Environmental and Social Management Framework
for the
Andhra Pradesh Health Systems Strengthening Project
Final Report
Volume -1: Main Report
February 2019
By
Strategic Planning and Innovations Unit (SPIU)
Department of Health, Medical and Family Welfare (DoHMFW)
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ABBREVIATIONS
AH Area Hospital
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
AP Andhra Pradesh
APPCB Andhra Pradesh Pollution Control Board
APTWD Andhra Pradesh Tribal Welfare Department
APVVP Andhra Pradesh Vaidya Vidhana Parishad
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
BMWM Bio-Medical Waste Management
BPL Below Poverty Line
CBMWTF Common Bio-Medical Waste Treatment Facility
CFM Community Forest Management
CH&FW Commissionerate of Health and Family Welfare
CHC Community Health Centre
CPCB Central Pollution Control Board, Govt. of India
DCHS District Coordinator of Hospital Services
DH District Hospital
DMHO District Medical and Health Officers
DoHFW Department of Healthand Family Welfare
DQC District Quality Consultant
DQM District Quality Manager
EA Environmental Assessment
EHR Electronic Health Record
EHS Environmental Health and Safety
ESMF Environmental and Social Management Framework
ETP Effluent Treatment Plan
ETP Effluent Treatment Plant
GAP Gender Action Plan
GoAP Government of Andhra Pradesh
GoI Government of India
HCF Health Care Facility
HDI Human Development Index
HDS Hospital Development Society
IMR Infant Mortality Ratio
IP Indigenous People
ITDA Integrated Tribal Development Agency
JFPC Joint Forest Protection Committees
JSY Janani Suraksha Yojana
LHV Leady Health Visitor
MCH Maternal and Child Health
MCP Mother and Child Protection
MMR Maternal Mortality Rate
MPDO Mandal Parishad Development Officers
MRO Mandal Revenue Officer
NCD Non-Communicable Diseases
NHM National Health Mission
NHSRC National Health Systems Resource Centre
ii
NQAS National Quality Assurance Standards
PA Protected Area
PDO Project Development Objectives
PESA The Panchayat (Extension to the Scheduled Areas) Act, 1996
PHC Primary Health Centre
PMMVY Pradhan Mantri Matritva Vandana Yojana
PMU Project Management Unit
PRI Panchayati Raj Institution
QA Quality Assurance SC Scheduled Cates
SC Sub-Centre
SERP Society for Elimination of Rural Poverty
SOP Standard Operating Procedure
SPIU Strategic Planning and Innovations Unit ST Scheduled Tribes
TDF Tribal Development Framework
TFR The Fertility Rate
TPPF Tribal Peoples Planning Framework
TRY Tribal Reform Yardstick
TSP Tribal Sub Plan
VHND Village Health Nutrition Day
VSS VanaSamrakshanaSamities
WHS Worker‟s Health and Safety
iii
TABLE OF CONTENT
EXECUTIVE SUMMARY............................................................................................................................... v
1 INTRODUCTION .................................................................................................................................... 1
1.1 A Brief Profile of Andhra Pradesh ..................................................................................................... 2
1.1.1 Socio-Economic Status ............................................................................................................. 2
1.2 Scheduled Tribes in Andhra Pradesh.................................................................................................. 5
1.3 Health Status in Andhra Pradesh ........................................................................................................ 6
1.4 Health Care Facilities (HCF) in Andhra Pradesh ................................................................................ 8
1.5 The Proposed Project ....................................................................................................................... 10
1.5.1 The Project Development Objectives....................................................................................... 10
1.5.2 Key Result Areas .................................................................................................................... 11
1.6 The Project Area .............................................................................................................................. 16
2 THE ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK(ESMF) .................... 18
2.1 Need for Environment and Social Management Framework (ESMF) ............................................... 18
2.2 Scope and Objectives of the ESMF .................................................................................................. 18
2.3 Methodology Adopted for ESMF Preparation .................................................................................. 19
3 ENVIRONMENTAL AND SOCIAL BASELINE ................................................................................ 21
3.1 Environment Profile of AP .............................................................................................................. 21
3.2 Physical and Cultural Resources in Andhra Pradesh ........................................................................ 26
3.3 Status of Biomedical Waste Management System in AP .................................................................. 26
3.3.1 Segregation and Collection of Waste ....................................................................................... 27
3.3.2 Storage and Transportation of Bio-medical Waste ................................................................... 27
3.3.3 Treatment and Disposal of Bio-medical Waste ........................................................................ 28
3.4 Current Practice of Infection Management in AP ............................................................................. 31
3.4.1 Worker‟s Health and Safety .................................................................................................... 32
3.5 Infrastructure Condition and Access ................................................................................................ 33
3.6 Current Information Education and Communication (IEC) Activity ................................................. 35
4 ENVIRONMENTAL AND SOCIAL POLICIES AND REGULATIONS .......................................... 39
4.1 Environmental Laws, Policies and Regulations ................................................................................ 39
4.2 Social Legal Framework .................................................................................................................. 46
4.3 World Bank Safeguard Policies ....................................................................................................... 49
4.4 Conclusion ...................................................................................................................................... 52
5 STAKEHOLDER CONSULTATIONS ................................................................................................ 53
5.1 Key Stakeholders ............................................................................................................................. 53
5.2 Stakeholder Consultation Process Adopted ...................................................................................... 53
5.3 Key Outcome of Stakeholder Consultations ..................................................................................... 56
6 ENVIRONMENTAL AND SOCIAL ASSESSMENT .......................................................................... 61
6.1 Environmental Risks and Impact ..................................................................................................... 61
6.2 Social Risk and Impact .................................................................................................................... 70
7 ENVIRONMENTAL MANAGEMENT PLAN .................................................................................... 76
7.1 The Process of Preparing Site Specific EMP .................................................................................... 76
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7.1.1 Screening of the Site Proposed Activities ................................................................................ 76
7.2 Key Environmental Risks and Potential Mitigation Measures .......................................................... 77
7.3 Environment Management Plan ....................................................................................................... 79
8 SOCIAL MANAGEMENT PLAN ........................................................................................................ 85
8.1 Key Social Risks Identified and Potential Mitigation Measures ....................................................... 85
8.2 Tribal (Indigenous People) Development Framework ...................................................................... 86
8.2.1 Socio-economic context of the state ........................................................................................ 86
8.2.2 Tribal Health Issues ................................................................................................................ 87
8.2.3 Tribal Reform Yardstick ......................................................................................................... 88
8.3 Inclusion Matrix .............................................................................................................................. 97
9 CITIZEN ENGAGEMENT AND GRIEVANCE REDRESS MECHANISM ................................... 104
9.1 Citizen Engagement and Outreach Strategies ................................................................................. 104
9.1.1 Hospital Development Societies (HDS) ................................................................................. 105
9.2 Grievance Redress Mechanism ...................................................................................................... 106
10 INSTIUTIONAL AND IMPELEMENTATION ARRANGEMENTS .............................................. 108
11 ESTIMATED BUDGET FOR IMPLEMENTING ESMF ................................................................. 111
11.1 Training Costs ............................................................................................................................... 111
11.2 Technical Costs For STP and ETP ................................................................................................. 112
11.3 CONSOLIDATED TOTAL COSTS .............................................................................................. 112
12 CONSULTATION AND DISCLOSURE ............................................................................................ 113
12.1 Consultation during the ESMF Preparation .................................................................................... 113
12.2 Disclosure ..................................................................................................................................... 113
ANNEXTURES
Annex 1: Environmental and Social Safeguard Screening Check List ...................................................... 115
Annex 2: Technical Specifications of DBPand ETP ................................................................................... 119
Annex3: Team Involved in Collection of Primary Data From Fied During ESMF preparation ............. 123
Annex 4: Questionnaire for Collection of Baseline Data ............................................................................ 125
Annex 5: Checklist for Stakeholder Consultations ..................................................................................... 130
Annex 6: Applicable Environmental Standards .......................................................................................... 132
Annex7: List of Monuments in Andhra Pradesh ........................................................................................ 137
Annex8: List of Protected Monuments in Andhra Pradesh ........................................................................ 143
Annex9: Minutes of the Disclosure Workshop on APHSSP ....................................................................... 150
v
EXECUTIVE SUMMARY
Background
1. The Government of Andhra Pradesh has over the years embarked on the journey to make
healthcare services accessible to every citizen of the state. The Department of Health and Family
Welfare (DoHFW) in this process have achieved considerable progress in enhanced healthcare service
delivery and quality with the embracing of new programs and health schemes together with adoption
of technologies. The department further plans to strengthens the health care services in the state and
with this in mind decided to leverage World Bank support to lend to the achievement of its health
sector vision by bringing in knowledge on performance-based financing, effectively targeting the
under-served and vulnerable population, and facilitating exchanges of experience with innovative
initiatives to address similar challenges with other Indian states and global best practices. It wants to
leverage the World Bank financing to scale-up initiatives that may otherwise not be replicated as
quickly with the objective of achieving the Sustainable development goals (SDGs).
The Project
2. The Project Development Objectives are to improve the quality of public health services,
enable patient-centred care and increase the utilization of integrated primary health care. Primary
health care in this context comprises MCH and NCD services provided at the PHC and SC level.
Primary health care in the state currently focuses on MCH services. The proposed operation will make
expand the scope of primary health care by including NCD screening, prevention and management at
the PHC and SC level.
3. The PDO will be measured through the key result indicators as below:
i. Increase in the number of CHCs and PHCs with quality certification (quality)
ii. Increase in the number of health facilities with an operational integrated online patient
management system (patient-centreed care)
iii. Of those citizens screened for non-communicable diseases, an increase in the percentage of
patients at risk who are actively managed at the subcentre or the primary health centre
(utilization)
iv. Increase in the percentage of pregnant women who receive full antenatal care (utilization)
4. The key program result areas identified are (i) Quality of Care, (ii) Comprehensive Primary
Health Care, and (iii) Empowering citizens to manage their healthcare.
Results Area 1 - Quality of Care: This results area will focus on improving the quality of
care in primary and secondary healthcare facilities, specifically, community health centres
(CHCs) and primary health centres (PHCs) through an accreditation approach. This will
involve strengthening existing health facility infrastructure and processes, as well as the
engagement of the private sector to support the achievement and maintenance of quality
service standards.
Among other activities, the NQAS accreditation of all facilities will be rolled out in a phased
manner with the objective of covering all 195 CHCs and 1147 PHCs over the five-year
project period. The first batch of 320 facilities have been selected with care to include at least
1 tribal or Vulnerable or geographically remote facility in each district to ensure that equity is
maintained for all sectors of population.
Results Area 2 – Integrated Primary Health Care: The primary focus of this results area
will be to provide integrated MCH and NCD health care at the primary level by expanding the
scope of services provided at PHCs and SCs to include NCD prevention, screening and
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management. Primary health care at present is largely limited to MCH services, with the
primary beneficiaries being women in the reproductive age group. This expanded scope and
outreach will be driven through innovative, technology-based solutions in partnership with
private sector providers.
Among other activities, an innovative technology-based approach to bring doctors closer to
the community and facilitate provision of NCD services at the SC level will also be
introduced. This will entail introducing tele-medicine services at the SC level. Private service
providers will be contracted to roll out this model of e-Subcentres (e-SC). The e-SC will
involve the establishment of a doctors‟ hub at the regional level with doctors dedicated for
tele-consultation at the SC level, a drug vending machine at the SC to dispense drugs based
on the doctor‟s prescription, multi-para monitoring equipment, and an information system
linked to an integrated e-health record system for patient management. The e-SC model will
be rolled out across approximately 6000 out of the 7507 SCs in the state, supported by the
project. Only urban and peri-urban SCs and SCs linked to the PHCs (called headquarter SCs)
will not be covered under this approach, as they have easy access to doctors.
Results Area 3 – Enabling patient-centred care: The focus under this results area will be on
using information technology and introducing policy reforms to enable patient centred care in
the state/public health system. The three key institutional measures that will be introduced to
facilitate this will include (i) the introduction of a unique ID based electronic health records
(EHR) system which will give patients access to their own health information and facilitate
their management through the public health system; (ii) a policy to enable patients access the
governments free drugs scheme at private pharmacies and not just government pharmacies;
and (ii) a system to capture patient reported experience and feed back to service improvement.
5. The proposed project aims to benefit the entire 53.6 million population of Andhra Pradesh as
it aims to strengthen the state public health system that is accessible to all. Focus will be on
strengthening the 7507 SCs, 1147 PHCs and 195 Community Health Centres across all 13 districts in
the State. The project will more specifically benefit patients with NCDs, as a key focus of the project
is expanding the scope of primary health services to include NCD prevention, screening and
management.
The Scope of the Environment and Social Management Framework (ESMF)
6. The primary objective of the project is to support Department of Health and family Welfare
(DoHFW), GoAP in improving the quality of public health services, enable patient-centred care and
increase the utilization of integrated primary health care in all districts of Andhra Pradesh. This will
include improving MCH and NCD services provided at the PHC and SC level. And, also expand the
scope of Primary health care in the state which is currently focuses on MCH services, to expand the
scope by including NCD screening, prevention and management at the PHC and SC level. As site
specific investments/ interventions are not known at each facility, an ESMF has been prepared to
guide investments such that they are environmentally and socially sound, and do not result in adverse
impacts.
7. Under the result area 1, the project also aims to also strengthen the biomedical waste
management system in the health care facilities in Andhra Pradesh. The nature of this project provides
tremendous opportunities to enhance the sanitation, hygiene and infection control and bio-medical and
other waste management systems and processes in the state to further promote sound public health
outcomes, while also ensuring that there are no adverse impacts to the environment. There is pressing
need to strengthen the capacity on waste management and infection control, ensure the availability of
human resources designated to waste management and strengthen the monitoring system to ensure
compliance with the Government of India's national regulations.
8. The primary objectives of ESMF is:
vii
To identify potential environmental and social (E&S) impacts of the activities undertaken
through the project.
To develop a simple and practical Environmental and Social Management Framework
(ESMF) that would be used by the project to mitigate adverse environmental and social
impacts of the supported activities.
Ensure compliance with applicable national and local legislations, regulations and policies
Ensure compliance with World Bank safeguard policies
Minimize the potential adverse impacts and maximize the potential positive impacts of the
proposed investments
Lay down the procedure for preparing investment specific environment and social
management plan
Methodology adopted for Preparation of ESMF
9. The ESMF has been prepared on the basis of environmental and social assessments which
involved gathering of data through both primary and secondary sources. This included consultations
with key stakeholders as well as desk research. The steps followed in developing the ESMF are
provided below:
i. Establishment of the social and environment baseline through desk research and study of the dimensions of the study area, describing the relevant physical, biological, and socioeconomic
conditions This also included desk research of similar bank operations to understand what
likely social and environmental impacts could be.
ii. Defining the legal / regulatory framework that will influence implementation of the proposed
projects and sub-projects and included review of national and state level acts and polices
applicable to proposed project. It also attempted to identify existing gaps in the current
implementation practices associated with the proposed project activities, so that they can be
addressed during implementation.
iii. Stakeholder Consultations has been carried out with all relevant stakeholders those who have
been identified through stakeholder analysis, these include government, communities, and
institutions. The consultation process has been carried out at two levels (district level and
health facility level. The objective of the consultation sessions is focused to improve the
project‟s interventionswith regard to environment and social management and to seek views
from the stakeholders on the environmental and social issues and the ways these could be
resolved. The procedure for conducting stakeholder and public consultations with relevant
consultation formats/ questionnaires/ checklists has been prepared and enclosed with the
ESMF,
iv. Identification the social and environmental impacts of the activities supported by the project.
This included identifying both positive and negative impacts to feed into development of
mitigation measures for any negative impacts.
v. Defining the mitigation methods to manage the social and environmental impacts - – this
included not only defining the measures required but also the training and capacity building
measures.
vi. Establishing the grievance redressal mechanism and citizen engagement plan (if any) in place
and establishing the grievance redressal mechanism, and citizen engagement plan suited to the
proposed project
vii. Defining the monitoring plan to oversee the implementation of social and environment
management and mitigation methods
viii. Preparing the gender action plan (GAP), and tribal development framework (TDF)
ix. Identifying the institutional capacity building and training requirements for implementing the
social and environment mitigation measures
viii
x. Preparing an estimated budget to undertake the provisions of the ESMF
10. While the secondary review included referring to a large set of data, publication, legislations,
government orders, and research articles, the primary data collection involved
Consultation with various Government departments and institutions including from
Department of Health and Family Welfare (DoHFW), Mission Director National Health
Mission, Andhra Pradesh VadiyaVidhan Parishad, State Quality Cell at DoHFW, Directorate
of Medical Education, APMSIDC, AP Tribal Welfare Department (APTWD), Andhra
Pradesh Pollution Control Board, and other state level institutions.
Consultation and collection of health facility data from a sample of HCF using questionnaire
on (i) Biomedical waste management, (ii) Infection control, and (iii) Social safeguard. This
included collection of data from about 211 HCFs across districts.
11. Based on the secondary review, primary data collection and consultations, the ESMF is
prepared detailing out various policies, guidelines and procedures that need to be integrated during the
planning, design and implementation cycle of the World Bank-funded project. The framework
describes the principles, objectives and approach to be followed for selecting, avoiding, minimizing
and/or mitigating the adverse environmental and social impacts that are likely to arise due to the
project.
12. An Environment and social assessment were conducted along with creation of environmental
and social baseline for the project and included information regarding environmental profile of state
including geographical, geophysical, climate, drainage, forests resources, protected areas such as
national parks and sanctuaries etc, and listed the physical and cultural resources as per the
Archaeological survey of India. The creation of baseline also involved primary data collection and
included collection of data from a total of 211 facilities (Sub Centres, PHCs, CHCs, AHs and DHs)
across 13 districts of Andhra Pradesh.
The Environment and Social Assessment
13. The state of Andhra Pradesh has about 5.3 percent of Scheduled Tribe (ST) population and
about 17.1 percent of Scheduled Caste (SC) population. The state also has Schedule-V areas as per
Constitution of India and has 9 ITDA areas across seven districts. For better health outcome the
project interventions need to be inclusive of caste, religion and gender.
14. There are four level of service delivery units based on the levels of care provided by these
units and includes in terms hierarchy of lowest to highest is (1) Sub‐Centres, (2) Primary Health
Centres, (3) Community Health Centres, and (4) District Hospitals. While, these HCFs provide
primary and secondary health care services, there are Teaching Hospitals attached to Medical/
Nursing Colleges and provides tertiary health care services. For the proposed project, the focus is
more at the primary care level. The district wise distribution of HCFs is presented in the Table below.
Table E1: Type of Health Care Facilities in Andhra Pradesh
Sl No. District CHC PHC SCs DH AH Teaching
Hospital
1 Vizianagaram 11 68 446 1 1 NA
2 Visakhapatnam 13 89 620 1 1 1
3 East Godavari 26 128 842 1 3 1
4 Krishna 12 88 600 1 2 1
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Table E1: Type of Health Care Facilities in Andhra Pradesh
Sl No. District CHC PHC SCs DH AH Teaching
Hospital
5 Chittoor 13 103 644 1 6 1
6 Kadapa 12 74 448 1 1 1
7 Srikakulam 15 80 465 1 2 1
8 West Godavari 14 91 637 1 3 NA
9 Anantapuram 15 88 586 1 2 1
10 Prakasam 14 90 526 1 3 1
11 Kurnool 18 87 543 1 1 1
12 Nellore 14 75 477 1 2 1
13 Guntur 17 86 680 1 2 1
Andhra Pradesh 194 1147 7514 13 29 11
Source: Commissioner of Health & Family Welfare, Andhra Pradesh, 2018
15. The primary study conducted across all districts and public health care facilities suggests
segregation and collection of medical waste practices is as per norms in District Hospitals (DH) and
lack marginally in Area Hospital (AH) and Community Health Centres (CHCs). However, it lacks
substantially in Primary Health Centre (PHC) and Sub-Centre (SC). Also, while there is separate
storage facility for BMW in large number of HCFs, the primary data suggests that the clearance of
waste takes more than 48 hours at majority of the times. While treatment of liquid waste before
discharge is certainly a concern across different types of facilities, there are reported incidence of
mixing of bio-medical waste into other wastes.
16. Treatment of liquid waste before discharge is a common concern across different types of
facilities, the APPCB is pursuing HCFs with more than 100 beds to provide Effluent Treatment Plant
(ETP) in the first phase of operations. However, there is need for instituting appropriate measures for
the facilities lower than 100 beds as well as for PHCs.
17. Overall the infection control measures are in place in each of the health care facilities with
mechanism for decontamination, hand washing, use of personal protective equipments, and handing
of sharps. These practices vary from different tiers of HCFs. While the District hospitals, Area
hospitals and CHC perform better on these indicators, the PHCs and SC requires further strengthening
on these areas.
18. The practice of worker‟s health and safety (WHS) measures are reported to be relatively
better in at District Hospital and Area Hospitals and reduces with hierarchy of the HCFs in Andhra
Pradesh. Table 16 below presents the status of various indicators on WHS across different type of
HCFs in Andhra Pradesh. This suggests the need for WHS in primary health care facilities.
19. In the state of Andhra Pradesh there are 11 CBMWTFs operational and catering to all 13
districts. These CBMWTF cater to both public and private HCFs in their respective area of operation.
While most of the District Hospital, Area Hospital, and CHCs are covered by the CBMWTF, the
primary data suggests only few PHCs being covered by the CBMWTF. Most of the PHCs and SCs
depend on in-situ treatment and disposal mechanism. Analysis of incineration capacity utilization of
these CBMWTFs suggest a maximum utilization of 38% Vishakhapatnam to minimum of 11% in
Prakasam district.
x
The World Bank Safeguard Policy Application
20. Apart from the national and state legislations and regulations, the key World Bank
Operational Policies triggered for the project to avoid, minimize or mitigate the adverse
environmental and social impacts, including protecting the rights of those likely to be affected or
marginalized by the proposed project is presented in the table below.
Table (E2): World Bank Policies
Safeguard Policies Applicable Explanation
Environmental
Assessment OP/BP 4.01 Yes
The project is considered as a Category B. OP 4.01 is
applicable as the project includes minor infrastructure
refurbishment at PHC and CHC level under the Results Area-
1. The project also supports health systems and service
augmentation measures, these interventions will result in
greater footfall at the facility level which will result in an
incremental increase in bio-medical and other wastes, and
risks arising from handling and disposal of healthcare wastes
and other products (clinical and infectious waste materials,
needles and sharps, and wastewater). This could lead to
adverse impacts to the environment and human health if not
managed appropriately. There are no potential large-scale,
significant or irreversible impacts associated with the proposed
project. The risks and impacts associated with minor civil
works for repair and rehabilitation will be localized and
temporary.
Performance Standards for
Private Sector Activities
OP/BP 4.03
No
Natural Habitats OP/BP
4.04 No
OP 4.04 is not triggered as the project will not finance any
interventions in natural habitats or that would adversely impact
natural habitats.
Forests OP/BP 4.36 No
OP 4.36 is not triggered for this project. The project will not
finance any interventions (health care centres including the
associated facilities such as access roads, deep burial pits) do
not impact forest areas and do not negatively affect local
wildlife and no conversion/degradation of forests is envisaged.
Pest Management OP 4.09 No
OP 4.09 is not triggered as the project will not finance or
promote the use of large scale/significant qualities of
pesticides or chemical pest control methods that would cause
adverse impacts to human health and the environment.
Physical Cultural
Resources OP/BP 4.11 Yes
OP 4.11 is triggered as a preventative measure. All minor civil
and renovation works will be restricted to already existing
HCF premises, and the project interventions will not impact
PCRs. However, in the event of unknown PCR within the area,
the ESMF includes measures for screening, avoiding and
managing impacts on these PCRs as well as chance-find
procedures in the event new resources are discovered during
project implementation.
Indigenous Peoples
OP/BP 4.10 Yes
Andhra Pradesh has nine districts that have been identified as
Schedule V areas. At the state level, ST population is
approximately 5%. Based on the current scope of result areas,
substantial engagement with ST/SC communities is foreseen.
An Environment and Social Management Framework will be
prepared to gauge issues of equity and inclusion w.r.t to access
xi
Table (E2): World Bank Policies
Safeguard Policies Applicable Explanation
and utilization of health services amongst vulnerable
communities. FPIC will carried out amongst disadvantaged
communities to identify social risks, capture the nuances of
inclusion and enhance citizen engagement mechanisms. The
ESMF will outline recommendations to be followed by the
Borrower to mitigate potential social risks. This is likely to
include preparation of a TDP.
Involuntary Resettlement
OP/BP 4.12 No
At this stage, no construction activities are envisaged under the
project. Hence, land acquisition/resettlement related issues
have been ruled out. However, to monitor application of the
policy through appraisal and implementation, a checklist will
be prepared to ensure that no instances of land acquisition
and/or encroachment are noticed within the project‟s scope.
This policy will be re-visited during appraisal.
Safety of Dams OP/BP
4.37 No
OP 4.37 is not triggered as the project will not construct any
new dam or carry out works on existing dams.
Projects on International
Waterways OP/BP 7.50 No
OP 7.50 is not triggered for this project as there are no
interventions planned/proposed that would impact
international waterways.
Projects in Disputed Areas
OP/BP 7.60 No
OP 7.60 is not triggered as the project is not proposed in any
disputed area
Environmental and Social Risk and Potential Mitigation Measures
21. The project is expected to impact positively on the health and socio-economic development of
the state. The project with the key objectives of achieving the three result areas viz. Quality of care,
Integrated Primary Health Care and enabling patient-centred care is expected to improve the
healthcare services through quality accredited facilities, extended reach with technology and patient
centric care initiatives and services. However, it is expected that there will be some environmental
risks and impact based on the numerous activities undertaken ranging from minor civil works
(refurbishment) to bio-medical waste management (e-wastes, liquid and solid wastes), infection
control and workers health safety concerns. The incorporation of environmental concerns during
planning, designing, implementation and monitoring stages by formulating Environmental
Management Guidelines/ Standard Operating Procedures (SOPs) and building capacities within the
institutional structure and the concerned agencies will be important to ensure compliance and to
enhance positive impacts and mitigate negative impacts in the development of the proposed project
activities.
22. The key environmental risks and potential mitigation measures is presented in the table
below.
Table (E3): Environmental Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
Result Area 1: Quality of care
1 1. Inadequate waste disposal
techniques
2. Risks of hazardous solid
1. Building capacity of HCF staffs on bio-medical
waste management – both solid and liquid. All
waste to be managed in accordance to the principles
of the biomedical waste management rules, 2016,
xii
Table (E3): Environmental Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
and liquid waste
3. Potential contamination
to soil and water
4. Condemnation of expired
drugs
and their implementation guidelines.
2. Impmentation of Checklist and ESMP for all
healthcare renovations.
3. Have SOPs for management of e-waste, plastics,
pharmaceuticals, and hazardous waste (x-ray
developer) both for staff and service provider.
4. ETP to be scaled up to CHC level which are going
to take up NQAS certification. For smaller facilities
with no sewerage connection, suitable
arrangements such as liquid disinfection, septic
tank and soak pit will be introduced.
5. No-run-off from site should allow to get into rivers
or accumulate at site or nearby areas
6. SoP for notification and disposal of expired
medicine.
7. Training calendar for healthcare staffs on BMW
management.
Result Area 2: Integrated Primary Health care
2 1. Continued supply of
electricity to facilities
required for e- e-sub-
centres
2. Safety standards to be
ensured for installation of
solar panels
3. Potential contamination to
soil and water from
Management of
laboratory waste – both
liquid waste and reagent
disposal
1. Installation of solar panels for uninterrupted power
supply. Design specifications to be made in such a
manner that incorporates adequate space for solar
panels as well as installation of battery and wiring.
2. SOP to be prepared for upkeep and O&M of
equipments installed.
3. Training module to be to be prepared for BMW
management, and training calendar to be prepared
for training of all MLPs on BMW management.
4. SOP to be prepared for laboratory waste
management and ETP to be built in each of the
laboratory to ensure adequate treatment of liquid
waste.
5. Training to be provided to laboratory staffs –
training calendar to be prepared
Result Area 3: Enabling patient-centred care
3 1. e-waste generation due to
enhanced services to be
monitored by HDS
1. SOPs for e-waste management need to be prepared.
2. Monitoring checklist to be prepared for HDS to
monitor the facility with environment risk
perspective.
3. Disclosure of adherence to various SOP to be made
public through health bulletins.
xiii
Table (E4): Social Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
Result Area 1: Quality of care
1 1. Accreditation process
involves improvement in
overall infrastructure and
services including
sanitation facilities for both
men and women.
2. The service contracts will
help improve services.
However, it is important to
ensure that it is inclusive
and non-discriminatory.
1. Screening of HCF where repair and renovations is
planned to rule out any adverse social impact.
2. Access to HCF for disabled population to be ensured.
3. The service contracts should include the clause on (a)
non-discrimination of services with respect to caste,
creed and gender, (b) prohibiting use of child labour,
(c) wage parity among men and women
Result Area 2: Integrated Primary Health care
2 1. ITDA, tribal areas and
difficult to reach areas may
be missed out.
2. Socio-cultural barriers
prevent women from
coming out for screening.
3. There is little awareness
about NCDs and cervical
cancer among women
population.
1. Special focus to be given to tribal and difficult to
reach areas. Geographical connectivity and social
diversity need to be included as variables in the
proposed plans. Sub-centre in ITDA/ tribal and hard
to reach areas to be prioritized.
2. Adequate IEC material to ensure awareness and
knowledge of services and their access, availability
and continuity of care among the target beneficiaries
including in the tribal areas with culturally
appropriate manner and in the language understood
by them.
3. To ensure adequate screening of women for NCDs
and cervical cancers, awareness generation and
behavior change activities will be conducted to
address socio-cultural barriers.
4. Capacity building of Village Health Committee
(VHC) may be useful to help to undertaking
discussions at the community level. And, the project
outreach strategy already plans to take up this and
proposes a STEP survey to assess NCD risk factors
and barriers under the project.
5. The project has planned the capacity building of
VHCs and SERP women‟s group is part of the core
project activities.
Result Area 3: Enabling patient-centred care
3 1. Patient data security could
become an issue if not
given priority.
2. Probability of mal practices
during drug dispensing.
1. Adequate data security to be ensured to safeguard the
privacy of the patient data such as AES encryption
and gateway control.
2. Adequate safeguard clause to be built into
empaneling pharmacies from any malpractice.
xiv
Table (E4): Social Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
3. Non- inclusion of women,
tribal, vulnerable groups in
the HDS.
4. Technologically
handicapped - Awareness
and knowledge towards
importance of feedback and
how to operate these kiosks
will be important.
3. Representative inclusion of all stakeholders in the
community, viz. women, tribal, vulnerable groups in
the HDS
4. IEC activities to create awareness and knowledge to
the citizens regarding access to their patients record.
Environment and Social Management Plan
23. Based on the above risks and potential mitigation measures, a stage wise Environment
Management Plan (EMP) and Social Management Plan (SMP) were prepared and presented in
Chapter-7 and Chapter-8 of the ESMF report and further details out the application of key mitigation
measures as mentioned above along with responsibilities and monitoring measures. As part of the
EMP and SMP, screening of the HCF where any repair or renovation being planned is proposed with
detail process of conducting the screening as per Annex-1 of this report. The screening and the EMP
also refers to key guidance to specific standards as per Annex-2 and Annex-6 of the report. The
Environment Action Plan and the Social Inclusion Matrix for the project is presented below.
xv
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
Planning Phase
General Site and Worker
Safety
Notification and
Worker Safety
i. The local communities/ public has been notified of the
works through appropriate notification and/or at publicly
accessible sites
ii. All legally required permits (to include not limited to
resource use, dumping, sanitary inspection permit have
been acquired for construction and/or rehabilitation
iii. All work will be carried out in a safe and disciplined
manner designed to the site to minimize impacts on
neighboring residents and environment.
iv. Workers‟ PPE will comply with international good
practice (hardhats, as needed masks and safety glasses,
harnesses and safety boots)
v. Appropriate signposting of the sites will inform workers
of key rules and regulations to follow.
vi. Sanitation facilities shall be provided for all site
workers.
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document.
Site level
monitoring by
HCF In-charge
Physical and Cultural
Properties
Historic sites i. If the HCF is located very close to such a structure, or
located in a designated historic district, notify and obtain
approval/permits from ASI/local authorities and address
all construction activities in line with local and national
legislation
ii. Ensure that chance finds provision is activated in case
any artifact is encountered in excavation
Screening will be
conducted by the
HCF In-charge.
