Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA2678 Project Name Accelerating Universal Access to Early and Effective Tuberculosis Care (P148604) Region SOUTH ASIA Country India Sector(s) Health (100%) Theme(s) Health system performance (30%), Tuberculosis (70%) Lending Instrument Investment Project Financing Project ID P148604 Borrower(s) Republic of India Implementing Agency Ministry of Health and Family Welfare Environmental Category B-Partial Assessment Date PID Prepared/Updated 06-Jan-2014 Date PID Approved/Disclosed 06-Jan-2014 Estimated Date of Appraisal 27-Dec-2013 Completion Estimated Date of Board 14-Mar-2014 Approval Decision I. Project Context Country Context India s population is 1.2 billion, with per capita gross domestic product (GDP) of US$ 1,489 in 2012. The government s 12th five-year Plan (2012-17) focuses on both rapid economic growth and inclusiveness, including an emphasis on development of human capabilities. Sectoral and institutional Context Although there has been progress over the past 15 years in controlling tuberculosis (TB), the disease, long associated with poverty, crowding and poor living conditions, remains a significant source of suffering in India, causing an estimated 2.2 million new cases and 270,000 deaths annually, representing the sixth most important cause of death and disability in the country. At the same time, multi-drug resistant TB (MDR-TB), difficult and expensive to diagnose and treat, is an emerging threat, as the disease becomes resistant to the standard medicines due to misuse of anti- TB drugs and interrupted treatment. It is estimated that there could be 50,000 new MDR-TB cases in India annually. Extensively drug resistant TB (XDR-TB) has also been identified in India. Between 1998 and 2006, the Revised National TB Control Program (RNTCP) scaled-up availability DOTS nationwide, supported by International Development Association (IDA) financing of US$ 115 million. Between 2006 and 2012, with support from a second IDA credit of US$ 179 million Page 1 of 5
(rated Satisfactory), RNTCP sustained its expansion, improved services for poor and high-risk groups, and initiated MDR-TB services. TB mortality and incidence are estimated to be slowly declining, contributing to India s achievement of MDG 6. Since its inception, RNTCP has evaluated over 55 million people for TB and initiated treatment for 16 million, saving the lives of millions. However, the annual number of TB cases diagnosed and treated by the program has reached a plateau: 1.5 million cases in 2012, which can be compared to 1.4 million six years earlier in 2006. Given that there are an estimated 2.2 million new TB cases every year, there are thus hundreds of thousands of TB cases, either not diagnosed or seeking care in the private sector, who are not reached by the program. At the same time, reducing incidence will require lessening the time that TB cases remain infectious in the community through identifying and diagnosing patients earlier after the onset of symptoms.the government s 12th Plan (2012-17) includes an emphasis on improving health care services and health outcomes. Noting that Central and State government funding for health services was 1.04% of GDP during the 11th Plan period (2007-12), the 12th Plan includes a commitment to raise this to 1.87% of GDP by 2017. RNTCP s 2012-17 National Strategic Plan has adopted the objective of universal access to quality TB diagnosis and treatment for all TB patients in the community, proposing a tripling of its budget (in absolute terms) compared to the previous five-year period. The National Strategic Plan adopts strategies to address the main challenges facing the program: (i) the need to reach more TB patients with support for effective diagnosis and treatment; (ii) the need to reduce the time TB cases are infectious in their communities; and (iii) the need to control MDR-TB. However, a recent slowing of economic growth has led to lower than planned program budgets during the past two years, slowing implementation of those strategies. II. Proposed Development Objectives To support the aims of India's National Strategic Plan for Tuberculosis Control to expand utilization of quality diagnosis and treatment services for people suffering from tuberculosis. III. Project Description 1. New strategies to reach more tuberculosis patients with earlier and more effective care in the public and private sectors 2. Scale-up and improve diagnosis and treatment of drug-resistant tuberculosis 3. Expand public tuberculosis services integrated with the primary health care system IV. Financing (in USD Million) Total Project Cost: 532.00 Total Bank Financing: 100.00 Financing Gap: 0.00 Page 2 of 5
For Loans/Credits/Others Amount BORROWER/RECIPIENT 335.00 International Development Association (IDA) 100.00 The Global Fund to Fight AIDS, Tuberculosis & Malaria 97.00 Total 532.00 V. Implementation The Central Tuberculosis Division (CTD) of the Ministry of Health and Family Welfare (MoHFW) will ensure technical standards, planning and oversight of the project, while the implementation of TB services will be done by the state government health services under the National Health Mission. The project components include the following priorities: Component 1: New Strategies to reach more tuberculosis patients with earlier and more effective care in the public and private sectors. (a) Support to patients seeking care in the private sector (b) Expansion of urban TB services (c) Improvement in ease of access to diagnosis of drug-sensitive and drug-resistant TB (d) Leveraging of information technology especially for the public private engagement strategy (e) Improvement in epidemiological understanding of TB through monitoring, evaluations and research. Component 2: Scale-up and improve diagnosis and treatment of drug-resistant tuberculosis. (a) Increase in capacity to manage and deliver MDR-TB services (b) Expansion of MDR-TB diagnostic capacity for more accessible and better quality of care (c) Development of MDR-TB and XDR-TB treatment services. Component 3: Expand public tuberculosis services integrated with the primary health care system. (a) Development of program management capacity (b) Further integration with primary health care system and expansion of TB service delivery. The Overall Implementation Risk for the project is assessed to be Moderate in view of the design and challenges around the implementation of new/innovative activities; possible capacity constraints to implement new and challenging strategies; accountability risks associated with expanding support to patients in the private sector; anti-tb drug supply and quality; and delays in fiduciary management. These risks will be mitigated by regular engagement and consultation with stakeholders (including regular joint missions) as well as planned strengthening of procurement, quality assurance measures and capacity. The Central TB Division will also contract necessary technical support to mitigate these risks. RNTCP has adopted a Social Action Plan which outlines measures to ensure universal access to and utilization of TB services in alignment with the National Strategic Plan (2012-17). The Social Action Plan provides for continued implementation of the Tribal Action Plan (2005) with necessary improvements specified by the National Strategic Plan. Additionally, RNTCP will implement its Page 3 of 5
VI. Environment Assessment and Biomedical Waste Management Plan, which refers to Government of India s existing Biomedical Waste Management Rules, Guidelines for Airborne Infection Control, Infection Management and Environment Plan (IMEP) and Indian Public Health Standards (IPHS). Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No 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 VII. Contact point World Bank Contact: Patrick M. Mullen Title: Senior Health Specialist Tel: 5785+79291 Email: pmullen@worldbank.org Borrower/Client/Recipient Name: Republic of India Contact: Ms. Sigy Thomas Vaidhyan Title: Director (MI), DEA, Ministry of Finance, Govt. of India Tel: 91-11-23092247 Email: sigy.t.vaidhyan@gmail.com Implementing Agencies Name: Ministry of Health and Family Welfare Contact: Central TB Division Title: Deputy Director General Tel: 911123018126 Email: ddgtb@rntcp.org Page 4 of 5
VIII.For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop Page 5 of 5