication of tests, radiological examinations etc.; d. maintaining registers or records at both the referring hospital and the receiving hospital. This information will facilitate the monitoring and evaluation of the referral system in terms of numbers, purpose of referral, destination (or source) of referral etc.; and finally, e. charging for referrals from the private sector (rates, financial procedures etc.) 6. Systematic dissemination of information about the referral system will be targeted to personnel in public and private sector health care facilities and to the public. A plan would be prepared within the first year of the project for both the initial dissemination of information and for periodic updating. (See also IEC) 7. The issues that will be considered in developing the information plan are: a. target groups, such as APVVP hospitals, PHC and sub-center staff, tertiary hospitals, medical colleges,practitioners in the private sector and public sector. b. communication media and channels to be used, such as a technical manual, leaflets, pamphlets, administrative directives, meetings and briefings for medical staff, community leaders and other health related personnel. 8. Referral protocols are also being developed as a pre-project activity by working groups of senior clinical specialists nominated by APVVP. These protocols will specify a. types of conditions that should be referred either for investigation or treatment at higher levels; and b. when and how to refer. This will include procedures to be followed before sending the patient to a higher level hospital i.e. investigations, stabilization etc.; the situations in which transport arrangements may be requested from APVVP or other specified sources for critically ill patients, or for patients requiring - 150 - Annex 11 Page 3 of 6 assistance in obtaining transport; guidelines specifying the essential information that should accompany the patient, e.g., standardized referral forms, investigation results, standardized feed-back formats etc. The information should be sufficient to ensure continuity in patient care, but not be too burdensome on the staff; and provide timely and adequate feedback on patients referred for investigation, on patients requiring follow-up management, and simple acknowledgement of attendance for all patients to enable monitoring of compliance with referral. c. counselling and information for tle patient prior to referral. Examples of topics to be included are: purpose of referral, how the referral will benefit the patient, location of the referral hospital and when to go, what is likely to happen at the referral hospital, what will be the cost to the patient and what precautions or preparations to make before going (e.g. for tests, for operations etc.) 9. This work is also being coordinated by the Commissionerate, and it is expected that the protocols will be printed and distributed during the first year of the project. 10. Clinical management protocols are being developed as a pre-project activity by working groups of senior clinical specialists nominated by the APVVP. The work is being coordinated by the Commissionerate. The clinical management protocols are primarily intended to provide guidelines and standards for management of conmnon conditions by doctors who do not have post-graduate qualifications in a particular specialty. In particular, the protocols will be applicable in community hospitals, in various facilities at the primary health care level, and in other hospitals where the doctor is not working under the direct supervision of a specialist. 11. Working Groups have been formed for the following specialties: General Medicine; Obstetrics and Gynecology; Paediatrics; Surgery, Orthopaedics, ENT, Ophthalmology, Dentistry; Anesthesia; and Diagnostic Specialties (pathology, biochemistry, radiology). 12. Protocols will be developed for all common conditions (based on epidemiological data) that are to be managed at community hospitals. Protocols for most of the common conditions are expected to be printed and distributed during the first year of the project. 13. An incentive system will be established with differentiated user fees for users and non- users, allowing patients to by-pass waiting lines when they carry a referral slip and providing other incentives to staff who honor the system. ImRroved Technical Support and Coordination with Primary Care 14. In order to be relevant and provide for the health needs of the community, the secondary level of health care should have close linkages with the primary care level. First, staff at the - 151 - Annex 11 Page 4 of 6 primary level (medical officers, multi-purpose workers, etc.) have a crucial function in informing the community of the services available at the referral hospitals, and helping patients to use such services appropriately. Second, there are several programs and services operating at the primary level under the management of the Departments of Health and Family Welfare, which would be strengthened through active coordination with the first referral level. Third, services provided by the hospitals could be augmented by the use of community resources. For example, emergency transportation and communication could be mobilized through the primary level programs. 15. In order to operationalise these concepts, APVVP and the Director of Health will, by the first year of the project: a. establish a District Referral Committee: and b. establish training and out-reach activities for primary care facilities. District Referral Committee 16. The members of the committee will include: District Coordinator (chairperson) District Medical and Health Officer Medical Superintendents of the Area Hospitals Deputy District Medical and Health Officers 17. The functions of the District Referral Committee will include: a. Preparing a zoning system. The zoning system will link identified community hospitals, community health centers and primary health centers with particular area or district hospitals for the purposes of (a) training and consultant out-reach visits; (b) as preferred referral sites; and (c) as the source for emergency ambulance services for critically ill patients; b. Monitoring the referral system and identifying and resolving problems. This will be done by regularly obtaining and assessing data from referral registers. Also the Committee will actively seek feedback from primary care staff, hospital staff and the community on problems experienced during referral; c. Mobilizing transport for referrals to hospitals. The Committee will liaise with NGOs and other government agencies to organize procedures to mobilize transport for patients; - 152 - Annex 11 Page 5 of 6 d. Coordinating programs for technical support. Technical support will include visits by consultants to community hospitals, community health centers and primary health centers for the purpose of providing consultant services and on-the-job training; e. Coordinating informal in-service training at referral centers for staff from lower levels; and, f. Exploring avenues of enhancing the role of hospital consultants in strengthening primary care programs such as safe motherhood, child survival, etc. Trainine and out-reach activities 18. Primary care facilities and community hospitals will be zoned and an identified area or district hospital will be responsible for providing technical support for each zone. 19. The referral hospitals will provide technical support through: a. dissemination of the Technical Manual to Primary Health Centers(PHC) and briefings for PHC and Community Hospital (CH) staff on the use of the Manual; b. clinical attachments for PHC and CH staff for training in specific clinical skills; c. week-end courses; d. regular meetings to discuss problems in clinical management; e. dissemination of the In-house Journal which is currently being produced by the APVVP; and f. out-reach visits to PHCs and CHs by consultants from APVVP hospitals for providing on-the-spot consultation for selected cases, and practical demonstrations of selected management techniques. 20. The District Coordinator will be responsible for coordinating the outreach visits by consultants. This will include transport arrangements and a regular schedule of visits by consultants from different specialties to community hospitals and PHCs. 21. Training plans and out-reach visit schedules will be presented to the District Referral Committee for approval and support. 22. APVVP will prepare Annual Plans for Technical Support and these plans will incorporate - 153 - Annex 11 Page 6 of 6 the district plans for training and out-reach visits. It is intended that technical support will be increased in a phased and incremental fashion. APVVP will coordinate and monitor implementation of the plans. - 154 - Annex 12 Page I of 5 Oualitv Assurance Program in APVVP Hospitals Planning the Oualitv Assurance (OA) component in the Project 1. A systematic Quality Assurance (QA) program is essential for monitoring and ensuring that project inputs of physical resources, manpower, training, and strengthening of management are actually translated into better quality of care. Such a system will empower managers, clinicians and technicians to monitor the quality of care provided by their own hospitals and assist in instituting rapid remediai measures whenever shortfalls in quality are detected. 2. It was agreed with APVVP that a systematic program of Quality Assurance would be developed to cover aspects of technical (clinical) quality, user satisfaction, and management of resources. Essential components of such a system, and steps needed to develop it were discussed with groups of senior clinical specialists and managers from APVVP hospitals. Working groups were nominated by the APVVP for the development of a QA program. 3. In-house capacity of hospitals to design and implement appropriate remedial measures for shortfalls in quality will be developed during the management training program. 4. QA Working Groups and the Management Training Working Group will prepare their own implementation plan which will show the activities planned annually during the life of the project. This implementation plan will take into consideration the activities described in this annex. Objectives and Scope of the QA Program 5. Objective. The objective of the QA program is to continuously improve the quality of care in APVVP hospitals by instituting on-going monitoring systems for identifying and investigating shortfalls in quality and implementing remedial measures to address these shortfalls. 6. Scope. Quality of care has many facets. These include: human aspects of caring, comfort, courtesy etc.; technical aspects such as effectiveness and safety of care; and managerial aspects such as utilization of resources, availability of services, timeliness, cleanliness etc. In order to operationalize a practical program of quality assurance, APVVP hospitals need to prioritize, select and define the aspects of care that are to be monitored. 7. Taking into consideration the dearth of local expertise in the field of QA and other competing demands on resources, APVVP has agreed that the program would initially focus on a few aspects of quality and services. 8. Decisions will also be made regarding the phasing of the program so that, as expertise is required, an increasing range of services and quality can be included in the program. - 155 - Annex 12 Page 2 of 5 9. The QA Working Group will make recommendations to APVVP on which aspects of quality will be initially included. The following list will be considered in making the selection: (a) Technical quality: effectiveness and safety of clinical care in areas of medicine, paediatrics, surgery, obstetrics, orthopaedics, anaesthesia and nursing. Examples are: preventable mortality and morbidity such as unacceptably high rates of hospital case fatality, post operative infection and complications etc. Another aspect of technical quality would be accuracy and/or reliability of laboratory tests and radiology. (b) Patient/community satisfaction: in terms of courtesy, caring, comfort and information. (c) Managerial quality: with regard to cleanliness; timeliness of investigations, and interventions; availability of drugs, tests, non-drug consumables, beds, staff etc; utilization of resources such as beds, manpower, and materials; availability, accuracy, and comprehensiveness of records; and down-time of major items of equipment and services. 10. The working groups that have been set up will make recommendations on the levels of services that should be included in the QA program. For example, whether recommendations on the level of services should include only those related to community hospitals, area hospitals and district hospitals or all hospitals; and whether it should cover in-patient care, out-patient care or both. 11. The working group will make recommendations on the phasing of the QA program. Recommendations will include aspects that are to be included in each phase, and proposed timing for the introduction of each phase. As an example, Phase 1 may include technical effectiveness in medicine, obstetrics and surgery; patient satisfaction;and managerial effectiveness. All these aspects could be monitored only in District hospitals. Phase 2 may include all aspects in Phase 1 plus technical-effectiveness or timeliness of laboratory tests, nursing care, radiology etc; patient satisfaction and comfort; and managerial effectiveness in terms of availability of drugs, utilization of beds etc. All these aspects could be monitored in area and district hospitals. The QA Steering Committee of APVVP will review the recommendations of the working groups and finalize the objectives and scope of the QA program. - 156 - Annex 12 Page 3 of 5 Developing a Suitable Climate of Opinion for OA 12. "The implementation of QA programs is subject to a variety of types and sources of resistance ..... it is extremely important that careful thought be given to the strategies and tactics ... to facilitate the development of activities at national, local and institutional levels" WHO Working Group, 1983 13. In order to create a climate conducive to the implementation of QA, APVVP will undertake the following steps: (i) identify opinion leaders from among professional groups such as doctors, nurses, etc.; from institutional groups such as managers, union leaders etc.; from managerial groups such as APVVP, district coordinators, etc.; and from the community through hospital boards, etc.; and (ii) plan a systematic program of consensus-building among opinion leaders. Suitable activities would include seminars to give information on the benefits and limitations of QA and include opinion leaders in consultative decision making regarding the development of the program. Some examples of activities would be to develop or review indicators, to set standards for quality, or to suggest aspects of quality that should be monitored. 14. Since consensus-building is a slow and iterative process, it will be necessary to plan and budget for these activities throughout the life of the project. One-day seminars for this purpose have been proposed. P.rogram Planning 15. It will be necessary to simultaneously develop the organizational structure and the activities of the QA program. Since quality should be the concern of all service providers in hospitals, it is recommended that, as far as possible, activities should be implemented by existing staff in the organization. The development of QA will therefore be a "learning by doing" process. However, as specialized technical input will be needed, it will be necessary to designate a local consultant as the technical advisor for the program, and provision will also be needed for external consultant support for training and program development at crucial stages of the project. 16. Organizational arrangements. APVVP will allocate responsibility for QA to the Joint Commissioner for Training and Referral in APVVP. The Joint Commissioner will: establish a QA Steering Committee for APVVP to determine phases and approve planned activities and monitor and evaluate progress; prepare annual action plans for program development; set up the necessary working groups; monitor the progress of each group; and coordinate planned activities. 17. APVVP has nominated a Working Group consisting of clinical specialists and hospital managers to initiate the activities that are listed in the section on Program Development. Other working groups will be formed subsequently to further develop the program. - 157 - Annex 12 Page 4 of 5 18. A local consultant is to be appointed as a Technical Advisor to provide developmental support. This will include providing technical support to Working Groups that will develop indicators and set standards (e.g. literature review, advice on validity, sensitivity, and specificity of indicators etc,.); review suitability of the available data or suggest suitable cost effective methods of collecting new data; provide training for pilot testing of selected indicators and data collection methods. 19. APVVP will identify hospital OA coordinators in each participating hospital who will be responsible for providing technical support and training for hospital groups performing the Quality Improvement activities (see below). - Developmental activities 20. Ouality Assessment. The first stage of program clevelopment will establish procedures for quality assessment. This involves regular periodic monitoring to assess the quality of selected aspects of care provided in hospitals. Several activities are needed to establish such a process in hospitals. QA working group will be responsible for implementing these steps with technical guidance from the Technical Advisor. Some of the steps may be initiated prior to project start-up. The early identification and appointment of the Technical Advisor is essential for program development. 21. The steps in setting up quality assessment for the selected areas of focus are: (a) identify suitable indicators for monitoring quality; (b) set acceptable standards; (c) pilot test methods of data collection e.g. routine records, interviews with patients, set up complaints mechanism, focus group discussions with selected "clients" e.g. women users, community leaders, tribal groups etc.; (d) review data that has been collected and review indicators and proposed standards; (e) establish regular on-going methods of data generation; and (f) establish procedures for reviewing the data and identifying hospitals which have shortfalls in quality. 22. Oualitv Improvement (01). Quality improvement activities need to be developed which can rapidly remedy shortfalls in quality. It will be necessary to develop skills and capacity within participating hospitals to design and implement such focussed and rapid problem-solving interventions. This activity will be integrated with management training. Priority for such training will be given to the hospital QA coordinators. 