DMHO to facilitate in
getting the respective
permissions
By District Level
Safeguard In
charge i.e. DQM
Implementation phase
General Rehabilitation and
/small civil works
Activities
Air quality /
Dust
i. Keep demolition debris in controlled area and spray with
water mist to reduce debris dust
ii. Suppress dust during pneumatic drilling/wall destruction
by ongoing water spraying and/or installing dust screen
enclosures at site
iii. Keep surrounding environment (sidewalks, roads) free
of debris to minimize dust
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
xvi
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
iv. There will be no open burning of construction / waste
material at the site
v. There will be no excessive idling of construction
vehicles at sites
Noise i. Construction noise will be limited to restricted times
agreed to in the permit.
ii. During operations the engine covers of generators, air
compressors and other powered mechanical equipment
should be closed, and equipment placed as far away
from residential areas as possible.
iii. Materials such as sand, cement, or other fine particles
should be kept properly covered. And moistened with
sprays of water.
iv. Unpaved, dusty roads should compact and then wet
periodically.
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
Drainage i. The worksite site will establish appropriate erosion and
sediment control measures to prevent sediment from
moving off site and causing excessive turbidity in
nearby streams and rivers.
ii. Keep all drains clear of silt and debris
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
Construction
waste
management
i. Waste collection and disposal pathways and sites will be
identified for all major waste types expected from works
activities.
ii. wastes will be separated from general refuse, organic,
liquid and chemical wastes by on-site sorting and stored
in appropriate containers.
iii. Construction waste will be collected and disposed
properly by licensed collectors
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
Toxic Materials Toxic /
hazardous waste
management
i. There will be no waste dumping in adjacent areas to the
HCF.
ii. Temporarily storage on site of all hazardous or toxic
HCF in charge/
Hospital
Administrator
District Level
Safeguard In
charge i.e. DQM,
xvii
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
substances will be in safe containers labeled with details
of composition, properties and handling information
iii. The containers of hazardous substances should be placed
in leak-proof container to prevent spillage and leaching.
iv. The wastes are transported by specially licensed carriers
and disposed in a licensed facility
v. Paints with toxic ingredients or solvents or lead-based
paints will not be used
and SPIU
Asbestos
Management
i. If asbestos is located on the project site, the following
provisions will apply
ii. Mark clearly as hazardous material
iii. When possible, the asbestos will be appropriately
contained and sealed to minimize exposure.
iv. The asbestos prior to removal (if removal is necessary)
will be treated with a wetting agent to minimize asbestos
dust Asbestos will be handled and disposed by skilled
and experienced professionals
v. If waste asbestos material is to be stored temporarily, the
wastes should be securely enclosed inside closed
containments and marked appropriately
vi. The removed asbestos will not be reused and will follow
the IS 11768 (1986) Recommendations for disposal of
asbestos waste material and CPCB Hazardous waste
rules, 2016.
HCF in charge/
Hospital
Administrator
District Level
Safeguard In
charge i.e. DQM,
and SPIU
Operations Phase
Disposal of Bio-medical
Waste
i. In compliance with national regulations the
rehabilitated health care facilities should include
sufficient infrastructure for medical waste handling and
disposal; this includes and not limited to:
a. Special facilities for segregated healthcare waste
(including soiled instruments “sharps”, and human
tissue or fluids) from other waste disposal:
Clinical waste: yellow bags and containers
HCF in charge/
Hospital
Administrator at the
facility level;
District Level
Safeguard In
chargei.e. DQM and
District Level
Safeguard In
charge i.e. DQM,
and SPIU
xviii
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
Sharps – Special puncture resistant
containers/boxes
Domestic waste (non-organic): black bags and
containers
b. Appropriate storage facilities for medical waste are
in place
c. If the activity includes facility-based disposal, such
as burial pits, the appropriate disposal options are
in place and operational.
ii. Develop SOPs for managing bio-medical and other
wastes within healthcare facilities (HCF) to ensure the
proper standard operating procedures based on the
NQAS accreditation standards are followed and
implemented.
iii. Build capacity of healthcare workers to manage
medical facilities and ensure good technical support in
implementing effective waste management system.
SPIU for capacity
building
SPIU for SOPs
Wastewater Treatment
Systems
Water Quality i. The approach to handling wastewater from larger HCFs
(installation or reconstruction) must be approved by a
qualified engineer.
ii. Before being discharged into receiving waters, effluents
from individual wastewater systems must be treated to
meet the minimal quality criteria set out by national
guidelines/ WBG guidelines on effluent quality and
wastewater treatment
iii. Monitoring of new wastewater systems (before/after)
will be carried out.
HCF in charge/
Hospital
Administrator and
District Level
Safeguard In charge
i.e. DQM
SPIU
Community Health and
Safety
Exposure to
hazardous health
care waste
i. Avoid mixing general health care waste with hazardous
health care waste to reduce disposal costs;
ii. Segregate waste containing mercury for special
disposal Management of mercury containing products
and associated waste should be conducted as per the
CPCB guidelines.
iii. Segregate waste with a high content of heavy metals
HCF in charge/
Hospital
Administrator
District Level
Safeguard In
charge i.e. DQM
and SPIU
xix
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
(e.g. arsenic, lead) to avoid entry into wastewater
streams
iv. Transport waste to storage areas on designated trolleys
/carts, which should be cleaned and disinfected
regularly
v. Separate residual chemicals from containers and
remove to leak-proof containers resistant to chemical
corrosion effects. Return unused chemicals to supplier
vi. Facilities should have permits for disposal of general
chemical waste (e.g. sugars, amino acids, salts) to
sewer systems.
vii. Larger quantities of chemical wastes are to be
transported to appropriate facilities for disposal, and
not be encapsulated or landfilled.
viii. Aerosol cans and other gas containers should be
segregated to avoid disposal via incineration and
related explosion hazard.
ix. HCFs should have impermeable floor with drainage
and designed for cleaning / disinfection.
x. Treatment Facilities receiving hazardous health care
waste should have all applicable permits and capacity
to handle specific types of health care waste.
Worker Health and Safety i. Development of Facility policies, procedures and
protocols (including SOPs), and awareness on infection
control policies, supervision and management
ii. Trainings should be provided to all healthcare and
sanitation workers on use of PPE, handling of infectious
materials and wastes (e. g. blood).
iii. The NQAS accreditation process support
implementation of the IMEP guidelines, project will
ensure the standardization of necessary procedures and
protocols (SOPs) will be carried out to safeguard the
workers in the facility.
Safeguard Consultant
at SPIU
SPIU
xx
TABLE (E5): ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
Management hygiene
within HCF
i. Hygiene promotion is important for health care workers
and patients. They should be given constant reminders
and information of the importance of infection control
such as handwashing points.
ii. Toilets should be cleaned whenever they are dirty, and at
least twice per day, with a disinfectant used on all
exposed surfaces.
iii. Water points, with soap and adequate drainage, should
be provided for all toilets, and their use should be
actively encouraged
iv. Toilets should be designed, built and maintained so that
they are hygienic and acceptable to use and do not
become centres for disease transmission. This includes
measures control fly and mosquito breeding, and a
regularly monitored cleaning schedule.
v. Posters and other visual information should be used to
promote infection control among healthcare workers and
patients.
HCH in charge District Level
Safeguard In
charge i.e. DQM
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Result Area 1: Quality of Care
Indicator 1: Increase in
the number of PHCs and
CHCs have more than 70
percent quality score,
sufficient to seeking
national certification,
supported to improve
quality and monitor
sustain quality.
1. Assessment of quality gaps undertaken by facility
and DoHFW staff
2. Training of the PHC and CHC Staff
3. Fill HR gaps
4. Minor infrastructure* enhancements
5. Minor furniture, equipment, other goods procured
6. Service contract to establish and maintain Quality
Tracking Dashboard System
7. PHCs and CHCs report to the system
Overall this set of activities will help
improve the quality of basic infrastructure
facilities in HCFs especially at sub-
centres and PHCs.
The project does not support any large-
scale construction and restricted to minor
repair and renovations and is restricted to
existing footprint of the HCF and hence
1. Screening of HCF using checklist as
per Annex-1 (PHC and sub-centres) for
ensuring the delivery of basic
infrastructure facilities especially in
tribal districts where repair and
renovations is planned. Cumulative
progress on delivery of basic
infrastructure primary health care
facilities to be reported by districts.
xxi
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
8. Service providers contracted and incentivized to
improve in clinical and non-clinical gaps
9. Maintenance and improvement of quality
monitored and supported
*infrastructure refers to minor building repairs and
modifications
no additional land is required.
2. Monitoring of HCFs (screening
checklist applicable) to rule-out
adverse impacts related to involuntary
resettlement of squatters and non-title
holders on government land.
Indicator 2: Increase in
number of CHCs and
PHCs NQAS certified
1. DoHFW administration organizes for review by
the national authorities as per the NQAS guidelines
(http://qi.nhsrcindia.org/national-quality-assurance-
standards)
Accreditation process involves
improvement in overall infrastructure and
services including sanitation facilities for
both men and women.
1. Access to HCF for disabled
population to be ensured.
2. In line with existing DoHFW policy,
a targeted approach to certify 13
PHCs (yearly) located in tribal
districts will be adopted.
Indicator 3: Increase in
coverage of core services
provided through
performance -based
contracts at CHCs and the
performance of those
services.
1. Sanitation service provider contracts
2. Biomedical equipment maintenance contract
3. Laboratory service contract
4. Tele-radiology service contracts
5. Patient satisfaction/ experience survey contract
The service contracts will help improve
services. However, it is important to
ensure that it is inclusive and non-
discriminatory.
3. The service contracts should include
the clause on (a) non-discrimination
of services with respect to caste, creed
and gender, (b) prohibiting use of
child labour, (c) wage parity among
men and women
4. Regular health-check-ups for contract
workers.
Indicator 4: Improved
pharmaceutical stock
management system at
the PHCs and CHCs.
1. Upgrading/ replacing of the supply chain software
with modern functionality
2. Management and operating of supply chain
3. Facility pharmacists incentivized to enter
information into the supply chain software
No specific social risk associated with
this activity, however building capacity
of personnel at geographically difficult to
reach PHCs (located in tribal/rural areas)
needs to be prioritized.
Result Area 2: Integrated Primary Health Care
Indicator 1: Increase in
the number of functional
e-sub-centres, including
with solar power energy
solution where
1. Service contract with teleconsultation provide and
operate the following: refurbish the facility, provide
the diagnostic and drug vending machine, computer
with internet and telemedicine solution, and doctors‟
hub
These set of activities will enhance the
capacity of Sub-centre. Sub-centre being
the first point of contact for health care
services it will improve quality of health
care in state.
5. Preparation of an annual action plan
to identify and target sub-centres
located in tribal areas for upgradation.
This is as per existing best practice
adopted by DoHFW.
xxii
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
appropriate and model
evaluated.
2. ANM staff work at the Sub-centres
3. Expanded list of essential drugs provided to sub-
centres
4. Policy decision will be taken about the extension
of solar power to subcentres
5. Installation, operation and maintenance of the
solar power at subcentres according to policy
decision
In line with existing DoHFW policy, a
positive targeting approach will be
adopted to upgrade e-sub-centres in tribal
and ITDA areas.
Training and capacity building of
personnel for e-sub centres located in
tribal and ITDA areas.
6. A robust awareness and IEC plan is
crucial for achieving increased usage
of public health facilities which
especially among tribal population
and other vulnerable groups. This will
also help achieving the key outcome
at the project level. It will be useful to
the understand perceptions at the
community level and designing tailor-
made campaigns (based on literacy
levels, household incomes, etc.) that
encourage usage of health facilities
amongst men and women.
Indicator 2: Increase in
the number of subcentres
with trained mid-level
service providers (BSC
nurses)
1. Recruitment and training of the MLPs
2. MLPs placed and working at subcentres
While this will enhance service quality, it
is important that the ITDA, other tribal
areas and difficult to reach areas are also
prioritized as they need the services the
most.
7. Preparation of an annual action plan
to a) map blocks/agencies that need to
be prioritized and b) identify and
target sub-centres located in
tribal/ITDA areas for upgradation.
This is as per existing best practice
adopted by DoHFW.
Indicator 3: Of those
citizens screened, an
increase in the number of
patients at high-risk* for
NCDs (hypertension and
diabetes) who are actively
managed at the first point
of contact-level
(subcentre, PHC)
1. Screening of Population by subcentre or PHC
staff
2. Laboratory/diagnostic tests undertaken
3. Risk-level and Treatment plan determined by
subcentre or PHC staff
4. Medication provided
5. Necessary studies, surveys contracted
While women tend to access services
geared towards maternal care and child
care, they often delay treatment seeking
behavior for diseases such as diabetes,
hypertension, breast, cervical and oral
cancers etc. This can be for a variety of
reasons including well-documented time-
poverty, double burden of unpaid
domestic work and patriarchal norms so
that women often put the health of their
children and male members of the family
at a higher priority than their own health.,
8. Preparation of a behavior change and
communication (BCC) strategy that is
interactive in nature. The objective
will be to address misconceptions and
spread awareness about NCDs such as
cervical cancer.
9. Capacity building of VHC may be
useful to help to undertaking
discussions at the community level.
And, the project outreach strategy
already plans to take up this and
proposes a STEP survey to assess
NCD risk factors and barriers under
xxiii
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
the project.
Indicator 4: Increase in
the percentage of women
screened in target age
group for cervical cancer
at subcentres or PHC
facilities
1. Screening of women by subcentre or PHC staff
2. VIA testing
3. Women at risk referred
4. Follow-up undertaken to ensure referral happens
5. Outreach activities enhanced
There is little awareness about cervical
cancer among the target population
including women. Also, women take laid
back approach when it comes to
prioritizing their health needs.
10. Preparation of a behavior change and
communication (BCC) strategy that is
interactive in nature. The objective
will be to address misconceptions and
spread awareness about NCDs such as
cervical cancer.
11. Preparation of a detailed action plan
to build capacity of Village Health
Committees to effectively discuss and
disseminate information on NCDs and
menstrual hygiene. The project has
planned the capacity building of
VHCs and SERP women‟s group is
part of the core project activities.
Indicator 5: Increase in
the percentage of women
that are registered in the
first trimester receive full
ANC care
1. ASHA identify the women and ANM registers
the pregnant women
2. IFA, TT1, blood test provided
3. Conduct ANC at the mobile medical units
4. Conducting of the Village Health Nutrition Days
by ANMs
There is a possibility that women from
tribal/rural areas do-not access full ANC
care.
12. Mapping of low performing areas.
13. Annual action plan to improve
delivery of full ANC care in tribal and
ITDA areas.
Result Area 3: Enabling patient-centred care
Indicator 1: Increase in
the number of facilities
actively using an
integrated online patient
management system
1. Service contract with the provider of the
integrated online patient management system
executed (HMIS solution, hosting of electronic
model record (EMR) data in state data centre,
equipment for EMR recording, establishment of
medical transcription hub, training of health care
Patient data security could become an
issue if not given priority.
14. Adequate data security to be ensured
to safeguard the privacy of the patient
data.
xxiv
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
staff for operating the patient management system)
Indicator 2: Increase in
the percentage of creation
of EMR for IPD and
chronic OPD cases
registered in the facilities
indicated in DLI 1
1. Service contract with the provider of the
integrated online patient management system
executed
2. Staff at the facilities are entering and using the
EMR
3. Facilities identify nodal officers for
implementation
This will help enhance proper follow-up
care with patient records. It has no
specific social risk with these set of
activities.
Indicator 3: Increase in
the percentage of patients
accessing information
(web-based, application-
based) through PHRMS
for which the EMR has
been created as per DLI2
1. Service contract with the provider of the
integrated online patient management system
executed
2. Facilities supported with an online patient
management system
3. Patients are informed about the system through
SMS
4. Information education activities are undertaken
for raising public awareness
No specific social risk associated to these
activities.
15. Awareness and knowledge to access
patients record and at an appropriate
time needs attention.
Indicator 4: Increase in
the number of empanelled
private pharmacies able
to dispense state financed
drugs to patients
1. Policy decision
2. Contracts with private providers
3. Information education activities are undertaken
for raising public awareness
While this will be help patients for easy
access to drugs, adequate attention to be
put in for ensuring ma practice of any
kind.
16. Adequate safeguard clause to be built
into empaneling pharmacies from any
malpractice.
17. Adequate monitoring mechanism to
be built towards this.
Indicator 5: Hospital
Development Society
(HDS) provide regular
monitoring and undertake
actions to improve quality
1. Administrative effort by the staff to communicate
with the communities and functional operation of
the Hospital Development Societies
2. Increase in monthly conducting of Hospital
Development Society (HDS) meetings
3. HDS members review patient experience
feedback, funds availability and activities to be
undertaken to fill the gaps identified during
As per existing norms, HDS should also
have representation from community and
should include women representation and
members of tribal and vulnerable groups.
18. HDS formation should be instructed
with respect to inclusion of women
and vulnerable group population
including tribal population where
applicable.
xxv
TABLE (E6): SOCIAL INCLUSION MATRIX
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
meetings
4. Minutes of meetings are recorded
Indicator 6: System
developed and rolled out
to measure and report
patient report experience
in a standardized and
confidential way.
1. Service contract with the provider of the
integrated online patient management system,
Kiosks installed and operated
2. Information on patient reported experience
collected in a credible way
3. Administrative effort by the DoHFW staff to
analyze and share analysis through health bulletins
4. IEC activities undertaken
Awareness and knowledge towards
importance of feedback and how to
operate these kiosks will be important.
19. Creation of a central, project level
Grievance Redressal Mechanism to a)
consolidate different complaint
numbers used by hospitals b) to
monitor the nature and pattern of
complaints across districts.
20. Adapting the IEC material received
under NHM to a) make it available in
local dialect b) using audio-visuals to
create awareness and disseminate
information.
xxvi
Institutional Arrangements and Monitoring Mechanism
24. The project follows the existing DoHFW governance and management structure for
implementation of the proposed project. This includes: (i) an Executive Committee (EC) under the
Chairmanship of the Principal Secretary, DoHFW; and (ii) the Strategic Planning and Innovations
Unit (SPIU) designated as Project Management Unit (PMU) under the leadership of the Mission
Director (MD), National Health Mission (NHM), to plan, coordinate, implement and monitor project
activities.The SPIU will consist of staff specialized in areas relevant to the core needs of the project
including a consultant for the Environmental and Social Safeguards. S/he will be assisted by District
level safeguard In-charge i.e. District Quality Manager in each district for ESMF implementation.
Further, at the HCF level, the administrative coordinator of the district will support screening of the
E&S checklist.
25. The monitoring of ESMF implementation will also be done as per the parameters set under
EMP and SMP and will be integrated into the regular monitoring of the project will be by the
responsible agencies/bodies/units for each of the key result areas. A monitoring report for the ESMF
implementation will also be part of quarterly, six monthly and annual review.
Estimated Budget for Implementing ESMF
26. Based on the preliminary estimation, a necessary budget has bene prepared for
implementation of ESMF. This enables preparedness for financial requirements and allows early
planning and appropriate budgeting. The indicative budget for ESMF will be integrated into the
component budget for implementation as per the activities planned. A total of INR 93.8crores
(equivalent to USD 13.5 million) is proposed for ESMF.
Disclosure
27. The findings of the draft ESMF was disclosed by the department in the disclosure workshop
organized on 12th
February 2019at Vijayawada. The ESMF report was finalized after incorporating
relevant comments and suggestions from the stakeholders. The final report of the ESMF will be
disclosed on the website of the Department of Health and Family Welfare GoAP and at World Bank‟s
external website prior to appraisal.
1
ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK FOR THE
ANDHRA PRADESH HEALTH SYSTEMS STRENGTHENING PROJECT
1 INTRODUCTION
1. The Government of Andhra Pradesh has over the years embarked on the journey to make
healthcare services accessible to every citizen of the state. The Department of Health and Family
Welfare (DoHFW) in this process have achieved considerable progress in enhanced healthcare service
delivery and quality with the embracing of new programs and health schemes together with adoption
of technologies. The department further plans to strengthens the health care services in the state and
with this in mind decided to leverage World Bank support to lend to the achievement of its health
sector vision by bringing in knowledge on performance-based financing, effectively targeting the
under-served and vulnerable population, and facilitating exchanges of experience with innovative
initiatives to address similar challenges with other Indian states and global best practices. It wants to
leverage the World Bank financing to scale-up initiatives that may otherwise not be replicated as
quickly with the objective of achieving the Sustainable development goals (SDGs).
2. The one problem statement that the department discovered over the years was the gap in the
reach of the medical consultancy services to remote areas where sub-centres exist. The challenge lay
in the limited availability of qualified doctors at those sub-centres. A patient who visits the sub-
centres seeking primary care is unable to avail of the service at the first point of contact. Therefore,
the patient is forced to travel to Primary Health Care centres (PHCs) or Community Health Centres
(CHCs) for the primary care that can be addressed at the sub-centre level. The Department in its effort
to address the problem statement has conceptualized a project which would increase the reach of
medical consultancy to those deprived earlier. The main objective of the project is the refurbishment
of the existing sub-centres across the state into e-subcentres. The e-subcentre as a concept would be
the conversion of sub-centres into comprehensive primary health care centres. The e-subcentres would
be equipped with Telemedicine infrastructure, drug dispensing machine, multipara monitor
equipment, consumables for certain defined laboratory tests for increased coverage of care services.
The e-subcentres would be connected to a central Medical Hub where a team of qualified doctors
shall provide tele consultancy over the network. The Auxiliary Nurse Midwife (ANM) staff stationed
at the subcentre would assist the tele consultancy process along with the services of dispensing of
common drugs and performing basic tests based on the tele consultancy sessions. This concept of
comprehensive primary health care using telemedicine technology would strengthen the capability of
the sub-centres in delivery of primary care services. Briefly the reach of quality healthcare with the
use of technology would ensure services at the first point of contact for patients who were deprived of
the same earlier.
3. The next revolutionary step being defined by the Health Department is the vision to empower
every citizen of the state to monitor their health electronically. The Government proposed a project
for the creation of electronic health record for every citizen visiting the public healthcare facilities
ranging from Teaching hospitals to Primary Health Centres. The Healthcare facilities would be
equipped with the technologies (both hardware and software) to enable the creation of electronic
health record for the patients. The medical history created for each episode pertaining to a patient is
stored electronically with highest level of encryption. The medical records are accessible by
authenticated users of the Government, healthcare staffs, doctors which would enable enhanced
healthcare services to every patient. This would also empower the government to monitor the level of
services being received at the individual level and ensures that no one is deprived of any services
entitled through National and State level health schemes.
4. The quality parameter of public health facilities is of high importance when the need for the
strengthening of the healthcare system is aimed at. This would boost the confidence of citizens in the
public health facilities once again when the private healthcare facilities are increasing their presence
2
in the state. The project aimed at achieving quality of care for the primary and secondary healthcare
facilities is being undertaken by the department. The objective would be to provide accreditation with
National Quality Assurance Standards (NQAS) to every primary and secondary healthcare facilities
established in the state.
1.1 A Brief Profile of Andhra Pradesh
5. The reorganized state of Andhra Pradesh was formed after the enactment of the Andhra
Pradesh Reorganization Act, 2014 because of bifurcation of the erstwhile state of united Andhra
Pradesh on 2nd
June 2014. Situated in the south-east of the country, it is the eighth-largest state in
India, covering an area of 162,970 sq.km. Andhra Pradesh has the second longest coastline of 974 km
among the states of India, after Gujarat. The state is bordered by Telangana in the north-west,
Chhattisgarh and Odisha in the north-east, Karnataka in the west, Tamil Nadu in the south, and to the
east lies the Bay of Bengal. The small enclave of Yanam, a district of Puducherry, lies to the south of
Kakinada in the Godavari delta on the eastern side of the state.
6. The state has varied topography ranging from the hills of Eastern Ghats to the shores of Bay
of Bengal that supports varied ecosystems, rich diversity of flora and fauna. There are two main rivers
namely, Krishna and Godavari, that flow through the state. The seacoast of the state extends along the
Bay of Bengal from Srikakulam to Nellore district. The plains to the east of Eastern Ghats form the
Eastern coastal plains. The coastal plains are for the most part of delta regions formed by the
Godavari, Krishna, and Penner Rivers
7. The state is made up of the two major regions of Rayalaseema, in the inland southwestern part
of the state covering Chittoor, Kurnool, YSR Kadapa, Anantapuram districts, and Coastal Andhra to
the east and northeast, covering Srikakulam, Vizianagaram, Visakhapatnam, East Godavari, West
Godavari, Krishna, Guntur, Prakasam and Nellore districts.
Figure-1: Districts and Regions of Andhra Pradesh
1.1.1 Socio-Economic Status
8. As per the 2011 census, Andhra Pradesh (AP) is the tenth most populous state, with 49.39
million inhabitants 4.08% of India‟s population) and a population density of 304 persons per Sq.km.
with sex ratio of 996 female per thousand males (higher than the national average of 943 female per
1000 males). There are 12.7 million households in the State and the average size of the household is
Rayalaseema
Coastal Andhra
3
3.95. AP is largely rural with 70.42% of the population living in rural areas and 29.58% living in
urban areas. The largest city in Andhra Pradesh is Visakhapatnam.
9. The overall literacy of the state is 67.41% compare the national average of 73%. The male
literacy is 74.8% and female literacy is 60% against the national average of 80.9% and 64.6%
respectively. In Andhra Pradesh, West Godavari district has the highest literacy rate of 74.6% and
Vizianagaram district has the lowest literacy rate with 58.9%.
Table -1: Demographic Details
Sl. No. District Sex Ratio % Literacy % Male
Literacy
% Female
Literacy
1 Srikakulam 1015 61.7% 71.6% 52.1%
2 Vizianagaram 1019 58.9% 68.1% 49.9%
3 Visakhapatnam 1006 66.9% 74.6% 59.3%
4 East Godavari 1006 71.0% 74.5% 67.5%
5 West Godavari 1004 74.6% 77.9% 71.4%
6 Krishna 992 73.7% 78.3% 69.2%
7 Guntur 1003 67.4% 74.8% 60.1%
8 Prakasam 981 63.1% 72.9% 53.1%
9 Nellore 985 68.9% 75.7% 62.0%
10 Y.S.R. Kadapa 985 67.3% 77.8% 56.8%
11 Kurnool 988 60.0% 70.1% 49.8%
12 Anantapur 977 63.6% 73.0% 54.0%
13 Chittoor 997 71.5% 79.8% 63.3%
Andhra Pradesh 996 67.4% 74.8% 60.0%
Source: Census, 2011
10. Of the total population Scheduled Cates (SC) constitute 17.10% and Scheduled Tribes (ST)
5.33%. Prakasam district has the highest SC population with 23.3% while Vishakhapatnam has the
lowest proportion of 7.7% Scheduled case population. Similarly, Visakhapatnam district has the
largest concentration of ST population with 14.4%, while Kurnool district has only about 2.04% ST
population. Out of the total scheduled tribes in Andhra Pradesh, approximately 50% reside in four
districts Vishakhapatnam (23%), East Godavari (11%), Nellore (10%) and Vizianagaram (9%).
Table-2: Proportion of Scheduled Caste and Scheduled Tribe
Sl. No. District Total Population
(in '000)
% SC % ST
1 Srikakulam 2,703 9.5% 6.1%
2 Vizianagaram 2,344 10.6% 10.0%
3 Visakhapatnam 4,291 7.7% 14.4%
4
Table-2: Proportion of Scheduled Caste and Scheduled Tribe
Sl. No. District Total Population
(in '000)
% SC % ST
4 East Godavari 5,154 18.3% 4.1%
5 West Godavari 3,937 20.6% 2.8%
6 Krishna 4,517 19.3% 2.9%
7 Guntur 4,888 19.6% 5.1%
8 Prakasam 3,397 23.2% 4.4%
9 Nellore 2,964 22.5% 9.7%
10 Y.S.R. Kadapa 2,882 16.2% 2.6%
11 Kurnool 4,053 18.2% 2.0%
12 Anantapur 4,081 14.3% 3.8%
13 Chittoor 4,174 18.8% 3.8%
Andhra Pradesh 49,387 17.1% 5.3%
Source: Census, 2011
11. According to the Socio Economic and Caste Census 2011, there are 13 districts in the State of
Andhra Pradesh, 670 tehsils, 14,514 gram-panchayats/ police stations. The total number of villages in
Andhra Pradesh are 17,521 and additionally there are 94 towns. The number of rural households is 9.1
million (70.4%) and urban households is 3.6 million (29.6%). While Vishakhapatnam is the most
urbanised district with 47.5% urban population, Srikakulam district is the least urbanised district with
16.2% urban population. The total workers account for 46.5% population compare to national average
of 39.8%.
Table-3: Rural Urban Distribution and Worker Participation
Sl. No. District % Rural
Population
% Urban
Population
Total
Workers
1 Srikakulam 83.8% 16.2% 47.7%
2 Vizianagaram 79.1% 20.9% 49.4%
3 Visakhapatnam 52.5% 47.5% 44.0%
4 East Godavari 74.5% 25.5% 40.6%
5 West Godavari 79.5% 20.5% 45.0%
6 Krishna 59.2% 40.8% 45.4%
7 Guntur 66.2% 33.8% 48.7%
8 Prakasam 80.4% 19.6% 50.1%
9 Nellore 71.1% 28.9% 44.4%
10 Y.S.R. Kadapa 66.0% 34.0% 45.8%
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Table-3: Rural Urban Distribution and Worker Participation
Sl. No. District % Rural
Population
% Urban
Population
Total
Workers
11 Kurnool 71.6% 28.4% 50.1%
12 Anantapur 71.9% 28.1% 49.9%
13 Chittoor 70.5% 29.5% 46.3%
Andhra Pradesh 70.4% 29.6% 46.5%
Source: Census, 2011
1.2 Scheduled Tribes in Andhra Pradesh
12. Scheduled Tribes are amongst the most marginalized and vulnerable segments of the society.
Literacy rate among the males and females among Scheduled Tribes at the state level is respectively
47.66% and 26.11%. The aggregate percentage of literacy rate for schedule tribes is around 37%
which is significantly lower than literacy rate of 67.35% at the state level. The STs have registered a
sex ratio of 1009 which is higher than the state average (997).
13. The list of Scheduled Tribes of Andhra Pradesh as per the Scheduled Castes and Scheduled
Tribes Orders (Amendment) Act, 2002 is provided in Table 4.
Table 4: List of Scheduled Tribes of Andhra Pradesh
S.No. Name of Tribe S.No. Name of Tribe
(a) List of Scheduled Tribes in AP
1 Andh, Sadhu Andh 18 Koya, DoliKoya, Gutta Koya, Kammara,
Koya, MusaraKoya, Oddi Koya, Pattidi,
Koya, Rajah, RashaKoya, Lingadhari,
Koya (ordinary), KottuKoya, Bhine and
Koya, Rajkoya
2 Bagata 19 Kulia
3 Bhil 20 Malis
4 Chenchu 21 Manna Dhora
5 Gadabas, Bodo Gadaba, GutobGadaba,
KallayiGadaba, ParangiGadaba,
KatheraGadaba, KapuGadaba
22 MukhaDhora, NookaDhora
6 Gond, Naikpod, Rajgond, Koitur 23 Nayaks
7 Goudu 24 Pardhan
8 Hill Reddis 25 Porja, Parangiperja
9 Jatapus 26 Reddidora
10 Kammara 27 Rona, Rena
11 Kattunayakan 28 Savaras, KapuSavaras, MaliyaSavaras,
KhuttoSavaras
12 Kolam 29 Sugalis, Lambadis, Banjara
13 Konda Dhoras, Kubi 30 Valmik
6
Table 4: List of Scheduled Tribes of Andhra Pradesh
S.No. Name of Tribe S.No. Name of Tribe
14 Konda Kapus 31 Yenadis, ChellaYenadi, KappalaYenadi,
ManchiYenadi, ReddiYenadi
15 Kondareddis 32 Yerukulas, Koracha, Dabba Yerukula,
KunchapuriYerukula, UppuYerukula
16 Kondhs, Kodi, Kodhu, DesayaKondhs,
DongriaKondhs, KuttiyaKondhs, Tikiria,
Kondhs, YenityKondhs, Kuvinga
33 Nakkala, Kurvikaran
17 Kotia, Bentho Oriya, Bartika, Dulia,
Holva, Sanrona, Sidhopaiko
34 Dhulia
(b) List of Particularly Vulnerable Tribal Groups (PTVGs) in AP
1 Chenchu
2 Gadabas, Bodo Gadaba, GutobGadaba, KallayiGadaba, ParangiGadaba, KatheraGadaba,
KapuGadaba
3 Kondareddis
4 Kondhs, Kodi, Kodhu, DesayaKondhs, DongriaKondhs, KuttiyaKondhs, TikiriaKondhs,
YenityKondhs, Kuvinga
5 Porja
6 Savara
Source: Census of India 2011
Fifth Scheduled Area in Andhra Pradesh
14. The tribal dominated areas in Andhra Pradesh have been declared as “Scheduled Areas” as
specified by the fifth schedule of the constitution. The list of Scheduled Areas in Andhra Pradesh is
provided below1:
Visakhapatnam Agency area (excluding the areas comprised in the villages of Agency
Lakshmipuram, Chidikada, Konkasingi, Kumarapuram, Krishnadevipeta, Pichigantikothagudem,
Golugondapeta, Gunupudi, Gummudukonda, Sarabhupalapatnam, Vadurupalli, Pedajaggampeta)
Sarabhupathi Agraharam, Ramachandrarajupeta Agraharam, and Kondavatipudi Agraharam in
Visakhapatnam district.
