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I. Basic Information
Date prepared/updated: 08/02/2012
Report No.: AC6758
1. Basic Project Data
Original Project ID: P071160
Original Project Name: India: Karnataka
Health Systems
Country: India
Project ID: P130395
Project Name: India: Karnataka Health Systems Additional Financing
Task Team Leader: Patrick M. Mullen
Estimated Appraisal Date: June 7, 2012
Estimated Board Date: August 30, 2012
Managing Unit: SASHN
Lending Instrument: Specific Investment
Sector: Health (100%)
Theme: Health system performance (40%);Social risk mitigation (20%);Injuries and
non-communicable diseases (15%);Child health (10%);Population and reproductive
health (15%)
IBRD Amount (US$m.):
IDA Amount (US$m.):
GEF Amount (US$m.):
PCF Amount (US$m.):
Other financing amounts by source:
Environmental Category: B - Partial Assessment
Simplified Processing
Simple []
Repeater []
Is this project processed under OP 8.50 (Emergency Recovery)
Yes [ ]
No [X]
or OP 8.00 (Rapid Response to Crises and Emergencies)
2. Project Objectives
To contribute to development of health services in Karnataka state, particularly in
underserved areas and among vulnerable groups, by filling gaps and supporting new
3. Project Description
The Karnataka Health System Development and Reform Project (KHSDRP), with IDA
financing of US$ 141.83 million, was approved in 2006, with an original closing date of
March 2012. Additional financing of US$ 70 million has been proposed to support
extension of the project to March 2015. The proposed additional financing will support
investments, innovations, pilots and evaluations that are intended to leverage the
effectiveness of anticipated continued increases in state and central government health
spending in Karnataka. Component 1 (Strengthening Existing Government Health
Programs) will involve continued support to organizational development and quality
assurance activities. Component 2 (Innovations in Service Delivery and Health
Financing) will continue investment in maternal and primary health care services, publicprivate contracting, activities supporting environmental health and regulation, and
support to a program that finances tertiary care for the poor. Additional activities will
include non-communicable disease prevention and control, road safety and emergency
health services, and a results-based financing (RBF) pilot. Component 3 (Project
Management, Monitoring and Evaluation) will continue support to project management
and monitoring and evaluation, with new investment in pilot information system
4. Project Location and salient physical characteristics relevant to the safeguard
This project is located in Karnataka, a southern state of India, and will be implemented
across the state. Particular pilot interventions will be initiated in specific districts. Since
the first phase of the project was prepared, there has been progress in health indicators in
the state. The physical characteristics of the state include a varied terrain with medium
hills to plain areas. The upgrading of existing healthcare facilities would be done within
the existing premises and would not be affecting any natural features in the landscape.
Moreover, each healthcare facility has provisions to treat liquid wastes under the first
phase of the project and would continue to follow the Biomedical Waste Management
and Disposal Rules.
5. Environmental and Social Safeguards Specialists
Ms Shreelata Rao-Seshadri (SASHN)
Mr Anupam Joshi (SASDI)
6. Safeguard Policies Triggered
Environmental Assessment (OP/BP 4.01)
Natural Habitats (OP/BP 4.04)
Forests (OP/BP 4.36)
Pest Management (OP 4.09)
Physical Cultural Resources (OP/BP 4.11)
Indigenous Peoples (OP/BP 4.10)
Involuntary Resettlement (OP/BP 4.12)
Safety of Dams (OP/BP 4.37)
Projects on International Waterways (OP/BP 7.50)
Projects in Disputed Areas (OP/BP 7.60)