23. Activities of the 01 group. In order to operationalize quality improvement, when a hospital is identified by the monitoring system as having a shortfall in quality, a QI Group will be formed among the staff who are responsible for the provision of care in the area which has a shortfall in quality. With the assistance of the QA Coordinator, the QI group will: (a) investigate factors contributing to shortfalls in quality; (b) develop strategies for remedying shortfalls in quality and prepare an implementation plan; (c) submit a report of the investigation and the implementation plan to the APVVP QA Steering Committee; and (d) implement the plan. - 158 - Annex 12 Page 5 of 5 24. The next cycle of periodic monitoring will demonstrate whether the activities of the QI group have been successful in improving quality. 25. In support of the QA strategy, the project will provide training, support materials such as manuals and guidelines, consultant support, annual workshops and study tours to "centers of excellence". - 159 - - Annex 13 Page 1 of 4 Information. Education and Communication Strategy Communication Support to Project Objectives 1. In seeking to improve the status of morbidity, mortality and disability of the people of Andhra Pradesh, this project's objective is to influence both the health seeking behavior of beneficiaries and the health dispensing behavior of service providers. Following would be the specific aspects of behavior that the project will target to influence, in line with the main objectives of the project. 2. Narrowing coverage gaps in the provision of health care and providing greater access to health services. While access and coverage are normally considered to be dependant on physical distance, there is strong evidence to indicate that service utilization also depends considerably on mental distance. This refers to the levels of awareness and comfort that exist in the minds of the beneficiaries - particularly tribals and other disadvantaged groups - with respect to the institutions and people providing the services. Reducing such mental distance would be a major requirement for the project to meet its objectives. 3. Im=roving system performance and the quality of services. The provision of additional facilities, equipment and clinical as well as technical training is expected to result in a significant improvement in the quality of service delivery. In addition, an important dimension of the service delivery is the sense of "care, courtesy and comfort" that patients perceive throughout their interaction with the system. In this context, bringing about the necessary changes in organization and management to substantially affect perceptions of the quality of service will require a systematic and sustained communication effort within each health facility. 4. Improving efficiency in the allocation and use of health resources. Since resources are currently being used to provide free services to some people who can contribute to the costs, allocative efficiency will be improved by increasing the APVVP system's capacity to recover a part of these costs. However, willingness to pay is a function not merely of ability to pay but also an assessment of what is being paid for. To the extent that specific groups or services can be identified for cost recovery, communications strategy can contribute to allocative efficiency by raising willingness to pay. - 160 - Annex 13 Page 2 of 4 Communications Strategy 5. Three broad strategies are proposed for the component: (a) increase awareness of the services provided by APVVP hospitals, particularly among lower income and disadvantaged groups (such as tribals), and thereby to increase utilization in a manner appropriate to each level of the system; (b) motivate all APVVP personnel to continuously practice standards of patient care such that the quality of services received by patients is enhanced; (c) promote APVVP's services to specific groups in a manner that increases their willingness to utilize these services and, where possible, to share in the costs of service delivery. 6. The strategy will be developed on the basis of decisions made with regard to: (a) who do we want to address, that is, identification of target groups; (b) what do we want to say to them, that is, selection of messages; and (c) what methods should we use to deliver a specific message to a particular target group, that is, media selection. *The rationale for each of these categories is as follows: 7. Target groups. While special groups, such as tribals, will require specific strategies based on their particular profiles (see separate section on Tribal Strategy), three segments will need to be included in the target audience for all institutions. First, government functionaries working at the grass roots level -- anganwadi workers, gram sevikas, school teachers, agricultural extension workers and multipurpose health workers -- should be targeted for information pertaining to the availability of different types of health care at different levels within the health care system. These workers are likely to be seen as opinion leaders by the populations they serve and they can be key information sources in spreading knowledge about the working of the referral system. Second, women should be considered as a priority target, since they are managers of the household's health status and have also demonstrated their capacity as a group to mobilize community response (for example, the anti-arrack and thrift groups in Andhra Pradesh). Third, patients who enter the APVVP system should be considered a priority target. Their word-of-mouth based on their first-hand experience will carry far more weight than any other channel of communication. The imperative of creating satisfied customers must be recognised for communication strategy to succeed. Fourth, private practitioners should be targeted because of their potential role in referring patients, and because they should be aware of the improved standards of care in APVVP. 8. Messazes. The content of the messages that comprise the IEC strategy will vary based on factors such as geography, seasonality and local considerations. For example, a - 161 - Annex 13 Page 3 of 4 hospital situated near a busy highway may find it necessary to spread awareness about its trauma unit: similarly, another institution located in a tribal area with high incidence of tuberculosis may choose to focus on its diagnostic services. In addition to such institution- specific content, APVVP should build its central strategy on two messages: first, that APVVP offers a range of services and, secondly, that APVVP cares. It would be useful to give much greater visibility to the Parishad's logo, since a large proportion of the beneficiaries are likely to be not literate. 9. Media selection. The most importanlt medium for the APVVP's communication strategy is its employees. The manner in which they treat outpatients, visitors and those who are admitted will have the greatest impact of all the possible channels that may be employed. It will, therefore, be essential to provide training on communication and education to staff on patient and visitor handling. Further, training inputs will have to be sustained and supplemented through periodic internal "campaigns" to remind employees of their role in delivering quality with courtesy. For the population outside the hospitals, the priority medium should be functionaries working in health and related sectors, who will be given in- house tours to enable them to understand the changes that have been instituted within APVVP hospitals. Other than such word-of-mouth oriented media aimed primarily at projecting APVVP's caring image and the referral system, the IEC strategy should rely on periodic waves of printed communication to higher levels in these departments. Finally, the use of well-designed signs within APVVP hospitals, as well as in PHCs, providing information on what services are available where, would be an efficient and low-cost medium. ImDlementation 10. Development and implementation of the IEC strategy will require the use of a professional communications agency. This could be done by APVVP employing the services of one of the full-service national agencies located in Hyderabad. The agency would be required to obtain a thorough understanding of the health system in AP and APVVP's role and objectives before being asked to proceed with the IEC component. The Joint Commissioner for Training, Referral, M&E and IEC, to be recruited in a newly created position, will have overall responsibility for IEC activities. The Deputy Commissioner for M&E and IEC, who is also to be recruited under the project, will be responsible for coordinating implementation arrangements of IEC activities at the district, area and community levels. 11. APVVP would ensure that at each hospital one person would be identified for providing local inputs and implementing programs. For District Hospitals and Area Hospitals, this responsibility would lie with the RMO, and for Community Hospitals it could be the responsibility of the MO in charge. The agency that will develop the IEC component will be required to conduct orientation programs for the key staff who will be coordinating - 162 - Annex 13 Page 4 of 4 the implementation and supervision of the activities. A plan for communication training should be developed and incorporated into the management training program. 12. Using the office of the District Collector (Project Officer, in the case of tribal areas), in-house tours would be provided to groups of functionaries so that the working of the referral system and the range of services available are understood. The District Coordinator would also deploy staff selectively to monthly meetings of other departments at the block or project (in the case of ICDS) level to explain the services and the system. 13. Timing. It is of utmost importance that communication activities be commenced only after the physical premises, equipment upgradation and manpower development steps have been completed. Prematurely initiated IEC activities can be extremely counter productive. - 163 - Annex 14 Page 1 of 6 Tribal Strate2 Introduction 1. According to the 1991 census, almost 4.2 million people in Andhra Pradesh (AP) (6.3 % of the population) are tribals. While one-third of this population is considered to be living in conditions similar to the standards of the mainstream, the others -- well over 2.5 million -- inhabit hilly and forest areas in remote and difficult terrain. Health Status and Epidemiology of Tribal Population 2. Several studies, conducted by the Tribal Cultural Research and Training Institute under the Tribal Welfare Department of the Government of AP, have documented the result of the deprivation suffered by this population. While maternal mortality among tribals is only slightly higher than the average for the state (4.4 compared to 4), in extreme cases such as the Chenchu tribe, a 1993 report found maternal mortality to be as high as 7, primarily because of tetanus. A 1992 study on the Chenchus found the Infant Mortality Rate (IMR) to be 215 per 1000 during the year of enquiry. Crude Death Rates for tribes such as the Savaras (15 per 1000), Gadabas (17.5 per 1000) and Jatapus (19.5 per 1000) are much higher than the 9.9 per 1000 average for the state. 3. A recent analysis of patient registers at PHCs has shown that the common diseases for which treatment was sought by tribal adults were respiratory infections (TB and bronchitis), fevers (malaria was reported at epidemic proportions in most Integrated Tribal Development Agencies), alimentary diseases (peptic ulcers, hyperacidity and dysentery) and aches and pains. The same analysis also showed that for children, the common ailments were gastro-enteritis (diarrhoea), respiratory infection, fevers, scabies and skin infections. Government Response to Tribal Problems 4. In AP, efforts to alleviate the conditions of tribals go back to the early part of this century. In 1917, areas inhabited by the tribals were declared as "scheduled" or "agency" areas and non-tribals were barred from purchasing land in such zones. Subsequently, in the Fifth Five Year plan, areas abutting the scheduled areas, where the tribal population was more than 50%, were declared as Tribal Subplan Areas and the Integrated Tribal Development Approach (ITDA) was begun. A few omissions were constituted as the Modified Area Development Approach (MADA) in the Sixth Five Year plan, whereby scattered areas with a minimum population of 10,000, at least 50% of which was tribal, were incorporated into the government's overall tribal policy. Finally, 17 clusters were started in 1989. These clusters have a population of at least 5,000, with a tribal concentration of at least 50%. - 164 - - Annex 14 Page 2 of 6 5. The special focus on tribal populations is administered by the Office of the Commissioner, Tribal Welfare, through eight Integrated Tribal Development Agencies (ITDAs) in the following districts: Vizianagaram, Srikakulam, Vishakapatnam, East Godavari, West Godavari, Khammam, Warangal and Adilabad. Each ITDA is headed by a Project Officer (PO), normally an officer from the IAS, who is also designated as Joint Collector and Additional District Magistrate. The District Collector is the Chairman of the ITDA in his district. A government order has given the PO single line control over several departments: health, community development, agriculture, horticulture, soil conservation and minor irrigation. Resources for tribal welfare activities are obtained from a compulsory proportion of each department's budget as well as from special GOI funds. 6. Another important feature of the response in AP is the Girijan Cooperative Corporation Ltd. (GCC), a state government undertaking established in 1956 primarily for supplying items of daily requirements and procuring and marketing forest produce brought in by the tribals. The GCC is an apex cooperative for 43 primary cooperative marketing societies and works closely with the ITDAs. Its track record, reach and credibility with tribal groups make it a potentially important dissemination point for IEC material aimed at influencing the health seeking behavior of tribals. 7. Recognizing that part of the reason for the current weakness in the health delivery system in tribal areas is caused by the unwillingness of medical personnel to serve in those areas, GOAP has also constituted the Tribal Medical Service. More than 500 Multipurpose Workers and some Medical Officers have been recruited into this service and will receive special benefits for serving continuously for a period of 5 years in a tribal area. This cadre of medical personnel should become available within the next 2-3 years. Key Determinants of Tribal Health Seeking Behavior 8. A Beneficiary/Social Assessment Study was undertaken by the Administrative Staff College of India (ASCI) on behalf of the Government of India (GOI) as part of project preparation. Its objectives were to: (i) undertake a social context analysis to establish the current distribution of and access to health care facilities in rural and tribal areas; (ii) conduct an institutional analysis to understand the supply factors which adversely affect health care utilization; and (iii) assess the perceptions and attitudes related to health needs and health seeking behavior of tribal populations. The report concluded that there were three key issues which determined the health seeking behavior of tribal people. 9. Physical Access. Clearly, publicly provided hospital services are inadequate in rural and tribal areas. The private and voluntary sectors have a significant presence in AP. However, more than 80% of private health facilities are located in urban areas, indicating that the access to private sector institutional care is much less in interior areas. In emergency situations requiring hospitalization, access to the beds provided by the Primary Health Centers (PHCs) and - 165 - Annex 14 Page 3 of 6 Community Health Centers (CHCs) would be critical for tribal people. When access to these beds was studied, the bed/population ratio dropped significantly from the state average of 0.41 per 1,000 to 0.18 per 1000 in rural and tribal areas. This is well below the norm of one bed per 1,000 suggested by the Seventh Five Year Plan. 10. Moreover, no additional budgetary provision is available for the supply of drugs and diet for patients admitted at PHCs, and PHC staff are required to handle such cases within the resources available to them. This creates resentment and has a significant adverse impact on the quality of care provided, which in turn negatively influences the utilization of PHC facilities. Medical staff in tribal PHCs are in any case resentful of their situation, and doctor absenteeism is a significant problem in tribal areas. 11. Another physical access issue is the average distance travelled by urban and rural populations in order to reach a health care facility. In urban areas, about 55% of sampled patients lived within 1 km. of a health care facility and only 0.78% needed to travel more than 10 kms. In rural areas, however, only 35% of sampled patients lived within 1 km. of a health care facility and almost 20% needed to travel more than 10 kms. This would undoubtedly have an impact on rural health seeking behavior since it would mean not only the loss of wages for an entire day (perhaps more), but also increased cost in terms of transportation, food, lodging etc. For women, the distance would be particularly burdensome, since they would have to make arrangements for child care as well as for a travel companion for themselves when going so far from their native village. 12. Social Access. Preliminary results from the qualitative survey conducted by ASCI indicate that tribals have a special set of social beliefs and practices which affect their health seeking behavior. For instance, tribals consider themselves to be ill only when they are incapable of performing their daily duties, and it is only then that they consider seeking medical attention. Most illnesses are first referred to local traditional healers for diagnosis and treatment. These traditional healers not only share a common set of beliefs with their patients, but are also easily accessible and affordable. 13. Most illnesses are attributed to supernatural causes and the prescribed treatment involves performing rituals to appease these supernatural beings. In addition, a variety of herbal medicines are also used to relieve pain, stress and other secondary symptoms. The tribals contact providers of modern medicine only when they do not get relief from the traditional treatment, as a last resort, or if they contract an illness which has no traditional remedy. Significantly, the three diseases for which the tribals routinely give preference to allopathic care are all subjects of national vertical programs: TB, malaria and diahhroea. 