East Godwari Agency area (excluding the area comprised in the village of Ramachandrapuram
including its hamlet Purushothapatnam in the East Godavari district)
West Godawari Agency area in West Godavari district.
Data includes the Submergence of Sch. Villages of 7 mandals from Khamman district to AP
State (as per Reorganization Act, 2014): Nellipapaka, Kunavaram, Chintoor and V.R.Puram in
East Godavari district and Burgampad, Kukunoor and Valaipadu in West Godavari district.
1.3 Health Status in Andhra Pradesh
15. The infant mortality rate in Andhra Pradesh in NFHS-4 is estimated at 35 deaths before the
age of one year per 1,000 live births. The under-five mortality rate for Andhra Pradesh is 41 deaths
per 1,000 live births. Infant mortality rates are higher in rural areas (40 per 1,000 live births)
compared to urban areas (20 per 1,000 live births)2. The maternal mortality rate (MMR) is reported to
1http://aptribes.gov.in/pdfs/table9.pdf
2 NFHS-4, 2015-16
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be 74 per 100,000 live births3. The Birth Rate is 16.4 compared to Death rate of 6.8 per 1,000
population. The average life expectancy at birth in Andhra Pradesh is 68.4 years for male and 72.1
years for female4. The fertility rate (TFR) in Andhra Pradesh is 1.8 children per woman. The fertility
in urban areas is 1.5 compared the 2.0 in rural areas.
16. In Andhra Pradesh, among mothers who gave birth in the last five years preceding the NFHS-
4 survey, 97% received antenatal care (ANC) for their last birth from a health professional (91% from
a doctor and 7% from an auxiliary nurse midwife (ANM), lady health visitor (LHV), nurse, or
midwife). Also, among mothers who gave birth in the five years preceding the NFHS-4 survey, 95%
registered the pregnancy for the most recent live birth, and among the registered pregnancies, 93%
received a Mother and Child Protection Card (MCP Card). About 76 percent of the women received
four or more antenatal care during the pregnancy with highest in Krishna district (88 percent) and
lowest in Guntur district (68 percent). About 92 percent of births take place in a health facility (mostly
a private facility) and only eight percent take place at home. Institutional births are more common
among women who have 12 or more years of schooling and women who are having their first birth
(NFHS-4).
17. NCDs in the State constitute 59.7 percent of the disease burden, while communicable,
maternal, neonatal and nutritional diseases constitute 27 percent and about 13.3 percent is from
injuries. In Andhra Pradesh, which is facing an epidemiological transition, NCD prevalence is higher
among men than women, therefore the lack of access to NCD care at primary level is likely to have
significant implications for health outcomes in the state5.
Figure 2: Prevalence of Diseases Among Men and Women in Andhra Pradesh
3https://niti.gov.in/content/maternal-mortality-ratio-mmr-100000-live-births
4 National Health Profile, 2018
5http://www.healthdata.org/sites/default/files/files/Andhra_Pradesh_-_Disease_Burden_Profile%5B1%5D.pdf
8
Source: The India State-Level Disease Burden Initiative. ICMR, PHFI and IHME, 2017. Available at
http://www.healthdata.org/sites/default/files/files/Andhra_Pradesh_-_Disease_Burden_Profile%5B1%5D.pdf
18. According to NFHS-4 survey, about 2.39% women and 3.16% men in the age group of 15-49
reported to have diabetes. The prevalence of hypertension among men in the age group of 15-49 is
somewhat higher than in women (18% among men compared to 13% among women), however, the
prevalence of any heart disease is slightly higher among women i.e. 1.4% compared to 1.35% among
men. Also, about 3% of women in the age group of 15-49 in Andhra Pradesh have high blood glucose
levels, and 5 percent have very high blood glucose levels, compared to 4% and 6% of men in the age
group of 15-49 have high and very high blood glucose levels. The cancer is the least common, with
95 women per 100,000 and 193 men per 100,000 reportedly suffering from cancer. In Andhra
Pradesh, about 34% of women have undergone an examination of the cervix, 5% have ever undergone
a breast examination, and 13% have ever undergone an examination of the oral cavity (NFHS-4).
1.4 Health Care Facilities (HCF) in Andhra Pradesh
19. There are four level of service delivery units based on the levels of care provided by these
units and includes in terms hierarchy of lowest to highest is (1) Sub‐Centres, (2) Primary Health
Centres, (3) Community Health Centres, and (4) District Hospitals. While, these HCFs provide
primary and secondary health care services, there are Teaching Hospitals attached to Medical/
Nursing Colleges and also provides tertiary health care services. The district wise distribution of
these HCFs is presented in the Table below.
Table 5: Type of Health Care Facilities in Andhra Pradesh
Sl No. District CHC PHC SCs DH AH Teaching
Hospital
1 Vizianagaram 11 68 446 1 1 NA
2 Visakhapatnam 13 89 620 1 1 1
3 East Godavari 26 128 842 1 3 1
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Table 5: Type of Health Care Facilities in Andhra Pradesh
Sl No. District CHC PHC SCs DH AH Teaching
Hospital
4 Krishna 12 88 600 1 2 1
5 Chittoor 13 103 644 1 6 1
6 Kadapa 12 74 448 1 1 1
7 Srikakulam 15 80 465 1 2 1
8 West Godavari 14 91 637 1 3 NA
9 Anantapuram 15 88 586 1 2 1
10 Prakasam 14 90 526 1 3 1
11 Kurnool 18 87 543 1 1 1
12 Nellore 14 75 477 1 2 1
13 Guntur 17 86 680 1 2 1
Andhra Pradesh 194 1147 7514 13 29 11
Source: Commissioner of Health & Family Welfare, Andhra Pradesh, 2018
20. Sub-Centre: Sub-centre is the first contact point between the primary health care system and
the community. As per the government norms, there is one sub‐centre for every 5,000 people in plain
areas and for every 3,000 people in non‐plain areas, e.g. hilly and tribal areas. These health services
include: antenatal, natal and postnatal care, immunization, prevention of malnutrition and common
childhood diseases, family planning counselling and services. They also provide drugs, free of cost,
for minor ailments such as diarrhoea, fever, worm infestation etc.
21. Primary Health Centres (PHC): The primary health centre is a rung above the sub‐centre in
the three‐tier health system in the state. It is a basic health care unit that provides integrated curative
and preventive health care to the population primarily in the rural areas, with emphasis on preventive
aspects of health care. The primary health centre, along with the sub‐centres, are designed to provide
more effective coverage to the rural population on the basis of one primary health centre for every
30,000 people in plain areas and one for every 20,000 people in hilly and tribal areas. Primary health
centres are the main service delivery units of rural health services, often the first main stop for health
services from a qualified doctor in the public sector for the sick. These health centres act as the first
referral unit to those who are directly reported by or referred from sub‐centres for curative and
preventive health care. Every primary health centre has 4–6 indoor beds for patients and it acts as a
referral unit for 6 sub‐centres.
22. Community Health Centres (CHC): These are the First Referral Units (FRUs) and form the
secondary level of health care provision. The community health centres are designed to provide
referral health care for cases from the primary health centres and for those patients in need of
specialist care who approach the centre directly. There are four primary health centres under each
community health centre, whereas each community health centre caters to approximately 120,000
people in plain areas and 80,000 people in tribal and hilly areas. The community health centres are
30‐bedded hospitals that provide specialist care in surgery and paediatrics, curative medicine,
obstetrics and gynaecology.
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23. District Hospitals: The district hospital functions as a secondary level of health care which
provides curative, preventive and promotive healthcare services to the people in the district. Every
district hospital is linked with other health service delivery units such as the sub‐district or sub-
divisional hospitals/ area hospitals, community health centres, primary health centres and sub‐centres.
The district hospitals cater to the people living in both urban areas, such as the district headquarters,
towns and adjoining areas, as well as the rural areas of the district. The district hospital works not
only as a curative centre but also as an interface with the institutions external to it, including referring
patients to other tertiary care centres such as medical college hospitals and other institutions for
specialized care including those controlled by non‐government and private voluntary health
organization.
1.5 The Proposed Project
24. The State ranks eighth out of twenty-one large states in India on overall health performance
on a National Health Index, which is a weighted composite of indicators in three domains (a) health
outcomes; (b) governance and information; and (c) key inputs and processes. It ranks a slightly higher
seventh on the same index when it comes to annual incremental change in performance indicating that
it is not only better than the national average but is also improving rapidly on health performance. The
state has also allocated 5 percent of its total public expenditure on health, which is higher than the
national average of 3.9 percent. In terms of share of GDP, at 1.1 percent, it is however comparable to
the national figure of approximately 1.15 percent of GDP on health. It has also clearly articulated its
health sector goals in its vision document – Sunrise Andhra Pradesh - Vision 2029, as achieving a
Human Development Index (HDI) of 0.9 and Healthy Adjusted Life Expectancy (HALE) of 64 years
by 2029, a gain of 0.4 points in HDI and 6 years in HALE from 2015. There have been significant
declines in maternal and infant mortality rates and an increase in service coverage in Andhra Pradesh
over the last decade. While the treatment at higher level facilities becomes the automatic response of
the health system, as primary level facilities are neither trained nor geared to carry out preventive,
promotive care or management of these chronic diseases. The result is a response that focuses on
treatment rather than prevention, early detection and management. Additionally, as NCD screening
and care is currently only available at secondary level and above, it often results in poorer access,
especially by men as accessing care could mean wage loss.
25. In spite of the economic progress the State is still a distance from achieving global
Sustainable Development Goals (SDGs) for health and from being the best performing state in India.
Its Maternal Mortality Ratio (MMR) is 74 per 100,000 live births, lower than the national average of
130 but much higher than its neighbouring State Kerala (46 per 100,000 live births). Similarly, Infant
Mortality Ratio (IMR) is 35 per 1000 live births, better than the national average of 40.7 but much
poorer than the 5.6 IMR of Kerala. The state is yet to introduce a comprehensive primary health care
program that covers both maternal and child health (MCH) and NCD services, actualizing the concept
of health and wellness necessary to achieve the SDG target 3.4 on NCDs. Thus, the State is at a stage
where it is making progress, but needs to innovate, consolidate and strengthen its systems to increase
its pace of achievement.
26. A basic review of the health system points to some gap areas, which if addressed, have the
potential of improving the health services and contribute to better health outcomes. And it is in this
context, the proposed project is being designed to address some of the key challenges above.
1.5.1 The Project Development Objectives
27. The Project Development Objectives are to improve the quality of public health services,
enable patient-centred care and increase the utilization of integrated primary health care.
28. Primary health care in this context comprises MCH and NCD services provided at the PHC
and SC level. Primary health care in the state currently focuses on MCH services. The proposed
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operation will make expand the scope of primary health care by including NCD screening, prevention
and management at the PHC and SC level.
29. The PDO will be measured through the key result indicators as below:
v. Increase in the number of CHCs and PHCs with quality certification (quality)
vi. Increase in the number of health facilities with an operational integrated online patient
management system (patient-centreed care)
vii. Of those citizens screened for non-communicable diseases, an increase in the percentage of
patients at risk who are actively managed at the subcenter or the primary health centre
(utilization)
viii. Increase in the percentage of pregnant women who receive full antenatal care (utilization)
1.5.2 Key Result Areas
30. The key program result areas identified are (i) Quality of Care, (ii) Comprehensive Primary
Health Care, and (iii) Empowering citizens to manage their healthcare.
31. Results Area 1 - Quality of Care: This results area will focus on improving the quality of
care in primary and secondary healthcare facilities, specifically, community health centres (CHCs)
and primary health centres (PHCs) through an accreditation approach. This will involve strengthening
existing health facility infrastructure and processes, as well as the engagement of the private sector to
support the achievement and maintenance of quality service standards.
32. In line with the States strategy, the project will aim to achieve the National Quality Assurance
Standards (NQAS) or accreditation for secondary and primary level facilities. The NQAS are quality
assurance standards developed by the National Health Systems Resource Centre (NHSRC),
Government of India for public health facilities and measure quality through eight broad areas, which
include service provision, patient rights, inputs, support services, clinical care, infection control,
quality management and outcome. Efforts to achieve NQAS accreditation will include (i) facility level
quality gap assessments; (ii) development and implementation of a quality action plan that will
include actions such as capacity building of health facility staff on clinical protocol and quality
checklists and decision support tools, equipment and minor upgradation works, quality assurance
(QA) teams at the facility, etc.; (iii) periodic assessments by the QA teams to track progress towards
achievement of benchmarks; and (iv) an external assessment to certify attainment of NQAS.
33. A key approach to address some of the quality gaps will be to contract or purchase services
from private providers that are better placed to provide these services. This includes clinical and non-
clinical or ancillary services such as sanitation and bio-medical waste management, diagnostic
services, tele-radiology, medical equipment maintenance, among others, which are critical in ensuring
efficient and quality service provision. This approach has already been successfully implemented in
the state for tertiary level facilities. For example, patient satisfaction for facility sanitation levels are
as high as 95 percent (as recorded through the RTGS) for facilities with sanitation service contracts.
The project will support the state roll out this approach to secondary level facilities and where
relevant to primary level facilities. In addition, it will support streamlining the service contracts as
performance-based contracts, adopting global best practices.
34. The NQAS accreditation of all facilities will be rolled out in a phased manner with the
objective of covering all 195 CHCs and 1147 PHCs over the five-year project period. The first batch
of 320 facilities have been selected with care to include at least 1 tribal or Vulnerable or
geographically remote facility in each district to ensure that equity is maintained for all sectors of
population. The State Quality team will be responsible for this component of the project.
35. Results Area 2 – Integrated Primary Health Care: The primary focus of this results area
will be to provide integrated MCH and NCD health care at the primary level by expanding the scope
12
of services provided at PHCs and SCs to include NCD prevention, screening and management.
Primary health care at present is largely limited to MCH services, with the primary beneficiaries being
women in the reproductive age group. This expanded scope and outreach will be driven through
innovative, technology-based solutions in partnership with private sector providers.
36. In terms of the scope of NCD services at PHCs and SCs, emphasis will be on screening,
identification of those „at risk‟ and subsequent management of the disease as per defined clinical
protocols. For women, there will be a more active screening approach, with all women above 30 years
being screened for diabetes, hypertension, breast, cervical and oral cancer, thyroid and vision by the
Auxiliary Nurse Midwife (ANM) at the SC and PHC level. The screening will be through mobile
medical units (run by a contracted service provider) as well as during regular visits to the PHCs and
SCs. For men, screening for diabetes, hypertension, oral, prostate, lung, gastro-intestinal cancer and
vision will be introduced at the PHC, delivered through a male health worker or doctor. A cadre of
trained mid-level service providers (MLPs) will also be recruited, trained and placed at the SC level to
facilitate integrated service provision.
37. To ensure screening is complemented by effective management of NCDs, clinical protocols
will be developed, and health staff trained on the same. Tools and systems to support management
will also be put in place. This will include (i) a mobile phone-based application to remind patients on
drug compliance and support them manage their disease; and (ii) a patient tracking system which
tracks uptake of drugs and follow-on diagnostics by patients to monitor their compliance to treatment.
Patients flagged by the system as not complying to management protocols will be followed up by
health workers (ASHAs and ANMs) during their outreach visits.
38. An innovative technology-based approach to bring doctors closer to the community and
facilitate provision of NCD services at the SC level will also be introduced. This will entail
introducing tele-medicine services at the SC level. Private service providers will be contracted to roll
out this model of e-Subcentres (e-SC). The e-SC will involve the establishment of a doctors‟ hub at
the regional level with doctors dedicated for tele-consultation at the SC level, a drug vending machine
at the SC to dispense drugs based on the doctor‟s prescription, multi-para monitoring equipment, and
an information system linked to an integrated e-health record system for patient management. The
service provider will also be responsible for ensuring maintenance and refurbishment of the SC as
needed. ANMs at the SC will be trained to facilitate the tele-consultations, support patients access
drugs from the vending machine, measure basic health parameters and enter patient data on the online
e-health record system.
39. As this e-SC model will require uninterrupted power supply to be fully operational and
optimally utilized, an assessment of power supply in all facilities will be carried out. Facilities without
access to uninterrupted power supply through the grid will be provided alternate solar electricity
options with backup storage capacity. The e-SC model will be rolled out across approximately 6000
out of the 7507 SCs in the state, supported by the project. Only urban and peri-urban SCs and SCs
linked to the PHCs (called headquarter SCs) will not be covered under this approach, as they have
easy access to doctors.
40. Efforts will also be made to educate and create awareness among the community about
screening, prevention and management of NCDs. This will be led by the health facility development
committees (HDCs) who will through appropriate signage and periodic camps in the community
highlight the provision of integrated MCH and NCD services at the PHCs and SCs. The HDCs,
through the ANMs will also facilitate the orientation of village level women self-help groups
federations under the Society for Elimination of Rural Poverty (SERP), Andhra Pradesh on the same.
In addition to service provision, the mobile medical units will also visit SCs in tribal and remote
locations on designated days to create awareness on NCD prevention, screening and management.
41. Interventions under this results area are expected to lead to a transformational redesign of
primary health care in the State and bring doctors and drugs closer to the community. It will reduce
13
the distance travelled by patients to access health care, reduce out of pocket expenditures and increase
utilization of primary health care services contributing to better health outcomes. It will also reduce
the increasing burden on higher level facilities for ailments that can easily be treated at the primary
level and strengthen referral systems ensuring better management of patients within the healthcare
system. In other words, it will strengthen the health systems ability to address the changing disease
burden of the state, or more specifically, the increasing burden of NCDs while continuing to focus on
the unfinished MCH agenda.
42. Results Area 3 – Enabling patient-centred care: The focus under this results area will be on
using information technology and introducing policy reforms to enable patient centred care in the
state/public health system. The three key institutional measures that will be introduced to facilitate
this will include (i) the introduction of a unique ID based electronic health records (EHR) system
which will give patients access to their own health information and facilitate their management
through the public health system; (ii) a policy to enable patients access the governments free drugs
scheme at private pharmacies and not just government pharmacies; and (ii) a system to capture patient
reported experience and feed back to service improvement.
43. The introduction of an online patient management or EHR system will empower citizens by
giving them online access to their health records that can be referred to by any public health facility
that the patient visits by using their unique ID. It will also enable health staff (doctor and nurses) to
provide better diagnosis, treatment, referral and management through the health system, improving
their responsiveness and decision making for patient care. In introducing such an integrated individual
electronic health records (EHR) system, lessons will be drawn from global experience and the system
will be introduced first for in-patient and chronic disease patients in a manner that does not increase
doctors‟ workload in terms of data entry.
44. A service contracting approach will be adopted for designing and managing this system. The
service contract will include the development of the necessary software, health service and
management modules, hardware, connectivity and maintenance. It will also include technology that
enables automatic transcription of diagnosis and prescriptions from manual forms filled by doctors.
The system will be rolled out in a phased manner starting with district hospitals and will be rolled out
down to the SC level over a period of 18 months.
45. Additionally, a key element of patient-centeredness is making services more accessible to
patients. Drugs for chronic patients not only constitute one of the major health expenses for
households, but also requires repeat visits to pharmacies. Benefits from the Government‟s free drug
scheme is only possible at Government pharmacies, which is often inconvenient for patients who have
to travel distances to access these reducing significantly their benefit. Thus, to address this key
constraint of chronic out-patients (primarily patients with NCDs) who need to buy drugs on a periodic
basis, the State will introduce a policy to empanel private pharmacies to dispense NCD-related drugs
free-of-charge to patients. The pharmacies will subsequently be reimbursed by the government under
the state‟s free drugs scheme. This will support patients who will be able to access NCD-related drugs
from private pharmacies closer to their home. A system to operationalize this policy reform will be
rolled out during the project period.
46. Emphasis under the project will also be placed on the establishment of a patient satisfaction
and feedback system to assess a patient‟s overall health facility experience across all facilities from
district hospitals to SCs. Analysis of data from this mechanism will be used to strengthen overall
service delivery as well as provide facility specific feedback to the HDCs. The monthly patient
satisfaction scores will be displayed at the facility by the HDCs, both acknowledging the feedback
received and making the facility accountable for improvement.
14
47. Summary of project financed activities is as below.
Table 6: Summary of Project Indicators and Activities
Project Indicator Main Activities
Result Area 1: Quality of Care
Indicator 1: Increase in the number of
PHCs and CHCs have more than
70 percent quality score, sufficient
to seeking national certification,
supported to improve quality and
monitor sustain quality.
1. Assessment of quality gaps undertaken by facility and
DoHFW staff
2. Training of the PHC and CHC Staff
3. Fill HR gaps
4. Minor infrastructure* enhancements
5. Minor furniture, equipment, other goods procured
6. Service contract to establish and maintain Quality
Tracking Dashboard System
7. PHCs and CHCs report to the system
8. Service providers contracted and incentivized to
improve in clinical and non-clinical gaps
9. Maintenance and improvement of quality monitored
and supported
*infrastructure refers to minor building repairs and
modifications
Indicator 2: Increase in number of
CHCs and PHCs NQAS certified
1. DoHFW administration organizes for review by the
national authorities
Indicator 3: Increase in coverage of
core services provided through
performance -based contracts at
CHCs and the performance of those
services.
1. Sanitation service provider contracts
2. Biomedical equipment maintenance contract
3. Laboratory service contract
4. Tele-radiology service contracts
5. Patient satisfaction/ experience survey contract
Indicator 4: Improved pharmaceutical
stock management system at the
PHCs and CHCs.
1. Upgrading/ replacing of the supply chain software
with modern functionality
2. Management and operating of supply chain
3. Facility pharmacists incentivized to enter information
into the supply chain software
Result Area 2: Integrated Primary Health Care
Indicator 1: Increase in the number of
functional e-sub-centres, including
with solar power energy solution
where appropriate and model
evaluated.
1. Service contract with teleconsultation provide and
operate the following: refurbish the facility, provide
the diagnostic and drug vending machine, computer
with internet and telemedicine solution, and doctors‟
hub
2. ANM staff work at the Sub-centres
3. Expanded list of essential drugs provided to sub-
centres
4. Policy decision will be taken about the extension of
solar power to subcentres
5. Installation, operation and maintenance of the solar
power at subcentres according to policy decision
15
Table 6: Summary of Project Indicators and Activities
Project Indicator Main Activities
Indicator 2: Increase in the number of
subcentres with trained mid-level
service providers (BSC nurses)
1. Recruitment and training of the MLPs
2. MLPs placed and working at subcentres
Indicator 3: Of those citizens screened,
an increase in the number of
patients at high-risk* for NCDs
(hypertension and diabetes) who
are actively managed at the first
point of contact-level (subcentre,
PHC)
1. Screening of Population by subcentre or PHC staff
2. Laboratory/diagnostic tests undertaken
3. Risk-level and Treatment plan determined by
subcentre or PHC staff
4. Medication provided
5. Necessary studies, surveys contracted
Indicator 4: Increase in the percentage
of women screened in target age
group for cervical cancer at
subcentres or PHC facilities
1. Screening of women by subcentre or PHC staff
2. VIA testing
3. Women at risk referred
4. Follow-up undertaken to ensure referral happens
5. Outreach activities enhanced
Indicator 5: Increase in the percentage
of women that are registered in the
first trimester receive full ANC
care
1. ASHA identify the women and ANM registers the
pregnant women
2. IFA, TT1, blood test provided
3. Conduct ANC at the mobile medical units
4. Conducting of the Village Health Nutrition Days by
ANMs
Result Area 3: Enabling patient-centreed care
Indicator 1: Increase in the number of
facilities actively using an
integrated online patient
management system
1. Service contract with the provider of the integrated
online patient management system executed (HMIS
solution, hosting of electronic model record (EMR)
data in state data centre, equipment for EMR
recording, establishment of medical transcription
hub, training of health care staff for operating the
patient management system)
Indicator 2: Increase in the percentage
of creation of EMR for IPD and
chronic OPD cases registered in the
facilities indicated in DLI 1
1. Service contract with the provider of the integrated
online patient management system executed
2. Staff at the facilities are entering and using the EMR
3. Facilities identify nodal officers for implementation
Indicator 3: Increase in the percentage
of patients accessing information
(web-based, application-based)
through PHRMS for which the
EMR has been created as per DLI2
1. Service contract with the provider of the integrated
online patient management system executed
2. Facilities supported with an online patient
management system
3. Patients are informed about the system through SMS
4. Information education activities are undertaken for
16
Table 6: Summary of Project Indicators and Activities
Project Indicator Main Activities
raising public awareness
Indicator 4: Increase in the number of
empaneled private pharmacies able
to dispense state financed drugs to
patients
1. Policy decision
2. Contracts with private providers
3. Information education activities are undertaken for
raising public awareness
Indicator 5: Hospital Development
Society (HDS) provide regular
monitoring and undertake actions
to improve quality
1. Administrative effort by the staff to communicate with
the communities and functional operation of the
Hospital Development Societies
2. Increase in monthly conducting of Hospital
Development Society (HDS) meetings
3. HDS members review patient experience feedback,
funds availability and activities to be undertaken to
fill the gaps identified during meetings
4. Minutes of meetings are recorded
Indicator 6: System developed and
rolled out to measure and report
patient report experience in a
standardized and confidential way.
1. Service contract with the provider of the integrated
online patient management system, Kiosks installed
and operated
2. Information on patient reported experience collected in
a credible way
3. Administrative effort by the DoHFW staff to analyze
and share analysis through health bulletins
4. IEC activities undertaken
1.6 The Project Area
48. The Projects which are being undertaken by the department includes the electronic health
record project, the e-sub-centre project and the NQAS certification quality care accreditation project
for secondary and primary level facilities. The scope of the electronic health record project includes
the healthcare facilities from the Teaching hospitals to the Primary Health Care centres spread across
the state. The main objective of the project is to enable the creation of electronic health record for
each patient visiting various healthcare facilities across the state. The e-Subcentre project is being
conceptualized for the sub-centres across the state to be enabled with telemedicine consultancy,
automatic drug dispensing machine etc. to transform them into comprehensive health care centres.
The NQAS certification project aims at achieving quality assurance standards for CHCs and PHCs
facilities across the state.
49. The proposed project aims to benefit the entire 53.6 million population of Andhra Pradesh as
it aims to strengthen the state public health system that is accessible to all. Focus will be on
strengthening the 7507 SCs, 1147 PHCs and 195 Community Health Centres across all 13 districts in
the State. The project will more specifically benefit patients with NCDs, as a key focus of the project
is expanding the scope of primary health services to include NCD prevention, screening and
management.
50. The project will also benefit the health sector staff, specially at the secondary and primary
levels, by strengthening their capacity and making additional resources available to achieve the health
goals of the State. They will also benefit from training, private sector partnerships, technology
solutions and improved working conditions that will allow them to operate at a higher level and
provide better quality care.
17
18
2 THE ENVIRONMENTAL AND SOCIAL MANAGEMENT FRAMEWORK(ESMF)
51. The Environment and Social Management Framework provides the guidance for the
prevention, minimization and/or mitigation of environmental and social issues arising due to the
implementation of the project and sub-project activities in the participating districts of Andhra
Pradesh.
2.1 Need for Environment and Social Management Framework (ESMF)
52. The primary objective of the project is to support Department of Health and family Welfare
(DoHFW), GoAP in improving the quality of public health services, enable patient-centred care and
increase the utilization of integrated primary health care in all districts of Andhra Pradesh. This will
include improving MCH and NCD services provided at the PHC and SC level. And also expand the
scope of Primary health care in the state which is currently focuses on MCH services, to expand the
scope by including NCD screening, prevention and management at the PHC and SC level. As site
specific investments/ interventions are not known at each facility, an ESMF has been prepared to
guide investments such that they are environmentally and socially sound, and do not result in adverse
impacts.
53. Under the result area 1, the project also aims to also strengthen the biomedical waste
management system in the health care facilities in Andhra Pradesh. The nature of this project provides
tremendous opportunities to enhance the sanitation, hygiene and infection control and bio-medical and
other waste management systems and processes in the state to further promote sound public health
outcomes, while also ensuring that there are no adverse impacts to the environment. There is pressing
need to strengthen the capacity on waste management and infection control, ensure the availability of
human resources designated to waste management and strengthen the monitoring system to ensure
compliance with the Government of India's national regulations.
54. The state of Andhra Pradesh has about 5.3 percent of Scheduled Tribe (ST) population and
about 17.1 percent of Scheduled Caste (SC) population. The state also has Schedule-V areas as per
Constitution of India and has 9 ITDA areas across seven districts. For better health outcome the
project interventions need to be inclusive of caste, religion and gender.
2.2 Scope and Objectives of the ESMF
55. The primary objectives of ESMF are as follows:
To identify potential environmental and social (E&S) impacts of the activities undertaken
through the project.
To develop a simple and practical Environmental and Social Management Framework
(ESMF) that would be used by the project to mitigate adverse environmental and social
impacts of the supported activities.
Ensure compliance with applicable national and local guidelines
Ensure compliance with World Bank safeguard policies
Minimize the potential adverse impacts and maximize the potential positive impacts of the
proposed investments
Lay down the procedure for preparing investment specific environment and social
management plan
56. The E&S assessment will include the stakeholder analysis and consultations; creation of
baseline data; review of relevant policies and legislations; institutional analysis and analysis of
administrative framework for any capacity gaps; and articulate key environment and social impacts
that require addressing to align with World Bank safeguard policies. Based on this, an Environmental
Management Plan (EMP), and a Social Management Plan including Tribal Development Framework
(TDF) and Gender Action Plan (GAP) have been prepared.
19
2.3 Methodology Adopted for ESMF Preparation
57. The ESMF has been prepared on the basis of environmental and social assessments which
involved gathering of data through both primary and secondary sources. This included consultations
with key stakeholders as well as desk research. The steps followed in developing the ESMF are
provided below:
xi. Establishment of the social and environment baseline through desk research and study of the dimensions of the study area, describing the relevant physical, biological, and socioeconomic
conditions This also included desk research of similar bank operations to understand what
likely social and environmental impacts could be.
xii. Defining the legal / regulatory framework that will influence implementation of the proposed
projects and sub-projects and included review of national and state level acts and polices
applicable to proposed project. It also attempted to identify existing gaps in the current
implementation practices associated with the proposed project activities, so that they can be
addressed during implementation.
xiii. Stakeholder Consultations has been carried out with all relevant stakeholders those who have
been identified through stakeholder analysis, these include government, communities, and
institutions. The consultation process has been carried out at two levels (district level and
health facility level. The objective of the consultation sessions is focused to improve the
project‟s interventionsabout environment and social management and to seek views from the
stakeholders on the environmental and social issues and the ways these could be resolved.
The procedure for conducting stakeholder and public consultations with relevant consultation
formats/ questionnaires/ checklists has been prepared and enclosed with the ESMF,
xiv. Identification the social and environmental impacts of the activities supported by the project.