II. Key Safeguard Policy Issues and Their Management
A. Summary of Key Safeguard Issues
1. Describe any safeguard issues and impacts associated with the proposed project.
Identify and describe any potential large scale, significant and/or irreversible impacts:
Environmental: Along with completion of ongoing capital investments, during the three
year extension the project will support upgrading of additional primary health care
facilities in order to provide round-the-clock services. Upgrading these facilities is
intended in particular to improve the availability of delivery and emergency obstetric care
services. The project will support investments and activities necessary to meet the Indian
Public Health Standards (IPHS) for PHCs, including necessary civil works and staff
The OP/BP 4.01 Environmental Assessment is triggered. However, given the type of
activities, the impacts would be minor, site-specific and manageable with appropriate
mitigation measures. There are no potential large- scale, significant and/or irreversible
impacts envisaged due to planned project investments. An Environmental Assessment
(EA) was carried out during preparation of Phase I, and particular environmental issues
were identified. These included:
Deficient provisions and practices in relation to bio-medical waste management
Poor sanitation facilities
Lack of adequate water supply
Poor construction quality of building facilities and lack of adequate operation and
Lack of personnel awareness on basic good environmental practices.
The identified issues were addressed through an Environmental Management Plan
(EMP) in Phase 1 that included appropriate management measures to mitigate the
impacts and address the identified issues. The EMP will be followed during the
Additional Financing phase as well. The project proposes to: (i) continue state-wide
implementation at primary, secondary and tertiary levels of a comprehensive Health Care
Waste Management Plan which covers all stages of bio-medical waste disposal
(segregation at the facility level, storage, and final disposal; (ii) implement IPHS
standards in all newly proposed construction to ensure quality of construction and
adequate provision of basic amenities such as water supply and sanitation; and (iii) to
extend its activities to the area of Food Safety, to ensure that the provisions of the
national Food Safety Act are adequately implemented, and structures and systems are in
place to enhance food safety practices. This will ensure provision, access and awareness
of safer food products to communities in both urban and rural areas.
Social: The key social safeguard issues include the following:
Significant disparities in achievement of health outcomes, between districts and
between rural and urban areas. In part this is caused by the concentration of a few remote
tribal areas and in part by the relative neglect of poor, low-productivity districts in
Northern Karnataka, where there is also a higher concentration of poor minorities.
Continuing disparities in the health outcomes of vulnerable groups, such as tribal
people and Scheduled Castes. These groups account for about 20 percent of the
population of Karnataka, and they are spread throughout the state.
Burden of out-of-pocket expenditures on the poor, particularly for catastrophic
illness, and the absence of an adequate social safety net.
Project Interventions: Equity in access to project benefits is an important issue for the
project. Its design aims to ensure this by: (i) focusing the development objectives on the
poor and vulnerable, thereby ensuring that progress in this area is regularly monitored
and reported on; (ii) increasing access to primary care services for the most vulnerable
and underserved by expanding initiatives started during Phase I. These include: financing
mobile health clinics run by non-governmental organizations (NGOs), contracting-in
specialists assigned to hospitals in under-served areas, contracting citizens' help desks in
hospitals designed to facilitate access to services by vulnerable groups, and training
auxiliary nurse-midwives (ANMs) who will serve in tribal areas; (iii) upgrading primary
health centers (PHCs) in 'backward' blocks as identified by a state government committee
so as to improve the quality and availability of primary care in these disadvantaged areas;
(iv) providing institutional support to the state government program financing tertiary
health care for Below Poverty Line (BPL) beneficiaries, designed to reduce catastrophic
out-of-pocket expenditure; (v) piloting in poorer areas of the state a results-based
financing (RBF) scheme incentivizing health facilities to provide a range of services; and
(vi) information, education and communication (IEC) activities to support all the above
interventions to enhance utilization of services by those most in need.
2. Describe any potential indirect and/or long term impacts due to anticipated future
activities in the project area:
Environmental: The continued implementation of the Health Care Waste Management
strategy put in place during Phase I is expected to provide positive long-term impact as it
would improve environmental management in primary health care. No potential indirect
and/or long-term impacts are envisaged due to anticipated future activities in the project
Social: The potential long-term impact would be a positive one on underserved groups
such as tribal people and Scheduled Castes, people below the poverty line, and those who
live in the most underserved areas of the state.
3. Describe any project alternatives (if relevant) considered to help avoid or minimize
adverse impacts.