14. Other reasons for the under utilization of public sector health facilities include: inconvenient working hours of the health care institutions; lack of in-patient care during emergencies; impersonal and detached behavior of the primary health care providers; - 166 - Annex 14 Page 4 of 6 unfamiliarity of the health care providers with tribal customs, leading to negative experiences for tribal patients; and belief that the health staff give the same medicines for all diseases, since most medicines are similar in physical appearance. 15. Economic Access. The data show that substantial costs - on fees, drugs, tests and transport - are being incurred by tribals possibly because they postpone seeking treatment until the problem has become very acute. When the households utilizing health facilities were classified into 10 fractile groups based on monthly per capita expenditure, it was evident that irrespective of per capita expenditure levels, the households in Andhra Pradesh were spending more or less equal amounts on health care. This would imply a regressive spending structure which acts as a disproportionate burden on tribals, the majority of whom belong to the lowest expenditure fractiles. 16. Moreover, the cost of private care, for both hospitalized and non-hospitalized illness episodes, ranges between 2 and 10 times the cost of care at public sector facilities. Due to these cost considerations, 62% of Scheduled Tribe (ST) households used public sector health facilities for hospitalization episodes as compared to only 33 % of other social groups; and with regard to ambulatory care, the proportion of households that utilized public sector health facilities was higher among the STs and SCs (35% and 31 % respectively) as compared to other social groups (14%). It is, therefore, imperative for the government to institute some policy changes which would reduce the costs to the tribals of utilizing public sector health facilities. Tribal Strategy and Project Activities in Supnort of the Tribal Strategir 17. Tribal people are expected to be a substantial project beneficiary group. The Beneficiary/Social Assessment Study identified, through surveys, the health care needs of tribal communities and constraints in the provision of these needs. Based on the findings of the study, a strategy has been recommended for delivering adequate and quality health care to members of these communities. The project strategy for tribal development is aimed at increasing the demand for hospital services in tribal areas by improving the quality of services and providing effective IEC to better inform the tribal population of the benefits of using health services at secondary hospitals. Following are the project activities in support of this tribal strategy: (i) increasing the bed strength in tribal hospitals: The project will increase the total number of upgraded beds in tribal areas from 270 to 560 -- an addition of 290 beds, at 3 area and 6 community hospitals. This will considerably improve tribal access to hospital-based services. (ii) strengthening linkages between primary and secondary health care services: The available evidence points to an urgent need for establishing linkages with primary health care services where tribal health needs are acute. It is necessary to strengthen linkages between the secondary and primary - 167 - Annex 14 Page 5 of 6 health systems, particularly with respect to the referral of tribal patients, by improving the design and reach of primary care services such that they can function effectively as first referral institutions. This would mean improving the quality of service and effectiveness and efficiency of service delivery at primary health care facilities by (a) increasing the awareness and sensitivity of medical staff, through appropriate IEC, to tribal customs and culture; and (b) providing some curative services along with preventive and promotive services at PHCs. This would be done by organizing "outreach camps" where CHC doctors, in coordination with PHC staff, would provide on-site specialist services. CHC doctors would be reimbursed for such outreach work through the APVVP budget. (iii) increasing incentives to medical staff in tribal areas: Staff would be provided with incentives to increase their committment to the tribal areas with the construction of an additional 42 Type II, 31 Type III and 23 Type IV new staff quarters for all medical staff in tribal hospitals. Moreover, other benefits will also be offered, such as giving preference to the children of doctors in tribal areas for admission at government-run residential schools and for places in schools for scheduled tribes and scheduled castes. Extra weightage will also be given to doctors and other staff for PG qualification admission and for fellowships; and they will have enhanced opportunities for transfer to an urban area after 4-5 years. Doctors hired directly into the newly constituted Tribal Health Service in AP would have their appointments formalized into regular government service after 4-5 years of service in tribal areas. This would encourage doctors and staff to work in tribal areas and provide quality services. This, in turn, will increase the credibility of the health care system for the tribal patients and encourage them to approach the health care facilities more readily when necessary. (iv) increasing the appropriate utilization of the non-tribal medical system by the tribal population: Since health seeking behavior in this population is biased towards curative rather than preventive action (see Para. 12), an IEC program targetted particularly at increasing tribal awareness of disease is needed. IEC would also need to increase the appropriate utilization of health services by tribals. It would incorporate the following ideas: (a) focussed communication aimed at the tribal practitioner to improve his skills at diagnosing ailments such as malaria and diahhroea and developing him as a referral point. Tribal practitioners would also be used as opinion leaders and would be given special incentives, such as free use of paying wards, for referring tribal patients to the PHC; (b) using shandies (tribal markets) to register the presence of the non-tribal medical system by, for instance, conducting screening and for promoting the need for early recognition of - 168 - Annex 14 Page 6 of 6 ailments; (c) group visits to primary and secondary facilities by tribal leaders and women to build familiarity as well as to sensitize staff; and (d) use of the 800 Daily Requirement Depots of the GCC to stimulate word-of-mouth about the primary and referral systems. (v) reducing the cost to tribals of utilizing the system: The analysis clearly shows that tribals are bearing a disproportionate burden of health care costs, and at the least, the very poorest (category 1 in the fractile tables) must be exempted from user charges, particularly for drugs and tests, which constitute the major share of expenditures incurred at public sector health facilities. Reduction in the cost burden to tribals will also be attempted by providing a rest area on or close to the health center premises for the attendants accompanying the patient and by promoting the Transport Reimbursement Fund available with each ITDA Project Officer. Where possible, APVVP will also coordinate with local NGOs to provide transportation and/or food to tribal patients and attendants. - 169 - Annex 15 Page 1 of 17 Summary of Construction Program DISTRICT DISTRICT HOSPITAL AREA HOSPITAL COMMUNITY HOSPITAL D.H. A.H. M.CH. Rs. C.H. M.CH. W&C PAED Total Maty H. Maly H SRIKAKULAM 1 2 0 0 6 0 0 0 9 VIZLNAGARAM I I I 1 0 2 0 0 0 5 VISAKAPATNAM 0 2 0 0 3 0 0 0 5 EASTGODAVARI 1 3 0 0 3 0 0 0 7 WESTGODAVARI 11 1 2 0 0 5 0 0 0 8 KRISHNA 1 2 0 0 4 0 0 0 7 GUNTUR 1 2 0 0 5 0 0 0 8 PRAKASAM inI 1 2 0 0 2 1 0 0 6 NELLORE I 2 0 1 0 0 0 1 5 CHITTOOR 1 2 0 0 5 0 0 0 8 CUDDAPAH 1 2 0 0 2 0 0 0 5 IV ANANTAPUR 1 3 0 0 7 0 0 0 11 KURNOOL I 1 0 0 2 0 1 0 5 MAHBOOBNAGAR 1 2 0 0 2 0 0 0 5 RANGAREDDY V 1 1 0 0 3 0 0 0 5 HYDERABAD 1 3 0 0 1 1 0 0 6 MEDAK 1 2 0 0 5 1 0 0 9 NIZAMABAD 1 3 0 0 1 0 0 0 5 VT ADILABAD 1 2 0 0 5 1 0 0 9 KARIMNAGAR I I 0 0 3 0 0 0 5 WARANGAL 0 2 0 0 2 0 0 0 4 KHAMMAM vii 1 2 0 0 2 0 0 0 5 NALGONDA 1 3 0 0 4 0 0 0 8 21 47 1 1 74 4 1 1 150 - 170 - Annex 15 Page 2 of 17 LIST OF DISTRICT, AREA AND COMMUNITY HOSPITALS SELECTED FOR RENOVATION AND EXTENSION SL. CODE HOSPITAL NAME NO. AND PLACE B E D S AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) SRIKAKULAM TOTAL POP.: 2321126 1. 101 D.H. SRIKAKULAM 230 20 250 88684 N.H.5;RLY.LINE 2. 102 A.H. PALAKONDA 30 70 100 24327 ITDA HQRS 13KM 3. 103 C. H. PATHAPATNAM 30 20 50 57304 TRIBAL 4. 104 C.H. NARASANNAPET 30 20 50 20120 N.H. 5. 105 A.H. TEKKALI 30 70 100 20830 6. 106 C.H. PALASA 30 20 50 15580 N.H.; RLY.LINE 7. 107 C.H. ITCHAPURAM 30 0 30 29645 8. 108 C.H. BARUVA 30 0 30 9. 109 C.H. SOMPETA 30 0 30 15783 RLY M LINE TOTAL: 470 220 690 272273 VIZIANAGARAM TOTAL POP.: 2110943 10. 201 D.H. VIZIANAGARAM 100 100 200) 160433 I. 205 M.CH. VIZIANAGARAM 50 50 100) 12. 202 A.H. PARVATIPURAM 30 70 100 43483 ITDA HQRS:TRIB 13. 203 C.H. S. KOTA 30 20 50 14. 204 C.H. GAJAPATINAGARAM 30 0 30 51623 TOTA L: 240 240 480 190231 VISAKHAPATNAM TOTAL POP.: 3285092 15. 301 D.H. NARSIPATNAM 30 70 100 84362 N.H.5;RLY.LINE 16. 302 A.H. ANAKAPALLI 32 68 100 29051 FLOOD PRONE 17, 303 C.H. ARAKU 30 20 50 41360 TRIBAL 18. 304 C.H. PADERU 30 20 50 44875 TRIBAL 19. 305 C.H. AGANAMPUDI (T) 10 40 50 TOTA L: 132 218 350 199648 EAST GODAVARI TOTAL POP.: 4541222 20. 401 D.H. RAJAHMUNDRY 250 0 250 358327 21. 402 A.H. AMALAPURAM 70 30 100 45969 FLOOD PRONE 22. 403 C.H. RAZOLE 30 20 50 11973 FLOOD PRONE 23. 404 A.H. RAMCHANDRAPURAM 44 56 100 36769 24. 405 C.IH. KOTHAPET 30 20 50 73868 FLOOD PRONE 25. 406 C.H. PRATHIPADU 30 0 30 68734 26. 407 A.H. RAMPACHODAVARAM 30 70 100 7844 TRIBAL;FLOOD PR 484 196 680 603484 TOTAL: - 171 - Annex 15 Page 3 of 17 SL. CODE HOSPITAL NAME NO. AND PLACE BE D S AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) WEST GODAVARI TOTAL POP: 3517568 27. 501 D.H. ELURU 340 10 350 212918 28. 502 C.H. KOVVUR 52 -2 50 36064 FLOOD PRONE 29. 503 A.H. TANUKU 70 30 100 62377 N.H.5;FLOOD PR. 30. 504 C.H. NARSAPUR 30 20 50 56358 FLOOD PRONE 31. 505 C.H. PALACOLE 30 20 50 56972 FLOOD PRONE 32. 506 A.H. TADEPALLIGUDEM 30 70 100 38979 N.H.5;RLY.LINE 33. 507 C.H. CHINTALAPUDI 30 0 30 76359 34. 508 C.H. BHIMAVARAM (T) 30 20 50 74266 RLY LINE;FLD.PR. TOTAL: 612 168 780 590527 KRISHNA TOTAL POP.: 3698833 35. 601 D.H. MACHALIPATNAM 338 12 350 159007 36. 602 C.H. AVANIGADDA 50 0 50 21700 CYCLONE PRONE 37. 603 C.H. NANDIGAMA 50 0 50 30059 N.H.;ACCIDENT 38. 604 A.H. NUZIVEEDU 30 70 100 42629 39. 605 C.H. THIRUVURU 50 0 50 24907 40. 606 A.H. GUDIVADA 100 0 100 101635 RLY. L LINE 41. 607 C.H. MYLAVARAM 30 0 30 52417 T O T A L 648 82 730 432354 GUNTUR TOTAL POP.: 4106999 42. 701 D.H. TENALI 100 100 200 143836 43. 702 C.H. REPALLE 30 0 30 36940 44, 703 A.H. BAPATLA 67 33 100 62688 RLY M. LINE 45. 704 A.H. NARASARAOPET 50 50 100 88766 IRR.PROJECT;NH 46. 705 C.H. MACHERLA 30 0 30 44022 NAT.CALAMITIES 47. 706 C.H. SATrENA PALLI 36 14 50 45400 48. 707 C.H. CHILKALURIPETA 0 30 30 49. 708 C.H. AMRAVATHI 0 30 30 TOTAL: 313 257 570 PRAKASAM TOTAL POP.: 2759166 50. 801 D.H. ONGOLE 150 50 200) 128128 N.H.5;RLY LINE 51. 806 M.CH. ONGOLE 30 20 50) 52. 802 C.H. KANIGIRI 50 0 50 21128 53. 803 A.H. CHIRALA 100 0 100 108359 RLY.M.LINE 54. 804 C.H. GIDDALURU 30 20 50 23494 55. 805 A.H. MARKAPUR 30 70 100 45358 TOTAL: 390 160 550 326467 - 172 - Annex 15 Page 4 of 17 SL. CODE HOSPITAL NAME NO. AND PLACE B E D S AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) NELLORE TOTAL POP.: 2392260 56. 901 D.H. NELLORE 250 0 2501 316445 57, 902 RS.MTY.HL. NELLORE 90 10 1001 58. 903 R.S.PEAD.HL. NELLORE 30 20 50) 59. 905 A.H. GUDUR 75 25 100 55962 N.H.5;RLY LINE 60. 906 A.H. KAVALI 60 40 100 65804 N.H.5:RLY UNE T O T A L: 505 95 600 438211 WFTB. & CD.HL. NELLORE 264- TO BE TRANSFERRED TO DIRECTOR OF HEALTH CHITTOOR TOTAL POP.: 3261118 61. 1001 D.H. CHITTOOR 270 30 300 133233 62. 1002 C.H. KUPPAM 30 0 30 15879 63. 1003 C.H. PUNGANUR 30 20 50 33863 64. 1004 A.H. MADANAPALLI 82 18 100 73729 65. 1005 A.H. SRI KALAHASTI 32 68 100 61575 66. 1006 C.H. VAYALPADU 30 0 30 41891 67. 1007 C.H. SATYAVEEDU 30 20 50 45664 68. 1008 C.H. PILER 30 20 50 48607 PILGRIM CENTRE TOTAL: 534 176 710 454441 CUDDAPAH TOTAL POP.: 2267769 69. 1101 D.H. CUDDAPAH 352 -2 350 215545 70. 1102 C.H. RAYACHOTI 30 20 50 51273 71. 1103 A.H. PULIVENDULA 34 66 100 28267 72. 1104 A.H. PRODDATUR 47 53 100 133860 73. 1105 C.H. RAJAMPET 32 18 50 26133 TOTA L: 495 155 650 455078 ANANTHAPUR TOTAL POP.: 3183814 74. 1201 D.H. ANANTAPUR 350 0 350 174792 75. 1203 C.H. RAYADURG 30 0 30 40833 76. 1204 C.H. GOOTY 36 14 50 37789 RLY.M LINE 77. 1205 A.H. KADIRI 62 38 100 71043 78. 1206 C.H. PENUKONDA 30 0 30 17012 79. 1207 A.H. HINDUPUR 100 0 100 104635 80. 1208 C.H. DHARMAVARAM 37 13 50 78747 RLY.UNE;PIL.CEN. 81. 1209 C.H. TADIPATRI 30 0 30 71043 82. 1210 A.H. GUNTAKAL 30 70 100 107560 RLY. LINE 83. 1211 C.H. URAVAKONDA 30 0 30 37789 84. 1212 C.H. MADAKASIRA 30 20 50 65984 TOTAL: 765 155 920 807227 - 173 - Annex 15 Page 5 of 17 SL. CODE HOSPITAL NAME NO. AND PLACE B E D S AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) C.D HL. ANANTAPUR 60 - TO BE TRANSFERRED TO DIRECTOR OF HEALTH KURNOOL TOTAL POP.: 2973024 85. 1301 D.H NANDYALA 100 100 200 120171 SUB-DIVL. HQRS. 86. 1302 C.H. BANAGANAPALLI 50 0 50 21278 87. 1303 A.H. ADONI 50 50 1001 135718 88. 1304 M.CH. ADONI 46 4 50) 89. 1306 A.H. YEMMIGANOOR 30 20 50 65118 T O T A L 276 174 450 342285 B. CAMP DISPENSARY, KURNOOL TO BE HANDED OVER TO DIRECTOR OF HEALTH MAHABOOBNAGAR TOTAL POP :3077050 90. 1401 D.H. MAHABOOB NAGAR 235 15 250 116775 91. 1402 A.H. GADWAL 40 60 100 40784 92. 1403 C.H. KALVAKURTHY 30 20 50 50542 93. 1404 A.H. NARAYANA PET 30 70 100 38434 94. 1405 C.H. SHADNAGAR 30 20 50 TOTAL: 365 185 550 246535 RANGA REDDY TOTAL POP.: 2551966 95. 1501 D.H. TANDUR 36 164 200 45369 96. 1502 C.H. MARPALLI 30 0 30 41231 97. 1503 C.H. VIKARABAD (n 30 20 50 39215 98. 1504 C.H. GHATKESAR CT) 30 20 50 12645 99. 1505 A.H. VANASTHALIPURAM(T) 10 90 100 TOTAL: 136 294 430 138460 HYDERABAD TOTAL POP.: 3145939 100. 1601 D.H. KING KOTI 100 100 200 (STATE CAPITAL) 101 1602 A.H. NAMPALLY 80 20 100 102. 1603 A H. MALAK PET 100 0 100 103. 1604 A.H. GOLKONDA 105 -5 100 104. 1605 M.CH.SBBB. SHALIBANDA 50 0 50 105. 1606 CL. DISP. KARVAN 0 - 0 106. 1607 CL. DISP. DUD BOWL] 0 - 0 107. 1608 CL. DISP. ALIYA BAD 0 0 108. 1609 CL. DISP. PANJASHAH 0 - 0 109. 1610 CL. DISP. MYSARAM 0 - 0 110. 1611 CL. DISP. MALAK PETA 0 - 0 Ill. 1612 CL. DISP. KHAIRATABAD 0 - 0 112. 1613 CL. DISP. SECRETARIAT 0 - 0 113. 1614 CL. DISP. PANJAGUTTA 0 - 0 114. 1615 CL. DISP. GARIB NAGAR 0 - 0 - 174 - Annex 15 Page 6 of 17 SL. CODE HOSPITAL NAME NO, AND PLACE B E D S AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) 115. 1616 CL. DISP. SANATNAGAR 0 - 0 116. 1617 CL. DISP. MUSHEERABAD 0 - 0 117. 1618 CL. DISP. KAAMATI PURA 0 - 0 118. 1619 CL. DISP. HIGH COURT 0 - 0 119. 1620 CL. DISP. BHAG AMBER PET 0 - 0 120. 1621 CL. DISP. DYD.DIV.WARDIO 0 - 0 121. 1622 CL. DISP. SEC.DIV.2-5&8 0 - 0 122. 1623 CL. DISP. SEC.DIV.WARDIO 0 - 0 123. 1624 CL. DISP. HYD.WARD 14 0 - 0 124. 1625 CL. DISP. HYD.WARD 17 0 0 125. 1626 CL. DISP. PURANAPOOL 0 - 0 126. 1627 CL. DISP. JUBLEE HILLS 0 - 0 127. 1628 C.H. BARKAS 30 20 50 TOTAL: 465 135 600 3145939 MEDAK TOTAL POP: 2269800 128. 1701 D.H. SANGA REDDY 220 30 250 50098 129. 1702 C.H. NARAYAN KHED 30 - 30 8600 130. 1703 C.H. A. JOGI PETA 36 14 50 20744 131. 1704 A.H. MEDAK 32 68 100 35756 NArL HIGHWAY 7 132. 1705 C.H. NARSAPUR 60 40 100) 54020 133. 1709 M.CH. SIDDIPET 0 50 501 134. 1706 C.H. NARSAPUR 30 - 30 39323 135. 1707 C.H. GAJWEL 30 20 50 55603 136. 1708 C.H. ZAHEERABAD 30 20 50 39590 NArL HIGHWAY 9 T O T A L: 468 242 710 303734 NIZAMABAD TOTAL POP.: 2037621 137. 1801 D.H. NIZAMABAD 302 48 350 240924 138. 1802 A.H. KAMA REDDY 30 70 100 48641 139. 1803 C.H. YELLA REDDY 30 0 30 39473 140. 1804 A.H. BANSWADA 40 60 100 19094 141. 1805 A.H. BHODAN 50 50 100 64386 TOTAL: 452 228 680 412518 ADILABAD TOTAL POP.: 2082479 142. 1901 D.H. ADILABAD 230 20 250 84233 143. 1902 C.H. SIRPUR 30 0 30 8518 144. 1903 C.H. KHANAPUR 30 20 50 47007 145. 1904 C.H. NIRMAL 40 10 50 5777 146. 1909 M.CH. NIRMAL 0 50 50 5m 147. 1905 A.H. BHAINSA 50 50 100 29664 148. 1906 A.H. MANCHERIAL 50 50 100 52626 RLY M UNE - 175 - Annex 15 Page 7 of 17 SL. CODE HOSPITAL NAME NO. AND PLACE BEDS AVAILABLE ADDL. REQD. TOTAL POPULATION REMARKS UPGRADED (LOCAL) 149. 1907 C.H. BELLAMPALLI 30 0 30 66608 150. 1908 C.H. UTNOOR 30 20 50 39999 TRIBAL TOTAL: 490 220 710 334432 KARIMNAGAR TOTAL POP.: 3037486 151. 2001 D.H. KARIMNAGAR 257 93 350 148349 152. 2002 C.H. METPALLI 30 20 50 31703 153. 2003 A.H. JAGITYAL 100 0 100 67965 154. 2004 C.H. PEDDA PALU 30 20 50 28234 155. 2005 C.H. MAHADEVAPUR 30 0 30 31241 TRIBAL TOTAL: 447 133 580 307492 WARANGAL TOTAL POP.: 2818832 156. 2101 A.H. JANGAON 30 70 100 34276 RLY. M. LINE 157. 2102 A.H, MAHABOOBABAD 40 60 100 28674 158. 2103 C.H. NARSAM PET 30 20 50 52774 159. 2104 C.H. ETURUNAGARAM 30 0 30 31899 TRIBAL TOTAL: 130 150 280 147623 KHAMMAM TOTAL POP.: 2215809 160. 2201 D.H. KHAMMAM 210 40 250 148646 RLY. M. LINE 161. 2202 C.H. SATTUPALLI 30 20 50 20053 162. 2203 C.H. PENU BALLI 46 4 50 43741 163. 2204 A.H. KOTHAGUDEM (NWRCF-50) 30 70 100 102061 INDL. & TRIBAL 164. 2205 A.H. BADRACHALAM (1) 44 56 100 35830 FLOOD PRONE TOTAL: 360 190 550 314501 NALGONDA TOTAL POP.: 2852092 165. 2301 D.H. NALGONDA 180 70 250 84674 RLY B LINE 166. 2302 A.H. SURYAPET 44 56 100 60563 N.H. 9 167. 2303 C.H. DEVARA KONDA 30 20 50 21105 168. 2304 C.H. RAMANNAPETA 30 20 50 48710 169. 2305 C.H. HUZURNAGAR 30 20 50 49490 170. 2306 A.H. NAGARJUNASAGAR () 100 - 100 20290 171. 2307 A.H. MIRYALGUDA (T) 30 70 100 65879 RLY B LINE 172. 