This included identifying both positive and negative impacts to feed into development of
mitigation measures for any negative impacts.
xv. Defining the mitigation methods to manage the social and environmental impacts - – this
included not only defining the measures required but also the training and capacity building
measures.
xvi. Establishing the grievance redressal mechanism and citizen engagement plan (if any) in place
and establishing the grievance redressal mechanism, and citizen engagement plan suited to the
proposed project
xvii. Defining the monitoring plan to oversee the implementation of social and environment
management and mitigation methods
xviii. Preparing the gender action plan (GAP), and tribal development framework(TDF)
xix. Identifying the institutional capacity building and training requirements for implementing the
social and environment mitigation measures
xx. Preparing an estimated budget to undertake the provisions of the ESMF
58. While the secondary review included referring to a large set of data, publication, legislations,
government orders, and research articles, the primary data collection involved:
(a) Consultation with various Government departments and institutions including from
Department of Health and Family Welfare (DoHFW), Mission Director National Health
Mission, Andhra Pradesh VadiyaVidhan Parishad, State Quality Cell at DoHFW, Directorate
of Medical Education, APMSIDC, AP Tribal Welfare Department (APTWD), Andhra
Pradesh Pollution Control Board, and other state level institutions.
20
(b) Consultation and collection of health facility data from a sample of HCF using questionnaire
on (i) Biomedical waste management, (ii) Infection control, and (iii) Social safeguard. This
included collection of data from about 211 HCFs across districts. The details of the type of
HCF and districts are given below.
Table 7: Sample HCF for Primary Data Collection
S.No. District District
Hospital
Area
Hospital CHC PHC SC Total
1 Anantapur 1 2 4 9 16
2 Chittoor 1 1 1 2 10 15
3 East Godavari 1 2 2 6 10 21
4 Guntur 2 4 10 16
5 Kadapa 1 2 4 11 18
6 Krishna 1 2 4 10 17
7 Kurnool 1 2 4 10 17
8 Nellore 1 1 2 4 10 18
9 Prakasam 1 1 2 4 10 18
10 Srikakulam 1 1 1 2 10 15
11 Vizag 1 4 5 10
12 Vizianagaram 1 2 4 6 13
13 West Godavari 1 2 4 10 17
Total 11 7 22 50 121 211
(c) In addition to collection of primary data from HCFs, a district level consultation was carried
out in five districts (East Godavari, Guntur, Prakasam, Nellore and Kadapa) comprising of a
range of stakeholders including (i) Medical staff - doctors, specialists, nurses, administrative
staff, staff in-charge of outreach activities, patient satisfaction surveys, etc.; (ii) ANMs and
ASHAs; (iii) District Medical and Health Officers (DMHOs), and Deputy DMHOs; (iv)
Supervisor in-charge of Area hospitals District hospitals and CHCs; NQAS -District Quality
Manager and District Quality Consultant; (v) Representatives from at least 5-6 village health
communities, including vulnerable groups and women; (vi) Representatives from service
providers of PPP programs; (vii) Officials working on Tribal Reform Yardstick (TRY); and
(viii) Representatives of self-help groups.
59. Based on the secondary review, primary data collection and consultations, the ESMF is
prepared detailing out various policies, guidelines and procedures that need to be integrated during the
planning, design and implementation cycle of the World Bank-funded project. The framework
describes the principles, objectives and approach to be followed for selecting, avoiding, minimizing
and/or mitigating the adverse environmental and social impacts that are likely to arise due to the
project.
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3 ENVIRONMENTAL AND SOCIAL BASELINE
3.1 Environment Profile of AP
60. Andhra Pradesh lies between 12°41' and 19.07°N latitude and 77° and 84°40'E longitude, and
is bordered by Telangana, Chhattisgarh, and Orissa in the north, the Bay of Bengal in the East, Tamil
Nadu to the south and Karnataka to the west. Among the other states, which are situated on the
country's coastal area, Andhra Pradesh has got a coastline of around 974 km, which gives it the
2nd
longest coastline in the nation. Two major rivers, the Godavari and the Krishna run across the state.
A small enclave 30 sq. km, the Yanam district of Puducherry, lies in the Godavari Delta in the north
east of the state. The state includes the eastern part of Deccan plateau as well as a considerable part of
the Eastern Ghats.
61. Geographical Profile: The State has three physiographic zones, the hilly region (having
Nallamalai, Erramalai hills and the Eastern Ghats having an altitude of 500 to 1400 m); the plateau
(having an altitude of 100 m to 1000 m) and the deltas of rivers (between the Eastern Ghats and the
Sea Coast).
62. Drainage: Andhra Pradesh is popularly referred to as a “River State”. Nearly 75% of the
State territory is covered by the basins of three major rivers - Godavari, Krishna and Pennar and their
tributaries. In addition, there are 17 other rivers like Sarada, Nagavali, Musi and other streams. The
Godavari with its 1,464 km length, of which about 772 km lies within the State, is the longest and the
broadest river in South India. Godavari, Krishna and Pennar are the 3 principal rivers of the State
which drain into the Bay of Bengal. Godavari with its tributaries Pranahita, Manjeera, Maneru,
Indravati, Kinnerasani, Pamuleru and Sileru, drains through the northern parts of the State. The River
Krishna with its tributaries Tungabhadra, Vedhavati, Hundri, Musi, Paleru and Munneru flows
through the central parts of the State. The River Pennar, the third biggest river, with its tributaries
Chitravati, Papaghni, Cheyyeru and Pincha drains through Rayalaseema region and Nellore district.
63. Geology and Mineral Resources: Andhra Pradesh is well known globally for variety of
rocks & minerals and called as 'RatnaGarbha', a state endowed with variety of minerals. Many of the
ancient travellers and historians have mentioned the ancient mining of Gold, diamond, base metals,
precious stones etc. The tertiary and quaternary formations with different litho units / rocks contain
host of industrial, non-industrial, metallic minerals. The geological formations of the project districts
are: (1) The unclassified Archaean crystalline rocks are mainly granite but in the Eastern Ghats they
comprise of granulite suites (khondalites and kodurites), (2) TheMiddle– Upper Proterozoic the
Cuddapahs and its equivalents; (3) The Mesozoic coal bearing Gondwana strata, (4) Eocene lava
flows (the Deccan traps) and (5) The semi-consolidated or unconsolidated tertiary and recent rocks.
64. The state of Andhra Pradesh is rich in minerals such as limestone (34%), coal (10%), mica
(86%), Dolomites (11%), bauxite (40%), barytes (96%), clays (30%), heavy mineral beach sand
(40%), manganese (10%), feldspar (11%), quartz, silica sand soapstone (16%), gold, diamonds (16%),
uranium, oil and natural gas, iron ore, semi-precious stones, granite (40%), slates, limestone slabs,
marbles, dimensional and building stones (40%).
65. Climate: The State experiences tropical climate with slight variations depending on the
elevation and maritime influence which varies according to the three regions. Rainfall is received
from both the South-West and North-East monsoons, predominantly the former, but precipitation
varies across the State. The climate of Andhra Pradesh is generally hot and humid. The summer
season in this state generally extends from March to June. During these months the moisture level is
quite high. The coastal areas have higher temperatures than the other parts of the state. In summer, the
temperature generally ranges between 20 °C and 40 °C. The summer is followed by the monsoon
season, which starts during July and continues till September. This is the season for heavy tropical
rains in Andhra Pradesh. The major role in determining the climate of the state is played by South-
West Monsoons. About one third of the total rainfall in Andhra Pradesh is brought by the North-East
22
Monsoons around the month of October in the state. The winters in Andhra Pradesh are pleasant. This
is the time when the state attracts most of its tourists. October to February are the winter months in
Andhra Pradesh. Since the state has quite a long coastline the winters are comparatively mild. The
range of winter temperatures is generally from 13 °C to 30 °C.
66. Forest Resources: The total notified forest area of the State is 36914.69 sq.km., which is
22.73% of the geographical area. They include Reserved, Protected- and Un-classed forests. The
Kadapa has the highest notified forest area of 5041 sq.km. and the Krishna has the lowest notified
forest area of 664 sq.km. in the State. As regards the ratio of notified forest to geographical area,
Vishakhapatnam District has the highest with 41.50% and Krishna is the lowest with 7.38%.
Figure 3: Forest Map of Andhra Pradesh
Source: Andhra Pradesh State of Forest Report, 2014.
67. In terms of the forest canopy cover density classes the State has 651.25 Km2 of Very Dense
Forest, 11810.20 Km2 of Moderately Dense Forest and 10938.50 sq.km. of Open Forest. The area of
the Scrub is 9241.79 sq.km., Non-Forest 3900.52 sq.km. and Water Bodies 372.51 sq.km..
68. In addition, there are 4,419 VanaSamrakshanaSamities (VSSs) or Joint Forest Protection
Committees (JFPCs) in the State. An area of 8426.11 sq.km. of notified forests, which is 22.8% of the
forest area, is under Community Forest Management (CFM).
69. The vegetation found in the state is largely of dry deciduous type with a mixture of Teak, and
species of the genera Terminalia, Dalbergia, Pterocarpus, Anogeissus etc. The hills of Eastern Ghats
add greatly to the Biological Diversity and provide centres of endemism for plants, birds and lesser
forms of animal life. The varied habitat harbours a diversity of fauna which includes Tiger, Panther,
Wolf, Wild Dog, Hyena, Sloth Bear, Gaur, Black Buck, Chinkara, Chow-singha, Nilgai, Cheetal,
Sambar and a number of Birds and Reptiles. The long sea coast provides the nesting ground for sea
turtles, the back water of Pullicat lake are the feeding grounds for Flamingo & Grey Pelican, the
23
estuaries of river Godavari and Krishna support rich mangrove forests with Fishing Cat and Otters as
key stone species.
70. Protected Area: The State has 16 Protected Areas (PA) – 13 Wildlife Sanctuaries, 3 National
Parks including one Tiger Reserve. Nagarjuna Sagar–Srisailam Tiger Reserve (NSTR) is the biggest
Tiger Reserve of India. Out of 36914.77 sq.km. of notified forest area, 8137.08 sq.km. is included in
the PA network.
Table 8: List of Protected Areas - Wildlife Sanctuaries and Zoological Parks in the State of
Andhra Pradesh
Name Location Description
Indira Gandhi Zoological Park Vishakhapatnam The Indira Gandhi
Zoological Park in
Visakhapatnam is located
on the national highway
and covers an area of 250
hectares. This is the
second largest zoological
park in the state, after
Hyderabad Zoo. It boasts
of a rich collection of
flora and fauna, including
some exotic species of
animals from Australia.
The Park has more than
400 varieties of fauna.
The main attraction of
Indira Gandhi Zoological
Park is undoubtedly the
big cats, in particular the
white tiger.
Kambalakonda Wildlife Sanctuary On NH5
(surrounded by
the Eastern Ghats
on three sides
and
the Bay of
Bengal
on the fourth)
It houses Indira Gandhi
Zoological Park. The
park has almost eighty
species with primates,
carnivores, mammals,
ungulates, reptiles and
birds. These includes
rhesus monkeys,
baboons, panthers, tigers,
wolves, hyenas, pythons,
tortoises, monitor lizards,
elephant, bison, sambar
deer, peacocks, ducks
and macaws.
Papikonda Wildlife
Sanctuary
East and West
Godavari Area
Located across an
approximate area of 591
km2 in the East and West
Godavri area. Fauna
found in this sanctuary
are tigers, panthers, gaur,
cheetal, chowsingha,
24
Table 8: List of Protected Areas - Wildlife Sanctuaries and Zoological Parks in the State of
Andhra Pradesh
Name Location Description
sambar, blackbuck,
mouse deer, barking deer,
sloth bears, wild hogs,
hyenas, jackals, wild
boar, marsh crocodiles
and a variety of birds.
Coringa Wildlife
Sanctuary
East Godavari
District
Located across an
approximate area of 236
km2 in the East Godavari
area. It has the rare,
endangered smooth
Indian otter, fishing cat
and estuarine crocodile.
Other fauna are jackals,
marine turtles, seagulls,
storks, ducks and
flamingos.
Krishna Wildlife
Sanctuary
Krishna District It is a wildlife sanctuary
and estuary located in
Krishna district of
Andhra Pradesh. The
sanctuary is home for
reptiles like the garden
lizard, the wall lizard,
tortoises and snakes.
Rollapadu Wildlife
Sanctuary
Kurnool District It is a wildlife sanctuary
located in Kurnool
district of Andhra
Pradesh in an area 6.14
km2. It is the only habitat
in the state for the rare
and highly endangered
great Indian bustard. The
blackbuck, wolf, jackal,
bonnet macaque,
Russell's viper and cobra
are also found.
Sri Penusila Narasimha Wildlife Sanctuary Nellore District It covers an area of
1030.85 km2 is managed
by the Andhra Pradesh
Forest Department
GundlaBrahmeswara
Wildlife Sanctuary
Kurnool and
Prakasam
District
It is located in Kurnool
and Prakasam Districts of
Andhra Pradesh. It covers
an area of 1194 km2 is
managed by the Andhra
Pradesh Forest
Department. The last
25
Table 8: List of Protected Areas - Wildlife Sanctuaries and Zoological Parks in the State of
Andhra Pradesh
Name Location Description
surviving pristine forests
of
Nallamalai tract, it is rich
in plants of
ethnobotanical value.
Sri Lankamalleswara
Wildlife Sanctuary
Kadapa District It is located in Kadapa
District of Andhra
Pradesh. It covers an area
of 464.42 km2 is
managed by the Andhra
Pradesh Forest
Department
AtapakaBirdSanctuary(KolleruWildlifeSanctuary) West Godavari
District
It is a largest freshwater
lake located in West
Godavari district of
Andhra Pradesh. The
sanctuary falls under
Kaikalur Forest Range. It
is
one of the Ramsar
convention wetland sites,
spread over an area of
308.55 sq.km.
TelineelapuramandTelukunchiBird Sanctuaries Srikakulam
District
It is located in
Srikakulam district of
Andhra
Pradesh. Every year, over
3,000 pelicans and
painted storks visit from
Siberia to these villages
during September and
stay until March.
Pulicat Lake Bird
Sanctuary
Nellore District It is a 481 sq.km
Protected area in Nellore
District ofAndhra
Pradesh state. Pulicat
Lake is the secondlargest
brackish-water ecosystem
in India
managed by the Andhra
Pradesh
ForestDepartment and
Tamil Nadu Forest
Department.
108 sq.km. of this
sanctuary is national park
area.
Kondakarla Ava Bird Sanctuary Vishakhapatnam Kondakarla Ava is
26
Table 8: List of Protected Areas - Wildlife Sanctuaries and Zoological Parks in the State of
Andhra Pradesh
Name Location Description
located in Visakhapatnam
District of Andhra
Pradesh. It is managed by
the Andhra Pradesh
Tourism Development
Corporation Comprises a
unique and endangered
forest type and the wet
evergreen forests. Its
recognized as Eco
Tourism destination.
Nagarjunsagar-Srisailam Tiger Reserve Spread over five
districts -
Kurnool District,
Prakasam
District, Guntur
District,
Nalgonda
District
Nagarjunsagar-Srisailam
Tiger Reserve is the
largest tiger reserve in
India. The reserve
spreads over five
districts, Kurnool
District, Prakasam
District, Guntur District,
Nalgonda District and
Mahbubnagar district.
The total area of the tiger
reserve is 3,728 km2
(1,439 sq mi).The core
area of this reserve is
1,200 km2 (460 sq mi).
The reservoirs and
temples of Srisailam are
major attraction for many
tourists and pilgrims
3.2 Physical and Cultural Resources in Andhra Pradesh
71. Andhra Pradesh has rich physical and cultural heritage across different districts. In addition to
various monuments, it also has an important excavation site at Dharanikota, (160 34′; 800 17‟), in
Guntur district. The site of Dharanikota is situated on the right bank of the Krishna and known as
Dhana-Kataka, and also covered the Buddhist by site of Amarawati. According to Arachnological
Survey of India, Andhra Pradesh has about 130 monuments across different districts of the state (see
Annex-7 for list of monuments in Andhra Pradesh) and about 182 monument protected sites (see
Annex-8 for list of protected monument sites in Andhra Pradesh).
3.3 Status of Biomedical Waste Management System in AP
72. The current status of the Bio-medical waste management in the public health facilities in
Andhra Pradesh was sampled using the Bio-medical and Social Safeguard checklists. A total of 211
facilities (Sub Centres, PHCs, CHCs, AHs and DHs) were selected across 13 districts of Andhra
Pradesh for this exercise. Care was taken to ensure that the sample was representative and included
the tribal and vulnerable areas of the state as per WB 4.10. Aspirational districts and Schedule V areas
and ITDA areas were identified and included in the sample to ensure that the information collected
27
was truly representative in consonance with WB guidelines. 152 rural, 27 tribal, 32 urban facilities
were covered in the survey.
3.3.1 Segregation and Collection of Waste
73. The primary study conducted across all districts and public health care facilities suggests
segregation and collection of medical waste practices is as per norms in District Hospitals (DH) and
lack marginally in Area Hospital (AH) and Community Health Centres (CHCs). However, it lacks
substantially in Primary Health Centre (PHC) and Sub-Centre (SC). While treatment of liquid waste
before discharge is certainly a concern across different types of facilities, there are reported incidence
of mixing of bio-medical waste into other wastes. Table-9 below presents the availability of
equipment and consumables and practices of segregation in different types of health facilities.
Table 9: Current Practice of Bio-medical Waste Segregation and Collection in AP
Sl.
No. Indicators DH AH CHC PHC SC Total
1 Segregation Being Done 100% 86% 100% 66% 32% 53%
2 Containers/ Bins Available 100% 100% 86% 72% 21% 46%
3 Colour coded containers as per BMWM
rules 2016 100% 86% 82% 52% 4% 31%
4 Needle destroyers available 100% 86% 86% 86% 57% 70%
5 Is spill treatment kit available 100% 86% 100% 68%
35%
6 Does the HCF have SOP for mercury
spill management 100% 86% 82% 68%
33%
7 BMW mixed with other waste 9% 29% 23% 42% 37% 35%
8 Is liquid waste being treated before
discharge into sewers. 91% 43% 32% 12% 1% 13%
Total Sample 11 7 22 50 121 211
Source: Primary Study, December 2018
3.3.2 Storage and Transportation of Bio-medical Waste
74. While there is separate storage facility for BMW in large number of HCFs, the primary data
suggests that the clearance of waste takes more than 48 hours at majority of the times. While the
record of waste generated is kept on daily basis at district hospitals, the same is not true for other type
of HCFs and which also reflects in filing annual report to AP-SPCB. Table below presents the current
practices of storage and transportation of BMW in different type of HCFs,
Table 10: Storage and Transportation of BMW in HCFs
Sl.
No. Indicators DH AH CHC PHC SC Total
1 Is any waste being stored at the facility
for more than 48 hours 64% 71% 45% 44% 30% 38%
2 Record of every day's waste generation 100% 71% 55% 28% - 20%
28
Table 10: Storage and Transportation of BMW in HCFs
Sl.
No. Indicators DH AH CHC PHC SC Total
available
3 Proper storage and internal and external
transport facility available 91% 57% 32% 26% 3% 18%
4 Separate route for the waste transport
through the HCF 45% 43% 14% 20% - 11%
5 Vehicle carrying BMW is authorized for
such specialised work 45% 43% 55% 38% - 23%
6 HCF have policy on the waste type,
collection time and weighing of waste 36% 43% 18% 22% - 13%
7 Annual Report to SPCB/ PCC 73% 14% 18% 10% - 9%
Total Sample 11 7 22 50 121 211
Source: Primary Study, December 2018
3.3.3 Treatment and Disposal of Bio-medical Waste
75. In the state of Andhra Pradesh there are 11 CBMWTFs operationaland catering to all 13
districts. These CBMWTF cater to both public and private HCFs in their respective area of operation.
While most of the District Hospital, Area Hospital, and CHCs are covered by the CBMWTF,the
primary data suggests only few PHCs being covered by the CBMWTF. Most of the PHCs and SCs
depend on in-situ treatment and disposal mechanism. Analysis of incineration capacity utilization of
these CBMWTFs suggest a maximum utilization of 38% Vishakhapatnam to minimum of 11% in
Prakasam district.
Table 11: CBMWTF in Different Districts and It’s Capacity Utilisation*
(For the Period of January 2016 to December 2016)
Sl.
No.
Name of
CBMWTF, and
Districts Covered
Coverage
Area
Total no
of HCFs
being
covered*
Total
no of
beds
covered
Total quantity
of BMW
collected from
member HCFs
(in kg/day)
Installed
capacity of
Incinerator
(Kg/day)
%
Incinerator
Capacity
Utilization
1 M/s. Rainbow
Industries -
Srikakulam &
Vizianagaram
170 km/
day
370 6,732 438 2000 18%
2 M/s. Maridi Eco
Industries
(Andhra) Pvt. Ltd.
- Visakhaptnam
600 sqkm 704 13,917 2,000 5000 38%
3 M/s. EVB
Technologies (P)
Ltd. - East.
Godavari District.
960 sqkm 525 11,589 679 2000 33%
29
4 M/s Safenviron&
Associates - West
Godavari
7,742
sqkm
524 6,068 510 2000 20%
5. M/s. Safenviron
(Unit-II) - Krishna
940 sqkm 752 12,848 1,468 5400 18%
6. M/s. Safenviron -
Guntur
600 sqkm 700 13,683 896 4000 16%
7. M/s. Ongole
Medical Waste
Treatment Facility
- Prakasam
17,626
sqkm
357 4,638 462 3600 11%
8. M/s. S S Bio Care
- SPSR Nellore
13,076
sqkm
601 7,921 1,011 2000 31%
9. M/s AWM
Consulting Ltd -
Chittoor
640 sqkm 449 9,552 975 2000 33%
10. M/s Sriven
Environ
technologies -
YSR Kadapa and
Anantapur
1170
sqkm
354 9,593 712 3600 18%
11. M/s Medical
Waste Solutions -
Kurnool
600 kms/
day
385 5923 690 2000 33%
Note: *Includes both public and private HCFs
Source: Annual Report Information on Bio-Medical Waste Management, APPCB, GoAP. Available at
http://appcb.ap.nic.in/wp-content/uploads/2017/08/Bio-Medical-Annual-Report-for-the-year-2016.pdf
76. While treatment of liquid waste before discharge is a common concern across different types
of facilities, the APPCB is pursuing HCFs with more than 100 beds to provide Effluent Treatment
Plant (ETP) in thefirst phase of operations.
77. The treatment method followed by the CBMWTF for treated waste is presented in the table
below.
Table 12: CBMWTF Method of Disposal of Treated Waste
(For the Period of January 2016 to December 2016)
Sl.
No.
Name of CBMWTF,
and Districts
Covered
Total quantity of
BMW collected
from member HCFs
(in kg/day)
Method of Disposal of Treated Waste
1 M/s. Rainbow
Industries -
Srikakulam &
Vizianagaram
438 (1) Incineration Ash: Quantity: Approx.: 60 Kg/Day;
Disposed by: TSDF*
(2) Sharps: PPC Quantity: 22; Disposed by: Sharp Pit
(3) Plastics: RED BAG; Quantity:65; Disposed by:
Authorized Dealers (After Autoclaving and Shredding)
(4) ETP sludge: 1 Kg/Day; Disposed by: TSDF
30
Table 12: CBMWTF Method of Disposal of Treated Waste
(For the Period of January 2016 to December 2016)
Sl.
No.
Name of CBMWTF,
and Districts
Covered
Total quantity of
BMW collected
from member HCFs
(in kg/day)
Method of Disposal of Treated Waste
2 M/s. Maridi Eco
Industries (Andhra)
Pvt. Ltd. -
Visakhaptnam
2,000 (1) Incineration Ash: Quantity: 60 to 70 kgs per day;
Disposed to: TSDF, Ramkypharmacity, Parawada
(2) Sharps: Quantity:25 Kgs/day; Disposed to: sharp pits
(3) Plastics: Quantity:75 kgs/day; Disposed to: Recyclers
(4) ETP sludge: Quantity:0.5kgs/day; Disposed to: TSDF,
Ramkypharmacity, parawad
3 M/s. EVB
Technologies (P)
Ltd. - East. Godavari
District.
679 (1) Incineration Ash: Quantity: 66.3 kg/day; Disposed by:
M/s EVB to TSDF, Parawada,Vizag for landfill.
(2) Sharps: Quantity: 2.0 kgs/day; Disposed into Sharp pits
(3) Plastics: Quantity: 10.6 kgs/day; Disposed to Recycler
M/s Heritage Polymers, Autonagar, Vijayawada
(4) ETP sludge: Quantity: Disposed by: M/s EVB to TSDF
4 M/s Safenviron&
Associates - West
Godavari
510 (1) Incineration Ash: Quantity: 37kg/day; Disposed by:
Secured landfill
(2) Sharps: Quantity:30kg/day; Disposed by: Sharp pit
(3) Plastics: Quantity: 80kg/day; Disposed by: recyclers
(4) ETP sludge: Disposed by: Secured Landfill
5. M/s. Safenviron
(Unit-II) - Krishna
1,468 (1) Incineration Ash: Quantity: 86 kg/day; Disposed by:
Secured landfill
(2) Sharps: Quantity: 135 kg/day; Disposed by: Sharp pit
(3) Plastics: Quantity: 381 kg/day; Disposed by:
Authorised Recyclers
(4) ETP sludge: Disposed by: Secured landfill
6. M/s. Safenviron -
Guntur
896 (1) Incineration Ash: Quantity: 62 kg/day; Disposed by:
Secured Landfill
(2) Sharps: Quantity: 72 kg/day; Disposed by: Sharp Pit
(3) Plastics: Quantity: 175kg/day; Disposed by: Authorized
Recycler
(4) ETP sludge: Disposed by: Secured Landfill
7. M/s. Ongole
Medical Waste
Treatment Facility -
Prakasam
462 (1) Incineration Ash: Disposed into Ash pits onsite;
Quantity: 62 Kgs/Day; Disposed by: CBMWTF
(2) Sharps: disposed into concrete pit Quantity: 69
Kgs/Day; Disposed by: CBMWTF
(3) Plastics: Quantity: 316 Kgs/Day; Disposed by:
authorized recyclers
(4) ETP sludge: Quantity: 22 Kgs/Month; Disposed by:
used as manure
8. M/s. S S Bio Care -
SPSR Nellore
1,011 (1) Incineration Ash: Quantity: 39 Kgs/day; Disposed by:
disposed into ash pits onsite
(2) Sharps: Quantity: 23 Kgs/Day; Disposed by: Into
concrete sharps pit onsite
(3) Plastics: Quantity: 55 Kgs/day; Disposed by: authorized
recyclers
(4) ETP sludge: Quantity: 20 Kgs/Month; Disposed by:
used as a manure
9. M/s AWM
Consulting Ltd -
Chittoor
975 (1) Incineration Ash: Quantity: 60 kg/day; Disposed to:
onsite landfill
(2) Sharps: Quantity: 49 kg/day; Disposed by: Onsite
31
Table 12: CBMWTF Method of Disposal of Treated Waste
(For the Period of January 2016 to December 2016)
Sl.
No.
Name of CBMWTF,
and Districts
Covered
Total quantity of
BMW collected
from member HCFs
(in kg/day)
Method of Disposal of Treated Waste
sharps pit
(3) Plastics: Quantity: 262 kg/day; Disposed by: Sent to
Authorized recyclers
(4) ETP sludge: Quantity: 30 kgs/month; Disposed to:
Onsite Landfill
10. M/s Sriven Environ
technologies - YSR
Kadapa and
Anantapur
712 (1) Incineration Ash: Quantity: 70 Kgs/day; Disposed to:
Ash pit onsite
(2) Sharps: Quantity: 11 kg/day; Disposed by: Sharps pit
(3) Plastics: Quantity: 64 kg/day; Disposed to: Authorized
recyclers
(4) ETP sludge: Quantity: 05 kgs/day; Disposed to: Onsite
Landfill
11. M/s Medical Waste
Solutions - Kurnool
690 (1) Incineration Ash: Quantity: 25 Kgs/day; Disposed to:
Ash pit
(2) Sharps: Quantity:10 kg/day; Disposed by: Sharp pit
(3) Plastics: Quantity: 25 kg/day; Disposed to: Authorized
recyclers
(4) ETP sludge: Quantity: 05 kgs/day; Disposed to: Onsite
landfill
Note: *TSDF - Treatment Storage and Disposal Facility
Source: Annual Report Information on Bio-Medical Waste Management, APPCB, GoAP. Available at
http://appcb.ap.nic.in/wp-content/uploads/2017/08/Bio-Medical-Annual-Report-for-the-year-2016.pdf
3.4 Current Practice of Infection Management in AP
78. Overall the infection control measures are in place in each of the health care facilities with
mechanism for decontamination, hand washing, use of personal protective equipments, and handing
of sharps. These practices vary from different tiers of HCFs. While the District hospitals, Area
hospitals and CHC perform better on these indicators, the PHCs and SC requires further strengthening
on these areas.
Table 13: Current Practice of Infection Management in AP
Sl.No. Questions DH AH CHC PHC SC Total
Decontamination of instruments
1 Is sterilizer available 100% 100% 100% 100% 4% 45%
2 Is it in good working condition 100% 100% 100% 100% 3% 44%
3 Are instruments rust free 100% 100% 95% 90% 27% 55%
Handling of sharps
4 Is puncture proof container available 100% 100% 100% 90% 33% 59%
5 Are sharps peeping out/ lying outside of 9% 33% 14% 34% 20% 22%
32
Table 13: Current Practice of Infection Management in AP
Sl.No. Questions DH AH CHC PHC SC Total
containers
6 Is needle cutter available 100% 100% 100% 98% 67% 80%
7 Is it in good working condition 100% 100% 100% 94% 64% 78%
Hand washing practices
8 Is liquid soap and clean water available 91% 100% 91% 70% 36% 55%
9 Is paper towel/ clean towel available 36% 67% 45% 50% 24% 34%
10 Is staff aware of hand washing practices 100% 100% 100% 96% 68% 81%
11 Are staff members washing their hands
properly 100% 100% 100% 92% 66% 78%
12 Are list of universal precautions available 100% 100% 91% 78% 33% 56%
Total Sample 11 6 22 50 120 209
Source: Primary Study, December 2018
3.4.1 Worker’s Health and Safety
79. The practice of worker‟s health and safety (WHS) measures are reported to be relatively
better in at District Hospital and Area Hospitals and reduces with hierarchy of the HCFs in Andhra
Pradesh. Table 16 below presents the status of various indicators on WHS across different type of
HCFs in Andhra Pradesh. This suggests the need for WHS in primary health care facilities.
Table 14: Worker’s Health and Safety
Sl.
No. Indicators DH AH CHC PHC SC Total
Use of Personal Protective Equipment
1 Is PPE (gloves, apron, mask etc.)
available? 100% 100% 100% 90% 71% 81%
2 Are staff trained on how to use and
dispose of this equipment? 100% 100% 100% 86% 51% 68%
3 Do employees wear protective
equipment (PPE) while on the job 100% 86% 95% 96% 65% 78%
4 Is there any incidence of occupational
injury/ accident 45% 29% 59% 32% 15% 26%
5 Is the record of such injury/ accident
with sufficient details available 36% 43% 32% 24% 2% 13%
Training on BMW Management
6 Is the BMWM training manual for staff
available 100% 86% 86% 64% 7% 36%
33
Table 14: Worker’s Health and Safety
Sl.
No. Indicators DH AH CHC PHC SC Total
7 Is the record of employees training
available 100% 86% 86% 64% 7% 36%
Health Safety
8 Is the medical record of waste handlers
available 100% 71% 77% 50% 2% 29%
9 Health check-up of all the employees (at
least once in a year) 100% 86% 82% 70% 8% 38%
10
Are all staff of HCF and those handling
BMW is immunized (against the
Hepatitis B and Tetanus)
100% 86% 91% 64% 26% 48%
Total Sample 11 7 22 50 121 211
Source: Primary Study, December 2018
3.5 Infrastructure Condition and Access
80. Most HCFs except some of the SC are connected to all weather road and on government land.
While most HCFs have adequate drinking water availability except some of the SCs, adequate toilet
facilities for men and women are lacking across the HCFs.
Table 15: HCFs Infrastructure Availability
Sl.
No. Indicator
DH AH CHC PHC SC Total
Urban Urban Urban Rural Urban* Rural Rural
1
Facility located on
government land free of
encumbrances?