Environmental: As a part of the EA, during preparation of Phase I, an analysis of
alternatives was undertaken with reference to practices that should be adopted in the
primary health care centers/sub-centers that are to be supported under the project. The
analysis revealed that the septic tank method for disposing of the placenta, the main biomedical waste, is more appropriate and the use of glass syringes is preferable to
disposable or auto-destructive syringes. These have been incorporated in the project
design and needle destroyers have been provided across the healthcare facilities.
Social: The project has adopted a multi-pronged approach to addressing the needs of
vulnerable populations by including both measures to improve the health of the state's
population generally, and specific ones focused on vulnerable groups. For example, the
general measures include support of increased expenditure on essential items in primary
and secondary health care; organizational development; and improving infrastructure and
systems across the board. Specific measures are to increase vulnerable communities'
access to good quality services while reducing the cost of care for the poorest.
4. Describe measures taken by the borrower to address safeguard policy issues. Provide
an assessment of borrower capacity to plan and implement the measures described.
The borrower has taken adequate measures to address safeguard policy issues. This
included undertaking an Environmental Assessment (during phase 1) and implementing
the agreed EMP, which included environmental management measures (including
guidelines for design, construction and operation of primary health care facilities,
organizational arrangements to implement the plan, training/capacity-building
requirements, communication arrangements, consultative processes/procedures,
monitoring arrangements and special studies to be done during project implementation).
The borrower has not only developed sufficient capacity to address environmental
safeguard policy issues during the phase 1 of the project but has successfully
mainstreamed good environmental management practices in the working of the State's
health department with close integration of the project's safeguard provisions with that of
National Rural Health Mission (NRHM). In fact, some of the environmental safeguard
provisions in handling and disposal of medical waste are now being funded through the
NRHM. These are continuing not only in the project invested healthcare facilities but also
in other facilities. Further, the state has increased its technical and managerial capacity
for addressing key environmental issues related to healthcare facilities by appointing two
full-time Environmental Officer (one each for liquid waste and solid waste) at the state
level and District Nodal Officers Environment (DNOE) in each district to ensure
implementation of biomedical waste management and disposal practices. In addition, the
State is developing a quality assurance group for all healthcare facilities, which would,
among other things will also monitor infection control and healthcare waste management
systems as part of quality healthcare service delivery.
A Social Assessment (SA) was carried out to develop a strategy and action plan to
improve health outcomes among the poor and disadvantaged, especially Scheduled
Castes (SCs) and Scheduled Tribes (STs). The assessment examined health-seeking
behaviors of these socio-economically vulnerable groups, their utilization of health
services, and perceptions of the formal/informal and public/private health sectors. The
assessment suggested a mix of strategies including: (a) public health measures; (b)
outreach to inaccessible areas (particularly tribal areas) and households (usually the
poorest or socially disadvantaged such as Scheduled Castes); (c) improvements at health
facilities (including infrastructure, equipment, drugs, and provider capabilities); (d)
involvement of private practitioners, and (e) health education.
The project's focus on vulnerable communities was partly the result of the findings of
the SA and other studies done during project preparation which highlighted the wide
differentials in health outcomes and access to health care in Karnataka. Accordingly a
Vulnerable Communities Health Plan (VCHP) was prepared including implementation
and monitoring arrangements and a strategy for continued participation. In addition, the
experience of implementing the various outreach initiatives during Phase I of the project
has helped identify successful initiatives that have had a substantial impact on access and
quality of care, such as mobile health clinics which will now be scaled up.
The GOK has the commitment and adequate capacity to implement the activities
identified. The elected local bodies (panchayats) at village and district levels will also
have a role in monitoring implementation. Village Health and Sanitation Committees
(VHSCs) have been trained and strengthened to support the project authorities in
monitoring activities down to the ground level. In addition, information technology
solutions are also being introduced under the project to enhance monitoring and
oversight. Adequate resources are available for these activities.
5. Identify the key stakeholders and describe the mechanisms for consultation and
disclosure on safeguard policies, with an emphasis on potentially affected people.