2308 C.H. BHONGIR (r) 30 20 50 40744 RLY M LINE TOTAL: 474 276 750 264542 GRAND - TOTAL :451 4349 14000 - 176 - Annex 15 Page 8 of 17 M.CH. HOSPITALS PARTICULARS BED STRENGTH SL. NAME AND PLACE PRESENT ADDL.REQD. TOTAL UPGD. NO. OF THE HOSPITAL 1. M.CH. NELLORE 90 10 100 (separate siie from DH) 2. M.CH. VIZIANAGARAM 50 50 100 (separate site from AH) 3. M.CH. ADONI 46 4 50 (separate site from AH) 4. M.CH. SHAH-ALI-BANDA 50 50 5. M.CH. SIDDIPET 0 50 50 (separate site from AH) 6. M.CH. ONGOLE 0 50 50 (separate site from DH) 7. M.CH NIRMAL 30 20 50 T O T A L: 266 184 450 TRIBAL HOSPITALS PARTICULARS BED STRENGTH SL.NO. NAME AND PLACE PRESENT ADDL.REQD. TOTAL UPGD. OF THE HOSPITAL 1. C.H. PATHAPATNAM 30 20 50 2. A.H. PARVATHIPURAM 30 70 100 3. C.H. ARAKU 30 20 50 4. C. H. PADERU 30 20 50 5. A.H. RAMPACHODAVARAM 30 70 100 6. C.H. UTNOOR 30 20 50 7. C.H. MAHADEVPUR 30 0 30 8. C.H. ETURUNAGARAM 30 0 30 9. AXH. KOTHAGUDEM 30 70 100 TOTAL: 270 290 560 4 ~ ~ ~ - 177 - Annex 15 Page 9 of 17 CATEGORY OF HOSPITALS HOSPITALS TOTAL BEDS COMMUNITY HOSPITAIS 30 BEDDED 25 750 50 BEDDED 49 2450 AREA HOSPITA1S 100 BEDDED 47 4700 DISTIICT HOSPITA1S 200 BEDDED 6 1200 250 BEDDED 8 2000 300 BEDDED I 300 350 BEDDED 6 2100 M.CH. HOSPITALS 50 BEDDED 5 250 100 BEDDED 2 200 PAEDIATRIC HOSPITAL 50 BEDDED I 50 CIVIL DISPENSARIES 22 0 TOTAL 172 14000 ABBREVIATIONS USED: D.H. : DISTRICT HOSPITAL C.H. : COMMUNITY HOSPITAL A.H. AREA HOSPITAL M.CH. MATERNITY AND CHILDREN'S HOSPITAL DISP. : DISPENSARY ) : TO BE TRANSFERRED FROM DIRECTORATE OF HEALTH/DME N.H. : NATIONAL HIGHWAY RLY. : RAILWAY PIL. : PILGRIM ANDHRA PRADESH VAIDYA VIDHANA PARISHAD STAFF QUARTERS AT DISTRICT, AREA AND COMMUNITY HOSPITALS SELECTED FOR UPGRADATION COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS. MILL RS. MILL RS.MILL I II III IV I 11 III IV I 11 III IV SRIKAIKULAM DIST. I 101 DH Srikaikulanm 0.000 1.050 1.050 1 2 0 4 0 0 0 0 0 0 4 0 2 102 AH Palakonda 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 3 103 CH Pathapatnam 0.000 3.700 3.700 0 0 0 0 0 0 0 0 0 5 3 2 Tribal 4 104 CH Narasannapet 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 5 105 AH Tekali 0.000 1.687 1.687 0 1 0 0 0 0 0 0 0 1 2 4 6 106 CH Palasa 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 7 107 CH Itchapurun 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 8 108 CH Baruva 0.027 1.365 1.392 0 1 0 0 0 1 0 0 0 1 2 2 9 109 CH Sompet 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 1 Total 0.027 17.021 17.048 1 4 0 4 0 1 0 0 0 16 21 20 oo 00 VIZLANAGARAM DIST. 10 201 DH Vizianagaram 0.046 1.760 1.806 0 1 1 2 0 1 1 2 1 1 3 2 11 202 MCH. Vizianagaram 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 4 4 12 203 AH Parvathipuram 0.000 5.650 5.650 0 0 0 0 0 0 0 0 0 6 6 6 Tribal 13 204 CH S. Kota 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 14 205 CH Gajapathinagaram 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.046 12.863 12.909 0 1 1 2 0 1 1 2 1 12 17 16 VISAKAPATNAM 15 301 AH Narsipatnam 0.007 1.687 1.694 0 1 0 0 0 1 0 0 0 0 2 4 16 302 AH Anakapalli 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 17 303 CH Araku 0.000 3.700 3.700 0 0 0 0 0 0 0 0 0 5 3 2 Tribal 18 304 CH Padcru 0.000 3.700 3.700 0 0 0 0 0 0 0 0 0 5 3 2 Tribal 19 305 CH Adanumpudi () 0.000 1.883 1.883 0 1 2 2 0 0 0 0 0 2 2 2 Total 0.007 12.657 12.664 0 2 2 2 0 1 0 0 0 13 12 14 2, 1 COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS.MILL RS.MILL RS.MILL I 11 III IV I 11 III IV I 11 III IV E. GODAVARI 20 401 DH Ra*munry 0.000 0.000 0.000 I 1 4 4 0 0 0 0 0 0 0 0 21 402 AH Analapuarn 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 22 403 CH Razole 0.000 1.8J3 1.SS3 0 0 0 0 0 0 0 0 0 2 2 2 23 404 AH.Ranach ndrnrn 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 24 405 CHH Koduhxi 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 25 406 CH Prathipadu 0.000 1.8S3 1.883 0 0 0 0 0 0 0 0 0 2 2 2 26 407 AH Ram hodavn 0.000 5.650 5.650 0 2 2 4 0 0 0 0 0 6 6 6 Tribal Total 0.000 14.673 14.673 1 3 6 S 0 0 0 0 0 14 16 20 W Er CODA VARI DIST. 27 501 DH. Eluiu 0.040 0.347 0.337 1 2 2 2 1 1 2 2 0 0 2 2 28 502 CH KKovuV u 0.000 1.383 1.333 0 0 0 0 0 0 0 0 0 2 2 2 29 503 AH. Tnuku 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 30 504 CH Nwusqr 0.000 1.8S3 1.S83 0 0 0 0 0 0 0 0 0 2 2 2 31 505 CHPakoIe 0.000 1.S83 1.883 0 1 0 0 0 0 0 0 0 2 2 2 32 506 AHTaiepaligudcm 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 33 507 CH. Chintlapudi 0.000 1.883 1.883 0 1 0 0 0 0 0 0 0 2 2 2 34 508 CHBhinuvuun(T) 0.011 1.417 1.428 0 1 0 0 0 1 0 0 0 1 2 2 Total 13.170 13.170 13.221 1 5 2 2 1 2 2 2 0 11 16 20 KRISHNA DIST. 35 601 DH Maahp bun 0.000 2.363 2.363 0 0 0 0 0 0 00 1 1 4 4 36 602 CH Avaigadda 0.004 1.365 1.369 0 1 0 0 0 1 0 0 0 1 2 2 37 603 AHNuzivecdu 0.035 1.169 1.204 0 1 0 0 0 1 0 0 0 0 2 4 38 604 CHThtinvunz 0.000 1.8S3 1.333 0 1 0 0 0 0 0 0 0 2 2 2 39 605 AH Gudivada 0.006 1.169 1.175 0 1 0 0 0 1 0 0 0 0 2 4 40 606 CH Mylavaruu 0.000 1.883 1.883 0 1 0 0 0 0 0 0 0 2 2 2 41 607 CHNamdigam 0.026 1.391 1.417 0 1 0 0 0 1 0 0 0 1 2 2 Totl 0.071 11.723 11.794 0 6 0 0 0 4 0 0 1 7 16 20 -l COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RSMILL RS.MILL RSMILL .I 11 III IV I If III IV I If HI IV GUNTUR DIST 42 701 DH Tcnali 0.000 2.863 2.863 0 0 0 0 0 0 0 0 1 1 4 4 43 702 CH Rapalle 0.000 1.883 1.883 0 1 0 0 0 0 0 0 0 2 2 2 44 703 AH Bapatla 0.000 1.687 1.687 0 1 0 0 0 0 0 0 0 1 2 4 45 704 AH Narsaraopet 0.000 1.687 1.6S7 0 0 0 0 0 0 0 0 0 1 2 4 46 705 CH Maacerla 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 47 706 CH Sattenapaili 0.000 1.883 1.883 0 1 0 0 0 0 0 0 0 2 2 2 48 707 CH Amravathi 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 49 708 CH Chilkaluipeta 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.000 15.652 15.652 0 3 0 0 0 0 0 0 1 13 18 22 PRAKASAM O 50 801 DHOngoIc 0.015 0.518 0.533 1 1 4 4 1 0 4 4 0 1 0 0 51 802 MCHOngolc 0.000 1.883 1.883 0 1 0 0 0 0 0 0 0 2 2 2 52 803 CH Kanigiri 0.010 1.365 1.375 0 1 0 0 0 1 0 0 0 1 2 2 53 804 AHChirala 0.000 1.169 1.169 0 1 4 0 0 0 0 0 0 0 2 4 54 805 CH Giddaluri 0.000 0.840 0.840 0 1 0 0 0 0 0 0 0 1 0 0 55 806 AHMarkapur 0.055 1.169 1.224 0 1 0 0 0 1 0 0 0 0 2 4 Total 0.080 6.944 7.024 1 6 8 4 1 2 4 4 0 5 8 12 NELLORE DIST. 56 901 DH NcIlore 0.079 2.345 2.424 0 1 0 0 0 1 0 0 1 0 4 4 57 902 RS MTY HL Nellorc 0.000 1.687 1.687 0 1 0 0 0 0 0 0 0 1 2 4 58 903 RS PAED HL Neliore 0.000 0.000 0.000 0 2 2 2 0 0 0 0 0 0 0 0 59 904 AH Gudur 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 60 905 AH Kavali 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 Total 0.079 7.406 7.485 0 4 2 2 0 1 0 0 1 3 10 16 ii l o u COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS.MILL RS.MILL RS.MILL I 11 III IV I 11 III IV I II III IV CHITTOOR DIST. 61 1001 DH Chitoor 0.000 1.694 1.694 1 1 0 4 0 0 0 0 0 0 4 4 62 1002 CH Kuppamn 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 63 1003 CH Punganur 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 64 1004 AH Madanapalli 0.000 0.788 0.788 0 1 1 2 0 0 0 0 0 0 3 0 65 1005 AH Srikalahasthi 0.000 1.687 1.687 0 1 0 0 0 0 0 0 0 0 2 2 66 1006 CH Vayalpadu 0.000 1.365 1.365 0 1 1 0 0 0 0 0 0 1 0 2 67 1007 CH Satyaveedu 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 68 1008 CH Piler 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.000 13.066 13.066 1 4 2 6 0 0 0 0 0 9 17 16 CUDDAPAII DIST. 69 1101 DH Cuddapah 0.000 0.644 0.644 1 5 4 0 0 0 0 0 0 0 0 4 70 1102 CH Rayachoti 0.000 1.365 1.365 0 1 0 0 0 0 0 0 0 1 2 2 oo 71 1103 AH Pulivendula 0.054 1.687 1.741 0 0 0 0 0 0 0 0 0 1 2 4 72 1104 AH Proddatur 0.005 0.745 0.750 0 0 1 1 0 1 1 1 0 0 1 3 73 1105 CH Rajampet 0.000 0.840 0.840 0 1 2 1 0 0 0 0 0 1 0 2 Total 0.059 5.281 5.340 1 7 7 2 0 1 1 1 0 3 5 15 ANANTHAPUR 74 1201 DH Ananthapur 0.028 0.000 0.028 1 3 0 6 1 1 4 4 0 0 0 0 75 1202 CH Rayadurg 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 76 1203 CH Gooty 0.010 1.365 1.375 0 1 0 0 0 1 0 0 0 1 2 2 77 1204 AH Kadiri 0.145 1.169 1.314 0 2 0 0 0 0 0 0 0 0 2 4 78 1205 CH Punukonda 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 79 1206 AH Hindupur 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 80 1207 CH Dharmavaramn 0.000 0.000 0.000 0 2 6 7 0 0 0 0 0 0 0 0 81 1208 CHTadipatri 0.000 1.365 1.365 0 1 0 0 0 0 0 0 0 1 2 2 82 1209 AH Guntakal 0.000 0.000 0.000 0 2 6 7 0 0 0 0 0 0 0 0 83 1210 CH Uravakonda 0.000 0.000 0.000 0 2 6 7 0 0 0 0 0 0 0 0 84 1211 CHMadakasira 0.000 0.518 0.518 0 1 4 2 0 0 0 0 0 1 0 0 Total 0.183 9.870 10.053 1 14 22 29 1 2 4 4 0 8 12 16 COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS.MILL RS. MILL RS.MILL I if III IV I 11 III IV I 11 III IV KURNOOL DIST. 85 1301 DH Nandyala 0.055 2.082 2.137 0 2 1 0 0 1 1 0 1 0 3 4 86 1302 CH Banaganapalli 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 87 1303 AH Adoni 0.024 1.169 1.193 0 1 0 0 0 1 0 0 0 0 2 4 88 1304 W&C Mty. HL Adoni 0.110 0.847 0.957 0 2 0 0 0 2 0 0 0 0 2 2 89 1305 CH Yemmiganoor 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.189 7.864 8.053 0 5 1 0 0 4 1 0 1 4 11 14 MAHABOOBNAGAR 90 1401 DH Mahboobnagar 0.155 0.000 0.155 1 1 6 6 1 1 4 4 0 0 0 0 91 1402 AH Gadwal 0.866 0.584 1.450 0 2 1 6 0 1 1 2 0 0 1 0 92 1403 CH Kalvakurithy 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 93 1404 AG Narayanapct 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 94 1405 CG Shadnagar 0.000 1.365 1.365 0 1 0 0 0 0 0 0 0 1 2 2 Total 1.021 5.519 6.540 1 4 7 12 1 2 5 6 0 4 7 8 1 RANGA REDDY 95 1501 DHTandur 0.000 2.863 2.863 0 0 0 0 0 0 0 0 1 1 4 4 96 1502 CH Vikarabad 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 97 1503 CH Marapally 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 98 1504 CGGhatkesar(T) 0.014 1.722 1.736 0 0 0 1 0 0 0 I 0 2 2 I 99 1505 AG Vanasthalipurar 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 Total 0.014 10.038 10.052 0 0 0 1 0 0 0 1 1 8 12 13 HYDERABAD DIST 100 1601 DH King Koti 0.166 2.863 3.029 0 0 0 1 0 0 0 1 1 1 4 4 101 1602 AH Namiapally 0.000 1.694 1.694 0 2 0 2 0 0 0 0 0 0 4 4 102 1603 AH Malakpet 0.000 1.162 1.162 0 0 2 0 0 0 0 0 0 1 0 4 103 1604 AH Golkonda 0.000 0.644 0.644 0 I 8 0 0 0 0 0 0 0 0 4 104 1605 Shalibanda 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 104 1606 CGSHarkas 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.166 10.129 10.295 0 3 10 3 0 0 0 1 1 6 12 20 *. COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS.MILL RS.MILL RS.MILL I 11 111 IV I If 111 IV I 11 III IV MEDAK DIST. 106 1701 DH Sangareddy 0.000 2.863 2.863 0 0 0 0 0 0 0 0 1 1 4 4 107 1702 CGNarayanKKhed 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 108 1703 CH A Jogipet 0.083 1.043 1.126 0 1 0 2 0 1 2 0 0 1 2 0 109 1704 AGMedak 0.013 1.169 1.182 0 1 0 0 0 1 0 0 0 0 2 4 110 1705 AHSiddipet 0.021 1.169 1.190 0 0 0 0 0 1 0 0 0 0 2 4 111 1706 CH Narsapur 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 112 1707 CH Gajwel 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 113 1708 CHZaheerabad 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 114 1709 MCH Siddipet 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.117 15.659 15.776 0 2 0 2 0 3 2 0 1 12 20 22 NIZAMABAD DIST. 115 1801 DHNizamabad 1.274 0.000 1.274 1 1 4 4 1 1 4 4 0 0 0 0 1 116 1802 AGKarnareddy 0.177 1.169 1.346 0 3 0 0 0 1 0 0 0 0 2 4 117 1803 CH Yellareddy 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 118 1804 AHBanswada 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 119 1805 AH Bhodan 0.155 0.847 1.002 0 1 0 0 0 1 0 0 0 0 2 2 Total 1.606 5.586 7.192 1 5 4 4 1 3 4 4 0 3 8 12 ADILABAD DIST 120 1901 DH Adilabad 0.000 2.863 2.863 0 0 0 0 0 0 0 0 1 1 4 4 121 1902 CH Sirpur 0.259 1.883 2.142 0 0 0 0 0 0 0 0 0 2 2 2 122 1903 CH Khanapur 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 123 1904 CHNirmal 0.000 1.169 1.169 0 2 0 0 0 0 0 0 0 0 2 4 124 1905 AH Bhainsa 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 125 1906 AH Mancheril 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 126 1907 CH Bellampalli 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 127 1908 CH Untnoor 0.012 3.540 3.552 0 0 0 1 0 0 0 1 0 5 3 I Tribal 128 1909 MCH Nirnal 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 Total 0.271 18.478 18.749 0 2 0 1 0 0 0 1 1 16 21 25 _ * #[~I COST OF TYPE OF STAFF S. HOSPITAL NAME AND RENOV OF COST OF TOTAL QTRS. (NO.) NO. CODE PLACE EXISTING QTRS. ADDL.QTRS. COST IN EXISTING RENOV. ADDL.NEW RS.MILL RS.MILL RS.MILL I 11 111 IV I 11 III IV I 11 1II IV KARIMNAGAR DIST 129 2001 DH Karimnagar 0.825 0.644 1.469 1 1 3 0 1 1 3 0 0 0 1 4 130 2002 CH Metpaili 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 131 2003 AHJagityal 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 2 132 2004 CH Paddapalli 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 4 2 2 133 2005 CH Mahadevapur 0.109 2.597 2.706 0 1 1 2 0 1 1 0 0 1 1 0 Tribal Total 0.934 8.694 9.628 1 2 4 2 1 2 4 0 0 8 8 10 WARANGAL DIST. 134 2101 AH Jangon 0.000 1.687 1.687 0 2 0 0 0 0 0 0 0 0 2 4 135 2102 AH Mahaboobabad 0.089 1.365 1.454 0 0 0 2 0 0 0 2 0 1 2 2 136 2103 CH Narsampet 0.000 0.847 0.847 0 2 0 0 0 0 0 0 0 0 2 2 137 2104 CH Eturunagaram 0.000 3.700 3.700 0 0 0 0 0 0 0 0 0 5 3 2 Tribal Total 0.089 7.599 7.688 0 4 0 2 0 0 0 2 0 6 9 10 KAMMAM DIST F 138 2201 DH Khammam 0.000 2.863 2.863 0 0 0 0 0 0 0 0 1 1 4 4 1 139 2202 CH Sattupalli 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 140 2203 CH Penuballi 0.000 0.322 0.322 0 2 2 0 0 0 0 0 0 0 0 2 141 2204 AH Kothagudem (NWRCF) 0.077 3.180 3.257 0 2 3 4 0 1 2 2 0 4 3 2 Tribal 142 2205 AH Badracham (T) 0.000 1.169 1.169 0 2 0 0 0 0 0 0 0 0 2 4 Total 0.077 9.417 9.494 0 6 5 4 0 1 2 2 1 7 11 14 NALGONDA DIST 143 2301 DH Nalgonda 0.185 0.000 0.185 0 2 8 6 1 1 4 4 0 0 0 0 144 2302 AH Suryapct 0.599 1.169 1.768 0 1 0 2 0 1 0 0 0 0 2 4 145 2303 CH Devarakonda 0.367 1.883 2.250 0 0 2 0 0 0 2 0 0 2 2 2 146 2304 CH Ramnannapet 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 147 2305 CH Huzumagar 0.000 1.883 1.883 0 0 0 0 0 0 0 0 0 2 2 2 148 2306 AH Nagaijunasagar (T) 0.242 0.000 0.242 0 2 12 6 0 1 2 4 0 0 0 0 149 2307 AH Miryalguda (T) 0.000 1.687 1.687 0 0 0 0 0 0 0 0 0 1 2 4 150 2308 AHBhongir(T) 0.099 0.511 0.610 0 1 2 2 0 1 2 2 0 1 0 0 Total 1.492 9.016 10.508 0 6 24 16 1 4 10 10 0 8 10 14 GRAND TOTAL 6.579 248.325 254.904 10 94 105 106 10 190 288 359 ii -1 SUMMARY OF STAFF OUARTERS UPGRADAllON EXUSTINQ RENOVATION NEW TAL 10 Type I Suprt 8 Type I Supitd.Qtrs. 10 94 Type 11 Medi 32 Type 11 Medical 190 Officer Officer (148 Sqm) 105 Type III Nur 38 Type III Nurses 288 & Class III & Class III (75 Sqm) 106 Type IV Class 38 Type IV Class IV 359 (46 sqm) 315 116 847 I- - A - 186 - AnneiL 16 Page I of II PROCUREMENT ARRANGEMENTS (Total Costs in USS Million) Procurement Method Intemational Local Competitive Competitive Force Consulting Bidding Bidding Shopping al Account Services Other /a Total b/ WORKS Civil Works - 63.59 - 2.12 - 707 70.66 (54.05) (1.80) (6.01) (60.06) GOODS Vehicles 1.82 - 0.10 - - - 1.92 (1 60) (0.08) (1.69) Fumiture - 1.88 0.63 - - - 2.51 (1.69) (0.56) (2.26) Equipment 6.00 4.59 2.65 - - - 13.23 (5.28) (4.04) (2.33) (11.65) Medical Lab Supplies - 0.77 0.78 - - - 1.55 (0.70) (0.70) (1.39) Medicines - 5.83 1.46 - - - 7.29 (5.25) (1.31) (6.56) Other Supplies - 1.62 2.43 - - - 4.04 (1.46) (2.18) (3.64) MIS/lEC Materials - 0.85 0.28 - - - 1.13 (0.76) (0.25) (I 02) CONSULTANCIES Project Prep & Implementation Support - - - - - 1.31 1.31 (Includes Local Training Services, Workshops) (1.31) (1.31) Institutional Development (includes - - - 8.00 - 8.00 Local Consultants, Studies) (8.00) (8.00) MISCELLANEOUS Fellowships - - - - 0.20 0.20 (0.20) (0.20) Salaries of Additional Staff - - - - 33.04 33.04 (24.62) (24.62) Operational Expenditures - - - - 6.95 6.95 (5.18) (5.18) Building Maintenance - - - - - 2.18 2.18 (1.56) (1.56) Equipment Maintenance - - - - - 4.90 4.90 (3.65) (3.65) TOTAL 7.82 79.13 8.31 2.12 8.00 53.52 158.90 (6.88) (67.95) (7.42) (1.80) (8.00) (40.95) (133.00) NOTES Note: Figures in Parenthesis are the respective amounts financed by IDA a/ Shopping includes Local Shopping and Intemational Shopping procedures - 187 - Pag 2 of 11 Estimated Value of Procurements by Project Year (In $US Million) Total ProJec Project ProJt Projec ectProet ct Project Procurement t YearI Yea Yeu Yea Yei Project Vale Method Year Year Year Yea Yea Year Year (US$ Mdb 1 2 3 4 5 6 7 Civil Works 56.5 LCB (80%) /a 2.64 5.42 11.12 19.87 14.51 2.96 - 3.5 Force Account (5%) 0.17 0.34 0.69 1.24 0.91 0.19 10.6 Other local methods (20%) 0.50 1.02 2.08 3.73 2.72 0.56 Vehicls 18 ICB (95%) /a 0.09 0.54 ] 0.91 j 0.28 - 0.1 Local Shopping 15 %) 0.00 0.03 1 0.05 002 - - Funiture 1.9 LCB(75%) /b |0.09 0.18 j 0.37 J 0.66 | 0.48 0.10 | 0.6 LocalShopping(25%) |0.03| 0.06 0.12 0.22 | 0.16 0.03T Equspert 7.9 ICB (60%) Ia 0.75 1.54 2.37 1.62 1.65 = = 2.7 LCB (20%) /b 0.25 0.52 0.79 0.54 0.55 0.7 Intermational Shopping (5%) 0.06 0.13 0.20 0.13 0.14 2.0 Local Shopping (15%) 0.19 0.39 0.59 0.40 0.41 _ Medical Lab Suppli 0.8 LCB(50%) /b 0.07 0.11 0.11 0.12 0.12 0.12 0.12 0.1 International Shopping (7%) 0.01 0.02 0.02 0.02 0.02 0.02 0.02 0.7 Loca Shopping(43%) 0.06 0.10 0.10 0.10 0.10 0.10 0.11 Med_tn| 5.8 LCB (80%) /b 0.54 0.83 | 085 0.87 0.89 0.91 0.93 0.4 International Shopping (6%) 0.04 0.06 0.06 0.07 0 07 0.07 0.07 1.0 Locai Shopping (14%) 0.09 0.15 0.15 0.15 0.16 0.16 0.16 Coinsuasablea 1.6 | LCB (40%) 0.15 0.23 0.24 0.24 0.25 0.25 0.26 2.4 1 Local Shopping (60%) 0.23 0.35 0.36 0.36 | 0.37 0.38 | 0.39 MlS/EC Materatls 09 LCB(75%) 0.02 0.05 010 014 0.18 0.18 019 0.3 Local Shopping (25%) 0.01 0.02 0.03 0.05 0.06 0.06 0.06 Lo1TrainigSrevkces 1.3 DirectContracting(100%) 0.12 0.25 0.26 0.26 0.20 0.21 - Consultas, Stmdies, Workshops 8.0 Consulting Services (100%) 0.37 0.80 1 .56 2.66 2.01 0.52 0.08 Buiding Majinenance 2.2 Direct Contracting (100%) - 0.10 0.21 0.32 0.32 0.44 0.79 e-tuine Maiermnce 4.9 Direct Contracting (100%) 0.22 0.41 0.57 0.67 | 0.99 1.01 1.03 NOTES: /a Detailed Specficalions already completed for first 2 years /b Specificatiom competed at 50% by negotiations: Most items are stand ard equipment and remaindcr of specifications will be completed by December 1994. - 188 - Annex 16 Page 3 of 11 Civil Works Procurement: Phases & Packa2es Bidding Packages 1. Listed below are the 28 bidding packages that have been assembled on the basis of geographic proximity and the required timing for phasing of the work under the project. Each bid package would be advertised and bid as a single entity, but with separate "line items" corresponding to the site locations in the package. For example, the first bid package shown will have six line items corresponding to the six site locations at Srikakulam, Palakonda, Narsannapet, Vizianagaram (D.H.), Gajapatinagaram, Vizianagaram (M.CH.) and Aganampudi. Prospective bidders will have the option of bidding on one or more of the line items, each of which will be evaluated independently of the other. Consequently, the bidding on this package may result in as many as six contracts (if the low bidder on each line item is a different contractor), or as few as one contract (if one single contractor was the low bidder for each and every line item in the bid package). Construction Supervision 2. Oversight of the construction program will be provided through the Civil Works Unit under the Joint Commissioner for General Services of the APVVP (see Organizational Chart on page 13, Annex 5). Supervision of the construction works at any given individual site, however, will be provided by a Junior Engineer deputed from the PWD or District Engineer's offices on a full time basis