100% 100% 100% 100% 100% 100% 63% 79%
2 Facility connected with all-
weather road 100% 100% 100% 100% 100% 98% 77% 86%
3
Does the facility require
minor civil works/
refurbishments?
91% 100% 100% 100% 100% 83% 71% 79%
4 Facility have a boundary wall 100% 100% 100% 100% 50% 81% 31% 56%
5 Facility have adequate
seating space 100% 100% 67% 85% 50% 71% 45% 59%
6 Facility have separate and
adequate toilets for women 91% 100% 78% 85% 100% 83% 28% 52%
7 Facility have Drinking Water
for Patients 100% 100% 100% 100% 100% 98% 37% 63%
Total Sample 11 6 9 13 2 48 121 210
Note: * Very small sample, hence, not to be considered
34
Table 15: HCFs Infrastructure Availability
Sl.
No. Indicator DH AH CHC PHC SC Total
Source: Primary Study, December 2018
81. On an average, population per PHC in AP ranges from 25,721 to 37,617 in various districts.
Similarly, population per SC ranges from 3,867 in Vishakhapatnam to 5,358 in Kurnool. These are
broadly following the population norms suggested for PHC and SC - which is 30,000 in plain areas
and 20,000 in hilly and tribal areas for PHC, and for SC it is 5,000 in plain areas and 3,000 in hilly
and tribal areas.
Table (16) Population Per Primary Health Facility
Sl. No. District
Primary Health Centres Sub Centres
No. Population per
health facility No.
Population per
health facility
1 Srikakulam 80 28,330 465 4,874
2 Vizianagaram 68 27,258 446 4,301
3 Visakhapatnam 89 25,052 620 3,867
4 East Godavari 128 30,239 842 4,572
5 West Godavari 91 34,376 637 4,926
6 Krishna 88 30,383 600 4,509
7 Guntur 86 37,617 680 4,757
8 Prakasam 90 30,365 526 5,118
9 S.P.S.R.Nellore 75 28,079 477 4,415
10 Chittoor 103 28,850 644 4,569
11 Kadapa 74 25,721 448 4,249
12 Anantapur 88 33,741 586 5,009
13 Kurnool 87 33,381 543 5,358
Total 1,147
7,514
82. Of the total HCFs, about 11% SCs, 13.3% PHC, 6.7% CHC and 6.9% AH are in tribal areas.
Table 19 below presents different type of HCFs in tribal areas in different districts.
Table (17): Number of Facilities in Andhra Pradesh (As on 05-12-2018)
Sl.
No
District SC PHC CHC AH DH
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
1 Anantapur 586 0 12 87 0 7 8 0 2 0 0 1
35
Table (17): Number of Facilities in Andhra Pradesh (As on 05-12-2018)
Sl.
No
District SC PHC CHC AH DH
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
Rur
al
Trib
al
Urb
an
2 Guntur 680 0 12 81 5 6 11 0 2 0 0 1
3 Kurnool 447 95 33 69 18 5 13 0 1 0 0 1
4 Kadapa 448 0 31 74 0 5 7 0 1 0 0 1
5 Krishna 593 0 28 88 0 4 8 0 2 0 0 1
6 Nellore 477 0 47 75 0 3 11 0 2 0 0 1
7 Prakasam 505 29 41 83 7 3 11 0 2 0 0 1
8 Srikakulam 307 158 14 53 27 4 10 1 2 0 0 1
9 Vizianagara
m 312 119 19 48 20 4 4 3 1 0 0 1
10 Visakhapatna
m 386 197 18 54 36 1 9 2 1 0 2 1
11 East
Godavari 705 135 15 101 26 6 15 5 3 0 0 1
12 West
Godavari 550 85 34 77 14 5 7 2 3 0 0 1
13 Chittoor 644 0 23 102 0 1 14 0 4 0 0 2
TOTAL: 664
0 818 327 992 153 54 128 13 26 0 2 14
Source: DoHFW, GoAP 2018
3.6 Current Information Education and Communication (IEC) Activity
83. The current IEC activities are liked to NHM implementation. IEC material is available on the
national NHM website under the headings of 1)Print materials, 2) Audio Materials 3) Video
Materials, 4) Training materials, 5) SBA Presentations 6) LaQshya.Table below presents the IEC
material available on NHM site in different types of media and thematic area. They are downloaded
and further adapted to local language and culture.
Table 18: IEC Materials Available at NHM Site for Different Thematic Areas
S.No. Type of Media Thematic Area
1 Print Media Maternal Health, MH Logo, MH Game, MH
Hoarding, MH Posters, MH Wall-painting.
Making Abortion Safer: ASHA ANM Booklet, Flip
and answer book, Kalyani Poster, Leaflet
2 Audio Materia MH Song, 48hours Stay , ANC, IFA, JSSK
3 Video Materials Making Abortion Safer, Safe Motherhood, 48-hrs
Jaldbazi, ANC , IFA Tablet, JSSK
36
Table 18: IEC Materials Available at NHM Site for Different Thematic Areas
S.No. Type of Media Thematic Area
4 Training Materials SBA Training Videos - Module 1 to module 5
SBA presentations:
1b Infection Prevention, 2a Quality Antenatal Care,
2b Antenatal Check-Up History taking, 2d Antenatal
Check-Up Abdominal Examination, 3a Antenatal
Care Laboratory Investigations, 3b Antenatal Care
Interventions, 3c.i Antenatal Care Counselling, 3d
Intrapartum Care Assessment, 4 Intrapartum Care
during labour, 5b Resuscitation of New born, 5c
Postpartum Care, 6b Quality of care
84. A typical example of IEC material currently being used in the health facilities of
Visakhapatnam district of Andhra Pradesh are given below. The same format is followed across all
the 13 districts of AP.
Table 19: LIST OF POSTERS REQUIRED FOR DH/AH, CHC, PHC
VISAKHAPATNAM DISTRICT
S
NO DISTRICT HOSPITAL /
AREA HOSPITAL COMMUNITY HEALTH
CENTRE PRIMARY HEALTH
CENTRE
1 Hand Washing Technique Hand Washing Technique National Vector borne disease
control programme
2 Needle Stick Injury Protocols
(Post Exposure Prophylaxis) Needle Stick Injury Protocols
(Post Exposure Prophylaxis) National TB Control
programme
3 Bio Medical Waste
Segregation Instructions Work Instructions for Bio
Medical Waste Segregation National Leprosy eradication
programme
4 Sharp Management to Avoid
Needle Stick Injuries Sharp Management to Avoid
Needle Stick Injuries National AIDS control
programme
5 CPR Protocols CPR Protocols National programme for
control of blindness
6 Adult Cardiac Arrest Adult Cardiac Arrest National Programme for the
health care of the geriatric
patients
7 Maternal Cardiac Arrest Maternal Cardiac Arrest
National programme for
prevention and control of
Cancer, Diabetes, Cardio
vascular, diseases and stroke
(NPCDCS)
8 Infant CPR Infant CPR Integrated disease
surveillance programme
9 Child CPR Child CPR National Health programme
for prevention and control of
deafness
10 Blood and Body Fluids Spill
Management Blood and Body Fluids Spill
Management National school health
programme
11 Mercury Spill Management Mercury Spill Management Universal Immunization
programme
37
Table 19: LIST OF POSTERS REQUIRED FOR DH/AH, CHC, PHC
VISAKHAPATNAM DISTRICT
S
NO DISTRICT HOSPITAL /
AREA HOSPITAL COMMUNITY HEALTH
CENTRE PRIMARY HEALTH
CENTRE
12 Triage Protocols Triage Protocols National Iodine deficiency
programme
13 Floor Directory Floor Directory National Tobacco Control
programme
14 Scope of Services Scope of Services Hand Washing Technique
15 List of National Health
Programs List of National Health
Programs Needle Stick Injury Protocols
(Post Exposure Prophylaxis)
16 Citizen Charter Citizen Charter Work Instructions for Bio
Medical Waste Segregation
17 Tariff Board Sharp Management to Avoid
Needle Stick Injuries
18 Medical Representatives Are
Not Entertained in OPD
Timings (9:00AM-2:00PM)
Medical Representatives Are
Not Entertained in OPD
Timings (9:00AM-2:00PM) CPR Protocols
19 Visiting Hours (12:00AM-
2:00PM and 4:00PM-
6:00PM)
Visiting Hours (12:00AM-
2:00PM and 4:00PM-
6:00PM)
Blood and Body Fluids Spill
Management
20 Children Below 12 Years Are
Not Allowed in Hospital Children Below 12 Years Are
Not Allowed in Hospital Mercury Spill Management
21 Entry In & Exit Out Entry In & Exit Out Triage Protocols
22 Herbal Garden Herbal Garden Scope of Services
23 No Parking No Parking List of National Health
Programs
24 Ambulance Parking Area Ambulance Parking Area Citizen Charter
25 Patient Rights and
Responsibilities Patient Rights and
Responsibilities
Visiting Hours (12:00AM-
2:00PM and 4:00PM-
6:00PM)
26 Grievance Redressal
Mechanism Grievance Redressal
Mechanism Children Below 12 Years Are
Not Allowed in Hospital
27 Keep This Area Clean Keep This Area Clean Entry In & Exit Out
28 Toilets - Male , Female &
Disable Friendly Toilets - Male , Female &
Disable Friendly Herbal Garden
29 Trolley Bay Trolley Bay No Parking
30 Wheel Chair Bay Wheel Chair Bay Ambulance Parking Area
31 Instructions to Use Lift Patient Rights and
Responsibilities
32 Switch Off Your Mobile
Phones Switch Off Your Mobile
Phones Grievance Redressal
Mechanism
33 Silence Please Silence Please Keep This Area Clean
34 Leave Your Foot Wear Out
Side Leave Your Foot Wear Out
Side Toilets - Male , Female &
Disable Friendly
38
Table 19: LIST OF POSTERS REQUIRED FOR DH/AH, CHC, PHC
VISAKHAPATNAM DISTRICT
S
NO DISTRICT HOSPITAL /
AREA HOSPITAL COMMUNITY HEALTH
CENTRE PRIMARY HEALTH
CENTRE
35 Hospital Is Not Responsible
for Your Personal Belongings Hospital Is Not Responsible
for Your Personal Belongings Trolley Bay
36 Restricted Entry - Authorized
Persons Only Restricted Entry - Authorized
Persons Only Wheel Chair Bay
37 Radiation Hazard -
Authorized Persons Only Radiation Hazard -
Authorized Persons Only Switch Off Your Mobile
Phones
38 Danger - Electrical Hazard -
Entry Is Prohibited Danger - Electrical Hazard -
Entry Is Prohibited Silence Please
39 Instructions to Handle Fire
Extinguisher (RACE &
PASS)
Instructions to Handle Fire
Extinguisher (RACE &
PASS)
Leave Your Foot Wear Out
Side
40 Emergency Assembly Point Emergency Assembly Point Hospital Is Not Responsible
for Your Personal Belongings
41 Don‟t Waste Water Don‟t Waste Water Restricted Entry - Authorized
Persons Only
42 Warning - This Area Is
Monitored By 24 Hours
Video Surveillance
Warning - This Area Is
Monitored By 24 Hours
Video Surveillance
Danger - Electrical Hazard -
Entry Is Prohibited
43 Diesel / Fuel - No Smoking -
No Open Flames Diesel / Fuel - No Smoking -
No Open Flames
Instructions to Handle Fire
Extinguisher (RACE &
PASS)
44 Linen / Laundry Segregation Linen / Laundry Segregation Emergency Assembly Point
Don’t Waste Water
Diesel / Fuel - No Smoking -
No Open Flames
Linen / Laundry Segregation
Linen / Laundry Segregation
39
4 ENVIRONMENTAL AND SOCIAL POLICIES AND REGULATIONS
4.1 Environmental Laws, Policies and Regulations
85. The following table presents the various acts and policies of GOI and GoAP, their purpose and the applicability.
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
1 Bio-medical Waste
Management (Amendment)
Rules,2018
Central Pollution Control
Board
Schedule 1: Categorization and Management
Schedule 2: Standards for treatment and disposal
of BMW
Schedule 3: Prescribed Authority and duties
Schedule 4: Label of containers, bags and
transportation of Bio-Medical waste
The provisions under the rules provide for both
solid and liquid medical wastes
Liquid waste should be treated with 1%
hypochlorite solution before discharge into
sewers.
Hospitals not connected to municipal WWTPs
should install compact on-site sewage treatments
(i.e. primary and secondary treatment,
disinfection) to ensure that wastewater
discharges meet applicable thresholds
Applicable
As per Accreditation requirements,
healthcare facilities are required to
develop Standard Operating
Procedures (SOPs) in the handling of
medical solid, liquid and radioactive
wastes.
While each district of AP has
CBMWTF which collects BMW from
different facilities mainly upto CHC
level, PHC and SC requires
strengthening to meet the necessary
requirements as per the legislation in
terms of segregation, storage,
transportation, treatment and handling
of hazardous waste.
On liquid BMW, there are significant
gaps in treatment and disposal of
wastewater from hospitals. While
treatment of liquid waste before
discharge is a common concern
across different types of facilities, the
APPCB is pursuing HCFs with more
40
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
than 100 beds to provide Effluent
Treatment Plant (ETP) in the first
phase of operations.
State and District advisory
committees on BMW should be
established and advise SPCBs etc. in
the handling of medical solid and
liquid wastes.
2 E-Waste (Management and
Handling) Rules 2011 as
Amendment up to 2018
Andhra Pradesh
Pollution Control Board
There are policies governing the responsible
disposal of e-waste generated by bulk
Consumers to address leakage of e-waste to
informal sector at all the stages of
channelization.
The 2016 Amendment brought health care
facilities (with turnover over INR 20 crore or
more than 20 employees).
Relevant as it is applicable for all
HCFs.
Given the range of electronic
equipments at the HCFs and their
consumables, it becomes important to
adhere to the said rules. The disposal
of E-wastes to be done at the
specified collection centres and
reported annually.
3 Plastic Waste Management
Rules 2016
Andhra Pradesh
Pollution Control Board
All institutional generators of plastic waste, shall
segregate and store the waste generated by them
in accordance with the Solid Waste Management
Rules, and handover segregated wastes to
authorized waste processing or disposal facilities
or deposition centres, either on its own or
through the authorized waste collection agency
Relevant as HCFs are generators of
large quantity of plastics, including
non-reusable types.
4 Hazardous Waste Rules,
2016
Andhra Pradesh
Pollution Control Board
To address the appropriate management of all x
ray wastes developer so that they are safely
handled and disposed.
Relevant to all HCFs with x-ray and
Labs. This will be quite important
with the proposed project plans to
strengthen the NCD screening at
41
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
primary level.
5 National Building Codes of
India 2016.
AP Public Works
Department
The Code provides regulations for building
construction by departments, and public bodies.
It lays down a set of minimum provisions to
protect the safety of the public about structural
sufficiency, fire hazards and health aspects. The
Code mainly contains administrative regulations,
development control rules and general building
requirements; fire safety requirements;
stipulations regarding materials, structural design
and construction (including safety); building and
plumbing services; signs and outdoor display
structures; guidelines for sustainability, asset and
facility management, etc.
Relevant to any repair and
renovation/ upgradation needed to
enhance the quality of care and for
strengthening NCD screening and
care.
6 Water (Prevention and
Control of Pollution) Act
1974
Air (Prevention and
Control of Pollution) Act
1981
Environment Protection
Act (and Rules), 1986 and
1996
Andhra Pradesh
Pollution Control Board;
A P Forest department
Provisions are largely to prevent air and water
pollution by not releasing untreated effluents and
harmful emissions from Generator sets and
incinerators.
Most provisions are already discussed under the
Bio-Medical Waste Rules.
Relevant to all HCFsand Central
Biomedical Waste Treatment
Facilities- largely complied with
regulations
7 Indian Penal Code (IPC) AP Department of Law Section 278 (making atmosphere noxious to
health) and Section 269 (negligent act likely to
spread infection or disease dangerous to life,
Relevant
Although individuals would require
providing evidence
42
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
unlawfully or negligently
8 The Constitution of India
(especially, Articles 15,16
and 46)
Constitution of India; AP
Department of Law
The Indian Constitution (Article 15) prohibits
any discrimination based on religion, race, caste,
sex, and place of birth. Article 16 refers to the
equality of opportunity in matters of public
employment. Article 46 directs the state to
promote with special care the educational and
economic interests of the weaker sections of the
people, particularly of the Scheduled Castes and
the Scheduled Tribes and also directs the state to
protect them from social injustice and all forms
of exploitation.
Relevant to overall project
9 The Indian Medical
Council Act 1956, and
Andhra Pradesh Medical
Council Act 1968;
The Indian Medical
Council (Professional
Conduct, Etiquette and
Ethics Regulations 2002);
The Indian Nursing
Council Act - 1947
Medical Council of
India; Nursing Council
of India; Andhra Pradesh
Dept of Health, Medical
and Family Welfare;
Andhra Pradesh Medical
Council
Provisions are applicable to practicing doctors
and medical professionals to provide quality
service to the patients or healthcare seekers.
Relevant- as all Medical Council
provides and license to doctors, while
Nursing council is the regulatory
body for nurses.
10 Infection Management and
Environment Policy
Framework, 2007:
Ministry of Health and
family Welfare, Govt of
India; Andhra Pradesh
Dept of Health, Medical
and Family Welfare
IMEP has been mainstreamed within the NHM
for infection control and worker safety- emphasis
on capacity building and training, applicable to
all healthcare centres.
Relevant- However, compliance and
implementation on the ground has
been disjointed, and requires a
coherent approach at HCF level and
guidance by the department.
11 CPCB has brought out Central Pollution Control Any activities from BMW temporary storage, Relevant- BMW is listed as
43
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
Guidelines that are relevant
for the health sector
CPCB Guidelines for
CBWTFs (2003).
CPCB Guidelines for
BMW Incinerators (2003).
Draft Guidelines for Bio-
medical Waste Incinerator,
2017
Guidelines for
Management of Healthcare
Waste in Health Care
Facilities as per Bio
Medical Waste
Management Rules, 2016
Guidelines for Bar Code
System for Effective
Management of Bio-
Medical Waste
Standards for treatment and
disposal of Bio medical
waste by Incineration
Environmentally Sound
Management of Mercury
Waste Generated from
Health Care Facilities.
CPCB Manual on Hospital
Waste Management
Board, Govt of India;
Andhra Pradesh
Pollution Control Board
transportation, and Disposal/treatment requires
valid license.
CPCB has also notified Revised Guidelines for
Common Bio-medical Waste Treatment and
Disposal Facilities which covers the location
setting of the incinerator, operational and
maintenance performance standards and
monitoring. The State Pollution Control Board
plays an important role in granting consent to
establish and operate license to the CTF
operators, which are largely private sector
players.
hazardous waste due to its infectious
characteristics. Also, each district is
covered through CBMWTF and these
guidelines regulate the functioning of
CBMWTFs.
44
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
12 Ancient Monuments and
Archaeological Sites and
Remains Act 1958
Archeological
Department, Govt. of
India
The act provides for the preservation of ancient
and historical monuments and archaeological
sites and remains of national importance, for the
regulation of archaeological excavations and for
the protection of sculptures, carvings and other
like objects. The Archaeological Survey of India
functions under the provisions of this act.
The rules stipulate that area near the monument,
within 100 metres is prohibited area. The area
within 200 meters of the monument is regulated
category. Any repair or modifications of
buildings in this area requires prior permission
Relevant, as some of the HCF may
come into the protected or the
regulated area as per the act, and any
construction including digging pit for
BMWM will require permission from
ASI.
13 Workman Compensation
Act 1923
Ministry of Labour and
Employment, GoI;
Department of Labour,
Andhra Pradesh
The Act provides for compensation in case of
injury by accident arising out of and during
employment.
Relevant, as some of the activities
require repair and renovation of
existing infrastructure of HCFs and
hence will involve construction
activities.
14 Minimum Wage Act 1948 Ministry of Labour and
Employment, GoI;
Department of Labour,
Andhra Pradesh
The Employer is supposed to pay not less than
Minimum Wages fixed by appropriate
Government as per provisions of the Act if the
employment is a schedule employment.
Relevant. The Minimum Wages Act
is applicable, and the contractor is
mandated to provide compliance as
per the act.
15 Payment of Wages Act
1936; and Equal
Remuneration Act 1976:
Ministry of Labour and
Employment, GoI;
Department of Labour,
Andhra Pradesh
The payment of wages act lays down as to by
what date the wages are to be paid, when it will
be paid and what deductions can be made from
the wages of the workers.
The Equal Remuneration Act provides for
payment of equal wages for work of equal nature
Relevant. These Acts are applicable,
and the contractor will be mandated
to provide compliance as per agreed
terms of payment of Wages.
45
Table 20: Environmental Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Source Department Objective and Provisions Applicability to the Project
to Male and Female workers and for not making
discrimination against Female employees in the
matters of transfers, training and promotions etc.
16 Child Labor (Prohibition &
Regulation) Act 1986
Ministry of Labour and
Employment, GoI;
Department of Labour,
Andhra Pradesh
The Act prohibits employment of children below
14 years of age in certain occupations and
processes and provides for regulation of
employment of children in all other occupations
and processes. Employment of Child Labor is
prohibited in Building and Construction Industry.
Relevant. As such the state prohibits
child labour and it is a criminal
offence to encourage child labour in
the state.
46
4.2 Social Legal Framework
86. This deals with various policies, acts, rules and regulations promulgated by the central
government related to social issues and relevant to present project. Applicable Acts and Policies
relevant in the context of the project have been reviewed and their relevance to the project is outlined
in Table below.
Table 21: Social Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Objective and Provisions Relevance to the Project
and key Findings
1 Right to Information Act,
2005
Provides a practical regime of right to
information for citizens to secure
access to information under the control
of Public Authorities. The act sets out
(a) obligations of public authorities
with respect to provision of
information; (b) requires designating of
a Public Information Officer; (c)
process for any citizen to obtain
information/disposal of request, etc.;
and (d) provides for institutions such as
Central Information Commission/State
Information Commission
Relevant as all documents
pertaining to the Project
requires be disclosed to
public.
2 The Right to Fair
Compensation and
Transparency in Land
Acquisition,
Rehabilitation and
Resettlement Act, 2013
Aims to ensure, a humane,
participative, informed and transparent
process for land acquisition with least
disturbance to the owners of the land
and other affected families and provide
just and fair compensation to the
affected families whose land has been
acquired or proposed to be acquired or
those that are affected by such
acquisition and make adequate
provisions for their rehabilitation and
resettlement and for ensuring that the
cumulative outcome of compulsory
acquisition should be that affected
persons become partners in
development leading to an
improvement in their post-acquisition
social and economic status.
Not applicable as no land
acquisition or resettlement
is anticipated.
3 Fifth Schedule Areas as
under Article 244(1) of
the Constitution of India
The schedule has been added to the
Constitution to protect the cultural
identity and economic rights of the
tribal people.
The schedule provides for the
administration and control of
Scheduled Areas and Scheduled Tribes.
In pursuance of this schedule, the
President of India had asked each of the
states to identify tribal dominated
Relevant to overall Project,
Scheduled-V areas and
districts where Panchayat
(Extension to the Scheduled
Areas) Act - PESA is
applicable.
47
Table 21: Social Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Objective and Provisions Relevance to the Project
and key Findings
areas. Areas thus identified by the
states were declared as Fifth Schedule
Areas.
The schedule enables the Government
to enact separate laws for governance
and administration of the tribal areas.
Para 5 of the schedule divulges the
power to the Governor of the State to
define laws applicable to the Scheduled
Areas. Specifically, the Governor of the
state can make regulations that may:
- Prohibit or restrict the transfer of
land by or among members of the
Scheduled Tribes in such areas;
- Regulate allotment of land to
members of the Scheduled Tribes
in such area
- Some of the proposed projects will
be in the Schedule V areas and in
such cases the provisions of Tribal
Peoples Planning Framework
(TPPF) will be triggered
4 The Panchayat
(Extension to the
Scheduled Areas) Act,
1996
The Ministry of Panchayati Raj, GoI,
under this Act mandates for the Fifth
Schedule areas to make legislative
provisions to give wide-ranging powers
to the tribes on matters relating to
decision-making and development of
their communities. The PESA Act
empowers the Gram Sabha (the council
of village adults) and the Gram
Panchayat to take charge of village
administration. Under the Act,
Government of India stipulates to
conduct consultations and obtain
consent for the development Program
from the tribal advisory council (TAC),
Gram Sabha and the Gram Panchayat
under the Fifth Schedule Areas.
Relevant to the Program –
All Tribal Sub Plan (TSP)
districts as 'High Priority
Districts' under National
Rural Health Mission. Also,
the Gram Sabha have
control over local
institutions and
functionaries including the
Health Sub-centres and
Anganwadi centres.
5 Andhra Pradesh
Government Land
Allotment Policy, 2012
The Government Land Allotment
Policy was formulated to create a set of
uniform guidelines for the extent and
rate of allocation of Government land
for various purposes to Government
departments and private organizations.
The policy states that Government land
should not be auctioned for resource
Not Applicable – as the
repair and renovations under
the project will be limited to
exiting footprint of the
HCF, and no additional land
is required.
48
Table 21: Social Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Objective and Provisions Relevance to the Project
and key Findings
mobilization, land assigned to poor
people for agriculture purpose should
not be resumed and in case of
inevitable resumption, alternate land
should be given to the said assignees
apart from rehabilitation; and AP
Management Authority (APLMA) is to
be constituted for processing and
recommending land allotment, with the
task of monitoring the utilization of
land for the intended purpose and
resumption of land in case of violation
of conditions.
6 Andhra Pradesh
Scheduled Castes Sub
Plan and Tribal Sub Plan
(Planning, Allocation and
Utilization of Financial
Resources) Act No. 1,
2013
The Act aims to ensure accelerated
development of Scheduled Castes and
Scheduled Tribes with emphasis on
achieving equality focusing on
economic, educational and human
development along with ensuring
security and social dignity and
promoting equity among SCs and STs
by earmarking a portion in proportion
to the population of SC and ST in the
state, of the total plan outlay of the
state of Andhra Pradesh as the outlay of
the SC Sub Plan/ Tribal Sub Plan of the
state.
Applicable - The project
must aim at inclusive
growth that includes SCs
and STs.
7 Janani Suraksha yojana Janani Suraksha Yojana (JSY) is a safe
motherhood intervention scheme
launched on 12 April 2005 by the
Prime Minister of India and being
implemented by the Government of
India and all state governments
including Andhra Pradesh under NHM.
It aims to promote institutional delivery
among poor pregnant women and to
reduce neo-natal mortality and
maternal mortality. The Scheme
integrates cash assistance with delivery
and post-delivery care, particularly in
states with low institutional delivery
rates.
Relevant as the proposed
program aims to improve
primary health care
services.
8 Pradhan Mantri Matritva
Vandana Yojana
Pradhan Mantri Matritva Vandana
Yojana is a maternity benefit program
run by the government of India. It was
introduced in 2016 and is implemented
by the Ministry of Women and Child
Development. It is a conditional cash
transfer scheme for pregnant and
Relevant as the proposed
program aims to improve
primary health care
services.
49
Table 21: Social Laws and Policies
Sl.
No.
Applicable Act/
Regulation/ Policy
Objective and Provisions Relevance to the Project
and key Findings
lactating women of 19 years of age or
above for the first live birth. It provides
a partial wage compensation to women
for wage-loss during childbirth and
childcare and to provide conditions for
safe delivery and good nutrition and
feeding practices. In 2013, the scheme
was brought under the National Food
Security Act, 2013 to implement the
provision of cash maternity benefit of
₹6,000.
9 TalliBidda Express It aims towards reduction of Maternal
Mortality Ratio (MMR) and Infant
Mortality Rates (IMR) is the High
Priority Area for the Government.
Providing referral transport to the
pregnant women is one of the
interventions for reduction of MMR. In
order to ensure provision of drop back
service to every pregnant woman from
hospital till home. It has a dedicated
fleet of vehicles to do so.
Relevant as the proposed
program aims to improve
primary health care
services.
10 NTR Baby kit Given Pneumonia infections in
underweight babies being one of the
reasons for mortality among new born,
the initiative aims to reduce IMR by
providing adequate supportive
measures. The kit contains utilities
including a pair of warm blankets, a
sleeping pouch, mosquito nets and
antiseptic lotions, and distributed to
new born babies.
Relevant as the proposed
program aims to improve
primary health care
services.
4.3 World Bank Safeguard Policies
87. The implementation of the World Bank Operational Policies seeks to avoid, minimize or
mitigate the adverse environmental and social impacts, including protecting the rights of those likely
to be affected or marginalized by the proposed project. Detailed overview of the Operation policies
triggered, and their explanation can be found in the Table below.
Table 22: World Bank Policies
Safeguard Policies Applicable Explanation
Environmental
Assessment OP/BP 4.01 Yes
The project is considered as a Category B. OP 4.01 is
applicable as the project includes minor infrastructure
refurbishment at PHC and CHC level under the
Results Area-1. The project also support health
systems and service augmentation measures, these
50
Table 22: World Bank Policies
Safeguard Policies Applicable Explanation
interventions will result in greater footfall at the
facility level which will result in an incremental
increase in bio-medical and other wastes, and risks
arising from handling and disposal of healthcare
wastes and other products (clinical and infectious
waste materials, needles and sharps, and wastewater).
This could lead to adverse impacts to the environment
and human health if not managed appropriately. There
are no potential large-scale, significant or irreversible
impacts associated with the proposed project. The
risks and impacts associated with minor civil works
for repair and rehabilitation will be localized and
temporary.
To ensure proper management of environmental
impacts that might result from the implementation of
the project‟s interventions, an Environmental and
Social Management Framework (ESMF) has been
prepared by DoH, GoAP. Based on the guidance
provided in this ESMF, a site-specific screening
checklist to be used prior to commencement of any
works and improvements at the facility level. The
ESMF provides clear environment health and safety
management guidelines for health care workers hired
under the various service contracts (biomedical waste
management, sanitation, and medical equipment
servicing). For further reference the EHS guidelines of
the World Bank Group, as they apply to the proposed
activities is available at
www.ifc.org/ehsguidelines.The ESMF also provides
the necessary framework for (i) strengthening of the
bio-medical waste management system, such that all
bio-medical waste generated are collected and
disposed in safe and sanitary manner (ii) health
facilities have adequate storage for bio-medical waste
within the premises, chemicals and wastewater
management systems, and the necessary equipment
for segregation of wastes for patient and worker
safety, (iii) health facilities are connected to a central
treatment plant, and where this is not possible, in-situ
disposal mechanisms are adopted (iv) labour and
healthcare staff will be provided with appropriate
vaccinations, personal protective equipment, and
trainings on waste handling and infection control, and
(iv) all wastewater is treated and disposed to meet
applicable water quality standards. The ESMF
references the WBG EHS Guidelines and the sector
guidance WBG Environmental Health and Safety
Guidelines for Health Care Facilities. The ESMF
includes detailed budget provisions for mitigation
measures and capacity building, monitoring and
51
Table 22: World Bank Policies
Safeguard Policies Applicable Explanation
reporting requirements at all levels of project
implementation.
Performance Standards for
Private Sector Activities
OP/BP 4.03
No
Natural Habitats OP/BP
4.04 No
OP 4.04 is not triggered as the project will not finance
any interventions in natural habitats or that would
adversely impact natural habitats.
Forests OP/BP 4.36 No
OP 4.36 is not triggered for this project. The project
will not finance any interventions (health care centres
including the associated facilities such as access
roads, deep burial pits) do not impact forest areas and
do not negatively affect local wildlife and no
conversion/degradation of forests is envisaged.
Pest Management OP 4.09 No
OP 4.09 is not triggered as the project will not finance
or promote the use of large scale/significant qualities
of pesticides or chemical pest control methods that
would cause adverse impacts to human health and the
environment.
Physical Cultural
Resources OP/BP 4.11 Yes
OP 4.11 is triggered as a preventative measure. All
minor civil and renovation works will be restricted to
already existing HCF premises, and the project
interventions will not impact PCRs. However, in the
event of unknown PCR within the area, the ESMF
includes measures for screening, avoiding and
managing impacts on these PCRs as well as chance-
find procedures in the event new resources are
discovered in the course of project implementation.