Environment: As a part of the EA, public/stakeholder consultations were carried out. In
addition, stakeholder consultations were done with selected civil society organizations.
To carry forward these consultations during project implementation, a consultation plan
has been included in the EMP. Once the environmental safeguard reports were
completed, these were disclosed. The draft final executive summary, EA and EMP
reports were made available in the KSHDP office in Bangalore. The executive summary
has been translated in the local language, Kannada, and disclosed to all District Health
Offices in the various districts. All these reports have been disclosed at the Bank's Info
Shop in New Delhi and Washington D.C.
Social: The state of Karnataka has a good track record in obtaining public perceptions
and creating a public voice in governance. Potential project beneficiaries (the poor,
women, adolescents, tribal people, etc.) have participated in project preparation through
the social assessment and other community-based studies. Different cadres of health staff
and officials, NGOs and other private sector representatives were involved in the SA
process, studies, and various workshops. NGOs have been widely involved in project
implementation; and village level panchayat bodies have also been trained and closely
involved in project implementation. The Vulnerable Communities Health Plan has been
disclosed on the Government of Karnataka website.
B. Disclosure Requirements Date
Environmental Assessment/Audit/Management Plan/Other:
Was the document disclosed prior to appraisal?
Date of receipt by the Bank
Date of "in-country" disclosure
Date of submission to InfoShop
For category A projects, date of distributing the Executive
Summary of the EA to the Executive Directors
Resettlement Action Plan/Framework/Policy Process:
Was the document disclosed prior to appraisal?
Date of receipt by the Bank
Date of "in-country" disclosure
Date of submission to InfoShop
Indigenous Peoples Plan/Planning Framework:
Was the document disclosed prior to appraisal?
Date of receipt by the Bank
Date of "in-country" disclosure
Date of submission to InfoShop
Pest Management Plan:
Was the document disclosed prior to appraisal?
Date of receipt by the Bank
Date of "in-country" disclosure
Date of submission to InfoShop
* If the project triggers the Pest Management and/or Physical Cultural Resources,
the respective issues are to be addressed and disclosed as part of the Environmental
Assessment/Audit/or EMP.
If in-country disclosure of any of the above documents is not expected, please
explain why:
C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the
ISDS is finalized by the project decision meeting)
OP/BP/GP 4.01 - Environment Assessment
Does the project require a stand-alone EA (including EMP) report?
If yes, then did the Regional Environment Unit or Sector Manager (SM)
review and approve the EA report?
Are the cost and the accountabilities for the EMP incorporated in the
OP/BP 4.10 - Indigenous Peoples
Has a separate Indigenous Peoples Plan/Planning Framework (as
appropriate) been prepared in consultation with affected Indigenous Peoples?
If yes, then did the Regional unit responsible for safeguards or Sector
Manager review the plan?
If the whole project is designed to benefit IP, has the design been reviewed
and approved by the Regional Social Development Unit or Sector Manager?
The World Bank Policy on Disclosure of Information
Have relevant safeguard policies documents been sent to the World Bank's
Have relevant documents been disclosed in-country in a public place in a
form and language that are understandable and accessible to project-affected
groups and local NGOs?
All Safeguard Policies
Have satisfactory calendar, budget and clear institutional responsibilities
been prepared for the implementation of measures related to safeguard
Have costs related to safeguard policy measures been included in the project
Does the Monitoring and Evaluation system of the project include the
monitoring of safeguard impacts and measures related to safeguard policies?
Have satisfactory implementation arrangements been agreed with the
borrower and the same been adequately reflected in the project legal
D. Approvals
Signed and submitted by:
Task Team Leader:
Environmental Specialist:
Social Development Specialist
Additional Environmental and/or
Social Development Specialist(s):
Mr Patrick M. Mullen
Mr Anupam Joshi
Ms Shreelata Rao-Seshadri
Mr Sanjay Srivastava
Ms Julie McLaughlin
Approved by:
Regional Safeguards Coordinator:
Comments: Cleared
Sector Manager:
Comments: Cleared