during the conduct of the actual construction effort at the given site to provide day to day supervision of the contractor's activities and to provide periodic reports to the Civil Works Unit at the APVVP. Salary costs for the engineers deputed at the construction site will be borne by the project. CODE TYPE LOCATION PHASE PACK COST (Rs.M) 101 D.H. SRIKAKULAM I 1 44.16 102 A.H. PALAKONDA I 1 17.90 104 C.H. NARASANNAPET I 1 7.51 201 D.H. VIZIANAGARAM I 1 30.85 204 C.H. GAJAPATINAGARAM I 1 4.43 205 M.CH. VIZIANAGARAM I 1 17.80 305 C.H. AGANAMPUDI (T) I 1 8.57 TOTAL: 131.21 1201 D.H. ANANTAPUR 1 2 40.29 1207 A.H. HINDUPUR 1 2 9.54 1210 A.H. GUNTAKAL 1 2 15.04 1301 D.H. NANDYALA I 2 43.42 1302 C.H. BANAGANAPALLI 1 2 9.62 1306 C.H. YEMMIGANOOR 1 2 4.24 1401 D.H. MAHABO0B NAGAR 1 2 43.22 1402 A.H. GADWAL 1 2 13.34 TOTAL: 178.70 - 189 - Annex 16 Page 4 of 11 CODE TYPE LOCATION PHASE PACK COST (Rs.M) 1504 C.H. GHATKESAR(T) 1 3 7.15 1601 D.H. KING KOTI 1 3 50.23 1602 A.H. NAMPALLY 1 3 10.02 1604 A.H. GOLKONDA I 3 18.93 1701 D.H. SANGA REDDY I 3 19.05 TOTAL: 105.38 2301 D.H. NALGONDA 1 4 49.99 2304 C.H. RAMANNAPETA 1 4 3.46 2305 C.H. HUZURNAGAR I * 4 4.31 2307 A.H. MIRYALAGUDA (T) 1 4 18.55 2308 C.H. BHONGIR (T) 1 4 1.93 TOTAL: 78.23 Sub-total Phase 1 493.52 401 D.H. RAJAHMUNDRY 2 5 11.18 405 C.H. KOTHAPET 2 5 8.06 501 D.H. ELURU 2 5 33.76 503 A.H. TANUKU 2 5 17.07 601 D.H. MACHALIPATNAM 2 5 56.38 606 A.H. GUDIVADA 2 5 13.63 TOTAL: 140.09 704 A.H. NARASARAOPET 2 6 15.59 708 C.H. AMARAVATHI 2 6 6.34 801 D.H. ONGOLE 2 6 15.44 803 A.H. CHIRALA 2 6 6.31 804 C.H. GIDDALURU 2 6 2.83 901 D.H. NELLORE 2 6 15.57 903 PD.H. NELLORE 2 6 4.09 TOTAL: 66.17 1001 D.H. CHITTOOR 2 7 46.37 1004 A.H. MADANAPALLI 2 7 10.77 1101 D.H. CUDDAPAH 2 7 43.21 1103 A.H. PULIVENDULA 2 7 15.09 TOTAL: 115.44 1704 A.H. MEDAK 2 8 14.48 1708 C.H. ZAHEERABAD 2 8 5.23 1801 D.H. NIZAMABAD 2 8 34.31 1802 A.H. KAMA REDDY 2 8 14.97 1901 D.H. ADILAABAD 2 8 58.16 1905 A.H. BHAINSA 2 8 15.43 TOTAL: 142.56 2001 D.H. KARIMNAGAR 2 9 47.45 2005 C.H. MAHADEVAPUR 2 9 1.81 2101 A.H. MAHABOOBABAD 2 9 19.61 2201 D.H. KHAMMAM 2 9 44.23 2205 A.H. BADRACHALAM(T) 2 9 10.81 TOTAL: 123.91 Subotai Phase 2 S58.16 - 190 - Annex 16 Page 5 of 11 CODE TYPE LOCATION PHASE PACK COST (Rs.M) 103 C.H. PATHAPATNAM 3 10 5.42 107 C.H. ITCHAPURAM 3 10 2.11 108 C.H. BARUVA 3 10 1.81 109 C.H. SOMPETA 3 10 2.16 303 C.H. ARAKU 3 10 9.09 304 C.H. PADERU 3 10 6.80 TOTAL: 27.40 403 C.H. RAZOLE 3 11 9.32 406 C.H. PRATHIPADU 3 11 2.60 407 A.H. RAMPACHODAVARAM 3 11 20.57 502 C.H. KUVVUR 3 11 2.57 505 C.H. PALACOLE 3 11 5.06 507 C.H. CHINTALAPUDI 3 11 3.28 508 C.H. BHIMAVARAM (T) 3 11 5.44 TOTAL: 48.83 602 C.H. AVANIGADDA 3 12 3.89 603 C.H/ NANDIGAMA 3 12 2.71 604 A.H. NUZIVEEDU 3 12 13.91 605 C.H. THIRUVURU 3 12 6.60 607 C.H. MYLAVARAM 3 12 2.15 TOTAL: 29.27 702 C.H. REPALLE 3 13 3.59 705 C.H. MAACHERLA 3 13 3.44 802 C.H. KANIGIR1 3 13 4.04 805 A.H. MARKAPUR 3 13 16.31 806 M.CH. ONGOLE 3 13 4.86 TOTAL: 32.24 1003 C.H. PUNGANUR 3 14 3.93 1006 C.H. VAYALPADU 3 14 1.64 1007 C.H. SATYAVEEDU 3 14 4.18 1008 C.H. PILER 3 14 4.40 1102 C.H. RAYACHOTI 3 14 3.03 1104 A.H. PRODDATUR 3 14 9.96 1105 C.H. RAJAMPET 3 14 3.99 TOTAL: 31.13 1203 C.H. RAYADURG 3 15 2.15 1204 C.H. GOOTY 3 15 3.08 1206 C.H. PENUKONDA 3 15 2.59 1209 C.H. TADIPATRI 3 15 1.58 1211 C.H. URAVAKONDA 3 15 0.14 1212 C.H. MADAKASIRA 3 15 4.34 TOTAL: 13.88 1403 C.H. KALVAKURTHY 3 16 4.12 1502 C.H. MARPALLI 3 16 2.12 1503 C.H. VIKARABAD (T) 3 16 5.35 1603 A.H. MALAK PET 3 16 3.21 2303 C.H. DEVARA KONDA 3 16 3.90 TOTAL: 18.70 - 191 - Annex 16 Page 6 of 11 CODE TYPE LOCATION PHASE PACK COST (Rs.M) 1702 C.H. NARAYAN KHED 3 17 2.65 1705 A.H. SIDDIPET 3 17 19.05 1706 C.H. NARSAPUR 3 17 2.10 1709 M.CH. SIDD1PET 3 17 9.32 1803 C.H. YELLA REDDY 3 17 3.14 TOTAL: 36.26 1907 C.H. BELLAMPALLI 3 18 1.98 1908 C.H. UTNOOR 3 18 9.07 2004 C.H. PEDDA PALLI 3 18 5.29 2104 C.H. ETURUNAGARAM 3 18 5.30 TOTAL: 21.64 Sub-total Phase 3 259.34 105 A.H. TEKKALI 4 19 18.20 106 C.H. PALASA 4 19 5.20 202 A.H. PARVATIPURAM 4 19 20.01 203 C.H. S. KOTA 4 19 6.57 301 A.H. NARSIPATNAM 4 19 19.76 302 A.H. ANAKAPALLI 4 19 20.23 TOTAL: 89.97 402 A.H. AMALAPURAM 4 20 14.21 404 A.H. RAMCHANDRAPURAM 4 20 13.15 504 C.H. NARSAPUR 4 20 6.22 506 A.H. TADEPALLIGUDEM 4 20 18.87 TOTAL: 52.45 701 D.H. TENALI 4 21 46.70 703 A.H. BAPATLA 4 21 14.91 706 C.H. SATTENA PALLI 4 21 6.50 707 C.H. CHILAKALURIPET 4 21 6.34 TOTAL: 74.45 902 M.CH. NELLORE 4 22 13.13 905 A.H. GUDUR 4 22 18.27 906 A.H. KAVALI 4 22 11.80 1002 C.H. KUPPAM 4 22 2.37 1005 A.H. SRI KALAHASTI 4 22 15.13 TOTAL: 60.70 1205 A.H. KADIRI 4 23 15.92 1208 C.H. DHARMAVARAM 4 23 1.51 1303 A.H. ADONI 4 23 12.48 1304 M.CH. ADONI 4 23 1.40 TOTAL: 31.31 1404 A.H. NARAYANA PET 4 24 18.03 1405 C.H. SHADNAGAR 4 24 6.84 1501 D.H. TANDUR 4 24 40.27 1505 A.H. VANASTHALIPURAM (T) 4 24 20.09 1605 M.CH. SHAH-ALI-BANDA. HYD 4 24 6.82 1628 C.H. BARKAS 4 24 4.87 TOTAL: 96.92 - 192 - Annex 16 Page 7 of 11 CODE TYPE LOCATION PHASE PACK COST (Rs.M) 1703 C.H. A JOGI PETA 4 25 5.01 1707 C.H. GAJWEL 4 25 4.36 1804 A.H. BANSWADA 4 25 15.28 1805 A.H. BHODAN 4 25 17.81 TOTAL: 42.46 1902 C.H. SIRPUR 4 26 6.34 1903 C.H. KHANAPUR 4 26 5.60 1904 C.H. NIRMAL 4 26 16.20 1906 A.H. MANCHERLAL 4 * 26 11.78 1909 M.CH. NIRMAL 4 26 9.32 TOTAL: 49.23 2002 C.H. METPALLI 4 27 4.88 2003 A.H. JAGITYAL 4 27 15.90 2102 A.H. JANGAON 4 27 16.27 2103 C.H. NARSAM PET 4 27 5.10 TOTAL: 42.15 2202 C.H. SATTUPALLI 4 28 2.82 2203 C.H. PENU BALLI 4 28 0.43 2204 A.H. KOTHAGUDEM(NWRCF50) 4 28 16.36 2302 A.H. SURYAPET 4 28 17.52 2306 A.H. NAGARJUNASARAR (T) 4 28 1.81 TOTAL: 38.94 Sub-total Phase 4 578.58 GRAND TOTAL: 1,919.60 - 193 - - Annex 16 Page 8 of 11 List of Eguipment to be procured for Each Hospital The attached list provides an example of equipment available at all APVVP hospitals in Srikakulum district. It also provides the equipment required at each facility as per norms. Such a list is available for all 23 districts and 150 APVVP hospitals. The list of equipment to be purchased on each facility will be based on this detailed list that has been developed by APWP during project preparation. DSRICT Elie L INV-1 D 30151 SRIKAKULAM 1 __ 3aeUS 2 ILO'dkLunderAn.dA&it4.cs vAworL -- - -___ O8w nvApiws I- M__ _____________________ Cst Utt U J k3~fjvIabI3t y-4 I Rqured -as Parnu -- _a TOTAL COST __ IAIGEQUIPMENT JRBLmN)1 JlI3f 911 1 ii t)I. 1 1LlL 1K n 11.13 2. 2U i.1.39.11 D 2 1A1322L I X-iu system (indA awltbon) 8m 26583 __ _1 -850 2 nAX-ray system (indA liWlabon) 700 21875 1 2 ___ __2 400__ 3_ lOOrLAX-ray system (ind .ista8tion) 330 10313 I__I 1 __ NBI I__1I 1 I __ 4 1320 4 moA laX-ray system 150 4888 1 I J N82 __ _ _ _ 0 0 5 Itad X-ray systwn 60 1875 __1 1 I 1 1 1 I I I 9 540 6Jlyasoroc scamw,, lknear 300 9375 1 0 o 7J asoric scamner, buma sacla 700 21875 _ I1_ _ 2 140 8JIbasoinic scannw, linear sector. upgrad. 9X) 28125 I 900 __________________ Ma3L~u1 1~D1Lunit un blUyL MayI94…Reqired-fas per vs - - _ TOTAL COST I CG machliu(l12-hkad) 1 7 531 2 _____I1 2 1I- I 2 1 I I 10 170 F 2 aricbacmnorjtm 25 781- 2 I I __ 2 50 3 I(with rscude) 85 2031 I 1 I 1 _____ 3 195 4 tsr 50~~~~~~~~~~s 1583 I 0 0 5 W~cIw unit 8 188 __ 2 I 1 I ___ 4 24 6 ladiarn heoter. infant. 4KW 8 1ee 1- I I I__ __ 3 18 7-rdoscope, fibe-appta 200 8250 I _ __ 1 200 8 Pirawvn miaocope 65 2031 I __1 65 g ryo Swxgecy. basic (ckrect attachmert) 5 156 1 I_ _ 5 10 .roSugery, da-klux8 250 I_ 3 24 1 hat-ae Ictro-pihyiotherapy urat 20 625 __ I 113 so 12 mta"o dil75 2344 __ __ I 75 13 (Boybs with FboTc) 125 3906 2 1 12 250 14 uetw c V(Boyaw wWrA FIDTec) 6-0 18e75 2_ 2 I 1 1 1 I I 1 1 I lb 800 1 5 cieOxwn.t 100 3125 ___1 I __ 3 300 I 18 ~~ ~~~~ ~~~~ ~ ~~5 158 I 2 I14 20 17 Nh iIbIe __ __ 21 6586 _ 1_ 3 _83 18 eesocope 3 94 3_… -- - __ 19 ervTtint 6 188 1I_ _I21 20 wegwncyrsousciAbon kit 20 625 3__ 3 2 I I2 1 I I 1 13 280 21 ogIiQdosCOP. nigid, .a" 2 63 _ 1 I13 S 22 eag(tENT swgeon) 1 31 2 .……- 1 23 LieA" rkaswnte 5 156 __1 I13 1s 24 Modcks Care equipt (for 7 Di orly) 250 7813 _ N63 __0 0 _ _ _ _ _ _ _ _ - - - - - - - - - _ _ - - - - - _ _~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~t- 2_ mws 2nnaventiaw. IdvWo.A C.ur*) _ _ _ PNEUMATIC HYRAULIC & Unit Co[ j kJ5~ va1Ia ty mayL94 u - - r.d -as pern - -TOTAL COST A ENUP ADIMUL ilL L121L lu- 121= lu- Ii m IL iM. in.~ IL ilL 111= iii. -ilL AL ilL Il in. nuD kLui 1- ~A Un. 1 4 438 1 1 __ __ 111 6 84 2 etalChai( 14 438 I I _ __ 1 I ___ 1 1 B 84 3kwotor (t,bxn. & conipresw) 21 856 I I 1 2 42 4- JIbsorac dental scale 21 656 I I 1 2 42 5Detalab ftme eg both. motor lthUe SW 20 625 I 20 8 ~~~~ario a 250 2 __ 1 I 1 1 I I 2 2 5 40 7 taV ble,hyd- 35 1094 3I 2 I I 1 I I I I I 2 70 8 S HP, cylaxdrc-hnontzmtI, 9KW 120 375.0 1 1 _ 1 2 I I 4 490 9 *HP, vrbcui-cyinder. OKW 30 938 5 I I I 1 1 NBAI_ I I 1 3 90 10 Wabclrca. wtth burrws. 24bn 6 188se _ I I I 1 I_ 1 I I 4 24 1 1 lamp OT, moble 8 250 2 _J_ I I I 1 I 3 I i 3 1 I I I 14 112 12 )T kts.ciing (shadow4ess) 45 1406 2 1 1 I 1 1 I 1 I I I I 5 225 13 :ocusing ghgfts, OT (mote) 1 31 __ __ 2 2 I I 2 1 I I 11 I11 14 ~uction appuratus (high vacLuminMTP) 8 250 2 1 I 2 2- I I 1 1 I I 10 80 _l55uction ap waras, elctnceal 5 156 10 13 1 2 I 2 2 5 1 1 _ 4 1 I 2 15 -75 16 Ooot scbon apparmus 1 31 2 1 I1 1 I I 1 1 I 10 10 17 aajexl,actor 2 63 2 I1 I I I I I I I 10 20 18 Stefiser.insbiument 3 94 10 2 1 1 2 1 32 a58 4 4 5 4 54 162 19 Setrny mactur (Wactr-egwy) 12 375 2 II 2 24 20 aLtery set, electric (Gyna.) I 31 I 2 I I 2 I 1 I I 1 1 1 1 21 __uom _t_OT ___gato 5 156 1 3 2 __ _ 2 ,I I I 8 40 IJiL~aaI JDILUIL vlabUty- May94- Reqired - as pan a - ___ TOTAL COST _ VLutIpYEQUIPMENT A R mJu[I.12L = m. iiiL IL 1 -1. 2L. iii. ID. 11.11.L1 I!U ii. 21 iL l -m- gmi JLil2L -L , NrociAst wdh Mff___g 2 _1 2 __ 1 1 _ 3 3 I 1 2 1 I 1 1 3 117 2 honw-Abalanco analybaVapt_cl _ Is 1 1 2 12 balance I~~~ 31 I __ I 1 1 I 1 I 1 7 7 4 color"ter a 250 2__ ¶ I I 1 1 I I 1 a 64 _ Wm _ph ___ ______ I 1 563 1 I 1 _3 5.4 __ 22 688 I I 22 _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5 156 _ _ I I 3 15 _ _Vatw _ __ba___ 3 914 1 I I 9 27 _0 n _ _ _ _ _ _ _ _ _ _ _ __y_ a 250 I 113 24 _ Ntrst,4bo 3 1 94 1 112_ 6 _2 ____g ___________ 4 125 3 __ II 2 1 1 1 1 I I 8 32 _3 _ _ _ _ __ug _ _ _ __m_ _c_ 8 250 _ _2 1 1 14 32 _L_ Id_p_t ___laborat_ 2 83 __1 I I 3 6a IS RokorMhaker (laboatory) 2 63 1 I I 2 4 16 onchtember (hmeauoeylometer) etc 1 31 2 I 1 _ __ 1 2 I I 2 I I 9 a__ 17 __ __ _ __ __ _ 15 469 I 3 45 18 ,kngr(~O0 6 188 2 1 I I I I 1 1 1 0i 60 __________ ________________ IMnfL=[ WaM aLJ aD ity -May'4 -- suire - a nora - .- - --___TOTAL COST 20 crotwor 12 375 1 _ _ __1 12 21 Den wax-.rr~bddvig 8 250 I_ _ 22 Tissue Procas,so 65 2031 1I 65 23 Bcxd-gas analysat (for 7 DH only) 450 I14083 _ _ N63 I0 0 24 Lovbabndi comparnIon (not in use oft abs) 1 3 1 0 0 25_ Tm.nstopwatch 0 7 22 11 1 I 1 1 1 1 1 9 6 3 26larmclock (trrer) 0 4 13 2 1 I 1 1 I 1 1 1 10 4 _______________ 1Ii1L~~~~at4 J~~1L4~IL !~~I~!yL Reu sprrsTOTAL COST _ REFRIGERATION & AC. PLANT j32 fl~3 1. 122= 191.. ii- _12_ iN. -121. 12. 11 2. 2 2 2.in l. l 21 _: a 1 ldrigmratcr. 165Wu 10 313 8 1I 1 J 2 5 I 2 4 1 I 1 1818 ____ ____ 2~~~~~~~ ~~~~~~ ~~ ~~~~~~~ __ _ I_ _ 38 60 2j eolrsgator, 300 Wres 20 625 23 6 3 kwcorUt.ow. wth stak,dse 28 875 5 3 5 I 1 - 5 I 1I 19 532 4Natar cooler, Ml20ktat IS 48(9 2 1 2 1 I 2 I 1 I i 165 5 boy n..uwy (cold store) 130 4063 3 2- I1 I 2 1 I1 1 3 1690 JUn[ JILiLf vaIabWty - May94…Requred_- as peton I -I - _ TOTAL COST VI, HOSPITAL PLANTM 12. lLIl J ALJN iL.IZ. 2± 12.iL IL ii.12 ilL L 12_ 1 am Ia2U LCII I Geertor, 15 KVA (incl wstabbon) 150 4688 I1 __ 1 I I 4 600 2 Gn*ator. 50 KVA (mci kUtIShSWI) 200 6250 __ _ _ __ 1__2 400 3 Gerator, 62 5 KVA (Ind onsbIAsbon) 250 78113 10 0 4 naweralor. 3KW 50 1563 ___ __2 100 5 rwncw.tcr. 5KW 70 2188 _ _ ¶____ 1 70 -lot water system (solorunmft, 1 lOOIst.) 20 6725 ____ 1 220 ________________________ __ U AUiaU JIJ U A !k t M MA'l -R - -quire as per norms - - - _ _ TOTAL COST /ll ADMINIST_ATIONfRECORDS Jfit_[ Jj-~ 11 123. -21- AII. 121. 12. IL -21 -l 122= lot . M 21 HI - - A2- IlL lL _ 1 AU_ A& 2 1W2LM r yp.wviter 5 156 1 3 3 1 I 3 1 I I I 15 75 2 ht11,eefp s0 2500 __ 1 80 3 loruo ntc 20 625 1 0 0 4 nmtercom(155ma) 80 2500__ I1 _ _ 2- 1SO 5 pnawcom (40 ins.) 200 6250 1 0 0 8 Faxmachino 30 938 __ 11 30 7TSlphone (ext.rnallmnes cl quarlers) I1I 344 4 __ 1 1 1 a 6 1 2 a 2 1 1 2 29 319 Librury facihtks 5 156 1 - _…_ 0 0 - i~~~~~~~~~~~MLQl&z AWA-VL3 OvaHabI tv Maq 4 - - Reqi e- as pe aom _ TOTAL COST _____________ ~~~~ABLML9 -MIIM(Ufl I2. 23 I23. 121 121. 12. 21 -21- 12= 2 123. 12. 12 21- . 121_ Il L 121 Il I -=MIL 1 ec 350 10938 2 - _ 1 I I I _ ii 2450 2 c-up 306 9375 I112 60 ________________________ _______ _______ GRAND: 19017~~~~~~~~~~~~~~~~~~~~~~~~~~~~GRND 1907 - 197 - Annex 17 Page 1 of 10 Implementation Plan 1. A key component of the project is strengthening the management capacity of APVVP to adequately address its increased responsibilities. The first aspect of strengthening APVVP's management is consolidating the existing institutional and management structure, and evaluating the arrangements from time to time to see whether the management system is producing the best results. APVVP is currently managed by its Governing Council consisting of 5 members of the medical profession and Legislative Assembly nominated by the Government of AP, and 5 ex-officio members that include the Secretaries of Health and Finance Departments, Commissioner Institutional Finance, Vice Chancellor of the University of Health Sciences and the Director of Health. The Governing Council has powers to make regulations, borrow money and to levy fees for services as well as the management of the Commissionerate. The Government has powers to issue directions to the Commissionerate in matters of inspection and control, to make rules and undertake audit of APVVP's accounts. The Commissioner, who is the Chairman of the Governing Council and is the Chief Executive, is appointed by the Government from among the members of the medical profession who have administrative experience. The AP law that established APVVP provides for Government of AP combining operator and regulator functions for secondary hospitals, i.e., the key government officials entrusted with supervisory authority are also members of the Governing Council. As those officials customarily do not participate, but send Departmental representatives, in meetings of the Governing Council, they are however able to adequately regulate the Governing Council and management of APVVP. APVVP is a legal devise to improve disbursements and contracting and increase participation of non-governmental organization, but is essentially part of the Government. It is therefore subject to audit and supervisory arrangements applicable to government agencies. At Negotiations, the Government of AP provided assurances that not later than July 1, 1997, GOAP would carry out, jointly with GOI and IDA, a detailed mid-term review of project progress including a management review of APVVP and thereafter implement its recommendations. 2. APVVP's organizational structure and the existing and proposed additional staff are shown in the chart in Annex 5. The second aspect of strengthening management will be achieved by the increased management training for professional cadres and on-going in-service training for clinical and technical cadres. This will facilitate the implementation of the quality improvement strategy of the project, through which new responsibilities are being allocated, and it is hoped that decision making will be decentralized down to the appropriate management level. The third aspect will consist of enhancing staff strength at the Head Office to undertake increased responsibilities and perform some new functions. Headquarters staff will be increased by adding 37 posts plus 3 additional posts will be created at the equipment storage facility at King Koti hospital in Hyderabad. This will provide the required staffing to meet the increased workload and reorient the structure of APVVP to meet its new challenges. Specific areas targeted for strengthening include the training and referral unit (6), the finance and audit unit (16), the Office of the Joint Commissioner, General (12) and the Office of the Joint Commissioner, Service Delivery (3). These changes are in line with the increased responsibilities assigned to APVVP through this project. - 198 - Annex 17 Page 2 of 10 3. The implementation capacity of AP Health and Medical Housing Infrastructure Development Corporation (APHMHIDC) would also be strengthened to deal with the increased supervision of civil works under the project through appointment of 2 full time architects and procurement of additional vehicles and computers. In addition, monitoring and evaluation capacity would be strengthened including improvement of the hospital management information system. The strengthening of the management information system (MIS) and the health management information system (HMIS) will facilitate systems improvement, wider access and improved data collection and utilization for planning and policy making, problem solving and monitoring. In AP, at the hospital level, both information collection and management are fairly rudimentary. The project will: (i) enhance and extend the computerized system through the provision of hardware and software, and consultancy support; (ii) establish trained and equipped information cells at HQ and district levels; (iii) train all management staff in appropriate record keeping; and (iv) introduce a completely revised medical record system for IPs and diagnostic services. 