Indigenous Peoples
OP/BP 4.10 Yes
Andhra Pradesh has nine districts that have been
identified as Schedule V areas. At the state level, ST
population is approximately 5%. Based on the current
scope of result areas, substantial engagement with
ST/SC communities is foreseen. An Environment and
Social Management Framework will be prepared to
gauge issues of equity and inclusion w.r.t to access
and utilization of health services amongst vulnerable
communities. FPIC will carried out amongst
disadvantaged communities to identify social risks,
capture the nuances of inclusion and enhance citizen
engagement mechanisms. The ESMF will outline
recommendations to be followed by the Borrower to
mitigate potential social risks. This is likely to include
preparation of a TDP.
Involuntary Resettlement
OP/BP 4.12 No
At this stage, no construction activities are envisaged
under the project. Hence, land acquisition/resettlement
related issues have been ruled out. However, in order
52
Table 22: World Bank Policies
Safeguard Policies Applicable Explanation
to monitor application of the policy through appraisal
and implementation, a checklist will be prepared to
ensure that no instances of land acquisition and/or
encroachment are noticed within the project‟s scope.
This policy will be re-visited during appraisal.
Safety of Dams OP/BP
4.37 No
OP 4.37 is not triggered as the project will not
construct any new dam or carry out works on existing
dams.
Projects on International
Waterways OP/BP 7.50 No
OP 7.50 is not triggered for this project as there are no
interventions planned/proposed that would impact
international waterways.
Projects in Disputed Areas
OP/BP 7.60 No
OP 7.60 is not triggered as the project is not proposed
in any disputed area
4.4 Conclusion
88. There are a number of national and state level policies related to the environmental and social
aspects of the project which would need to be considered while managing the project and this chapter
summarized these policies. In addition, various World Bank safeguard policies come into effect on
account of proposed project interventions and these were also summarized in the chapter.
53
5 STAKEHOLDER CONSULTATIONS
5.1 Key Stakeholders
89. Given the Commissionerate of Health and Family Welfare(CH&FW) is responsible for
planning, implementation, facilitation, coordination, supervision and monitoring of all activities
relating to health – preventive, promotive and curative services; comprehensive reproductive and
child health services; capacity development of the public health system; and all matters relating to
primary and secondary hospital services and their interface with the tertiary health system. All
programmes, schemes and activities implemented by the Govt. for the promotion of public health and
family welfare in the state including the centrally sponsored schemes and externally financed projects,
shall be executed through CH&FW.The CH&FW comprises the following divisions: Directorate of
Public Health & Family Welfare (DoPHFW), AP Vaidya Vidhana Parishad (APVVP), Directorate of
Institute of Preventive Medicine (DoIPM), and Indian Institute of Health & Family Welfare (IIHFW).
90. The key secondary stakeholders include the CH&FW along with its directorates including
NHM and APVVP, and other collaborating departments such as Andhra Pradesh Tribal Welfare
Department (APTWD), and Andhra Pradesh Pollution Control Board (APPCB). This includes staff
members of health care facilities (HCFs) at district and below and functionaries and representatives of
other departments including ITDA officials and district administration.
91. The primary stakeholders included the community members including women and children
across all districts and tribal areas, local community-based organizations (CBOs) such as SHGs etc.
and NGOs, members of Panchayati raj Institutions (PRIs) and other local institutions associated with
in promoting and providing health services.
5.2 Stakeholder Consultation Process Adopted
92. Consultation with various Government departments and institutions including key officials
from Commissionerate of Health and Family Welfare (CH&FW), Directorate of Public Health and
Family Welfare (DoPHFW), Mission Director National Health Mission, Andhra Pradesh
VadiyaVidhan Parishad, State Quality Cell at DoHFW, Directorate of Medical Education, APMSIDC,
Tribal Welfare Department (APTWD), Andhra Pradesh Pollution Control Board, and other state level
institutions were conducted in an iterative manner to seek key information and suggestions in
identifying the key environmental and social impacts and potential mitigation measures associated
with the proposed project at various stages of ESMP preparation.
93. While the initial consultations were done during the primary data collection from about 211
HCFs including 121 Sub-Centres, 50 PHCs, 22 CHCs, 7 Area Hospitals and 11 District Hospitals
across all 13 districts of AP, a more systematic consultations with various stakeholders were
conducted through as a district level consultation in five districts i.e. East Godavari, Guntur,
Prakasam, Nellore and Kadapa, comprising of a range of stakeholders including (i) Medical staff -
doctors, specialists, nurses, administrative staff, staff in-charge of outreach activities, patient
satisfaction surveys, etc.; (ii) ANMs and ASHAs; (iii) District Medical and Health Officers
(DMHOs), and Deputy DMHOs; (iv) Supervisor in-charge of Area hospitals District hospitals and
CHCs; NQAS -District Quality Manager and District Quality Consultant; (v) Representatives from at
least 5-6 village health communities, including vulnerable groups and women; (vi) Representatives
from service providers of PPP programs; (vii) ITDA officials/ officials working on Tribal Reform
Yardstick (TRY); and (viii) Representatives of self-help groups.
94. The AP Quality team consisting of State Program Officer, 1 State Consultant, 1 Programme
assistant, 13 district quality consultants, 13 district quality managers worked to organize and conduct
both the first and second stakeholder consultations. The details process of planning and holding the
consultation is presented below.
54
Planning stage
95. As part of the ESMF report, consultations were to be held with all levels of stakeholders
involved in the APHSSP project. The first level of consultations was undertaken by the quality team
of DoHMFW. The second level was a quantitative data collection exercise in HCF facilities spread
across 13 districts through Biomedical and social safeguard checklists. On the basis of the information
extracted from the two checklists a qualitative questionnaire was designed and district level
stakeholder consultations were conducted to obtain first-hand accounts from defined categories of
stakeholders. The questionnaire is attached as an Annex-4. On the basis of the four parameters of
tribal, aspirational, rural and urban 5 districts were selected for further consultations as below with
their specific characteristics.
1. East Godavari - Tribal
2. Nellore – Rural
3. YSR Kadapa – Aspirational District
4. Prakasam – Rural
5. Guntur – Urban
96. The community representatives were informed about the purpose of the consultation, date and
venue six days in advance so that the concerned staff could bring in stakeholders from (a) Medical
staff including doctors, specialists, nurses, administrative staff, staff in-charge of outreach activities,
patient satisfaction surveys, etc.; (2) ANMs and ASHAs; (3) District Medical and Health Officer
(DM&HO) and District Coordinator Hospital services (DCHS); (4) Deputy DMHO; (5)
Superintendent In- charge of (i) District hospitals, (ii) Area hospitals, and (iii) CHCs; (6) NQAS -
District Quality Consultant and District Quality Manager; (7) Representatives from at least 5-6 village
health communities, including vulnerable groups and women; (8) Representatives from service
providers of PPP programs; (9) Officials working on Tribal Reform Yardstick (TRY) (if applicable to
the district); and (10) Representatives of self-help groups, in accordance with the World Bank‟s
OP4.10 requirements. The Director, SPIU O/o Special Chief Secretary, DoHMFW sent out
instructions through a detailed email to the district authorities on 17.12.2018 through the state quality
team that Training session would be conducted for the Teams constituted to conduct the Stakeholder
consultations at District level. The training session for the teams was scheduled between 2.00 pm and
3.00 pm on the 19th
of December at the respective District Collector office video conferencing halls.
97. The team consisted of the following
1. District Medical & Health Officer (DMHO)
2. District Coordinator of Hospital Services (DCHS)
3. A member nominated by the DCHS
4. District Quality Consultant
5. District Quality Manager
6. District Program Officer (rural under NHRM)
98. The Training material and Draft Questionnaire was shared with all the District team members
with an instruction to go through and attend the VC to raise the doubts and also clarification and the
process.
99. Also, the arrangements for the stakeholder consultation at each District were as follows:
A. Meeting hall (capacity for 75 persons) equipped with sound system, LED screen arrangement,
video recording and photography arrangement for the stakeholder consultation sessions
before 20th December 2018. This was done by the DMHO and intimated to the SPIU.
B. Identify the Stakeholders name wise in each District mentioned above at Point no 1 to 10.
This was again attended to by the O/o the DMHO and the DCHS.
55
C. Combined Signed copy (by DMHO & DCHS) of Participants list to be submitted to
DPH&FW, Commissioner APVVP, Director SPIU & SQC. This was submitted to the SPIU
from all five districts on 21st December 2018.
100. The DPH&FW and Commissioner APVVP were requested to instruct the DMHOs and
DCHSs of the 5 Districts to take up this qualitatively to collect the information during the
consultations which will help preparing the ESMF Document before 29th December 2018.
101. The Program Officer Q.A and Trainings (The PO Q.A and trgs), in consultation with the
nodal officer ESMF was requested to co-ordinate the stakeholder consultations sessions in the five
districts and complete it before 27th December 2018 and submit the proceedings to the nodal officer
for preparation of ESMF document. The PO Q.A and trgs was also requested to prepare the schedule
dates and venue in coordinate with Districts and inform to DPH&FW, Commissioner APVVP and
Director SPIU. With specific reference to the tribal community participation the DMHO and Deputy
DMHO were instructed to ensure that there were representatives from the ITDA areas and TRY
officials along with representatives from self-help groups working in the tribal areas of the district.
Video conference
102. As planned the Videoconference was held on the 19th
of December 2018 and moderated by
the Director SPIU. Instructions were provided to the District teams that they were to conduct the
consultations ensuring that it a free-flowing, multi-way discussion broadly structured around the
questionnaire (Annex-5). The moderators were to avoid making aggressive remarks, providing
incorrect information and not to dismiss any gaps that are pointed out in the delivery of health
facilities, especially in tribal and aspirational districts. The moderators were to also make efforts to be
sensitive to community perceptions, social norms, especially while discussing issues related to
delivery and usage of health facilities in tribal communities. Accurate documentation of the feedback
received, photographs and videography of the consultation process and compulsory Attendance sheet
was stressed. Specific instructions were provided on the venue seating arrangement and the
importance of ensuring that all 10 categories of stakeholders were included in the consultation,
especially in tribal areas. It was informed that representatives from the ITDA areas in the selected five
districts should be included. This should be reached out in local language and the means of
communication used should be easily accessible to identified community representatives.
103. The district teams requested that instead of administering all 22 questions to all 10 categories
of stakeholders it would be more productive if the categories relevant to each of the questions were
identified so that the information elicited would be relevant, specific and actionable. Accordingly,
each question was then provided with an explanation below on how to administer and what
information was to be elicited along with the categories of stakeholders for whom it was relevant. The
importance of this input was seen when the consultations were actually conducted. The ease with
which the audience was able to zone in to a quick turn-around time and provide well-articulated
appropriate responses. This greatly reduced the vagueness generally associated with responses to
qualitative questionnaires.
Expenditure for the consultation was met through NHM funds on a reimbursement basis. The district
quality team consisting of District Quality consultant and District Quality Manager coordinate the
same with the District level authorities to conduct the consultations. Travel arrangements for the
stakeholders to and from the venue were made at the respective administrative levels and costs
consolidated and presented for reimbursement to NHM AP.
Holding Consultations
104. On the 23rd
of December 2018 stakeholder consultations were simultaneously conducted in all
five districts in their chosen venues successfully. Summary of the consultations are attached as
Annexes to the main report. The training provided in the video conference helped in smoothly
conducting the proceedings with structured focused thinking of the audience well moderated by the
56
district teams. The 22-point questionnaire with 11 environment and 11 social related questions was
well administered and elicited responses from all stakeholders. The DQC and DQM who were well
versed in administering questionnaires out of their experience in the NQAS program were able to
steer the discussions to structured outcomes. It was ensured that the signatures of all the attendees
were taken, the documents scanned, and sent to the SPIU.
105. The photos and Videos taken of the event were shared with the ESMF nodal officer, SPO QA
and trainings and the SPIU through Google Drive by the respective O/o the DMHO. The same were
downloaded at the other end so multiple copies were maintained and also for cross verification that all
5 districts had complied to the instructions.
Documentations
106. On 28th
of December the final report from received. The reports were scientifically designed
to synchronize with the questions so that specific and relevant information elicited from the
respondents could be consolidated easily. Guntur 65, YSR Kadapa 69, Prakasam 137, East Godavari
80, Nellore 75, a total of 426 stakeholders from 5 districts attended the consultations and provided
responses to the questionnaires. The responses were consolidated at the district level and reports
prepared by the DPO NHM and the DMHO offices. These were then consolidated into the below
report.
107. Timeline for stakeholder consultations.
Sl.no Date Activity
1 17th Dec 2018 1. Intimation regarding Stakeholder consultation as part of ESMF sent to
District level authorities to constitute the consultation teams.
2. Arrangement for a VC for training in conducting the consultation.
3. Questionnaire and covering letter shared.
2 19th Dec 2018 1. Training conducted for District teams through VC
2. Questionnaire explained with reference to the 10 stakeholder groups.
3 23rd
Dec 2018 1. Stakeholder consultations conducted simultaneously in five districts.
2. Coordinated by quality consultants and staff.
3. Minutes recorded, photographs taken, Video recorded
4 28th Dec 2018 1. Documentations, photographs and Videos of all five districts reach the
SPIU.
A detailed documentation of each of the consultation is presented as separate volume of this report.
5.3 Key Outcome of Stakeholder Consultations
108. Social Safeguards
Health is considered as one of the top priority services among local population - health and
transportation are rated to be the top priorities among community followed by water,
electricity and education.
Majority of the patient using public health facilities are poor/ belong to BPL - among the
users of the public health facilities, most districts expressed that majority of patients visited
belong to below poverty line (BPL) people mainly belonging to SC, ST, BCand economically
backward OCs. The ratio of BPL among patients is about 70% and most of them are from
agriculture background especially farmers, agriculture labours and Construction workers.
57
Most of the health facilities located in such a manner that enhance accessibility - The Health
facilities are largely accessible to the target population with all the Sub-Centres are situated in
the village and in accessible areas; about 85% of the Primary Health Centres are also situated
in the accessible areas and the 15% PHCs are outskirts of the village/town but within 1-2 km
distance of the main village/ town and have road accessibility. All the Secondary and tertiary
care facilities are situated in the main towns and accessible to the communities. However, the
accessibility in tribal areas is not as good due to difficult terrain. Most of the patients coming
to tribal PHCs come either by walk or over crowded public transport due to poor
transportation facilities.
More women footfall than men in health facilities – The ratio of women patients visiting the
HCFs are higher and account to about 60% of the overall OPD patients. Across the districts,
on an average daily OP load is around 20-30 at SC level, at the PHC OP is 150-200, at CHC it
is about 300 to 400, and at DH/AH OP load varies from 300 – 600 per day. The OPD register
is maintained and they are also recording OP in e-Aushadi in gender disaggregated manner.
HCF staffs aware of their roles and responsibilities on onset of disaster – The nine coastal
districts of Andhra Pradesh is a regular victim of natural disasters mainly cyclone and floods
and across district HCF staffs reported being aware of their roles and responsibilities as
defined under the district disaster management plan and also actively take part in its
preparation. All NQAS accredited facilities have good disaster management plan and all
members are aware of chain of command. This is monitored regularly by the District
Collector in all nine coastal districts.
Patient satisfaction monitoring is well integrated in most HCFs - Feedback and patient
satisfaction is conducted in all facilities. At the time of visiting the facility, the staff interact
with OP and IP patients to know their satisfaction levels on patient services. However, the
quality group expresses the need for improving the patient feedback collection mechanism in
disaggregated manner to help improve services.
IEC and outreach activities are being done as per scheduled program–The IEC being
implemented in coordination with other health directorates on all the health programs
including RBSK (Mukya Mantri Bala Suraksha karyakramam, RKSK, RNTCP, NLEP,
NPCB, Maternal Health (NTR Baby Kits, Delivery kits, JSSK, JSK, PMSMA, PMMVY
Programmes, NIDDCP, NPCDCS(Male and Female master Health check-ups) NPHCE,
NTCP, NVBDCP, NACO programmes, Healthcare ATM, Free Drugs & Supply Chain, NTR
Vaidya Seva, and NTR vaidyaParikshalu. In addition, at the village level IEC is done through
school health education, VHND meeting, ANC clinics, and implementation of all national
health programmers, hand wash, Swatch Barath and Palaklarimpi I and II.
The Hospital Development Society (HDS) exists from PHC and above HCFs and review key
performance indicators of the HCF - The Hospital Development Society (HDS) is there in all
PHC, CHC, AH and DH across different districts in the state. HDS committee actively
involved in Hospital development, drugs local purchasing, HDS funds utilization and the
committees are mainly focus on Better improvement and good service delivery.
Prioritizing health needs among women shows mixed response across districts - While
proportion of female patients are more than men in public HCFs, the priority to visit HCF for
services at an early stage of any disease has mixed response among women.
Health care ATMs6 functional in tribal areas - The main aim of these ATMs is to address
patient care where there is no medical officer available by using multi-parameter monitor
6 To address the shortage of doctors at PHC level – which is 26% nationally and 18% in Andhra Pradesh,
Healthcare ATMs were started. The Healthcare ATM is for PHCs without doctors or those with work load of
less than 15 patients per day. It uses SMS based patient vital parameter monitor, non-invasive Haemoglobin
meter, on-site urine sensitivity device connected to a medical call centre (108/104/DH) where qualified doctor
receive patient details. The doctor prescribes the drugs, command of which is sent to the facility and a free
58
operated by Para Medical Staff of concerned medical officer. It is working in remote tribal
areas through invocation method, networking based through SMS service. Each ATM
consists of Drug Wending Machine, Multi-parameter monitor, Non-invasive Hemoglobin
Meter, and the ATM has about 32 blocks for prescribed medicine. The staff fill these blocks
with the concerned medicines whenever it is empty and monitor the drug consumption on
daily basis by concerned pharmacist and Medical Officer. The Medical Officer, pharmacist
and staff nurse are trained on operating of these ATMs and also on submission of Reports.
109. Environment Safeguards
Segregation of Bio-medical waste requires strengthening at PHC and Sub-centre -
Segregation is happening in all the CHC, AH, DH and also initiated at PHC level recently.
However, segregation at PHC and at sub centres level needs improvement. In many cases
waste is brought from sub-centres to PHC for disposal. The disposal at PHCs is largely
through deep burial and sharp pits.
With the incremental increase in waste generated through the proposed project will add little
impact – It is expected that the incremental increase I waste generated due to project will also
follow similar process as for rest of the waste and it is expected that the project will support in
terms of improving man power, budget, infrastructure and capacities in bio-medical waste
management.
Expectation that the proposed project will help improve mechanism for reducing hospital
acquired infections – Theproposed project will help prevent hospital acquired infections
(nosocomial infections) by safe disposal of infectious waste and reducing the risk to health
personnel and the patient. This will include provision of HR, budget and training for the same.
The risk management requires upgrading skill and knowledge and preparing sustainable plan
for risk management at HCF level – therisks will be managed through upgrading the skills
and knowledge on how to manage the bio-medical waste and infection management risks by
proper training and capacity building of HCF staff and to make a sustainable plan for
prevention of these risks in future.
The HCFs lack management of liquid waste – AtDH, AH and CHC level, chlorination tank is
used to disinfect the lab equipments and mix it with liquid waste but at the PHC and in sub
centres level Hypo Chlorine Solution is being used for disinfection. There is no effluent
treatment plan (ETP) at present at HCFs and proposal has been sent to APVVP for setting up
ETP at District hospital and Area hospital before scaling it to other facilities.
The proposed project is expected to help improve the effluent treatment as well as bio-medical
waste in suitable manner so that there are no risks to the environment including to soil and
water bodies – The project will help strengthen the system so that the environmental pollution
can be prevented. Infections and harmful chemicals are neutralized and disposed in proper
manner so that they are not harmful to soil and water bodies.
The Environment Health and Safety performance monitoring requires strengthening in PHCs
and SCs – TheEnvironment Health and Safety performance is monitored in Teaching hospital,
DH, AH, CHC through SSP surveillance. Online portal and manual scoring by MS, RMO,
Nursing Superintendent/ Head nurse. In PHC no proper monitoring is there. After
Kayakalpprogramme implementation it is happening in some PHC. No EHS monitoring
happens in SC level. In NQAS accredited facilities and Kayakalp winner facilities it is
monitored regularly. The Quality assurance team in the District and slowly extending this
monitoring process to all health care facilities.
generic drug vending machine is dispensed at the facility. The 3-5 minute cycle connects the patient & ANM at
facility, the remote doctor and provides "Diagnostics-Doctor-Drug" to the patient. The entire process is free of
internet to avoid communication failure.
59
The adequate availability of the consumables are not there at PHC and SC level – Some of
the institutions have color coated bins, bags, PPEgears for staff, puncture proof containers,
while all the institutions have needle cutters. While at PHC level and SC level, theneedle
cutters are there and some of the PHCs have color coated bins, it is not there in most of the
PHCs and SCs.
Health checkups and immunization requires strengthening at PHC and SC level – Health
checkups and immunization is happening DH, AH, CHC and some PHC once in a year. All
Kayakalp implemented facilities following Health check-ups and immunization. It is not
happening in sub-centres.
Waste management committee at HCF is often missing – While the CBMWTF is contracted
out for the bio-medical waste management at the DH, AH, CHC level and some PHCs as
well, and the facility in-charge responsible for waste management and infection control, with
review by HSD and quality assurance team for further suggestions and actions. All NQAS
accredited facilities managing Hospital infection control management committees,
Biomedical waste management committees, but all other HCFs will not have such
committees. There is no such committee at SC level. Wherever these committees are there, it
is perceived to be sufficient to guide and implement but need Infrastructure and trained
manpower to extend further trainings to all staffs for capacity building.
Mechanism for disposal of chemical reagents requires strengthening – Atall health care
facilities Chlorination tanks are being used for disposal of chemical reagents and
disinfectants. In small scale /Lab waste disinfected with Hypochlorite solution. After the
treatment it is drained into municipality drains.
Photographs of Stakeholder Consultations
Stakeholder Consultation at East Godavari
Group discussion during Stakeholder
Consultation at East Godavari
Stakeholder Consultation at Kadapa
Stakeholder Consultation at Kadapa
60
Stakeholder consultation at Prakasam
Group discussion during Stakeholder
Consultation at Prakasam
Stakeholder consultation at Guntur
Group discussion during Stakeholder
Consultation at Guntur
Stakeholder consultation at Nellore
Group discussion during Stakeholder
Consultation at Nellore
61
6 ENVIRONMENTAL AND SOCIAL ASSESSMENT
6.1 Environmental Risks and Impact
Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Result Area 1: Quality of Care
Indicator 1: Increase in
the number of
PHCs and CHCs
have more than 70
percent quality
score, sufficient to
seeking national
certification,
supported to
improve quality
and monitor sustain
quality.
1. Assessment of quality gaps undertaken by
facility and DoHFW staff
2. Training of the PHC and CHC Staff
3. Fill HR gaps
4. Minor infrastructure* enhancements
5. Minor furniture, equipment, other goods
procured
6. Service contract to establish and maintain
Quality Tracking Dashboard System
7. PHCs and CHCs report to the system
8. Service providers contracted and incentivized to
improve in clinical and non-clinical gaps
9. Maintenance and improvement of quality
monitored and supported
*infrastructure refers to minor building repairs
and modifications
Activities are likely to introduce
positive environmental, health, and
safety provisions for HCFs, at the
same due to better service provisions,
and footfall at the HCFs, there will be
an incremental increase solid,
biomedical7 and liquid waste streams
(chemical reagents, wastewater
effluents).
If waste streams are not adequately
treated or disposed, there could be
impacts /contamination to
surrounding soil, water and air
environments and on nearby
communities.
i. Building capacity of HCF
staffs on bio-medical waste
management – both solid
and liquid.
ii. All waste streams (solid and
liquid waste will be
managed in accordance to
the principles of the
biomedical waste
management rules, 2016,
and their implementation
guidelines.
iii. SOPs for management of e-
waste, plastics,
pharmaceuticals, and
hazardous waste (x-ray
developer) both for staff
and service provider will be
utilized.
iv. SoP for notification and
disposal of expired
medicines so that it is not
disposed in regular solid
and liquid waste streams
7The HCFs waste streams including bio-medical waste, solid wastes, e-waste, plastics, pharmaceuticals, and hazardous waste (x-ray developer).
62
Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
v. Checklist and SOP for
infection control measures
will be utilized
vi. Health and safety SOPs to
be prepared and
incorporated in the service
contract of various service
provider for sanitation
services, bio-medical
services, and laboratory
services
vii. ETP to be scaled up to PHC
level, ETP should be
provided to treat the
washing water generated
viii. STP should be provided to
treat the sewage generated
due to domestic use
ix. No-run-off from site should
allow to get into rivers or
accumulate at site or nearby
areas
x. The project design by
nature addresses the issue of
poor health care waste
management and its key
performance indicator will
measure the increased
number of health care
facilities meeting
environmental and liquid
63
Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
and solid waste
management standards, as
required by the Government
of India.
xi. To facilitate the
implementation of the
regulation on Bio- Medical
Waste Management Rules,
the following mitigation
actions should be in place:
a. Requirements for system
managing the medical
wastes (labelling, sorting) in
each department and the
temporary storage chamber,
and the transportation from
each department to the
temporary storage chamber;
b. The requirements for
transfer and reporting of
medical wastes within the
HCF and between the
disposal centre.
c. Emergency mitigation
measures for
accidents/leakages/spills
and release of medical
waste
d. Protection/OHS for workers
during the sorting,
collection, transportation
64
Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
The potential long-term risk could be
associated with poor operations and
maintenance of waste treatment and
disposal technology.
and temporary storage.
e. Where facilities are too
remote and not viable to be
connected to CBMWTF,
decentralized systems such
as deep burial pit8 will be
constructed on site.
f. In the absence of onsite
wastewater Treatment in
HCFs, a septic tank and
soak pit system will be
constructed such that all
wastewater is adequately
disinfected and then
disposed adequately.
g. For larger facilities, ETP
will be established in DH
and AH. For smaller
facilities with no sewerage
connection, suitable
arrangements such as liquid
disinfection, septic tank and
soak pit will be introduced.
This is being mitigated through the
provision of EHS capacity building
and training of relevant service
providers/operators maintained and
financed by the Government.
8For specifications of Deep burial pit and to avoid any residual impacts to soil and water quality refer to Annex - 3
65
Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
The project will also provide
capacity building support to ensure
occupational safety measures are
followed by healthcare staff in
facilities.
In larger hospitals, an internal
system for occupational health and
safety management needs to be
established and reviewed by the
government/nodal authority. The
system includes the procedures,
institutional arrangement,reporting,
mechanism, materials preparation,
and training plan, regarding the
aspects of fire prevention,
prevention and control of
occupational diseases, e.g.
infectious disease, radiation,
chemical exposure, skin disease, etc.
Indicator 2: Increase in
number of CHCs
and PHCs NQAS
certified
1. DoHFW administration organizes for review by
the national authorities
Accreditation process involves
improving the BMWM and other
environmental hygiene, so it will be
beneficial.
1. Set up mechanism for building
and sustaining BMW
management, sanitation and
hygiene standards
Indicator 3: Increase in
coverage of core
services provided
through
performance -
1. Sanitation service provider contracts
2. Biomedical equipment maintenance contract
3. Laboratory service contract
4. Tele-radiology service contracts
5. Patient satisfaction/ experience survey contract
Increase in coverage of core services
will enhance quality services. The
contracts for various service provision
require proper detailing of
specifications and monitoring of the
1. SOPs to be prepared and
incorporated in the service
contract of various service
provider for sanitation services,
bio-medical services, and
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Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
based contracts at
CHCs and the
performance of
those services.
same for better adherence.
Most hospitals are not treating liquid
wastes before releasing into the
municipal drains or release into the
environment – and hence shall be
included in the part of service
provision standards.
laboratory services
2. As mentioned above, ETP to be
scaled up to PHC level
Indicator 4: Improved
pharmaceutical
stock management
system at the PHCs
and CHCs.
1. Upgrading/ replacing of the supply chain
software with modern functionality
2. Management and operating of supply chain
3. Facility pharmacists incentivized to enter
information into the supply chain software
Mechanism for disposal of expired
medicine requires standard protocol to
be followed.
1. SOP for notification and
disposal of expired medicine
Result Area 2: Integrated Primary Health Care
Indicator 1: Increase in
the number of
functional e-sub-
centres, including
with solar power
energy solution
where appropriate
and model
evaluated.
1. Service contract with teleconsultation provide
and operate the following: refurbish the
facility, provide the diagnostic and drug
vending machine, computer with internet and
telemedicine solution, and doctors‟ hub
2. ANM staff work at the Sub-centres
3. Expanded list of essential drugs provided to sub-
centres
4. Policy decision will be taken about the extension
of solar power to subcentres
5. Installation, operation and maintenance of the
solar power at subcentres according to policy
decision
The e-sub-centres are expected to
enhance the outreach services in areas
where no medical officer is available
and help improve overall health care in
Andhra Pradesh. However, the e-sub-
centre requires uninterrupted reliable
power supply to be functional.
Safety standards to be ensured for
installation of solar panels.
The option for Solar power at
alternative and other inverter/ UPS
based power supply will require proper
wiring system as well as the storage
1. Design specifications to be
made in such a manner that
incorporates adequate space for
solar panels as well as
installation of battery and
wiring.
2. SOP to be prepared for upkeep
and O&M of equipments
installed.
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Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
for battery requires proper planning as
well for environmental safety.
Indicator 2: Increase in
the number of
subcentres with
trained mid-level
service providers
(BSC nurses)
1. Recruitment and training of the MLPs
2. MLPs placed and working at subcenters
This will enhance service provision
capacity. Along with other trainings,
training on BMW management
modules will help knowledge base and
in turn better adherence to the BMWM
rules 2018.
1. Training module to be to be
prepared for BMW management
2. Training calendar to be prepared
for training of all MLPs on
BMW management.
Indicator 3: Of those
citizens screened,
an increase in the
number of patients
at high-risk* for
NCDs
(hypertension and
diabetes) who are
actively managed
at the first point of
contact-level
(subcentre, PHC)
1. Screening of Population by subcentre or PHC
staff
2. Laboratory/diagnostic tests undertaken
3. Risk-level and Treatment plan determined by
subcenter or PHC staff
4. Medication provided
5. Necessary studies, surveys contracted
Management of laboratory waste –
both liquid waste and reagent disposal
in absence of proper effluent treatment
can cause soil and water contamination
to local environment.
1. SOP to be prepared for
laboratory waste management
and ETP to be built in each of
the laboratory to ensure
adequate treatment of liquid
waste.
2. Training to be provided to
laboratory staffs on infection
control and biomedical waste
management– training calendar
to be prepared
Indicator 4: Increase in
the percentage of
women screened in
target age group
for cervical cancer
at subcentres or
1. Screening of women by subcentre or PHC staff
2. VIA testing
3. Women at risk referred
4. Follow-up undertaken to ensure referral happens
5. Outreach activities enhanced
Other than the risk already mentioned
above from diagnostic and laboratory
services, there are no additional
environmental risk.
1. As mentioned above
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Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
PHC facilities
Indicator 5: Increase in
the percentage of
women that are
registered in the
first trimester
receive full ANC
care
1. ASHA identify the women and ANM registers
the pregnant women
2. IFA, TT1, blood test provided
3. Conduct ANC at the mobile medical units
4. Conducting of the Village Health Nutrition Days
by ANMs
No major environmental risk
associated with this activity.
Result Area 3: Enabling patient-centreed care
Indicator 1: Increase in
the number of
facilities actively
using an integrated
online patient
management
system
1. Service contract with the provider of the
integrated online patient management system
executed (HMIS solution, hosting of electronic
model record (EMR) data in state data centre,
equipment for EMR recording, establishment
of medical transcription hub, training of health
care staff for operating the patient management
system)
While this will enhance services, it
will also have increased e-waste.
Currently the e-waste management is
not adequate across different tiers
HCFs.
1. Preparation of SOP to manage
e-waste coming out from CFs
and laboratories to adhere to e-
water management policy.
Indicator 2: Increase in
the percentage of
creation of EMR
for IPD and
chronic OPD cases
registered in the
facilities indicated
in DLI 1
1. Service contract with the provider of the
integrated online patient management system
executed
2. Staff at the facilities are entering and using the
EMR
3. Facilities identify nodal officers for
implementation
No major environmental risk
associated with this activity.
Indicator 3: Increase in
the percentage of
patients accessing
1. Service contract with the provider of the
integrated online patient management system
executed
No major environmental risk
associated with this activity.