4. The initial phase of project implementation will focus on developmental activities including project launch, monitoring mechanisms and performance indicators, strengthening health MIS system, initiating in-service training of staff in clinical, management and equipment matters, strengthening the functions and appointing staff at the head office and supplying equipment to existing hospitals to improve the quality of service to existing hospital facilities. The first phase of the implementation plan for the civil works program will consist of completing the renovation and extension of APVVP headquarters and the first phase of the hospital upgradation program consisting of 25 hospitals. During the initial phase the implementation plan would be to: complete topographical site surveys and soil tests; finalize and complete all drawings including site development plans, invite bids and commence construction for 150 hospitals under the four planned phases (see Annex 17); and complete over 50 percent of phase I and phase II and about 25 % of phase III and phase IV; and prepare and complete all drawings including site development plans, launch bids and sign contracts of all 150 hospitals requiring upgradation. About 30 percent of total construction is expected to be completed by the end of the second year. At Negotiations, the Government of AP provided assurances that it would review with IDA annually by December 31 of each year the progress of project implementation over the preceding twelve months and prepare an annual work plan for the following twelve months acceptable to IDA. 5. In addition, other aspects of project implementation are covered in: Annex 13 - Information, Education and Communication Strategy; Annex 14 - Tribal Strategy; Annex 15 - Summary of Construction Program; Annex 16 - Procurement Arrangements; Annex 18 - Performance Indicators; Annex 19 - Supervision Plan; and Annex 20 - Forecast of Expenditures and Disbursements. - 199 - Annex 17 Page 3 of 10 Civil Works: Implementation Plan Activity Responsibility Starting Completion Date Date PHASE I Sites Acquisition Medical Corporation and March/94 March/94 DMHO Topographical Surveys Medical March/94 March/94 Corporation/Private Firm Soil tests Medical Corporation/State Febr/94 June/94 Engineering College Preliminary Designs Private Firms April/94 July/94 Final Drawings Private Firms May/94 Sept/94 Site Development Plans Private Firms June/94 Sep/94 Completion of bid Documents Private Firms July/94 Oct/94 Floating of bids Medical Corporation Dec/94 Jan/95 Evaluation of bids Medical Corporation Jan/95 Feb/95 Contract signing MOH March/95 April/95 Construction period Contractors June/95 Aug/97 Guarantee period Sep/96 Aug/98 PHASE II Sites Acquisition Medical Corporation and March/94 March/94 DMHO Topographical Surveys Medical March/94 March/94 Corporation/Private Firrn Soil tests Medical Corporation/State April/94 June/94 Engineering College Preliminary Designs Private Firms April/94 Sept/94 Final Drawings Private Firms July/94 Nov/94 Site Development Plans Private Firms July/94 Nov/94 Completion of bid Documents Private Firms Nov/94 Jan/95 Floating of bids Medical Corporation Feb/95 March/95 Evaluation of bids Medical Corporation March/95 April/95 Contract signing MOH May/95 June/95 - 200 - Annex 17 Page 4 of 10 Activity Responsibility Starting Completion Date Date Construction period Contractors July/95 Oct/97 Guarantee period Oct/96 Oct/98 PHASE III Sites Acquisition Medical Corporation and March/94 May/94 DMHO Topographical Surveys Medical March/94 May/94 Corporation/Private Firm Soil tests Medical Corporation/State June/94 Oct/94 Engineering College Preliminary Designs Private Firms Dec/94 March/95 Final Drawings Private Firms Feb/95 June/95 Site Development Plans Private Firms May/95 July/95 Completion of bid Documents Private Firms June/95 Oct/95 Floating of bids Medical Corporation Oct/95 Jan/96 Evaluation of bids Medical Corporation Dec/95 Feb/96 Contract signing MOH Feb/96 April/96 Construction period Contractors April/96 March/98 Guarantee period July/97 March/99 PHASE IV Sites Acquisition Medical Corporation and March/94 Dec/94 DMHO Topographical Surveys Medical April/94 Feb/95 Corporation/Private Firm Soil tests Medical Corporation/State July/94 Feb/95 Engineering College Preliminary Designs Private Firms April/95 Aug/95 Final Drawings Private Firms July/95 Nov/95 Site Development Plans Private Firms Aug/95 Dec/95 Completion of bid Documents Private Firmns Nov/95 March/96 Floating of bids Medical Corporation Feb/96 April/96 - 201 - Annex 17 Page 5 of 10 Activity Responsibility Starting Completion Date Date Evaluation of bids Medical Corporation March/96 June/96 Contract signing MOH May/96 Aug/96 Construction period Contractors July/96 Oct/98 Guarantee period Sep/97 Oct/99 A.P. District Level Health Systems Project Implementation Plan I 1 99M 991 1 ,I 91 9 1999" 31 91 t#91W IMMI ^ II U * IF1 3 5. 1I ^1 [Im *1 31^ I AI V101M I Fg I II S 1 II S IF, A 54^11 *1 * I1 F1.1A II 1 AI F^1< *1 I[ f I,. d CIVIL WORKS - PHASE 1(25 Hospitals) CIVIL WORKS - PHASE 11 (28 Hospitlsk) S-~ Ac9s.*o SdT..V& -1 b SnkllHM 1 1 11 I II I1 III IL I I I I I I I I I11l l t~~~~~ ,< S .1 BdT -. Co.~~~~~I d B.i O,nss.5 ~~~~ ~LLI1- L Cw.csY S3..(4 CII W~ORK HS 1(8Hsias S- A,"uwd A.P. District Level Health Systems Project Implementation Plan MI *II I I . I I * I _ CIVIL WORKS-PHAIE ( Hosp Ital,s AI ) qSI0Ik^J'I1 li I I $II dIFl)A .1 PI" Albq.I, I i I Al Flbq 1 Al I-IL" 1 $ ASI 1zDI I FI^^1^ I[ Al Si I CIVIL WORKS - PHASE IIV (50 Hospitals) S-sqlli g A., ;111111111111111111111111111111'1111111111111111111111111111111111 < i,. .bi1 T C"IVIL WOKD -PAE V(4gopias C-..~~~~~~~~~~ ~~~~~~~~~~ sqz-t A.P. District Level Health Systems Project Implementation Plan 33 334 1 3 3m 1 33 1 9 13 31 Ils ISfSA SAA llN t I~ f I0I, S1AJJ *I-1F *fl4b S1 1.JO SqD1I SIq IIA SII1I# 5I 5I54 b 11 AI $ 5,1q 55Iq---JJ4I PR] I~ Slql I ASIJq I 5i41 0 551. ;;; EQUIPMENT DTRICT. ARA & COMMUMT HOSPITALS (TOTAL 15_ CDps.. wks."p.3sS -ISSo. Ph,p.s. b. d 8 B."YP.d To. T FURNISHINGS DISTRICr, AMEA a COMMBUNfl HOQPrfAL (MOAL 1se *.pld1- 1mFN11 A I S 1 j ISa3llllllllllllllllllIIIIIIIIIIIIIMlTI HIl I lll F..1_ I." Wew" "u -lb ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~ I. xF_ _M _ ___ _. jSA wSSS& 0 __1___- |1l11111 hft.p.. b1Wt60:1Wt IIIII T ITIIIM IiklllLiil B.6~ ~ gS E .9- -ll ,M141111111111111 dh A ImAulllllll A.P. District Level Health Systems Project Implementation Plan tfFil h IF I IMli20 *SR 99s I W111 I81 11 I 919190 99 I J VI 9IA9 VI) I lA JJI 9 * J 1 0 9J*I4A1 19 N1 I I A l I -I I COMPONENT ACTIVITIES UPGRADE CLINICAL EFFECTIVENESS PF,,- I dllu*T.A-9 M-1 lI III I III I I 111111111 I I11111111 IIII1111I I I II I I1111111111I111111III ENHANCE STAFF SKILLS (CLINICAL) Wpk k S^- T... _ I_ II 11111111111111111111111111111111 0 Un QUALITY ASSURANCE IN HOSPITALS |PHASE I0 ~- DI Hp.I I I I IIIIIIIIIIIIII\II IMPROVE REFERRAL SYSTEM DI ft-A 'C11 '1 1'1 11 T.9a.q 0.0 PI4C dono.. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ........ I" I lt ll tt t:@ I I I | | || || §§ i| |§ "| "" |" |" "" " " " i | " " | | §i i! i| i| *§ §| §§ |§cmI-TI A.P. District Level Health Systems Project Implementation Plan VEHICLES C,a"..w Hp.1.d I> O q Performance Indicators Table 1: Physical Completion Targets Hospital Upgradation Hospital Bids Adverfised % Bids Evaluated % Contrcts Signed % Construction Start % Physical Completion _ No. of Beds Upgradation I_ _ _ _ _ __ _ _ _ _ _ _ PLanned Actual Planned Acanz Planned Actal Planned Actual Planned Actual Baseline Planned Actal Phase I' Di7strict 1515 Amea 465 Community 270 Phase 11r District 2949 Area 632 Comnity ____ __ __ __ Phase MW District 0 Area 297 Community l 1400 Phasc IV4 Distrit 136 Area 1186 Community ________651 I In Phase I, 25 hospitals are planned for upgradation including 8 District, 8 Area and 9 Community hospitals. 2 In Phase II, 28 hospitals are planned for upgradation including 11 District, 11 Area and 6 Community Hospitals. 3 In Phase III, 50 hospitals are planned for upgradation, including 6 Area and 44 Community Hospitals. o I In Phase IV, 47 hospitals are planned for upgradation, including 2 District, 25 Area and 20 Community Hospitals. C Table 2: Physical Completion Targets Staff Ouarters Staff Quarters Bids Advertised % Bids Evalusted % Contracts Signed % Constnuction Start % Physical Completion % No. of Staff Quarters (new & upgraded) Planned Actua Planed Actual Planned Actua Planned Actal Planned Actual Baseline Planned Actua Pluase!I Typel1 4 Type U 20 Type Ini 35 Type TV ________ 45 P[aE I IILiLEl Type ! 7 Type!!1 26 Type In 29 N Type IV ____ ___260 Phase 1n Type!I 0 Type U 23 Type InI 20 Type IV _ __ 16 Phase IV Type!I 0 Type II 29 Type Ill 23 Type IV _ _ ___ _ _ __ _ ___ _ __21 - 209 - Annexc IS Page 3 of 24 Table 3: HosDital Activity Indicatorse Baseline Targetse Previous Current Percent Change Percent Change Review Review Current/Previous Current/Previous 1. Bed Capacity3 2. Cumulative inpatient days during past 6 months 3. Admissions during past 6 months 4. Outpatient Consultations (new and repeat) 5. Turnover rate 6. Bed Occupancy rate' 7. Average length of stay (days)' 8. Outpatient per bed day Table 6 provides baseline data fbr each category by hospital. I Hospital Activity Indicators are largely based on Mahapatra and Berman, 'Using Hospital Activity Indicators to Evaluate Performance in Andhra Pradesh, India', International Journal of Health PlAnnin and Mau,ement, Vol. 9, pp. 199-211; 1994. 2 Where applicable. 3 Total for all APVVP hospitals. I Average for APVVP hospitals. - 210 Annex 18 Page 4 of 24 Table 4: Hospital Efficiency Indicators' Baseline Previous Current Percent Change Percent Change Review Review Current/Previous Current/Baseline Clinical Services # of Major Surgeries % of Major Surgeries to Admission # of Deliveries % of Deliveries to Admission Emerzency Service Index Emergency OP ratio' Emergency entry ratio' __l Diagnostic Services # of Imaging and electro medical tests % of Imaging and electro medical test to admission # of Laboratory test % of Laboratory test to admission Non Clinical Services # of Post-mortems % of post-mortems to admission % of post-operative case fatality % of infection acquired in the hospital (nosocomial infection) Table 7 provides baseline data tar each category Sy hos;ital. I Hospital Efficiency Indicators are largely based on Mahapatra and Berman, op. cit. 2 Emergency outpatient ratio in the ratio of emergency outpatients to total outpatients. 3 Emergency entry ratio is the ratio of admissions during emergency hours to total admissions. - 211 - Anncx 18 Page 5 of 24 Table 5: Ouality Access and Effectiveness Indicators (cont'd) J Baseline [ Previous Review Current Review Inpatient waiting time (min) Outpadent waiting time (mfin) Patient satisfaction with doctors and other medical staff rating (scale of 1-7) Patient satisfaction with services offered rating (scale of 1-7) Patient satisfaction with facilities available rating (scale of 1-7) Hospital cleanliness rating (scale of 1-7) Hospital staffing. equipment and drug norms % of staffing norms met for doctors 89.3 % of staffing norms met for nurses 88.1 % of staffing norms met for other categories of staff 93.2 % of equipment norms met at facility 30.1' % availabiliy of drugs to norms at facility - Trainin % Clinical taining cumcula prepared % Trainers attended clinical training of trainers workshop l. Coverage of chemical training: short courses nurses ANMS doctors others X Coverage of clinical training: practical training special nursing doctors others X Coverage of management training at: APVVP district hospital area hospital cormunity hospital X Coverage of equipment training and maintenance 4 Table 8 provides baseline data for percentage of equipment norms met at each facility. - 212 - Annex 18 Page 6 of 24 Table 5: Ouality Access and Effectiveness Indicators (cont'd) |__________________P_ _Baseline Previous Review Current Review Ouality Assurance Proeram N of disciplines that have implemented QA in DH # of indicators implemented % of investigations completed % of remedial actions reported EEC % of S spent against targets for materials % of awareness among target groups of APVVP services % awareness among tribal population of services provided % awareness of user charges among outpatients % awareness of user. charges among inpatients % awareness among doctors of referal system: PHC to community hospitals Community hospitals to area hospitbls Area hospitals to district hospitas _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ MIS J of supervisory reports based on MIS daa received by APVVP from its hospitals Cost Recovery # of beds delineated as paying beds (only DH & AH) % of beds delineated as paying beds to total beds at facility (only DH & AH) Amount of S recovered from paying beds Amount of $ recovered from other chargea TA1LS 4: A.P.VAIDYA VIDHANA PARISHAD, HYDXRABAD HOSPITAL ACTIVITY INDICATORS FOR THS PfRIOD OF 1/94 TO 06/94 Avg. len of stay - IP days/(Discharge+deaths)z B.O.Rate-(IPdays/No.of days)/bedo100; Turn Over Rate - (bads*no.of days-IP)/(Dis+dths) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ - - - - - - - - - - - - - - - - - - _ _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -_ _ - - - Hosp. H Hospital Name & Place I Bed I Cumulative I Admissions Out patient Turn Bed Avg.Lan Out Patient Code I Capa-I Inpatient I during past Consultants over Occupancy of Stay j Per Bed day I city I days during | 6 months I (New & Repeat)j Rate I Rats I I past 6 mnthal I I I I I 101 DISTRICT HOSPITAL 230 34206 3278 186392 2.35 82.17 10.82 5.45 SRIAXAULAM 102 COMMUNITY HOSPITAL 30 3690 1212 27444 1.46 67.96 3.09 7.44 PALAKONDA 103 COMMUNITY HOSPITAL 30 1146 153 18191 31.04 21.10 8.30 15.87 PATHAPATNAM 104 COMMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 NARASANNA PITA 105 COMMUNITY HOSPITAL 30 7091 991 40989 -1.65 130.59 7.05 5.78 TEKSALI 106 COMMUNITY HOSPITAL 30 1406 167 7734 32.98 25.89 11.52 5.50 PALASA 107 COMMUNITY HOSPITAL 30 777 98 14445 57.44 14.31 9.59 18.59 ITCHAPUPAM 108 COYMUNITY HOSPITAL 30 1003 131 11642 35.42 18.47 8.02 11.61 BARUVA 109 COMMUNITY HOSPITAL 30 1853 866 14102 4.19 34.13 2.17 7.61 SOMPSTA ( 470 51172 6896 320939 5.07 60.15 7.66 6.27 201 DISTRICT HOSPITAL 150 26124 3546 97393 0.31 96.22 7.87 3.73 VIZIANAGARAN 202 COMKUNITY HOSPITAL 30 6106 1316 41817 -0.57 112.45 5.17 6.85 PARVATIPURAM 203 COMMUNITY HOSPITAL 30 1203 426 44080 11.04 22.15 3.14 36.64 S.XOTA 204 COMMUNITY HOSPITAL 30 6148 1195 28509 -0.61 113.22 5.21 4.64 GAJAPATHINAGARAM 240 39581 6483 211799 0.64 91.12 6.53 5.35 301 COMMUNITY HOSPITAL 30 3597 307 23524 6.34 66.24 12.45 6.54 NARSIPATNAM 302 COMMUNITY HOSPITAL 32 2384 598 56388 6.74 41.16 4.71 23.65 ANAXAPALLI 303 COMMUNITY HOSPITAL 30 268 41 6092 99.27 4.94 5.15 22.73 ARAFU 304 COMMUNITY HOSPITAL 30 605 89 18223 56.76 11.14 7.12 30.12 PADERU 122 6854 1035 104227 16.34 31.04 7.35 15.21 0 O: X - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - A.P.VAIDYA VIDHANA PARISHAD, HYDRRABAD HOSPITAL ACTIVITY INDICATORS FOR THE PERIOD OF 1/94 TO 06/94 Avg. ln of stay - IP days/(Discharge+deaths); B.O.Rate-(IPdays/No.of days)/beds100; Turn Over Rate - (beds*no.of days-IP)/(Dis+dtha) Hasp. Hospital Name & Place j Bad I Cumulative I Admissions Out patient |Turn |Bd Avg.Len Out Patient Cods I Capa-| Inpatient I duritng past | Consultants Over Occupancy of stay Per Bed day city [ days during | 6 months I (New & Repeat)l Rate j Rate I I past 6 mnthsl I I 401 DISTRICT HOSPITAL 250 31141 3491 183186 4.04 68.82 8.92 5.88 RAJAm(UNDRY 402 COMKUNITY HOSPITAL 70 9079 1206 39899 2.97 71.66 7.52 4.39 AMALPURAM 403 COMMUNITY HOSPITAL 30 2014 377 15527 9.79 37.09 5.77 7.71 RAZOLZ 404 COKMMNITY HOSPITAL 44 8652 1566 61599 -0.46 108.64 5.75 7.12 RAMACHANDRAPURAM 405 COMMUNITY HOSPITAL 30 4349 718 46205 1.70 80.09 6.83 10.62 KOTHAPRT 406 COMMUNITY HOSPITAL 30 1600 260 13898 15.44 29.47 6.45 8.69 PRATHIPADU 407 COMMUNITY HOSPITAL 30 5207 893 18221 0.28 95.89 6.59 3.50 RANPACHODAVARAN 484 62042 8511 378535 3.11 70.82 7.54 6.10 ----------------------------------------------------------- ----- -- __-- _____----- ----- _---- ---------- 501 DISTRICT HOSPITAL 340 55727 7561 216000 0.77 90.55 7.41 3.88 RLURU 502 COMMKNITY HOSPITAL 52 0 0 0 0.00 0.00 0.00 0.00 KOVVUR 503 COMKUNITY HOSPITAL 70 8447 1327 97682 3.25 66.67 6.50 11.56 TAMUKU 504 COKMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 RARSAPUR 505 COMMUNITY HOSPITAL 30 3549 448 25813 4.37 65.36 8.25 7.27 PALACOLR 506 COMMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 TADEPALLIGUDEM 507 COMKUNITY HOSPITAL 30 1160 262 14661 17.15 21.36 4.66 12.64 CHINTALAPUDI 582 68883 9598 354156 3.84 65.39 7.26 5.14 601 DISTRICT HOSPITAL 338 39684 4688 112538 4.60 64.87 8.50 2.84 MACHALIPATNAM 602 COOU3NITY HOSPITAL 50 3991 462 38183 10.88 44.10 8.58 9.57 AVANIGADDA 603 COMKUNITY HOSPITAL 50 3920 664 39219 7.95 43.31 6.08 10.00 NANDIGAMA 604 COMMUNITY HOSPITAL 30 3551 642 44445 3.68 65.40 6.95 12.52 NUZIVEEDU to 605 COMMUNITY HOSPITAL 50 2029 416 32068 19.24 22.42 5.56 15.80 JQ THIRUVURV Xi 606 AREA HOSPITAL 100 10609 1632 62077 4.86 58.61 6.89 5.85 GUDIVADA ~ X A.P.VAIDYA VIDHANA PARISHAD, HYDZRABAD HOSPITAL ACTIVITY INDICATORS FOR THE PERIOD OF 1/94 TO 06/94 Avg. len of stay - IP days/(Discharge+deaths); B.O.Rate.(IPdays/No.of days)/beds*100; Turn Over Rate - (beds*no.of days-IP)/(Dis.dths) Hosp. Hospital Nnes & Place I Bd I Cumulative I Admissions I Out patient Turn Bed j Avg.Len Out Patient Cods I Capa-j Inpatient I during past I Consultants Over Occupancy I of Stay Per Bed day city I days during | 6 montha | (New & Repeat)l Rate I Rate I I I past 6 mnthsl I I I 607 COMMUNITY HOSPITAL 30 4717 765 33210 0.96 86.87 6.37 7.04 NYLAVARAN 648 68501 9269 361740 5.46 58.40 7.67 5.28 701 ARZA HOSPITAL 100 14380 1660 67038 2.31 79.45 8.92 4.66 TSNALI 702 CONNWNITY HOSPITAL 30 5277 666 32455 0.24 97.18 8.13 6.15 RZPALLS 703 CONKUNITY HOSPITAL 67 5992 1273 83199 4.99 49.41 4.87 13.89 BAPATLA 704 CONHUNITY HOSPITAL 50 1870 257 32355 26.89 20.66 7.00 17.30 NARASARAO PZTA 705 COMMUNITY HOSPITAL 30 4011 511 53968 2.90 73.87 8.20 13.45 NAACEZRLA 706 COMMUNITY HOSPITAL 36 3484 867 55393 4.18 53.47 4.80 15.90 SATTENA PALLI 708 CIVIL DISPENSARY 0 0 0 27637 0.00 0.00 0.00 0.00 CHILARALURI PZTA 313 35014 5234 352045 4.35 61.80 7.04 10.05 801 DIST. HOSPITAL 190 17490 1892 80579 8.98 50.86 9.29 4.61 ONGOLS 802 COMMUNITY HOSPITAL 50 0 0 0 0.00 0.00 0.00 0.00 KANIGIRI 803 CONMUNITY HOSPITAL 100 10249 1108 45042 8. 29 56.62 10.82 4.39 CHIRALA 804 COMMUNITY HOSPITAL 30 4240 819 27439 1.66 78.08 5.91 6.47 GIDDALURU 805 COMMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 MANIAPUR 400 31979 3819 153060 11.39 44.17 9.01 4.79 901 DIST. HOSPITAL 250 5374 621 22414 67.36 11.88 9.08 4.17 NELLORZ 902 R.S. hTY. HOSPITAL 90 0 0 0 0.00 0.00 0.00 0.00 NELLORE 903 R.S.PAEDIATRIC HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 NELLORS I 904 W.F.T.B. & C.D. HOSP 264 43255 951 0 4.71 90.52 44.96 0.00 to NZLLORI e &o A.P.VAIDYA VIDRANA PARISHAD, HYDERARAD HOSPITAL ACTIVITY INDICATORS FOR THE PfRIOD OF 1/94 TO 06/94 Avg. ln of stay - IP days/(Discharge+deaths); B.O.Rate.