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Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
information (web-
based, application-
based) through
PHRMS for which
the EMR has been
created as per
DLI2
2. Facilities supported with an online patient
management system
3. Patients are informed about the system through
SMS
4. Information education activities are undertaken
for raising public awareness
Indicator 4: Increase in
the number of
empaneled private
pharmacies able to
dispense state
financed drugs to
patients
1. Policy decision
2. Contracts with private providers
3. Information education activities are undertaken
for raising public awareness
Enhanced dispensing of drugs will
improve health services. However, it
requires supply chain to be strengthen
and SOP for disposal of expired
medicine.
1. As mentioned above, SOP to be
prepared for disposal of expired
medicines.
Indicator 5: Hospital
Development
Society (HDS)
provide regular
monitoring and
undertake actions
to improve quality
1. Administrative effort by the staff to
communicate with the communities and
functional operation of the Hospital
Development Societies
2. Increase in monthly conducting of Hospital
Development Society (HDS) meetings
3. HDS members review patient experience
feedback, funds availability and activities to be
undertaken to fill the gaps identified during
meetings
4. Minutes of meetings are recorded
No major environmental risk
associated with this activity. HDS can
closely monitor the mitigation of risks
as mentioned above and will
strengthen the institutional mechanism
for monitoring of the same.
1. Monitoring checklist to be
prepared for HDS to monitor the
facility with environment risk
perspective.
Indicator 6: System
developed and
rolled out to
measure and report
1. Service contract with the provider of the
integrated online patient management system,
Kiosks installed and operated
2. Information on patient reported experience
No major environmental risk
associated with this activity. Health
bulletins should also cover
implementation review of
1. Disclosure of adherence to
various SOP to be made public.
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Table (23): Environment Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
patient report
experience in a
standardized and
confidential way.
collected in a credible way
3. Administrative effort by the DoHFW staff to
analyze and share analysis through health
bulletins
4. IEC activities undertaken
environmental and health safety
measures.
6.2 Social Risk and Impact
Table (24): Social Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Result Area 1: Quality of Care
Indicator 1: Increase in
the number of
PHCs and CHCs
have more than 70
percent quality
score, sufficient to
seeking national
certification,
supported to
improve quality
and monitor sustain
quality.
1. Assessment of quality gaps undertaken by
facility and DoHFW staff
2. Training of the PHC and CHC Staff
3. Fill HR gaps
4. Minor infrastructure* enhancements
5. Minor furniture, equipment, other goods
procured
6. Service contract to establish and maintain
Quality Tracking Dashboard System
7. PHCs and CHCs report to the system
8. Service providers contracted and incentivized to
improve in clinical and non-clinical gaps
9. Maintenance and improvement of quality
monitored and supported
*infrastructure refers to minor building repairs
and modifications
Overall this set of activities will help
improve the quality of basic
infrastructure facilities in HCFs
especially at sub-centres and PHCs.
The project does not support any large-
scale construction and restricted to
minor repair and renovations and is
restricted to existing footprint of the
HCF and hence no additional land is
required.
1. Screening of HCF (PHC and
sub-centres) for ensuring the
delivery of basic infrastructure
facilities where repair and
renovations is planned.
Cumulative progress on delivery
of basic infrastructure primary
health care facilities to be
reported by districts.
2. Monitoring of HCFs (screening
checklist applicable) to rule-out
adverse impacts related to
involuntary resettlement of
squatters and non-title holders
on government land.
3. Implementation of ESMP as per
the ESMF wherever
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Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
renovations/civil works are
planned.
Indicator 2: Increase in
number of CHCs
and PHCs NQAS
certified
1. DoHFW administration organizes for review by
the national authorities
Accreditation process involves
improvement in overall infrastructure
and services including sanitation
facilities for both men and women.
21. Access to HCF for disabled
population to be ensured.
22. In line with existing DoHFW
policy, a targeted approach to
certify PHCs located in tribal
districts will be adopted.
Indicator 3: Increase in
coverage of core
services provided
through
performance -
based contracts at
CHCs and the
performance of
those services.
1. Sanitation service provider contracts
2. Biomedical equipment maintenance contract
3. Laboratory service contract
4. Tele-radiology service contracts
5. Patient satisfaction/ experience survey contract
The service contracts will help
improve services. However, it is
important to ensure that it is inclusive
and non-discriminatory.
1. The service contracts should
include the clause on (a) non-
discrimination of services with
respect to caste, creed and
gender, (b) prohibiting use of
child labour, (c) wage parity
among men and women
2. Regular health-check-ups for
contract workers.
Indicator 4: Improved
pharmaceutical
stock management
system at the PHCs
and CHCs.
1. Upgrading/ replacing of the supply chain
software with modern functionality
2. Management and operating of supply chain
3. Facility pharmacists incentivized to enter
information into the supply chain software
No specific social risk associated with
this activity, however building
capacity of personnel at geographically
difficult to reach PHCs (located in
tribal/rural areas) needs to be
prioritized.
Result Area 2: Integrated Primary Health Care
72
Table (24): Social Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Indicator 1: Increase in
the number of
functional e-sub-
centres, including
with solar power
energy solution
where appropriate
and model
evaluated.
1. Service contract with teleconsultation provide
and operate the following: refurbish the
facility, provide the diagnostic and drug
vending machine, computer with internet and
telemedicine solution, and doctors‟ hub
2. ANM staff work at the Sub-centres
3. Expanded list of essential drugs provided to sub-
centres
4. Policy decision will be taken about the extension
of solar power to subcentres
5. Installation, operation and maintenance of the
solar power at subcentres according to policy
decision
These set of activities will enhance the
capacity of Sub-centre. Sub-centre
being the first point of contact for
health care services it will improve
quality of health care in state.
In line with existing DoHFW policy, a
positive targeting approach will be
adopted to upgrade e-sub-centres in
tribal and ITDA areas.
Training and capacity building of
personnel for e-sub centres located in
tribal and ITDA areas.
1. Preparation of an annual action
plan to identify and target sub-
centres located in tribal areas for
upgradation. This is as per
existing best practice adopted by
DoHFW.
Indicator 2: Increase in
the number of
subcentres with
trained mid-level
service providers
(BSC nurses)
1. Recruitment and training of the MLPs
2. MLPs placed and working at subcentres
While this will enhance service
quality, it is important that the ITDA,
other tribal areas and difficult to reach
areas are also prioritized as they need
the services the most.
1. Preparation of an annual action
plan to a) map blocks/agencies
that need to be prioritized and
b)identify and target sub-centres
located in tribal/ITDA areas for
upgradation. This is as per
existing best practice adopted by
DoHFW.
Indicator 3: Of those
citizens screened,
an increase in the
number of patients
at high-risk* for
NCDs
(hypertension and
diabetes) who are
1. Screening of Population by subcentre or PHC
staff
2. Laboratory/diagnostic tests undertaken
3. Risk-level and Treatment plan determined by
subcentre or PHC staff
4. Medication provided
5. Necessary studies, surveys contracted
While women tend to access services
geared towards maternal care and child
care, they often delay treatment
seeking behavior for diseases such as
diabetes, hypertension, breast, cervical
and oral cancers etc. This can be for a
variety of reasons including well-
documented time-poverty, double
1. Preparation of a behavior
change and communication
(BCC) strategy that is
interactive in nature. The
objective will be to address
misconceptions and spread
awareness about NCDs such as
cervical cancer.
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Table (24): Social Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
actively managed
at the first point of
contact-level
(subcentre, PHC)
burden of unpaid domestic work and
patriarchal norms so that women often
put the health of their children and
male members of the family at a
higher priority than their own health.,
Indicator 4: Increase in
the percentage of
women screened in
target age group
for cervical cancer
at subcentres or
PHC facilities
1. Screening of women by subcentre or PHC staff
2. VIA testing
3. Women at risk referred
4. Follow-up undertaken to ensure referral happens
5. Outreach activities enhanced
There is little awareness about cervical
cancer among the target population
including women. Also, women
take laid back approach when it
comes to prioritizing their health
needs.
1. Preparation of a behavior
change and communication
(BCC) strategy that is
interactive in nature. The
objective will be to address
misconceptions and spread
awareness about NCDs such as
cervical cancer.
2. Preparation of a detailed action
plan to build capacity of Village
Health Committees to
effectively discuss and
disseminate information on
NCDs and menstrual hygiene.
Indicator 5: Increase in
the percentage of
women that are
registered in the
first trimester
receive full ANC
care
1. ASHA identify the women and ANM registers
the pregnant women
2. IFA, TT1, blood test provided
3. Conduct ANC at the mobile medical units
4. Conducting of the Village Health Nutrition Days
by ANMs
There is a possibility that women from
tribal/rural areas do-not access full
ANC care.
1. Mapping of low performing
areas.
2. Annual action plan to improve
delivery of full ANC care in
tribal and ITDA areas.
Result Area 3: Enabling patient-centered care
74
Table (24): Social Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Indicator 1: Increase in
the number of
facilities actively
using an integrated
online patient
management
system
1. Service contract with the provider of the
integrated online patient management system
executed (HMIS solution, hosting of electronic
model record (EMR) data in state data centre,
equipment for EMR recording, establishment
of medical transcription hub, training of health
care staff for operating the patient management
system)
Patient data security could become an
issue if not given priority.
1. Adequate data security to be
ensured to safeguard the privacy
of the patient data.
Indicator 2: Increase in
the percentage of
creation of EMR
for IPD and
chronic OPD cases
registered in the
facilities indicated
in DLI 1
1. Service contract with the provider of the
integrated online patient management system
executed
2. Staff at the facilities are entering and using the
EMR
3. Facilities identify nodal officers for
implementation
This will help enhance proper follow-
up care with patient records. It has no
specific social risk with these set of
activities.
Indicator 3: Increase in
the percentage of
patients accessing
information (web-
based, application-
based) through
PHRMS for which
the EMR has been
created as per
DLI2
1. Service contract with the provider of the
integrated online patient management system
executed
2. Facilities supported with an online patient
management system
3. Patients are informed about the system through
SMS
4. Information education activities are undertaken
for raising public awareness
No specific social risk associated to
these activities.
1. Awareness and knowledge to
access patients record and at an
appropriate time needs attention.
Indicator 4: Increase in
the number of
empaneled private
1. Policy decision
2. Contracts with private providers
3. Information education activities are undertaken
While this will be help patients for
easy access to drugs, adequate
attention to be put in for ensuring ma
1. Adequate safeguard clause to be
built into empaneling
pharmacies from any
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Table (24): Social Risks and Impacts
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
pharmacies able to
dispense state
financed drugs to
patients
for raising public awareness
practice of any kind. malpractice.
2. Adequate monitoring
mechanism to be built towards
this.
Indicator 5: Hospital
Development
Society (HDS)
provide regular
monitoring and
undertake actions
to improve quality
1. Administrative effort by the staff to
communicate with the communities and
functional operation of the Hospital
Development Societies
2. Increase in monthly conducting of Hospital
Development Society (HDS) meetings
3. HDS members review patient experience
feedback, funds availability and activities to be
undertaken to fill the gaps identified during
meetings
4. Minutes of meetings are recorded
As per existing norms, HDS should
also have representation from
community and should include
women representation and
members of tribal and vulnerable
groups.
1. HDS formation should be
instructed with respect to
inclusion of women and
vulnerable group population
including tribal population
where applicable.
Indicator 6: System
developed and
rolled out to
measure and report
patient report
experience in a
standardized and
confidential way.
1. Service contract with the provider of the
integrated online patient management system,
Kiosks installed and operated
2. Information on patient reported experience
collected in a credible way
3. Administrative effort by the DoHFW staff to
analyze and share analysis through health
bulletins
4. IEC activities undertaken
Awareness and knowledge towards
importance of feedback and how to
operate these kiosks will be important.
1. Creation of a central, project
level Grievance Redressal
Mechanism to a) consolidate
different complaint numbers
used by hospitals b)to monitor
the nature and pattern of
complaints across districts.
2. Adapting the IEC material
received under NHM to a)make
it available in local dialect b)
using audio-visuals to create
awareness and disseminate
information.
76
7 ENVIRONMENTAL MANAGEMENT PLAN
7.1 The Process of Preparing Site Specific EMP
110. Given the site-specific investments/ interventions are not known at each facility, the ESMF
will guide investments and activities in a manner that they are environmentally and socially sound,
and do not result in adverse impacts. The objective of the ESMF is to:
Ensure integration of environmental and social safeguards into the planning process at state
and district level
Describe the procedures to ensure compliance with the applicable regulatory, and policy
obligations described earlier in the report
Describe the role and responsibilities of the concerned agencies/ institutions and the capacity
building requirements to enable effective management of the potential environmental and
social impacts.
111. In order to prepare the site specific EMP, the process will include:
1. Screening of key environmental and social risk arising out of the project activity( checklist in
annex 1)
2. Identify the risk and apply the potential mitigation measures as outlined in the ESM document
or seek guidance from expert on the same
3. Build capacities for smooth implementation an adherence as per ESMF
4. Consultation and disclosure of the site-specific plan
5. Ensure compliance to legal and regulatory framework in implementation of the proposed
activity,
6. Monitoring and Reporting
7.1.1 Screening of the Site Proposed Activities
112. Purpose: The screening process is the first step in the ESMF process. The purpose of
screening is twofold:
To ensure that activities that are likely to cause significant negative environmental or social
impacts are not supported
To ensure that all supported activities are in accordance with the laws, regulations of the
Government and with the safeguard policies of the World Bank.
113. Responsibility for Screening: The HCF in-charge i.e. ANM for SC, MO for PHC and CHC,
Hospital Administrator for AH and DH will undertake the Screening using the Screening Checklist
(see Annex-1) as part of the technical preparation work for activities under the guidance of
Environmental and Social Safeguard consultant at SPIU, and delegated staffs for ESMF
implementation at district level i.e. District Quality Manager (DQM).Both the DQM and HCF in-
charge will be trained by the SPIU for conducting the screening in proper manner.
114. When the Screening will be done: It is proposed that the screening will be done at the time
of planning for the intervention activities in that HCF.
115. Screening Report: Once the screening is completed a copy of the screening report to be
compiled by the District Level Safeguard In charge i.e. DQM and sent to SPIU for information.
77
7.2 Key Environmental Risks and Potential Mitigation Measures
116. The APHSSP project is expected to impact positively on the health and socio-economic
development of the state as a whole. The project with the key objectives of achieving the three result
areas viz. Quality of care, Integrated Primary Health Care and enabling patient-centred care is
expected to improve the healthcare services through quality accredited facilities, extended reach with
technology and patient centric care initiatives and services.
117. During the various phases of the APHSSP implementation, it is expected that there will be
environmental risks and impact based on the numerous activities undertaken ranging from minor civil
works (refurbishment) to bio-medical waste management (e-wastes, liquid and solid wastes). The
incorporation of environmental concerns during planning, designing, implementation and monitoring
stages by formulating Environmental Management Guidelines/ Standard Operating Procedures
(SOPs) and building capacities within the institutional structure and the concerned agencies will be
important to ensure compliance and to enhance positive impacts and mitigate negative impacts in the
development of the proposed project activities.
118. The below table presents the potential environmental risks or impacts are identified for the
APHSSP project with the classifications done on the basis of the Result Areas.
Table (25): Environmental Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
Result Area 1: Quality of care
1 Inadequate medical waste
disposal techniques with
increase in waste generation
Risks of hazardous solid and
liquid waste causing
contamination to soil and water
Disposal of expired drugs
1. Carry out environment and social screening as per
Annexure 1 and implement the ESMP as needed
where there are impacts identified.
2. Building capacity of HCF staffs on bio-medical waste
management – both solid and liquid and infection
control measures.
3. All waste to be managed in accordance to the
principles of the biomedical waste management rules,
2016, and their implementation guidelines.
4. SOPs for management of e-waste, plastics,
pharmaceuticals, and hazardous waste (x-ray
developer) both for staff and service provider will be
utilized.
5. SoP for notification and disposal of expired medicines
so that it is not disposed in regular solid and liquid
waste streams
6. SOP for biomedical waste management system will be
utilized
7. Checklist and SOP for infection control measures will
be utilized
8. Health and safety SOPs to be prepared and
incorporated in the service contract of various service
provider for sanitation services, bio-medical services,
and laboratory services
9. ETP to be scaled up to CHC level which are going to
take up NQAS certification. For smaller facilities with
no sewerage connection, suitable arrangements such as
liquid disinfection, septic tank and soak pit will be
introduced.
10. No-run-off from site should allow to get into rivers or
accumulate at site or nearby areas
78
Table (25): Environmental Impacts and Mitigation Measures
Sl. No. Risks/Impact Mitigation Measures
11. SoP for notification and disposal of expired medicines
so that it is not disposed in regular solid and liquid
waste streams
12. Training calendar for healthcare staffs on BMW
management.
13. Infection control measures inspection checklists to be
prepared and utilized by hospital administrator.
14. Ensure all sterilization and disinfection equipment is
in proper working condition.
15. Disclosure of adherence to SOP to be made public
through health bulletins.
Result Area 2: Integrated Primary Health care
2 Continued supply of electricity
to facilities required for e- e-
sub-centres including
installation of solar rooftop
supply
Potential contamination to soil
and water from Management of
laboratory waste – both liquid
waste and reagent disposal
1. Carry out environment and social screening as per
Annexure 1 wherever civil works are envisaged and
implement the ESMP as needed where there are
impacts identified.
2. Installation of solar panels for uninterrupted power
supply. Design specifications to be made in such a
manner that incorporates adequate space for solar
panels as well as installation of battery and wiring.
3. Safety standards to be ensured for installation of solar
panels
4. Batteries need to be disposed as per the Batteries
(Management and Handling) Rules, 2001.
5. SOP to be prepared for O&M and safety of solar
equipments installed.
6. Training module to be to be prepared for BMW
management, and worker health and safety and
training calendar to be prepared for training of all
MLPs on BMW management.
7. SOP to be prepared for laboratory waste management
and connection to ETP/ soak pit to be provided in each
of the laboratory to ensure adequate treatment of liquid
waste.
8. Liquid waste effluent should meet discharge standards
of government of India before final disposal.
9. Training to be provided to laboratory staffs – training
calendar to be prepared
Result Area 3: Enabling patient-centred care
3 Increase in E-waste generation
due to enhanced services to be
monitored by HDS
1. SOPs for e-waste management will be prepared along with
monitoring checklist
2. Trainings to be provided on e-Waste management to all
healthcare and laboratory workers. This will be integrated
into the overall environmental safeguards trainings.
3. Disclosure of adherence to SOP to be made public through
health bulletins.
79
7.3 ENVIRONMENT MANAGEMENT PLAN
119. Based on the risks assessed, below is the Environment Management Plan (EMP) with specific activities at different stages of the project.
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
Planning Phase
General Site and Worker
Safety
Notification and
Worker Safety
vii. The local communities/ public has been notified of the
works through appropriate notification and/or at publicly
accessible sites
viii. All legally required permits (to include not limited to
resource use, dumping, sanitary inspection permit have
been acquired for construction and/or rehabilitation
ix. All work will be carried out in a safe and disciplined
manner designed to the site to minimize impacts on
neighboring residents and environment.
x. Workers‟ PPE will comply with international good
practice (hardhats, as needed masks and safety glasses,
harnesses and safety boots)
xi. Appropriate signposting of the sites will inform workers
of key rules and regulations to follow.
xii. Sanitation facilities shall be provided for all site
workers.
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document.
Site level
monitoring by
HCF In-charge
Physical and Cultural
Properties
Historic sites iii. If the HCF is located very close to such a structure, or
located in a designated historic district, notify and obtain
approval/permits from ASI/local authorities and address
all construction activities in line with local and national
legislation
iv. Ensure that chance finds provision is activated in case
any artifact is encountered in excavation
Screening will be
conducted by the
HCF In-charge.
DMHO to facilitate in
getting the respective
permissions
By District Level
Safeguard In
charge i.e. DQM
Implementation phase
General Rehabilitation and
/small civil works
Air quality /
Dust
vi. Keep demolition debris in controlled area and spray with
water mist to reduce debris dust
Contractor
responsibility at site;
HCF in charge/
Hospital
80
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
Activities vii. Suppress dust during pneumatic drilling/wall destruction
by ongoing water spraying and/or installing dust screen
enclosures at site
viii. Keep surrounding environment (sidewalks, roads) free
of debris to minimize dust
ix. There will be no open burning of construction / waste
material at the site
x. There will be no excessive idling of construction
vehicles at sites
SPIU to ensure
relevant clauses being
included in the
contract document
Administrator
and District Level
Safeguard In
charge i.e. DQM
Noise v. Construction noise will be limited to restricted times
agreed to in the permit.
vi. During operations the engine covers of generators, air
compressors and other powered mechanical equipment
should be closed, and equipment placed as far away
from residential areas as possible.
vii. Materials such as sand, cement, or other fine particles
should be kept properly covered. And moistened with
sprays of water.
viii. Unpaved, dusty roads should compact and then wet
periodically.
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
Drainage iii. The worksite site will establish appropriate erosion and
sediment control measures to prevent sediment from
moving off site and causing excessive turbidity in
nearby streams and rivers.
iv. Keep all drains clear of silt and debris
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
contract document
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
Construction
waste
management
iv. Waste collection and disposal pathways and sites will be
identified for all major waste types expected from works
activities.
v. wastes will be separated from general refuse, organic,
liquid and chemical wastes by on-site sorting and stored
in appropriate containers.
Contractor
responsibility at site;
SPIU to ensure
relevant clauses being
included in the
HCF in charge/
Hospital
Administrator
and District Level
Safeguard In
charge i.e. DQM
81
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
vi. Construction waste will be collected and disposed
properly by licensed collectors
contract document
Toxic Materials Toxic /
hazardous waste
management
vi. There will be no waste dumping in adjacent areas to the
HCF.
vii. Temporarily storage on site of all hazardous or toxic
substances will be in safe containers labeled with details
of composition, properties and handling information
viii. The containers of hazardous substances should be placed
in leak-proof container to prevent spillage and leaching.
ix. The wastes are transported by specially licensed carriers
and disposed in a licensed facility
x. Paints with toxic ingredients or solvents or lead-based
paints will not be used
HCF in charge/
Hospital
Administrator
District Level
Safeguard In
charge i.e. DQM,
and SPIU
Asbestos
Management
vii. If asbestos is located on the project site, the following
provisions will apply
viii. Mark clearly as hazardous material
ix. When possible, the asbestos will be appropriately
contained and sealed to minimize exposure.
x. The asbestos prior to removal (if removal is necessary)
will be treated with a wetting agent to minimize asbestos
dust Asbestos will be handled and disposed by skilled
and experienced professionals
xi. If waste asbestos material is to be stored temporarily, the
wastes should be securely enclosed inside closed
containments and marked appropriately
xii. The removed asbestos will not be reused and will follow
the IS 11768 (1986) Recommendations for disposal of
asbestos waste material and CPCB Hazardous waste
rules, 2016.
HCF in charge/
Hospital
Administrator
District Level
Safeguard In
charge i.e. DQM,
and SPIU
Operations Phase
Disposal of Bio-medical
Waste
iv. In compliance with national regulations the
rehabilitated health care facilities should include
sufficient infrastructure for medical waste handling and
HCF in charge/
Hospital
Administrator at the
District Level
Safeguard In
charge i.e. DQM,
82
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
disposal; this includes and not limited to:
d. Special facilities for segregated healthcare waste
(including soiled instruments “sharps”, and human
tissue or fluids) from other waste disposal:
Clinical waste: yellow bags and containers
Sharps – Special puncture resistant
containers/boxes
Domestic waste (non-organic): black bags and
containers
e. Appropriate storage facilities for medical waste are
in place
f. If the activity includes facility-based disposal, such
as burial pits, the appropriate disposal options are
in place and operational.
v. Develop SOPs for managing bio-medical and other
wastes within healthcare facilities (HCF) to ensure the
proper standard operating procedures based on the
NQAS accreditation standards are followed and
implemented.
vi. Build capacity of healthcare workers to manage
medical facilities and ensure good technical support in
implementing effective waste management system.
facility level;
District Level
Safeguard In charge
i.e. DQM and SPIU
for capacity building
SPIU for SOPs
and SPIU
Wastewater Treatment
Systems
Water Quality iv. The approach to handling wastewater from larger HCFs
(installation or reconstruction) must be approved by a
qualified engineer.
v. Before being discharged into receiving waters, effluents
from individual wastewater systems must be treated in
order to meet the minimal quality criteria set out by
national guidelines/ WBG guidelines on effluent quality
and wastewater treatment
vi. Monitoring of new wastewater systems (before/after)
will be carried out.
HCF in charge/
Hospital
Administrator and
District Level
Safeguard In charge
i.e. DQM
SPIU
Community Health and
Safety
Exposure to
hazardous health
xi. Avoid mixing general health care waste with hazardous
health care waste to reduce disposal costs;
HCF in charge/
Hospital
District Level
Safeguard In
83
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
care waste xii. Segregate waste containing mercury for special
disposal Management of mercury containing products
and associated waste should be conducted as per the
CPCB guidelines.
xiii. Segregate waste with a high content of heavy metals
(e.g. arsenic, lead) to avoid entry into wastewater
streams
xiv. Transport waste to storage areas on designated trolleys
/carts, which should be cleaned and disinfected
regularly
xv. Separate residual chemicals from containers and
remove to leak-proof containers resistant to chemical
corrosion effects. Return unused chemicals to supplier
xvi. Facilities should have permits for disposal of general
chemical waste (e.g. sugars, amino acids, salts) to
sewer systems.
xvii. Larger quantities of chemical wastes are to be
transported to appropriate facilities for disposal, and
not be encapsulated or landfilled.
xviii. Aerosol cans and other gas containers should be
segregated to avoid disposal via incineration and
related explosion hazard.
xix. HCFs should have impermeable floor with drainage
and designed for cleaning / disinfection.
xx. Treatment Facilities receiving hazardous health care
waste should have all applicable permits and capacity
to handle specific types of health care waste.
Administrator charge i.e. DQM
and SPIU
Worker Health and Safety iv. Development of Facility policies, procedures and
protocols (including SOPs), and awareness on infection
control policies, supervision and management
v. Trainings should be provided to all healthcare and
sanitation workers on use of PPE, handling of infectious
materials and wastes (e. g. blood).
vi. The NQAS accreditation process support
Safeguard Consultant
at SPIU
SPIU
84
TABLE 26: ENVIRONMENT ACTION PLAN
ACTIVITY PARAMETER MITIGATION (AS APPLICABLE) RESPONSIBILITY MONITORING
implementation of the IMEP guidelines, project will
ensure the standardization of necessary procedures and
protocols (SOPs) will be carried out to safeguard the
workers in the facility.
Management hygiene
within HCF
vi. Hygiene promotion is important for health care workers
and patients. They should be given constant reminders
and information of the importance of infection control
such as handwashing points.
vii. Toilets should be cleaned whenever they are dirty, and at
least twice per day, with a disinfectant used on all
exposed surfaces.
viii. Water points, with soap and adequate drainage, should
be provided for all toilets, and their use should be
actively encouraged
ix. Toilets should be designed, built and maintained so that
they are hygienic and acceptable to use and do not
become centres for disease transmission. This includes
measures control fly and mosquito breeding, and a
regularly monitored cleaning schedule.
x. Posters and other visual information should be used to
promote infection control among healthcare workers and
patients.
HCH in charge District Level
Safeguard In
charge i.e. DQM
85
8 SOCIAL MANAGEMENT PLAN
8.1 Key Social Risks Identified and Potential Mitigation Measures
120. The APHSSP project has both environmental and social ramifications since Andhra Pradesh
has a geographical cultural, economic and social diversity. Any health care delivery system will need
to address and include all the variables affecting the population of the state. With reference to chapter
6 of the ESMF, the potential social risks and impacts of APHSSP were identified and appropriate
mitigation measures drafted through consultations with both primary and secondary stakeholders.
Chapter 5 on stakeholder consultations has brought to fore the ground level needs and anticipated
impact of the project. Keeping the above in mind the social management plan across the three key
results areas has been drafted.
121. The key results area being a) Improvement of quality in both process and facility through
NQAS, b) leveraging technology and advance laboratory techniques to raise the standards of SCs and
PHCs, c) patient-centric care using technology through an electronic health record, quality monitoring
and feedback systems, the social management plan encompasses all the risks and impacts identified
under the above three result areas.
Result Area 1: Quality of care
Risks / Impact:
Accreditation process involves improvement in overall infrastructure and services including
sanitation facilities for both men and women.
The service contracts will help improve services. However, it is important to ensure that it
is inclusive and non-discriminatory.
Mitigation Measures:
Screening of HCF where repair and renovations is planned to rule out any adverse social
impact.
Access to HCF for disabled population to be ensured. The service contracts should include
the clause on (a) non-discrimination of services with respect to caste, creed and gender, (b)
prohibiting use of child labour, (c) wage parity among men and women
Result Area 2: Integrated Primary Health care
Risks / Impact:
ITDA, tribal areas and difficult to reach areas may be missed out.
Socio-cultural barriers prevent women from coming out for screening.
There is little awareness about NCDs and cervical cancer among women population.
Mitigation Measures:
Special focus to be given to tribal and difficult to reach areas. Geographical connectivity and
social diversity need to be included as variables in the proposed plans. Sub-centre in ITDA/
tribal and hard to reach areas to be prioritized.
Adequate IEC material to ensure awareness and knowledge of services and their access,
availability and continuity of care among the target beneficiaries including in the tribal areas
with culturally appropriate manner and in the language understood by them.
To ensure adequate screening of women for NCDs and cervical cancers, awareness generation
and behavior change activities will be conducted to address socio-cultural barriers.
86
Result Area 3: Enabling patient-centred care
Risks / Impact:
Patient data security could become an issue if not given priority.
Probability of mal practices during drug dispensing.
Non- inclusion of women, tribal, vulnerable groups in the HDS.
Technologically handicapped - Awareness and knowledge towards importance of feedback
and how to operate these kiosks will be important.
Mitigation Measures:
Adequate data security to be ensured to safeguard the privacy of the patient data such as AES
encryption and gateway control.
Adequate safeguard clause to be built into empaneling pharmacies from any malpractice.
Representative inclusion of all stakeholders in the community, viz. women, tribal, vulnerable
groups in the HDS
IEC activities to create awareness and knowledge to the citizens regarding access to their
patients record.
8.2 TRIBAL (INDIGENOUS PEOPLE)DEVELOPMENT FRAMEWORK
122. The presence of STs in the project area triggers the World Bank‟s Indigenous People‟s Policy
(OP4.10). The state is divided into 13 districts with presence of scheduled tribes (STs) varying across
these districts. Further, five districts have blocks/agencies identified as Schedule Areas as per the
Andhra State Order (Cesar), 1955 and A.P Reorganization Act, 2014. These districts have been
covered under the AP Health Systems Project.
123. Consistent with requirements of the OP, a Tribal Development Framework (TDF) is prepared
to ensure informed consultations and targeted outreach among tribal populace during preparation and
implementation, promote their inclusion and participation in project interventions, institutions and
benefit sharing; and enable the project to adopt socially and culturally compatible ways of working
among tribal beneficiaries.
124. The Tribal Development Framework includes mapping of interventions currently being
undertaken by the state government to enhance access to health services and interventions being
planned under the project to strengthen institutional capacity and service delivery of public health
facilities amongst tribal and marginalized communities.
8.2.1 Socio-economic context of the state
125. Geography: Srikakulam, Vizianagram, Vishakhaptanam, East Godavari and West Godavari
districts in the state are identified as Integrated Tribal Development Agencies. (ITDA). Some of the
prominent tribal groups in the state include Savara, Jatapu, Jatapu, Kondadora, Savara, Gadaba,
Kondadora, Bagata, Kondh, Valmiki, Porja, Kondadora, Koya, Koya, Yerukula, Kondareddi.
126. In 2011, population of SC and ST is about 13.9 and 5 million comprising 16.4% and 5.6%
respectively of the total population in the state. Andhra Pradesh accounts for about 6.9% of total
population of SCs, and 6.0% of the total STs in India. As compared to all-India, the percentage of SCs
in the total population was marginally lower while ST population was nearly 2 percentage points
lower in the state. The share of the state with respect to the population of the country India had
declined. Although proportion of the SC/ST population has increased over time in the state as well as
87
all-India, rate of increase in the state seems to be relatively lower than all-India average.