(IPdays/No.of days)/beds*1001 Turn Over Rate - (beds*no.of days-IP)/(Dis+dths) RoHp. Hospital Name & Place J Bed F Cumulative I Admissions j Out patient j Turn |Bd Avg.Len out Patiant Code I Capa-I Inpatient I during past I Consultants Over Occupancy of Stay Per Bed day I city | days during | 6 months I (NHw & Ropeat)| Rate I Rate I I past 6 nthul I I I 905 COVUVWITY HOSPITAL 75 920 207 20915 64.57 6.78 4.69 22.73 GVDUR 906 COMMUNITY HOSPITAL 60 5673 1527 36001 3.52 52.24 3.85 6.35 RAVALI 769 55222 3306 79330 26.04 39.67 17.13 1.44 1001 DIST. HOSPITAL 270 36127 7044 135138 1.84 73.92 5.23 3.74 CHITTOOR 1002 CONWUITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 RVPAJi 1003 COMMUNITY HOSPITAL 30 2876 536 15310 4.77 52.97 5.38 5.32 PUVGANUR 1004 COCNITY HOSPITAL 82 0 0 0 0.00 0.00 0.00 0.00 N) NADANAPALLI 1005 COMMUWITY HOSPITAL 32 4576 1036 29894 1.23 79.01 4.62 6.53 0' SRI KALAY ASTI 1006 COMMUNITY HOSPITAL 30 4174 718 27389 1.82 76.87 6.05 6.56 VAYALPADU 1007 COC8ONITY HOSPITAL 30 3504 932 21540 2.27 64.53 4.12 6.15 SATYAVUUDU 1008 COMMDNITY HOSPITAL 30 6025 1282 59023 -0.49 110.96 4.93 9.80 PILSR 534 57282 11548 288294 3.52 59.27 5.12 5.03 1101 DIST. HOSPITAL 352 64929 10346 159587 -0.12 101.91 6.22 2.46 CUDDAPAH 1102 COMUDNITY HOSPITAL 30 7673 1240 85007 -1.79 141.31 6.13 11.08 RAYACHOTI 1103 CONNDNITY HOSPITAL 34 4373 473 42865 4.40 71.06 10.80 9.80 PULIVlDDULA 1104 COMMUNITY HOSPITAL 47 10871 1176 97333 -2.10 127.79 9.67 8.95 PRODDATUR 1105 CONUNSITY HOSPITAL 32 5794 1419 77854 0.00 100.03 4.48 13.44 RAJAVP T 495 93640 14654 462646 -0.28 104.51 6.45 4.94 1201 DIST. ROSPITAL 350 20472 3560 38339 12.04 32.32 5.75 1.87 1HA2P0P6R oL 1202 C.D. HOSPITAL 60 7065 230 25599 15.95 65.06 29.68 3.62 0 ANANTAPUR A.P.VAIDYA VIDHANA PARISHAD, HYDERABAD HOSPITAL ACTIVITY INDICATORS FOR THE PERIOD OF 1/94 TO 06/94 Avg. len of stay - IP days/(Discharge+deatha); B.O.Rate-(IPdays/No.of days)/beds*100; Turn Over Rate - (beds*no.of days-IP)/(Dis+dths) Haop. Hospital Eame & Place I Bd I Cumulative I Admissions I Out patient Turn B Bed I Av.Ln out Patient Code I Capa-I Inpatient I during past I Consultants Over Occupancy I of Stay Per Bed day city days during | 6 months I (Now & Repeat)l Rate I Rate I | past6mthfl I I I I 1203 COhMUNITY HOSPITAL 30 4609 1315 57052 0.69 84.88 3.88 12.38 RAYADURG 1204 COMMUNITY HOSPITAL 36 6248 1688 32350 0.15 95.89 3.58 5.18 SOOTY 1205 COMMUNITY HOSPITAL 62 6133 989 157154 5.77 54.65 6.95 25.62 KADIRI 1206 CONMUNITY HOSPITAL 30 10281 1967 45150 -2.68 189.34 5.69 4.39 PENUXONDA 1207 AREA HOSPITAL 100 26253 4787 70197 -1.69 145.04 5.45 2.67 HINDUPUR 1208 COMMUNITY HOSPITAL 37 5133 1907 66146 0.86 76.65 2.83 12.89 DaRKNAVARAN 1209 COMMUNITY HOSPITAL 25 3377 1259 26301 0.92 74.63 2.70 7.79 TADIPATRI 1210 COMMUNITY HOSPITAL 30 725 342 57347 14.34 13.35 2.21 79.10 GUNTAXAL I 1211 COMMUNITY HOSPITAL 30 5678 985 40571 -0.27 104.57 6.18 7.15 URAVAKONDA 1212 COUKUNITY HOSPITAL 30 4643 721 26826 1.14 85.51 6.75 5.78 NADAXASIRA 820 100617 19750 643032 2.49 67.79 5.23 6.39 1301 COMMUNITY HOSPITAL 100 13348 2570 137494 1.85 73.75 5.21 10.30 NANDYALA 1302 CONKMWITY HOSPITAL 50 8045 1382 58112 0.78 88.90 6.28 7.22 BANAGANAPALLI 1303 COMMUNITY HOSPITAL 50 9357 1496 96854 -0.22 103.39 6.65 10.35 ADONI 1304 W & C YTY. HOSPITAL 46 8252 8623 100886 0.01 99.11 1.06 12.23 ADONI 1305 CIVIL DISPENSARY 0 0 0 17033 0.00 0.00 0.00 0.00 B.CANP, KURNOOL 1306 COMMUNITY HOSPITAL 30 6834 1538 44621 -0.92 125.86 4.48 6.53 YXYMIGANOOR 276 45836 15609 455000 0.28 91.75 3.15 9.93 1401 DIST. HOSPITAL 235 25535 10363 214384 1.65 60.03 2.48 8.40 MAHABOOB NAGA" 1402 COMMUNITY HOSPITAL 40 1781 567 74147 9.78 24.60 3.19 41.63 GADWAL 1403 COMMUNITY HOSPITAL 30 5629 1433 66427 -0.14 103.66 3.98 11.80 _L XALVAxnRTHY 1404 COMMUNITY HOSPITAL 30 6440 1334 55928 -0.78 118.60 4.97 8.68 NARAYANA PET FJ A. P. VAIDYA VIDRANA PARISHAD, HYDfRARAD HOSPITAL ACTIVITY INDICATORS FOR TEX PERIOD OF 1/94 TO 06/94 Avg. len of stay - IP days/(Discharge+deathf); B.O.Rate-(IPdays/No.of days)/beds-100; Turn Over Rate - (beds*no.of days-IP)/(Dis+dths) Hoop. Hospital Name & Place I Bed I Cumulative I Admissions I Out patient Turn Bed Avg.Len Out Patient Code I Capa-I Inpatient I during past I Consultents Over j Occupancy of Stay Per Bed day I city I days during | 6 monthA I (Now & Repeat)l Rate R-ate- I I past 6 mnthel I I I 1405 COIrUNI7TY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 SHADlaRAR 365 39385 13697 410886 1.97 59.62 2.90 10.43 1501 COUNGITY HOSPITAL 36 1177 289 16590 19.07 18.06 4.20 14.10 TONDUR 1502 COISUNITY HOSPITAL 30 2968 569 41273 5.57 54.66 6.71 13.91 YARPALLI 66 4145 858 57863 10.80 34.70 5.74 13.96 1601 AREA HOSPITAL 100 15463 1035 80724 3.08 85.43 18.09 5.22 ra KING KOTI 1602 AREA HOSPITAL 80 9525 1274 154627 4.17 65.78 8.02 16.23 °° NAMPALLY 1603 AREA HOSPITAL 100 17783 2707 277365 0.12 98.25 6.75 15.60 MNAIAK PET 1604 AREA HOSPITAL 105 0 0 0 0.00 0.00 0.00 0.00 GOLKONDA 1605 SB.B.B. MTY. HOSPIT 50 5041 815 88775 6.68 55.70 8.40 17.61 SHA-ALI BANDA, HYD 1606 CIVIL DISPENSARY 0 0 10 71180 0.00 0.00 0.00 0.00 KARVAN 1607 CIVIL DISPBNSARY 0 0 0 72707 0.00 0.00 0.00 0.00 DUD BONLI 1608 CIVIL DISPENSARY 0 0 0 55593 0.00 0.00 0.00 0.00 ALIYA BAD 1609 CIVIL DISPENSARY 0 0 0 11533 0.00 0.00 0.00 0.00 PANJASHAH 1610 CIVIL DISPENSARY 0 0 0 28918 0.00 0.00 0.00 0.00 MYSARAM 1611 CIVIL DISPENSARY 0 0 0 34151 0.00 0.00 0.00 0.00 MALAX PITA 1612 CIVIL DISPENSARY 0 0 0 35693 0.00 0.00 0.00 0 .00 XHAIRATABAD 1613 CIVIL DISPENSARY 0 0 0 17449 0.00 0.00 0.00 0.00 SRCRXTARIAT 1614 CIVIL DISPENSARY 0 0 0 38981 0.00 0.00 0.00 0.00 PANJAGUTTA 1615 CIVIL DISPENSARY 0 0 0 35617 0.00 0.00 0.00 0.00 IARIB NAGAR 1616 CIVIL DISPENSARY 0 0 0 58302 0.00 0.00 0.00 0.00 SAXAT NAOAR IL 1617 CIVIL DISPENSARY 0 0 0 23667 0.00 0.00 0.00 0.00 MUSEnnrDsAD" A.P.VAIDYA VIDH'ANA PARISHAD, HYDERABAD HOSPITAL ACTIVITY INDICATORS FOR THE PERIOD OF 1/94 TO 06/94 Avg. l-n of stay . IP days/(Dircharge+deaths); B.O.Rate-(IPdays/No.of days)/beds*100; Turn Over Rate - (beds'no.of days-IP)/(Dis+dths) Haop. j Hospital Name & Place I Bed I Cumulative I Admissions I Out patient Turn Bed J Avg.Len Out Patient Code I Capa-I Inpatient I during past I Consultants Over Occupancy of Stay Per Bed day I city I days during | 6 months I (New & Repeat)| Rate Rate I I past 6 nthsl I I I 1618 CIVIL DISPENSARY 0 0 0 50183 0.00 0.00 0.00 0.00 KAAKATI PURA 1619 CIVIL DISPENSARY 0 0 0 12720 0.00 0.00 0.00 0.00 HIGH COURT 1620 CIMVL DISPENSARY 0 0 0 18583 0.00 0.00 0.00 0.00 BHAG AMBER PET 1621 CIVIL DISPENSARY 0 0 0 16962 0.00 0.00 0.00 0.00 HYD DIV. WARD 10 1622 CIVIL DISPENSARY 0 0 0 23977 0.00 0.00 0.00 0.00 SEC DIV. 2,3,4,5 a 8 1623 CIVIL DISPENSARY 0 0 0 38952 0.00 0.00 0.00 0.00 SEC DIV. 10 WARD 1624 CIVIL DISPENSARY 0 0 0 26811 0.00 0.00 0.00 0.00 BYDERABAD 14 WARD 1625 CIVIL DISPENSARY 0 0 0 43664 0.00 0.00 0.00 0.00 r. HYDERABAD 17 WARD F' 1626 CIVIL DISPENSARY 0 0 0 41722 0.00 0.00 0.00 0.00 HYDERABAD WARD 21 1627 CIVIL DISPENSARY 0 0 0 11271 0.00 0.00 0.00 0.00 JUBLEE HILLS 1628 COMMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 BARTAS 465 47812 5841 1370127 6.89 56.81 9.06 28.66 1701 DIST. HOSPITAL 220 0 0 0 0.00 0.00 0.00 0.00 SANGA REDDY 1702 COMMUNITY HOSPITAL 30 3978 559 17988 2.76 73.26 7.55 4.52 NARAYAN KHED 1703 COMMUNITY HOSPITAL 36 3056 636 54580 6.15 46.90 5.43 17.86 A. JOGI PETA 1704 COMMUNITY HOSPITAL 32 6343 1200 29600 -0.46 109.51 5.35 4.67 MEDAK 1705 COMMUNITY HOSPITAL 60 2348 942 21705 9.98 21.62 2.75 9.24 SIDDIPET 1706 COMMUNITY HOSPITAL 30 0 0 0 0.00 0.00 0.00 0.00 NARSAPUR 1707 COMMUNITY HOSPITAL 30 1527 250 28657 16.33 28.12 6.39 18.77 GAJWEL 1708 COMMUNITY HOSPITAL 30 1605 416 10432 9.66 29.56 4.05 6.50 ZAEBERARAD 468 18857 4003 162962 17.50 22.26 5.01 8.64 1801 DIST. HOSPITAL 302 29709 5640 158996 4.44 54.35 5.29 5.35 NIZA UASAD A. P .VAIDYA VIDHANA PARIShAD, HYDERABAD HOSPITAL ACTIVITY INDICATORS FOR THE PERIOD OF 1/94 TO 06/94 Avg. ln of stay . IP days/(Discharge+deaths); B.O.Rate-(IPdays/No.of days)/beds*100; Turn Over Rate - (beds-no.of days-IP)/(Dis+dths) Hoop. Hospital Name & Place I Bed I Cumulative I Admissions I Out patient Turn fBed I Avg.Len | Out Patient Code I Capa-I Inpatient I during past J Consultants Over Occupancy I of Stay Per Bed day I city I days during | 6 months I (New & Repeat)| Rate | Rate I I past 6 mnthsl I I I I 1802 COMMUNITY HOSPITAL 30 6117 1215 39767 -0.57 112.65 5.06 6.50 KAMA REDDY 1803 COMMUNITY HOSPITAL 30 3951 581 24144 2.68 72.76 7.17 6.11 YELLA REDDY 1804 COMMUNITY HOSPITAL 40 3438 738 37427 5.17 47. 49 4. 68 10 .89 BANSWADA 1805 COMMUNITY HOSPITAL 50 5717 790 41990 4.32 63.17 7.42 7.34 BHODAN 452 48932 8964 302324 3.70 59.81 5.51 6.18 1901 DIST. HOSPITAL 230 26273 5278 92788 2.90 63.11 4.97 3.53 ADILAABAD 1902 COMMUNITY HOSPITAL 30 486 129 12904 40.20 8.95 3.95 26.55 SIRPUR 1903 COMMUNITY HOSPITAL 30 6232 831 44294 -0.97 114.77 7.53 7.11 0 KNANAPUR 1904 COMMUNITY HOSPITAL 40 7861 1098 45175 -0.57 108.58 7.17 5.75 NIRMAL 1905 COMNUNITY HOSPITAL 30 7922 1990 28000 -1.26 145.89 4.01 3.53 BHAINSA 1906 CONNUNITY HOSPITAL 50 4883 942 44871 4.32 53.96 5.07 9.19 MANCHERIAL 1907 COMMUNITY HOSPITAL 30 1159 211 24763 19 .59 21.34 5. 32 21.37 BELLAMPALLI 1908 COMMUNITY HOSPITAL 30 3680 495 11536 3.68 67.77 7.73 3.13 UTNOOR 470 58496 10974 304331 2.42 68.76 5.33 5.20 2001 DIST. HOSPITAL 257 37480 4961 351793 2.04 80.57 8.45 9.39 KARIMMAGAR 2002 COMMUNITY HOSPITAL 30 5933 1107 37036 -0.46 109.26 5.42 6.24 rMPALLI 2003 COMMUNITY HOSPITAL 40 8563 1421 197881 -0.93 118.27 6.05 23.11 JAGITYAL 2004 COMMUNITY HOSPITAL 30 4538 830 42815 1.11 83.57 5.64 9.43 PEDDA PALLI 2005 COHMUNITY HOSPITAL 30 3481 803 41450 2.50 64.11 4.47 11.91 MAHADEVAPUR ------------------~~----------------------------------------------------------------------------------NtX 387 59995 9122 670975 1.18 85.65 7.03 11.18 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --------------------~~~~~~= E CD A.P.VAIDYA VIDHANA PARISAD, HYDZRA8AD HOSPITAL ACTIVITY INDICATORS POR TEE PERIOD OF 1/94 TO 06/94 Avg. len of atay . IP days/(Diocharge+deathm); B.O.Rate.(IPdays/No.of days)/bedm*100; Turn Over Rate - .(bed*no.of dayo-IP)/(Dicidths) Roep. Hospital Name & Place I Bed I Cumulative I Admissions I Out patient Turn | Bed Avg.Len | Out Patient Code I | Capa-| Inpatient I during past I Consultants | Over Occupancy | of Stay | Per Bed day | city | days during | 6 months | (New & Repeat)| Rate Rate past 6 nmthhl I 2101 COX#UUITY ROSPITAL 40 6797 1128 70065 0.39 93.88 5.96 10.31 AH4ABOODADAD 2102 C0ITUNrTr ROSPITAL 30 2860 725 46476 3.60 52.67 4.01 16.25 JANGYA 2103 COUYNtIT HOSPITAL 30 5888 1545 45783 -0.32 108.43 4.10 7.78 ERHUUAM PET 2104 CONMITY ROSPITAL 30 771 219 15634 21.67 14.20 3.59 20.28 130 16316 3617 177958 2.06 69.34 4.65 10.91 2201 DIST. HOSPITAL 210 34135 2951 169850 1.43 89.81 12.58 4.98 - 2202 COUUUMITY ROSPITAL 30 1069 146 25994 36.34 19.69 8.91 24.32 SATTUPALLI 2203 COXUUITY BOSPITAL 46 2884 511 18259 11.55 34.64 6.12 6.33 PHR= BALLI 2204 COXYUNITY HOSPITAL 30 4783 610 21667 1.23 88.08 9.06 4.53 OTNAGMUD F 316 42871 4218 235770 3.74 74.95 11.19 5.50 ------------------------------------------------------------------__---------__--------------------- 2301 DIET. HOSPITAL 180 28883 5396 85320 0.72 88.65 5.60 2.95 RUAlooDA 2302 COU RnITY HOSPITAL 44 8687 2126 100492 -0.40 109.08 4.80 11.57 SURTAPXT 2303 COUNITY HOSPITAL 30 7546 1711 70093 -1.25 138.97 4.47 9.29 DEVARA KORDA 2304 COUUUbITY HOSPITAL 30 6106 1163 41697 -0.58 112.45 5.28 6.83 R3APETA 2305 COUUITY OSPITAL 30 3579 688 41859 2.91 65.91 5.64 11.70 314 54301 11084 339461 0.19 96.42 5.24 6.19 n- A.P.VAIDYA VIDHANA PARISHAD, HYDERABAD HOSPITAL EFFICIENCY INDICATORS FOR THE PERIOD 1/94 TO 06/94 Hosp. Hospital Name Beds CLINICAL SERVICES I EMERGENCY SERVICE INDEX DIAGNOSTIC SERVICES I NON CLINICAL SERVICES Code & Place I---_-__- -I -------------- -------- --------------------- - I--------------------------- I j IV oof # of I of E Emergency- I Emergency- |# of 1 of o # of 0 of |# of I of k of 1 1 ofl I Major I Major I Deli-| Deli-I OP Ratio I IP Ratio Imaging I & EM I Labor- Lab. I Post IPm to I post- Iinfe-I I Surg. I surg. I yeri-I ver- I I I 6Electroj Tests I atory I Tests| mort- lAdmn. I opr. Iction| I I I to I ies I ies I I IMedical I to Admnj Tests j to I ems I I case lacqd.1 I | Admn. I | to I Tests I I I Admn I (Pm) | I tata- linthel I I I I I Admn.1 I I I I I I I I lity IHosptlI 101 DISTRICT HOSPITAL 230 608 18.55 404 12.32 0.003 0.050 2082 63.51 27578 841.31 802 24.47 1.80 0.00 SRIKAKULAM 201 DISTRICT HOSPITAL 150 505 14 .24 597 16.84 7.410 40.720 5 0.14 15760 444.44 103 2.90 0.00 0.00 VIZIANAGARAM 401 DISTRICT HOSPITAL 250 473 13.55 249 7.13 0.001 0.047 4716 135.1 37462 1073.1 139 3.98 0.00 0.00 RAJAHMUNDRY 402 COMMUNITY HOSPITAL 70 1626 151.41 75 6.22 0.000 0.014 249 20.65 2592 214.93 21 1.74 0.00 0.00 AMALAPURAM 403 COMMUNITY HOSPITAL 30 54 14.32 18 4.77 0.006 0.239 296 78.51 837 222.02 29 7.69 0.01 0.00 RAZOLE 404 COMMUNITY HOSPITAL 44 473 30.20 272 17.37 0.001 0.020 214 13.67 11636 743.04 59 3.77 0.06 0.00 RAMACHANDRAPURAM 6- 405 COMMUNITY HOSPITAL 30 253 35.24 152 21.17 0.000 0.019 146 20.33 3636 506.41 16 2.23 0.00 0.00 KOTHAPET 406 COMMUNITY HOSPITAL 30 3 1.15 15 5.77 0.000 0.000 0 0.00 1064 409.23 30 11.54 0.00 0.00 PRATHIPADU 407 COMMUNITY HOSPITAL 30 2 0.22 32 3.58 0.014 0.291 143 16.01 0 0.00 9 1.01 0.00 0.00 RAMPACHODAVARAM 501 DISTRICT HOSPITAL 340 1673 22.13 915 12.10 0.020 0.574 3864 51.10 44128 583.63 220 2.91 0.01 0.00 ELURU 502 COMMUNITY HOSPITAL 52 248 22.13 224 ...... 2.260 2.020 0 ..... 6007 ..... 42 .... 0.00 0.00 KOVVUR 503 COMMUNITY HOSPITAL 70 231 17.41 103 7.76 0.007 0.023 158 11.91 2021 152.30 30 2.26 0.01 0.00 TANURU 504 COMMUNITY HOSPITAL 30 10 1.85 30 5.56 0.038 0.250 0 0.00 3509 649.81 1 0.19 0.00 0.00 NARSAPUR 505 COMMUNITY HOSPITAL 30 49 10.94 71 15.85 0 .005 0.161 64 14.29 1434 320.09 25 5.58 0.00 0.00 PALACOLE 506 COMMUNITY HOSPITAL 30 119 21.96 83 15.31 0.031 0.000 0 0.00 4101 756.64 0 0.00 0.00 0.00 TADEPALLIGUDEM 507 COMMUNITY HOSPITAL 30 560 213.74 124 47.33 0.143 0.473 0 0.00 3301 1259.9 27 10.31 0.02 0.00 CHINTALAPUDI 601 DISTRICT HOSPITAL 338 522 11.13 987 21.05 0.055 0.111 1563 33.34 39924 851.62 75 1.60 0.02 0.00 MACHALIPATRAM 602 COMMUNITY HOSPITAL 50 27 5.64 126 27.71 0.015 0.301 0 0.00 5899 1276.8 56 12.12 0.00 0.00 AVANIGADDA 603 COMMUNITY HOSPITAL 50 0 0.00 129 19.43 0.008 0.566 92 13.86 8220 1238.0 12 1.81 0.00 0.00 NANDIGAMA 0* A.P.VAIDYA VIDHANA PARISHAD, HYDERABAD HOSPITAL EFFICIENCY INDICATORS FOR THE PERIOD 1/94 TO 06/94 Hosp. Hospital Name Beds | CLINICAL SERVICES I EMERGENCY SERVICE INDEX I DIAGNOSTIC SERVICES I NON CLINICAL SERVICES Code & Place ------------------------ P --------------------------I -I---I-------------- - J---------------------------- t of It of I # of I t of E Emergency- I Emergency- | of I t of I c of It of I t of I t of I t of I t ofl I Major IMajor I Deli-I Deli-I OP Ratio j IP Ratio I Imaging I I & EM I Labor- ILab. j Post |Pm to I post- linfe-I I Surg. ISurg. j veri-I ver- I I I &Electrol Tests I atory I Testsl mort- lAdmn. I opr. Ictioni I I jIto I ies I ies | |Medical I to Admnl Tests Ito j ems j I case Jacqd.1 I I IAdmn. I I to I I ITests I I IAdmn I (Pm) I I fata- linthel IjI I I I Admn | I I I I I I I I lity iHosptl| 604 COMMUNITY HOSPITAL 30 89 13.86 71 11.06 0.000 0.000 0 0.00 6482 1009.7 34 5.30 0.00 0.00 NUZIVEEDU 605 COMMUNITY HOSPITAL 50 13 3.13 138 33.17 0.000 0.000 0 0.00 0 0.00 0 0.00 0.00 0.00 THIRUVURU 606 AREA HOSPITAL 100 346 21.20 343 21.02 0.021 0.309 62 3.80 0 0.00 62 3.80 0.01 0.00 GUDIVADA 607 COMMUNITY HOSPITAL 30 43 5.62 195 25.49 0.024 0.163 36 4.71 3233 422.61 15 1.96 0.00 0.00 MYLAVARAM 801 DIST. HOSPITAL 190 278 14.69 200 10.57 0.038 0.253 1062 56.13 22254 1176.2 160 8.46 0.01 0.00 ONGOLE 901 DIST. HOSPITAL 250 755 14.69 144 ...*-. 1.020 8.410 3162 ..... 28858 ...... 174 ..... 1.35 0.00 NELLORE 1001 DIST. HOSPITAL 270 2142 30.41 1156 16.41 0.070 0.694 2551 36,22 113221 1607.3 106 1.50 0.06 0.00 CHITTOOR 1201 DIST. HOSPITAL 350 940 30.41 978 ...... 0.112 1.090 4783 ..... 25777 ...... 182 ..... 1.67 0.00 0 ANANTAPUR 1401 DIST. HOSPITAL 235 504 4.86 1093 10.55 8.930 6.070 637 6.15 6620 63.88 324 3.13 1.38 0.00 MAHABOOB NAGAR 1601 AREA HOSPITAL 100 164 15.85 54 5.22 0.021 0.025 1431 138.3 13659 1319.7 0 0.00 0.00 0.00 KING KOTI 1602 AREA HOSPITAL 80 4 0.31 315 24.73 2.670 23.820 262 20.57 7676 602.51 0 0.00 0.00 0.00 NAMPALLY 1603 AREA HOSPITAL 100 342 12.63 1407 51.98 0.009 1.014 2200 81.27 17774 656.59 0 0.00 0.00 0.00 MALAK PET 1604 AREA HOSPITAL 105 109 6.18 342 19.38 0.140 0.000 681 38.58 8307 470.65 0 0.00 0.00 0.00 GOLKONDA 1605 S.B.B.B. MTY. HOSPIT 50 279 34.23 401 49.20 2.500 35.330 493 60,49 2562 314.36 0 0.00 0.00 0.00 SHA-ALI BANDA, HYD 1701 DIST. HOSPITAL 220 979 34.23 572 * ..... 1.480 2.100 2496 ..... 685 * - --- - 128 ..... 0.13 0.00 SANGA REDDY 1801 DIST. HOSPITAL 302 1128 12.25 971 10.55 0.068 0.614 2854 31.00 15098 163.98 234 2.54 0.17 0.00 NIZAMABAD 1901 DIST. HOSPITAL 230 386 7.31 798 15.12 0.071 0.250 2263 42.88 19768 374.54 36 0.68 0.01 0,00 ADILAABAD 1903 COMMUNITY HOSPITAL 30 32 3.85 122 14.68 0.016 0.484 208 25.03 0 0.00 28 3.37 0.00 0.00 KHANAPUR 1904 COMMUNITY HOSPITAL 40 274 129.86 168 79.62 0.093 0.578 588 278.7 388 183.89 41 19.43 0.00 0.00 NIRMAL 1905 COMMUNITY HOSPITAL 30 268 13.47 533 26.78 0.024 0.262 398 20.00 0 0.00 38 1.91 0 0.00 0.00 BHAINSA to A.P.VAIDYA VIDHANA PARISHAD, HYDERABAD HOSPITAL EFFICIENCY INDICATORS FOR THE PERIOD 1/94 TO 06/94 Hosp. I Hospital Name ] Beds ] CLINICAL SERVICES I EMERGENCY SERVICE INDEX DIAGNOSTIC SERVICES , NON CLINICAL SERVICES Code & Place - I-________ -___- ___-- ---I------- ----------- ----I-------------- I------------ #[ # I o IoE oft t of Emergency- Emergency- | of ot of # of I S of [ of S a of S t of I oft I Major I Major I Deli-I Deli-I OP Ratio I IP Ratio Imaging I & EM Labor I Lab. I Post |Pm to I post- Jinfe-I I Surg. I Surg. I veri yer- J I &Electrol Tests I atory I Testsl mort- |Admn. a opr. |ctioni I I to I ies [ ies | I IMedical I to Admni Tests I to j ems I I case ,acqd.j I I Admn. I to I I |Tests I I I Admn I (Pm) I I fata- linthel I I I I I Admn.| I I I I I I I I lity IHOsptlI 1906 COMMUNITY HOSPITAL 50 149 15.82 262 27.81 0.139 0.598 827 87.79 0 0.00 177 18.79 0.00 0.00 MANCHERIAL 1907 COMMUNITY HOSPITAL 30 74 35.07 16 7.58 0.000 0.351 0 0.00 2233 1058.3 38 18.01 0.00 0.01 BELLAMPALLI 2001 DIST. HOSPITAL 257 854 17.21 548 11.05 0.000 1.770 560 11.29 12241 246.74 180 3.63 1.01 0.00 KARIMMAGAR 2002 COMMUNITY HOSPITAL 30 255 23.04 247 22.31 0.000 3.840 0 0.00 2142 193.50 39 3.52 1. 05 0.00 METPALLI 2003 COMMUNITY HOSPITAL 40 360 25.33 73 5.14 0.000 0.000 247 17.38 2133 150.11 77 5.42 1.15 0.00 JAGITYAL 2004 COMMUNITY HOSPITAL 30 415 50.00 268 32.29 0.000 3.880 83 10.00 900 108.43 50 6.02 1.25 0.00 PEDDA PALLI 2005 COMMUNITY HOSPITAL 30 0 0.00 85 10.59 0.000 0.000 0 0.00 0 0.00 0 0.00 0.00 0.00 MAHADEVAPUR 2101 COMMUNITY HOSPITAL 40 258 22.87 99 8.78 0.000 0.000 148 13.12 1836 162.77 37 3.28 1.01 0.00 N) MAHABOOBABAD 4- 2102 COMMUNITY HOSPITAL 30 583 80.41 216 29.79 0.000 2.580 44 6.07 83 11.45 38 5.24 1.25 0.00 JANGAM 2103 COMMUNITY HOSPITAL 30 351 22.72 316 20.45 0.000 0.000 0 0.00 668 43.24 0 0.0C 1.20 0.00 NARSAM PET 2104 COMMUNITY HOSPITAL 30 0 0. 0 17 7.76 0.000 0.000 252 115.1 474 216.44 33 15.07 1.20 0.00 ETURNAGAR AM 2201 DIST. HOSPITAL 210 627 2.12 260 0.88 0.056 1.300 123 0.42 4443 15.06 184 0.62 0.00 0.00 KHAMMAM 2202 COMMUNITY HOSPITAL 30 0 0.00 81 5.5$ 0.001 1.020 0 0.00 0 0.00 36 2.47 0.04 0.00 SATTUPALLI 2203 COMMUNITY HOSPITAL 46 25 4.89 82 16.05 0.008 0.153 I 0.00 945 184.93 40 7.83 0.04 0.00 PENU BALLI 2204 COMMUNITY HOSPITAL 30 9 1.48 385 63.11 0 002 0.059 0 C.00 960 157.38 42 6.89 0.06 C.00 KOTHAGUDEM 2301 DIST. HOSPITAL 180 1114 20.64 963 17.8s 12.930 3.130 1963 36.38 10693 198.17 126 2.34 0.40 0.00 NALGONDA 2302 COMMUNITY HOSPITAL 44 905 42.57 235 11.05 2.500 16.500 511 24 04 2026 95.30 118 5.55 C.19 0.00 SURYAPET 2303 COMMUNITY HOSPITAL 30 863 50.44 431 25.19 2.4i0 18.70J 43 2.51 1969 115.08 41 2.4C _.91 0.00 DEVARA KONDA 2304 COMMUNITY HOSPITAL 30 453 38.95 203 17.45 4.070 31.150 141 12.12 7793 671.08 55 4.73 C.13 0.00 RAMANNAPETA 2305 COMMUNITY HOSPITAL 30 53 7.70 61 8.87 C.084 5.460 0 C1.1 0 1.C0 46 6.69 1.71 0.00 HUZURNAGAR Ct - 225 - Annex 18 Page 19 of 24 TABLE 5: QUALITY ACCESS AND EFFECTIVENESS INDICATORS %OF EQUIPMENT NORMS MET AT FACILITY HOSP HOSPITAL BASELINE CODE NAME 101 DISTRICT HOSPITAL 37 SRIKAKULAM 102 COMMUNITY HOSPITAL 46 PALAKONDA 103 COMMUNITY HOSPITAL 17.5 PATHAPATNAM 104 COMMUNITY HOSPITAL 57.8 NARASANNAPETA 105 COMMUNITY HOSPITAL 17.9 TEKKALI 106 COMMUNITY HOSPITAL 27.3 PALASA 107 COMMUNITY HOSPITAL 14.5 ITCHAPURAM 108 COMMUNITY HOSPITAL 5 BARUVA 109 COMMUNITY HOSPITAL 40 SOMPETA 201 DISTRICT HOSPITAL 39.3 VIZIANAGARAM 203 COMMUNITY HOSPITAL 30 PAR VATIPURAM 204 COMMUNITY HOSPITAL 53 S.KOTA 205 COMMUNITY HOSPITAL 8 GAJAPATHINAGARAM 202 M.CH. HOSPITAL 17.2 VIZIANAGARAM 301 COMMUNITY HOSPITAL 33.5 NARSIPATNAM 302 COMMUNITY HOSPITAL 37 ANAKAPALLI 303 COMMUNITY HOSPITAL 3 ARAKU 304 COMMUNITY HOSPITAL 6 PADERU 305 COMMUNITY HOSPITAL 0 AGANAMPUDI (T) 401 DISTRICT HOSPITAL 52 RAJAHMUNDRY 402 COMMUNITY HOSPITAL 27 AMALAPURAM 403 COMMUNITY HOSPITAL 57.1 RAZOLE 404 COMMUNITY HOSPITAL 13.2 RAMACHANDRAPURAM - 226 - Aimex 18 Page 20 of 24 HOSP HOSPITAL BASELINE CODE NAME 405 COMMUNITY HOSPITAL 68.1 KOTHAPET 406 COMMUNITY HOSPITAL 43 PRATHIPADU 407 COMMUNITY HOSPITAL 16.9 RAMPACHODAVARAM 501 DISTRICT HOSPITAL 31.3 ELURU 502 AREA HOSPITAL 60.6 KOVVUR 503 COMMUNITY HOSPITAL 11.7 TANUKU 504 COMMUNITY HOSPITAL 27 NARSAPUR 505 COMMUNITY HOSPITAL 17 PALACOLE 506 COMMUNITY HOSPITAL 29 TADEPALLIGUDEM 507 COMMUNITY HOSPITAL 7 CHINTALAPUDI 508 COMMUNITY HOSPITAL 13.6 BHIMAVARAM (T) 601 DISTRICT HOSPITAL 49.8 MACHALIPATNAM 602 COMMUNITY HOSPITAL 31.1 AVANIGADDA 603 COMMUNITY HOSPITAL 23 NANDIGAMA 604 COMMUNITY HOSPITAL 51.3 NUZIVEEDU 605 COMMUNITY HOSPITAL 36.4 THIRUVURU 606 AREA HOSPITAL 21.9 GUDIVADA 607 COMMUNITY HOSPITAL 15 MYLAVARAM 701 AREA HOSPITAL 25 TENALI 702 COMMUNITY HOSPITAL 35.3 REPALLE 703 COMMUNITY HOSPITAL 13.1 BAPATLA 704 COMMUNITY HOSPITAL 60 NARASARAO PETA 705 COMMUNITY HOSPITAL 50.3 MAACHERLA 706 COMMUNITY HOSPITAL 19.1 SATTENA PALLI 707 COMMUNITY HOSPITAL 4 AMARAVATI (T) 708 CIVIL DISPENSARY 4 CHILAKALURI PETA 801 DIST. HOSPITAL 50.6 ONGOLE - 227 - Annex 18 Page 21 of 24 HOSP HOSPITAL BASELINE CODE NAME 802 COMMUNITY HOSPITAL 29.8 KANIGIRI 803 AREA HOSPITAL 16.4 CHIRALA 804 COMMUNITY HOSPITAL 25.4 GIDDALURU 805 COMMUNITY HOSPITAL 18 MARKAPUR 806 M.Ch.ONGOLE 0 901 DIST. HOSPITAL 52 NELLORE 902 M.CH.(RS.MTY)HOSPITAL 59 NELLORE 903 R.S.PAED.HOSPITAL 14 NELLORE 905 COMMUNITY HOSPITAL 43.2 GUDUR 906 COMMUNITY HOSPITAL 15.7 KAVALI 1001 DIST. HOSPITAL 36 CHITTOOR 1002 COMMUNITY HOSPITAL 10 KUPPAM 1003 COMMUNITY HOSPITAL 21 PUNGANUR 1004 COMMUNITY HOSPITAL 19.9 MADANAPALLY 1005 COMMUNITY HOSPITAL 39 SRI KALAHASTI 1006 COMMUNITY HOSPITAL 17.4 VAYALPADU 1007 COMMUNITY HOSPITAL 17.4 SATYAVEEDU 1008 COMMUNITY HOSPITAL 12.2 PILER 1101 DIST. HOSPITAL 36.7 CUDDAPAH 1102 COMMUNITY HOSPITAL 26 RAYACHOTI 1103 COMMUNITY HOSPITAL 41 PULIVENDULA 1104 COMMUNITY HOSPITAL 75 PRODDATUR 1105 COMMUNITY HOSPITAL 16.8 RAJAMPET 1201 DIST. HOSPITAL 54 ANANTAPUR 1203 COMMUNITY HOSPITAL 50.5 RAYADURG 1204 COMMUNITY HOSPITAL 18.5 GOOTY 1205 COMMUNITY HOSPITAL 9 KADIRI - 228 - Anne 18 Pa2e 22 of 24 HOSP HOSPITAL BASELINE CODE NAME 1206 COMMUNITY HOSPITAL 28.4 PENUKONDA 1207 AREA HOSPITAL 56 HINDUPUR 1208 COMMUNITY HOSPITAL 13.4 DHARMAVARAM 1209 COMMUNITY HOSPITAL 15.8 TADIPATRI 1210 COMMUNITY HOSPITAL 36 GUNTAKAL 1211 COMMUNITY HOSPITAL 11 URAVAKONDA 1212 COMMUNITY HOSPITAL 63 MADAKASIRA 1301 COMMUNITY HOSPITAL 20 NANDYALA 1302 COMMUNITY HOSPITAL 29 BANAGANAPALLI 1303 COMMUNITY HOSPITAL 110 ADONI 1304 W & C MTY. HOSPITAL 70 ADONI 1306 COMMUNITY HOSPITAL 50.2 YEMMIGANOOR 1401 DIST. HOSPITAL 39.3 MAHABOOB NAGAR 1402 COMMUNITY HOSPITAL 53 GADWAL 1403 COMMUNITY HOSPITAL 33 KALVAKURTHY 1404 COMMUNITY HOSPITAL 49 NARAYANA PET 1405 COMMUNITY HOSPITAL 40 SHADNAGAR 1501 COMMUNITY HOSPITAL 18 TANDUR 1502 COMMUNITY HOSPITAL 51 MARPALLI 1503 COMMUNITY HOSPITAL 13 VIKARABAD (I') 1504 COMMUNITY HOSPITA 4.1 GHATAKESAR (M) 1505 COMMUNITY HOSPITAL 5 VANASTHALIPURAM (M) 1601 AREA HOSPITAL 80 KING KOTI 1602 AREA HOSPITAL 43.9 NAMPALLY 1603 AREA HOSPITAL 56 MALAK PET 1604 AREA HOSPITAL 50 GOLKONDA 1605 S.B.B.B. MTY. HOSPIT 86 SHA-ALI BANDA, HYD - 229 - Anna 18 Page 23 of 24 HOSP HOSPITAL BASELINE CODE NAME 1628 COMMUNITY HOSPITAL 2 BARKAS 1701 DISTRICT HOSPITAL 65.7 SANGA REDDY 1702 COMMUNITY HOSPITAL 44.1 NARAYAN KHED 1703 COMMUNITY HOSPITAL 19 A. JOGI PETA 1704 COMMUNITY HOSPITAL 85.5 MEDAK 1705 COMMUNITY HOSPITAL 19.8 SIDDIPET 1706 COMMUNITY HOSPITAL 53 NARSAPUR 1707 COMMUNITY HOSPITAL 55.3 GAAJWEL 1708 COMMUNITY HOSPITAL 50 ZAHEERABAD 1709 M.CH. HOSPITAL 0 SIDDIPET 1801 DIST. HOSPITAL 50 NlZAMABAD 1802 COMMUNITY HOSPITAL 56 KAMA REDDY 1803 COMMUNITY HOSPITAL 51.8 YELLA REDDY 1804 COMMUNITY HOSPITAL 41 BANSWADA 1805 COMMUNITY HOSPITAL 50 BHODAN 1901 DIST. HOSPITAL 28.1 ADILAABAD 1902 COMMUNITY HOSPITAL 10 SIRPUR 1903 COMMUNITY HOSPITAL 60 KHANAPUR 1904 COMMUNITY HOSPITAL 12.3 NIRMAL 1905 COMMUNITY HOSPITAL 41 BHAINSA 1906 COMMUNITY HOSPITAL 42 MANCHERIAL 1907 COMMUNITY HOSPITAL 18.8 BELLAMPALLI 1908 COMMUNITY HOSPITAL 13.1 UTNOOR 1909 M.CH. HOSPITAL 0 NIRMAL 2001 DIST. HOSPITAL 51 KARIMNAGAR 2002 COMMUNITY HOSPITAL 11.5 METPALLI 2003 COMMUNITY HOSPITAL 16.4 JAGITYAL - 23U - Annex 18 Page 24 of 24 HOSP HOSPITAL BASELINE CODE NAME 2004 COMMUNITY HOSPITAL 17 PEDDA PALLI 2005 COMMUNITY HOSPITAL 9 MAHADEVAPUR 2101 COMMUNITY HOSPITAL 42 MAHABOOBABAD 2102 COMMUNITY HOSPITAL 70 JANGON 2103 COMMUNITY HOSPITAL 6 NARSAM PET 2104 COMMUNITY HOSPITAL 2.6 ETURNAGARAM 2201 DIST. HOSPITAL 33.5 KHAMMAM 2202 COMMUNITY HOSPITAL 12.2 SATTUPALLI 2203 COMMUNITY HOSPITAL 36 PENU BALLI 2204 COMMUNITY HOSPITAL 17.5 KOTHAGUDEM 2205 COMMUNITY HOSPITAL 37 BADRACHALAM (T) 2301 DIST. HOSPITAL 42.2 NALGONDA 2302 COMMUNITY HOSPITAL 74 SURYAPET 2303 COMMUNITY HOSPITAL 10 DEVARA KONDA 2304 COMMUNITY HOSPITAL 17.7 RAMANNAPETA 2305 COMMUNITY HOSPITAL 23.4 HUZURNAGAR 2306 AREA HOSPITAL 47 NAGARJUNASAGAR (T) 2307 COMMUNITY HOSPITAL 46.3 MIRYALAGUDA (T) 2308 COMMUNITY HOSPITAL 5 BHONGIR (T) AVERAGE PERCENTAGE(%) OF 30.11% A. P. V. V. P. HOSPITALS - 231 - Annex 19 Page 1 of 4 Supervision Plan General Routine Supervision 1. The core of the routine supervision process will be the six-monthly Bank supervision missions. An indispensable basis for this will be the six-monthly progress report to be submitted by APVVP and the Department of Health Medical and Family Welfare of GOAP. The large, costly and complex civil works component will be covered by a special extra system of locally- based supervision undertaken by APHMHIDC. 2. Mission Freguency. Scheduling, Programs. Regular Bank supervision missions will visit the project approximately every six months. Thus if the project is launched in early 1995, supervision missions would be scheduled between April and May, 1995 and between October and November, 1995; and so on for each year of the project. 3. On each supervision mission the project coordinator (the Commissioner of APVVP) will present a six-monthly progress report on the status of implementation for review and discussion. The Managing Director of APHMHIDC will also make a presentation about the progress of civil works component to be incorporated in an overall progress report. The Secretary, and in his absence, the Joint Secretary of the Department of Health, Medical and Family Welfare will update the mission on the progress on policy issues of the project. 4. Each supervision mission will include field trips visiting a sample of district, area and community hospitals. The mission will be appropriately staffed as discussed below. Tribal areas in every state will be visited at least once every year. During yearly mission visits, and about once every six months, a tribal specialist will visit a sample of project sites and facilitate the six monthly supervision missions. 5. Composition of Missions. The missions will be led by the Bank task manager and will include as appropriate at the time, specialists in hospital management, public health, hospital equipment matters, economics, general management training, IEC and tribal issues and MIS. Specialists may also visit the states separately and individually by prior arrangement between the task manager and APVVP and the Department of Health, Medical and Family Welfare. In addition, required specialists in other areas may occasionally be included in missions as needed. 6. Additional Missions. In addition to the above, the task manager may visit AP with or without specialist colleagues, in between routine supervision missions as needed for trouble- shooting or emergencies, or during the first year of the project in order to help ensure that project implementation gets off to a smooth start. The task manager may also, by prior arrangement with APVVP and the Department of Health, Medical and Family Welfare, authorize individual specialists to make separate between-mission visits to AP. - 232 - Annex 19 Page 2 of 4 7. Supervision of Policy Reforms: Six monthly supervision will monitor compliance of the Policy Reform program. An economist and a management specialist will be assigned responsibility during supervision missions to monitor compliance and progress on policy matters. 8. Special Arrangements for Civil Works. The civil works component is complex and costly and covers more than 150 hospitals of varying size. It therefore cannot be adequately supervised in the field by an architect visiting twice a year for a couple of weeks. A pyramidal, locally-based system of field monitoring for this component will therefore supplement the supervision arrangements described above. There will be three layers, as follows: (a) The first layer will be the maintenance of a civil works archive in the Human Resources Unit of the Bank's Delhi office, under the day-to-day supervision of one of the staff members. APVVP/APHMHIDC will send to this archive particulars of each hospital for renovation and extension for which construction begins. This will include final as-built drawings and contracts entered into for renovations and extensions. (b) The second layer will consist of local consultant architects who will report to the project task manager and will: (i) review new arrivals in the archives once a month or once every two months as necessary depending on the volume of arrivals, and screen them for any departures from criteria or other features agreed upon at appraisal; (ii) in some cases, just prior to the regular Bank supervision missions and under a briefing from the mission leader, visit the state to: (a) discuss cases departing from criteria set out in the technical manual with the Managing Director of APHMHIDC and the Commissioner of APVVP; and (b) make site visits to an appropriate sample of district, area and community hospitals departing from criteria; (iii) after these visits, report findings to the Commissioner of APVVP and the Managing Director APHMHIDC and to the regular mission architect at the start of the supervision mission, as well as filing a report of the findings in the project archives. (c) The third layer will consist of the regular supervision missions. At the start of each mission, the mission architect will review the reports of the local architect consultants and discuss them with APWP and APHMHIDC. The architect will then make site visits, in the state visited by the mission, to any identified problem buildings plus a random sample, drawn by him/her, of the buildings reviewed by the local consultants during the previous six months. 8. Six-Monthly Project Progress Report: This will report on the Performance Indicators - 233 - Annex 19 Page 3 of 4 highlighted in Annex 18. Corresponding computer software will be provided to the APVVP for use in report preparation. The format will be followed as is for the first year of the project. It will then be evaluated by APVVP in time for the third supervision mission, discussed at the joint meeting, and revised as necessary by agreement between APVVP and the mission team. The Mid-Term Project Review 9. The Mid-Term Review of project progress will be carried out by an IDA mission and APVVP, with a separate sub-review by the Department of Health, Medical and Family Welfare, and submitted to IDA approximately half way through the project period; if the project is launched in early 1995, this point would be approximately early 1998. The entire review process should take two to three months. The findings of the review would then be discussed during the next regular supervision mission. This mission would first hold a general meeting with APVVP and the Department of Health, Medical and Family Welfare to discuss the findings of the Review. 10. The principal aim of the Mid-Term Review is to determine if there are any major problems or issues in the project which necessitate re-thinking the original project design and making mid-course corrections. It also may be used for a preliminary evaluation of the impact of the project, if the project has progressed sufficiently to expect any impact. 11. The Mid-Term Review will consist of an internal stocktaking from the project records and MIS of the progress of project activities as measured against the original program and time schedule set out in the SAR and Implementation Plan (see Annex 17) plus optimal additional parts as appropriate. Notes should be included on the status of fulfillment of project agreements and covenants, on the results of the evaluation of a management review, project's policy reforms aspects such as cost recovery policies, and on progress with the strategies for improving services to tribal groups. The stocktaking may also include indicators of the burden of disease and epidemiology. 12. A final Mid-Term Review Report will be submitted to IDA and discussed with the following supervision mission. It should highlight any major problems, issues, bottlenecks or delays in the project execution and the prospects for resolving them and completing the project on time. 13. The Mid-Term Review may be extended beyond those issues discussed above if this is considered appropriate and useful. APVVP and the Department of Health Medical and Family Welfare would decide upon the full review content, in consultation with IDA, at the beginning of planning for the review. Further elements of the review could include: - 234 - Annex 19 Page 4 of 4 (a) a management audit of APVVP; (b) a repeat of the beneficiary social assessment and training and communicationneeds assessments carried out as part of project preparation; (c) special in-depth evaluative studies of the private health sector, workforce issues etc.: (d) reviews of project progress by an external agency. However, this would be at the discretion of APVVP. Role of the Resident Mission 14. The human resources group of the New Delhi office has been strengthened to carry out an increasing share of the supervision work for human resources projects in India. This group will play an important role in this project. First, our senior public health adviser in Delhi may be asked to follow-up on fundamental issues. Our local public health specialist in Delhi will help monitor the project on a regular basis, follow-up on key implementation issues, and trouble shoot in the field, as needed. He/she will be assisted by a local staff specializing in the administration of projects. Procurement issues and guidance will be handled by the Delhi Office Procurement and Accounting Group. That same group will handle accounting, auditing, disbursement, and flow of funds issues. These actions will be part of the overall supervision program noted above. - 235 - ANNEX20 Page 1 of 1 FORECAST OF EXPENDITURES AND DISBURSEMENTS Expenditures Disbursements Cumulative Semester as % of From Appraisal IDA Fiscal Year Semester Cumulative Semester Cumulative /b Total Date --------------------------------- US$ Million -------------------------------- FY95 Ist (Jul 94 - Dec 94) /a 4.27 4.27 3.00 3.00 0% 1 2nd (Jan 95 - Jun 95) 4.27 8.54 1.00 4.00 3% 2 FY96 Ist (Jul 95 - Dec 95) 8.50 17.04 4.00 8.00 6% 3 2nd (Jan 96 - Jun 96) 8.50 25.54 5.30 13.30 10% 4 FY97 ist (Jul 96 - Dec 96) 14.29 39.83 5.20 18.50 14% 5 2nd (Jan 97 - Jun 97) 14.29 54.12 10.60 29.10 22% 6 FY98 Ist (Jul 97 - Dec 97) 20.15 74.27 10.70 39.80 30% 7 2nd (Jan 98- Jun 98) 20.15 94.41 10.70 50.50 38% 8 FY99 Ist (Jul 98 - Dec 98) 17.67 112.09 10.60 61.10 46% 9 2nd (Jan 99 - Jun 99) 17.67 129.76 10.60 71.70 54% 10 FY2000 1st (Jul 99 - Dec 99) 8.26 138.02 15.90 87.60 66% 11 2nd (Jan 2000 - Jun 2000) 8.26 146.28 5.30 92.90 70% 12 FY2001 Ist (Jul 2000 - Dec 2000) 6.31 152.59 15.90 108.80 82% 13 2nd (Jan 2001 - Jun 2001) 6.31 158.90 16.00 124.80 94% 14 FY2002 Ist (Jul 2001 - Dec2001) 0.00 158.90 8.20 133.00 100% 15 Closing Date: September 20, 2001 a/: Including Special Account and Retroactive Financing b/: Disbursement projections based on Regional Profiles for similar type projects - 236 - Annex 21 Page 1 of 1 Documents Available in Proiect File 1. Andhra Pradesh Vaidya Vidhana Parishad (APVVP) Project Report: Project for the Development of the Secondary Level Health Care System in Andhra Pradesh - January 1994. 2. APVVP Project Report: Project for the Development of the Secondary Level Health Care System in Andhra Pradesh - 7 November 1993. 3. APVVP: Cost Estimates for Renovations/Upgradations/Extensions/Staff Quarters - November 1993. 4. APVVP: Brief Report on Health Sector Analysis in Andhra Pradesh - 1992. 5. APVVP: Site Survey of Public Secondary Hospitals in Andhra Pradesh (23 Volumes). 6. APVVP: Note on Organization and Achievements - 1992. 7. APVVP: Proceedings of Workshop on Norms for Hospital Services and Equipment - November 1993. 8. APVVP: Approved Drug List and Hospital Formulary - 1990. 9. Concept Paper of the Project for the Strengthening and Upgradation of the First Line Referral Hospitals in Andhra Pradesh - Government of India, 1993. 10. IDA Preparation Mission: Andhra Pradesh District Health Systems Project, Back to Office Report - July 1993. 11. IDA Preparation Mission: Andhra Pradesh District Health Systems Project, Back to Office Report - November 1993. 12. IDA Preappraisal Mission: Andhra Pradesh District Health Systems Project, Back to Office Report - February 1994. 13. A Review of the Private Health Sector in Andhra Pradesh - G. Kumara Swamy Reddy, January 1994. Study undertaken as part of project preparation. 14. The Beneficiary/Social Assessment Study - ASCI, 1994 (forthcoming). 15. Burden of Disease and Cost-Effectiveness Study - ASCI, 1994 (forthcoming).