127. Urbanization: Trends of urbanization amongst these communities indicate that about 27.3%
of the total population in Andhra Pradesh was located in urban areas in 2001 whereas the degree of
urbanization for SC/ST communities is very low: 7.5% for STs and 17.2% for SCs. Across districts, a
similar pattern was seen with a few exceptions; urbanization was higher all community average in
Vizianagaram and Visakhapatnam districts for SCs and in Prakasam for STs. Between these two
communities‟ urbanization was higher for STs higher than that of the SCs particularly in Krishna,
Nellore, Chittoor and Kadapa districts. It was vice-versa in other districts. The highest degree of
urbanization for SCs was observed in Hyderabad district, followed by Visakhapatnam, Rangareddy,
Adilabad, Vizianagaram and Kurnool districts. The lowest urbanized SCs was observed in
Mahabubnagar district followed by Medak, Prakasam and Nalgonda. Similarly, the most urbanized
district for STs was also Hyderabad, followed by Guntur, Krishna, Kurnool and Prakasam districts.
The least urbanized district for STs was Srikakulam followed by Mahabubnagar, Nizamabad and
Vizianagaram. It is also noticed that the degree of urbanization among STs was below 5% in eight
districts.
128. Literacy: A disaggregated analysis by gender and caste shows that ST women were the most
backward and their literacy rate was one-fourth of the state average. This suggests that ST female
adults could not avail of the desired benefit from literacy campaigns and/or from formal schooling
facilities as compared to SC female adults in rural Andhra Pradesh. SC male adults, however, could
benefit from these initiatives to improve their literacy position between 1991 and 2001 (Reddy et al.
2008).
129. Economic profile: There is a decline in the percentage of ST households who were cultivators
indicates loss of land resources and corresponding increase in the dependency on agricultural labour
between 1991 and 2001 (Census data). It is to be noted that the percentage of population depending
on agriculture labour in the state has increased only in the case of ST, whereas it declined for SCs.
Among the cultivator households, the majority are marginal and small cultivator households across all
social groups including those belonging to STs9. However, these groups, especially the STs, are
unaware of modern methods of cultivation and use outmoded techniques. Besides, they get a low
price for their output due to inadequate basic infrastructure coupled with limited access to market.
8.2.2 Tribal Health Issues
130. Typically, development policy argues that strategies and approaches adopted for disease
control in non-tribal areas cannot be automatically adopted in the tribal areas, which are characterized
by dispersed populations, poor communications; acute poverty; low literacy; and social and cultural
variations. At the state level, an early pilot using innovative technology-based approach to facilitate
provision of NCD services at the SC level was introduced. An early pilot of this model in 40 SCs in
tribal areas indicated positive results with an increase in out-patients at the SC from an average of 18
out-patients per month in the first quarter of implementation to 39 out-patients per month by the
second quarter. This included tele-medicine services at the SC level, bring doctors closer to the
community.
131. A well-designed evaluation will be carried out to assess the impact and effectiveness of the
model as it is scaled up from 40 to 6190 SCs. The findings will feed into improvements in program
design. The approach will also be well documented and disseminated through inter-state and
international knowledge exchange events contributing to global knowledge on health service delivery.
9Revised Draft: January 2013 Situation Assessment Analysis of SC/STs in Andhra Pradesh – M. Venkatanarayana Page 15
88
8.2.3 Tribal Reform Yardstick
132. Tribal Health has remained a priority area for the Government of Andhra Pradesh. In order to
ensure focused approach across the 7 ITDAs, adequate interface with the broader development agenda
is much required. More importantly and strategically, given that the development would be brought
collectively by several departments, a “yardstick” for measurement of successes and failures would
need to be developed so that to ascertain the attainment of objectives in a time bound manner. While
strengthening of programs, facilities and strategies to reach more tribal area residents would need to
be re-emphasized, key general developmental parameters of the ITDAs would also need to be put in
place in coordination with other departments and agencies. The Tribal Reform Yardstick (TRY)
Program is aimed to translate efforts into results in a time-bound manner. The Government through
G.O.Ms.No.89 dated 07.06.2017 have constituted the TRY programme in order to ensure the focused
approach across the 7 ITDAs along with the firm commitment for providing health care to people in
tribal areas.
133. The TRY framework Indices as arrived out of multi departmental consultations, including the
feedbacks and suggestions received from ITDAs, have been categorized into health and other
developmental components and are enumerated below. Each indicator would have a baseline, an
estimated quarterly target for FY 2017-18 and FY 2018-19. The achievements shall be presented to
the Government of AP on a quarterly basis. A minimum increase/betterment by 12.50% per quarter
for each of the indicators would be kept as target and the achievement shall be rated against this
target. Apart from achieving development in the tribal areas and enhancement in health indicators, the
TRY program shall bring economic growth stimulants such as 125% reimbursement to hospitals in
Tribal Areas under NTR-Vaidya Seva&Aarogya Raksha Programs, development of Araku as a Health
Valley through Araku Medical Rehabilitation Infrastructure Township (AMRIT) project.
134. Health Indices: Under the Programs, Health, Social well-being and general development
indices shall be captured as per following indices chart, across all associated departments:
Table (27): Tribal Reform Yardstick (TRY) Health and Social Well Being Indices
S.No. Key Indicator Baseline
(FY)
Target
(FY)
Quarterly
Targets
1 Availability of Drugs:
No. of Drugs & percentage availability
2 Diagnostics workload:
No. of tests/month
3 ChandrannaSancharaChikitsa coverage density in
Shandis
4 Feeder Ambulance service density per Ambulance
5 PPP based SNCU (Sick new born care unit) in all
CHCs
6 PPP based sub-centres in telemedicine mode
7 Select non- 24X7 PHCs into 24X7 PHCs
8 At least state of art Area Hospitals in all ITDAs
9 Area Hospitals @ 1 Lakh population (over and
above point-8)
10 District Hospitals @ 5 Lakh population
11 Mission Organizations adoption of ITDAs for
89
Table (27): Tribal Reform Yardstick (TRY) Health and Social Well Being Indices
S.No. Key Indicator Baseline
(FY)
Target
(FY)
Quarterly
Targets
supporting CHCs, AHs and DHs
12 OT modernization in 24X7 PHCs, CHCs & DHs
13 Ultra-sonography services at all CHCs
14 Availability of LLINs
135. Developmental Indices:
Table (28): Tribal Reform Yardstick (TRY) General Development Indices
Sl. No. Key Indicator Baseline
FY
Target
FY
Quarterly
Targets
1 Road Density & road connectivity to all villages in all
ITDAs (% of villages with
road)
2 Mobile connectivity density
3 Water supply to all panchayats & villages
4 Literacy Levels
5 Marriage age for girls
136. The Government plans to set up the TRY task force under the Chairmanship of Chief
Secretary to the Government of Andhra Pradesh with the representatives from the following
departments:
1. The Principal Secretary to Government, Tribal Welfare Department - Member
2. The Principal Secretary to Government, Health, Medical and Family Welfare Department -
Member
3. Advisor to Government, Health, Medical and Family Welfare Department - Member
4. The Secretary to Government, Women Development & Child Welfare, Department - Member
5. The Principal Secretary to Government, Education Department - Member
6. The Principal Secretary to Government, Water Resources Department. - Member
7. The Principal Secretary to Government, IT & Communications Department - Member
8. The Principal Secretary to Government, Tourism Department - Member
9. The Principal Secretary to Government, Roads & Buildings Department - Member
10. The Spl. CS to Government, Panchayat Raj & RWS Department - Member
11. Project officers of all ITDAs - Members & to perform as convener with a rotational duty of 6
months each.
137. The task force shall also have all Project Officers, ITDAs as members and each Project
Officer, ITDA shall have a rotational duty of 6 months to serve as Program Coordinator. The task
force shall meet once in a month to review the progress and will also submit report on the progress
achieved by concerned departments to Government of AP, on a quarterly basis. The taskforce shall
further constitute sub committees for speedy progress of work & its monitoring. The sub committees
shall include that on health and family welfare; general development; and infrastructural development
including medical tourism.
138. The below table indicates the quarterly targets for the TRY indicators.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
90
(2018-19)
1 Availability of Drugs:
No. of Drugs &
percentage availability
QTR I QTR II QTR III QTR IV
PHC- 138 160 160 160 160 160
CHC-215 249 249 249 249 249
AH -230 270 270 270 270 469
All the essential drugs (EML) shall be supplied to all the hospitals and capping on quarterly consumption removed.
Hospitals are permitted to draw 25% extra than the allotted budget to mitigate seasonal diseases. The target increase
in drug availability shall be achieved in the Quarter 1 of 2017-18
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET (2018-
19)
2 Diagnostics workload:
No. of tests/month
722 samples/
month (19 tests at
PHC level, 40
tests at CHC level
and 62 tests at AH
level)
4000 samples / month (50 % of that in
Vijayawada city) LFT, Serum
Creatinin, Thyroid profile,
Haemoglobinopathes on outsourcing
shall be included in Q2 at PHC level
2000 samples /
month by Q-2
(increase by 250
samples per
month)
As of now 7 tests are outsourced and 12 tests are being conducted in-house and it is proposed to conduct 11 tests
including LFT, Serum Creatinin, Thyroid profile, Haemoglobinopathes on outsourcing and a total 23 tests shall be
done at PHC level. The CHC and AH shall have 21 and 42 tests done on outsourcing in addition to the 19 tests at
CHC and 19 tests at AH done in the in-house labs.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
3 ChandrannaSanchara
Chikitsa coverage
density in Shandis
29 CSCs are
serving 4435 ST
beneficiaries per
MMU
QTR I QTR II QTR III QTR
IV
Additional 15
are proposed
2 Vehicles for Seetampeta
2 Vehicles for Parvathipuram
6 Vehicles for Paderu
2 Vehicles for RC Varam
2 Vehicles for Chintoor
2 Vehicles for Sirsailam
As of now 29 ChandrannaSancharaChikitsa vehicles are plying in tribal areas and keeping in view of the periodicity
of the shandies and density of participation, 15 more CSC vehicles shall serve the tribal people (density of
participation is 3000-6000 per shandy).
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
4 Feeder Ambulance 72 special QTR I QTR II QTR III QTR IV
91
service density per
Ambulance
ambulances 144
As of now 72 special ambulances are plying in ITDA areas and in view of poor road connectivity, their utilization
is 0.6 patient per day per ambulance. Hence, 144 Feeder Ambulances are proposed at the rate of two per special
ambulances, and all the 144 Feeder Ambulances shall be positioned in second quarter of the 2017-18. RFP to be
floated for procurement of feeder ambulances.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
5 PPP based SNCU (Sick
new born care unit) in all
CHCs
5 QTR I QTR II QTR III QTR IV
21
RFP to be floated for all 21 additional & 5
existing SNCUs
As of now 5 special new born care units (SNCUs) are available and 6 bedded SNCUs shall be established in all 21
CHCs and Area Hospitals. Similarly, the new CHCs which are going to be established shall also have a six bedded
SNCUs to provide services to sick new born and to reduce the IMR in tribal areas.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
6 PPP based sub-centres in
telemedicine mode
0 QTR I QTR II QTR III QTR IV
20 20 40
RFP to be floated and 20 Sub-Centres to be
completed by Q2
All the sub centres located 3 kilometers away from the all-weather roads shall be provided with telemedicine facility
and an additional ANM for in-house services to the patients visiting the sub centre.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
7 Select non- 24X7 PHCs
into 24X7 PHCs
49 QTR I QTR II QTR III QTR IV
106
Out of 155 PHCs, 49 PHCs are working as 24X7 PHCs and the remaining 106 PHCs shall be converted into 24X7
in a phased manner keeping in view of the delivery load and the OP IP load. Each new 24X7 PHC shall be
supported with additional one Medical Officer and 3 staff nurses.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
8 At least state of art
Area Hospitals in
all ITDAs
7 QTR I QTR II QTR III QTR IV
1 1
Yerragon-dapalem KR Puram
92
in ITDA Srisailam
area
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
QTR I QTR II QTR III QTR IV
1 3 3
9 Area Hospitals @
1 Lakh population
(over and above
point-8)
7 Yerragondapalem Salur,
Rajavomm
agi,
KR Puram
Chintapalli,
Munchingp
ut,
Anantha
As the AH Paderu is going to be upgraded as District Hospital, Chintapalli shall be upgraded as Area Hospital and the,
Lothugedda, KD peta, shall be upgraded as CHCs
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET (2018-
19)
10 District Hospitals
@ 5 Lakh
population
The Area Hospital Paderu shall be upgraded as District Hospital and all the 19
specialities shall be established in DH Paderu in Q3 & Q4 of 2017-18
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
11 Mission
Organizations
adoption of ITDAs for
supporting CHCs,
AHs and DHs
0 QTR I QTR II QTR III QTR IV
RFP to be floated seeking presentations/plans/budgets and
subsequent allotment of all qualified Mission Organizations by
Q2 including CSR funding/Mission Organization support
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
12 OT modernization
in 24X7 PHCs,
CHCs & DHs
0 - 24x7 PHCs
0 – CHCs
0 - AHs
QTR I QTR II QTR III QTR IV
155 – 24x7
PHCs
19 –CHCs
7 - AHs
All the OTs in PHCs shall be modernized with Rs. 318 lakhs at the rate of 3 lakhs per PHC, and all the CHCs and AHs
OTs shall be modernized with Rs. 1061 lakhs by 2018-19. Rate contract of the equipment is already under process for
modernization of all OTs in CHCs and AHs.
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
13 Ultra-sonography 0 QTR I QTR II QTR III QTR IV
93
services at all CHCs 19 +7
All 26 included in Tele-Ultrasonography Tender and to be completed by Q2. All the CHCs have the ultra-sonogram
machine and the abdominal screening facility shall be ensured with trained manpower for the benefit of the tribal
patients from the quarter 2 and the new hospitals to be established shall have the same facility
Sl No. Key Indicator BASELINE TARGET (2017-18) TARGET
(2018-19)
14 Availability of LLINs 3.5 lakhs QTR I QTR II QTR III QTR IV
10.75
lakhs
7 lakhs
GOI was addressed to supply of 21 lakhs LLINs and keeping in view of the family size all the tribal people shall be
provided the LLINs and keeping in view of their longevity, 50% of them shall be replaced for continuous protection
from the mosquito bite.
139. The achievement of the above quarterly targets for the various Health Indices under TRY
needs proper planning and continuous monitoring. The DoHFW has made a continuous effort with
focused strategies on TRY schemes implementation in tribal areas for various key indicators.
140. As on date, the government of AP has converted all the 153 PHCs in Tribal areas as round the
clock PHCs by sanctioning additional 604 posts. The services are being monitored with regular field
visits and reviews are conducted to stabilize the PHCs to serve as 24x7 to tribal. The IEC activities
are conducted in a routine manner and extensive filed visits by the district programme officers are
performed to make the PHCs operational 24x7. There is a notable increase in the number of birth
deliveries being conducted at these PHCs. Presently in ITDA Paderu, PHC Ededulapalem, U
Cheedipalem, Korukonda,Gemmili, Gomamngi, Lambasingi, Bheemavaram, RJ Palem and
Sunkarametta are conducting deliveries above 10 per month after July 2018. The birth delivery at
home were reduced from a considerable number of 999 (April-June 2018) to 698 (July-September
2018) with the continuous monitoring and field operations by the ANMs, Supervisory staffs and
doctors.
141. The availability of drugs in all the health facilities is being taken care by the APMSIDC
which supervises the supply of drugs. On the implementation front, the task is being performed by the
Medical Officers of PHCs who informs the drugs indent through online supply chain platform at
appropriate time. The monitoring for the drugs availability is taken up by the Director, Health at the
state level, District Medical & Health Officer (DM&HO) and Additional District Medical & Health
Officer (Addl. DM&HO) at district level.
142. The control of seasonal diseases like dengue and malaria in the state are done through the
distribution of LLIN mosquito nets along with other activities in the tribal areas. Additionally, Anti
larval operations by the involvement of all the stakeholders, Program Officer (PO) ITDA, Panchayati
Raj, Mandal Parishad Development Officers (MPDO) and Mandal Revenue Officer (MRO), school
children are carried out in the tribal areas.
Table (29): Control of Seasonal Diseases in ITDA Areas
ITDA 2016 2017
2018 (Up to 21st October
42nd Week)
Malaria Dengue Malaria Dengue Malaria Dengue Malaria
94
Total Cases
Tribal Total Cases
Tribal Total Cases
Tribal Total Cases
Tribal Total Cases
Tribal Total Cases
Tribal % decrease over
previous year
Seetampeta 693 587 114 0 592 424 57 10 253 150 66 0 64.62
Parvathipuram 2939 2635 53 8 1877 1614 46 8 301 252 99 0 84.39
Paderu 6479 4502 1127 32 4836 3791 983 35 1914 1371 2385 118 60.55
RC
varam&Chintoo
r
9061 8854 336 13 5897 5757 170 3 1544 1516 418 4 73.67
KR Puram 730 692 32 4 498 476 61 0 194 189 102 0 60.30
Srisailam 420 114 48 2 93 37 322 2 41 0 8 2 100.00
Total 20322 17384 1710 59 13793 12099 1639 58 4247 3478 3078 124 71.25
143. The government has extended 4 additional tests at PHC level in tribal areas and the Medical
officers are being made aware of the extended scope of laboratory tests. A series of meetings were
being held with MPHs male and Female, MPHEOs, CHOs, PHNs to spread the message. The
laboratory tests services at the tribal area PHCs are being provided by PPP service provider. The state
nodal officer, district level DM&HO, ITDA level Addl. DM&HO and MO at PHC level ensures the
proper laboratory services are being provided under TRY.
144. In addition to regular panchayati wise monthly services at the door steps by MMUs, 15 more
ChandrannaSancharaChikitsa (MMU) services at shandis in tribal areas depending on the density of
participation are made available to provide more health care to the tribals. Each MMU is
operationalised with one Medical officer, a staff nurse, a Lab technician, Pharmacist and a Pilot.
Required diagnostic tests shall be done and all essential drugs shall be dispensed at the MMUs. The
OP registrations per shandi were improved from 25 to 36 in the ITDA areas. The MMU are being
monitored by state level nodal officer, along with district level DM&HO and at ITDA level by the
Addl. DM&HO.
145. Government of AP taken up a noble initiative in tribal areas to extend the ambulance services
by way of 108 bike ambulances to the last mile where the conventional ambulances could not reach .
The 108 bike ambulances are being manned by two trained EMT for round the clock services, medical
oxygen, 12 minor equipment, 5 essential drugs, 32 categories of surgical and consumables. These 108
bike ambulances are serving to the remote tribal areas for all emergencies to save the lives in golden
hour. The patient utilization was improved from 60 to 130 per day across the ITDAs. Similarly, the
immunization was also linked to feeder ambulance services to achieve the full immunization goal.
The Feeder ambulance service is being implemented on PPP mode. The State Nodal officer along
with district level DM&HO and at ITDA level the Addl. DM&HO. are the implementing authorities.
Table (30): Extend the Ambulance Services in ITDA Areas
ITDA Name Feeder Ambulances Count Cases Served as on date
ITDA- Paderu 42 3044
ITDA- R.C.Varam 21 3829
ITDA- Chintoor 6 885
ITDA- Parvathipuram 24 1715
ITDA- Seethampeta 15 1263
ITDA- K.R. Puram 8 1272
ITDA- Srisailam 6 338
TOTAL 122 12346
95
146. There are 26 first referral units (FRUs) in ITDA areas of the Andhra Pradesh. However, the
speciality care for neonates was a far and non-entity till 2017. However, the Government of AP under
TRY has taken up initiatives to establish sick new born care units (SNCUs) in all CHCs & Area
hospitals in ITDA areas. Accordingly, 21 SNCU mini with 5 beds were established and Paediatrician
and 5 staff nurses and support staff are serving round the clock in these SNCUs mini. Each SNCU
mini is equipped with central oxygen and 28 categories of equipment, required drugs and
consumables. The initiative is being planned under the supervision of Commissioner, APVVP and
State Nodal Officer. The concerned Medical Officer at CHCs and AHs are required to report the
proper functioning of SNCUs in their respective facilities to the DM&HOs, Addl. DM&HOs or
DCHS periodically.
147. Medical officer services on telemedicine mode at 40 sub centres (20 in ITDA Paderu and 10
each in ITDA Rampachodavaram and ITDA Parvathipuram) were made available in order to improve
health advice and telemedicine treatment for habitations located at more than 3km in the interior
areas. All e-sub centres are equipped with drug vending machines with 36 category of drugs,
telemedicine, diagnostics such as blue tooth-based BP apparatus, digital thermometer and other
haemoglobinometer. Various IEC activities are being conducted to popularize the services of
telemedicine at the sub centres. The ANMs at the Sub Centre are trained to establish the tele
consultancy sessions with the medical officers. The project is being implemented in the ITDA areas
by the state Nodal officer through selected Service Provider.
148. Area Hospitals are being established at all the 7 ITDA areas. As part of Operation Theatre
modernization program, 26 hospitals operation theatres were modernized with latest equipment for
providing state of art health care at tribal locations. The equipment for OT modernization is being
supplied by APMSIDC to the hospitals which are monitored at the facility level by the Medical
Officer and Superintendents.
149. In view of significant paedaladema cases reported in tribal areas, government of AP has
started 10 bedded dialysis units in five hospitals in tribal areas. The Area Hospital Palakonda,
Parvathipuram, Paderu, Rampachodavaram located in tribal areas and Narsipatnam and Tekkali in sub
plan areas are serving tribal patients for dialysis services. The dialysis facility at Rampachodavaram
was started in July and at Paderu it was started during August 2018.
Keeping on view of the special conditions in tribal areas, 31 birth waiting homes were constructed for
early attendance to the hospital for safe delivery.
Table (31): Birth Waiting Homes in ITDA Areas
ITDA NUMBER OF BIRTH
WAITING HOMES
NUMBER OF WOMEN
AVAILED SERVICES
Seethampeta 5 923
Parvathipuram 4 765
Paderu 4 2003
Rampachodavaram 9 1245
K.Ramachandrapuram 5 397
Srisailam 4 218
TOTAL 31 5551
150. The tribal areas generally register many Severe Acute Malnutrition (SAM) and Moderate
Acute Malnutrition (MAM) children and many of them have to visit far of places for management or
96
they will drop out from the SAM/MAM treatment. To address this problem, the government has
sanctioned additional five Nutrition Rehabilitation Centre (NRCs) at Munchingput, Araku,
Narsipatnam, Koonavaram and Chintoor.
151. To work in convergence with Women Development & Child Welfare, Department for TRY
schemes, many AWCs are being visited by the health officials. Discussion with CDPOs of 7 ITDAs
for bringing convergence in conduct of immunization, management of MAM/SAM children,
provision of food to the pregnant women and children at AWCs are being taken up.
152. For the proper implementation of TRY objectives all the supervisors are being advised to
maintain the regular field visits and submit the detailed activity carried out in the week in respect of
1. Maternal health and child health activities including immunization.
2. TB control measures and new incentives to ASHAs and incentives to patients.
3. 108 bike ambulances and their utilization impact.
4. Availability of SNCU mini established at facilities.
5. eSubCentres and use of the services of Medical officer on telemedicine mode.
6. Importance of early detection of the high-risk pregnancy and follow up for safe motherhood.
7. PMMVY and its importance for early enrollment and release of incentives.
8. Review of sub centre wise institutional deliveries and home deliveries.
9. Better birth planning instructions and the ANC care for pregnant women.
153. The TRY have greatly improved the care services in the tribal areas and to further strengthen
the services the capacity building to ANMs and MOs on MCH services needs to be planned out. The
monitoring needs to be regularized through weekly visit by DM&HOs and other District Programme
Officer to the ITDA areas for inspection.
97
8.3 Inclusion Matrix
Table (32): Inclusion Matrix
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
Result Area 1: Quality of Care
Indicator 1: Increase in
the number of PHCs
and CHCs have more
than 70 percent quality
score, sufficient to
seeking national
certification, supported
to improve quality and
monitor sustain quality.
1. Assessment of quality gaps undertaken by
facility and DoHFW staff
2. Training of the PHC and CHC Staff
3. Fill HR gaps
4. Minor infrastructure* enhancements
5. Minor furniture, equipment, other goods
procured
6. Service contract to establish and maintain
Quality Tracking Dashboard System
7. PHCs and CHCs report to the system
8. Service providers contracted and
incentivized to improve in clinical and non-
clinical gaps
9. Maintenance and improvement of quality
monitored and supported
*infrastructure refers to minor building repairs
and modifications
Overall this set of activities will help
improve the quality of basic
infrastructure facilities in HCFs
especially at sub-centres and PHCs.
The project does not support any
large-scale construction and restricted
to minor repair and renovations and is
restricted to existing footprint of the
HCF and hence no additional land is
required.
3. Screening of HCF using checklist
as per Annex-1 (PHC and sub-
centres) for ensuring the delivery of
basic infrastructure facilities
especially in tribal districts where
repair and renovations is planned.
Cumulative progress on delivery of
basic infrastructure primary health
care facilities to be reported by
districts.
4. Monitoring of HCFs (screening
checklist applicable) to rule-out
adverse impacts related to
involuntary resettlement of
squatters and non-title holders on
government land.
Indicator 2: Increase in
number of CHCs and
PHCs NQAS certified
1. DoHFW administration organizes for review
by the national authorities as per the NQAS
guidelines (http://qi.nhsrcindia.org/national-
quality-assurance-standards)
Accreditation process involves
improvement in overall infrastructure
and services including sanitation
facilities for both men and women.
23. Access to HCF for disabled
population to be ensured.
24. In line with existing DoHFW
policy, a targeted approach to
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Table (32): Inclusion Matrix
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
certify 13 PHCs (yearly) located
in tribal districts will be adopted.
Indicator 3: Increase in
coverage of core
services provided
through performance -
based contracts at
CHCs and the
performance of those
services.
1. Sanitation service provider contracts
2. Biomedical equipment maintenance contract
3. Laboratory service contract
4. Tele-radiology service contracts
5. Patient satisfaction/ experience survey
contract
The service contracts will help
improve services. However, it is
important to ensure that it is inclusive
and non-discriminatory.
25. The service contracts should
include the clause on (a) non-
discrimination of services with
respect to caste, creed and gender,
(b) prohibiting use of child labour,
(c) wage parity among men and
women
26. Regular health-check-ups for
contract workers.
Indicator 4: Improved
pharmaceutical stock
management system at
the PHCs and CHCs.
1. Upgrading/ replacing of the supply chain
software with modern functionality
2. Management and operating of supply chain
3. Facility pharmacists incentivized to enter
information into the supply chain software
No specific social risk associated with
this activity, however building
capacity of personnel at
geographically difficult to reach
PHCs (located in tribal/rural areas)
needs to be prioritized.
Result Area 2: Integrated Primary Health Care
Indicator 1: Increase in
the number of
functional e-sub-
centres, including with
solar power energy
solution where
appropriate and model
evaluated.
1. Service contract with teleconsultation
provide and operate the following: refurbish the
facility, provide the diagnostic and drug
vending machine, computer with internet and
telemedicine solution, and doctors‟ hub
2. ANM staff work at the Sub-centres
3. Expanded list of essential drugs provided to
These set of activities will enhance
the capacity of Sub-centre. Sub-centre
being the first point of contact for
health care services it will improve
quality of health care in state.
In line with existing DoHFW policy,
27. Preparation of an annual action
plan to identify and target sub-
centres located in tribal areas for
upgradation. This is as per existing
best practice adopted by DoHFW.
28. A robust awareness and IEC
planscrucial for achieving
increased usage of public health
99
Table (32): Inclusion Matrix
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
sub-centres
4. Policy decision will be taken about the
extension of solar power to subcentres
5. Installation, operation and maintenance of
the solar power at subcentres according to
policy decision
a positive targeting approach will be
adopted to upgrade e-sub-centres in
tribal and ITDA areas.
Training and capacity building of
personnel for e-sub centres located in
tribal and ITDA areas.
facilities which especially among
tribal populationand other
vulnerable groups. This will also
help achieving the key outcome at
the project level. It will be useful
to the understand perceptions at
the community level and
designing tailor-made campaigns
(based on literacy levels,
household incomes, etc.) that
encourage usage of health
facilities amongst men and
women.
Indicator 2: Increase in
the number of
subcentres with trained
mid-level service
providers (BSC nurses)
1. Recruitment and training of the MLPs
2. MLPs placed and working at subcentres
While this will enhance service
quality, it is important that the ITDA,
other tribal areas and difficult to reach
areas are also prioritized as they need
the services the most.
29. Preparation of an annual action
plan to a) map blocks/agencies
that need to be prioritized and
b)identify and target sub-centres
located in tribal/ITDA areas for
upgradation. This is as per existing
best practice adopted by DoHFW.
Indicator 3: Of those
citizens screened, an
increase in the number
of patients at high-risk*
for NCDs
(hypertension and
diabetes) who are
actively managed at the
first point of contact-
1. Screening of Population by subcentre or
PHC staff
2. Laboratory/diagnostic tests undertaken
3. Risk-level and Treatment plan determined by
subcentre or PHC staff
4. Medication provided
While women tend to access services
geared towards maternal care and
child care, they often delay treatment
seeking behavior for diseases such as
diabetes, hypertension, breast,
cervical and oral cancers etc. This can
be for a variety of reasons including
well-documented time-poverty,
double burden of unpaid domestic
30. Preparation of a behavior change
and communication (BCC)
strategy that is interactive in
nature. The objective will be to
address misconceptions and
spread awareness about NCDs
such as cervical cancer. 31. Capacity building of VHC may be
useful to help to undertaking
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Table (32): Inclusion Matrix
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
level (subcentre, PHC)
5. Necessary studies, surveys contracted work and patriarchal norms so that
women often put the health of their
children and male members of the
family at a higher priority than their
own health.,
discussions at the community
level. And, the project outreach
strategy already plans to take up
this and proposes a STEP survey
to assess NCD risk factors and
barriers under the project.
Indicator 4: Increase in
the percentage of
women screened in
target age group for
cervical cancer at
subcentres or PHC
facilities
1. Screening of women by subcentre or PHC
staff
2. VIA testing
3. Women at risk referred
4. Follow-up undertaken to ensure referral
happens
5. Outreach activities enhanced
There is little awareness about
cervical cancer among the target
population including women. Also,
women take laid back approach when
it comes to prioritizing their health
needs.
32. Preparation of a behavior change
and communication (BCC)
strategy that is interactive in
nature. The objective will be to
address misconceptions and
spread awareness about NCDs
such as cervical cancer. 33. Preparation of a detailed action
plan to build capacity of Village
Health Committees to effectively
discuss and disseminate
information on NCDs and
menstrual hygiene. The project
has planned the capacity building
of VHCs and SERP women‟s
group is part of the core project
activities.
Indicator 5: Increase in
the percentage of
women that are
registered in the first
trimester receive full
1. ASHA identify the women and ANM
registers the pregnant women
2. IFA, TT1, blood test provided
3. Conduct ANC at the mobile medical units
There is a possibility that women
from tribal/rural areas do-not access
full ANC care.
34. Mapping of low performing areas.
35. Annual action plan to improve
delivery of full ANC care in tribal
and ITDA areas.
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Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
ANC care 4. Conducting of the Village Health Nutrition
Days by ANMs
Result Area 3: Enabling patient-centreed care
Indicator 1: Increase in
the number of facilities
actively using an
integrated online
patient management
system
1. Service contract with the provider of the
integrated online patient management system
executed (HMIS solution, hosting of electronic
model record (EMR) data in state data centre,
equipment for EMR recording, establishment
of medical transcription hub, training of health
care staff for operating the patient management
system)
Patient data security could become an
issue if not given priority. 36. Adequate data security to be
ensured to safeguard the privacy
of the patient data.
Indicator 2: Increase in
the percentage of
creation of EMR for
IPD and chronic OPD
cases registered in the
facilities indicated in
DLI 1
1. Service contract with the provider of the
integrated online patient management system
executed
2. Staff at the facilities are entering and using
the EMR
3. Facilities identify nodal officers for
implementation
This will help enhance proper follow-
up care with patient records. It has no
specific social risk with these set of
activities.
Indicator 3: Increase in
the percentage of
patients accessing
information (web-
based, application-
based) through
PHRMS for which the
EMR has been created
1. Service contract with the provider of the
integrated online patient management system
executed
2. Facilities supported with an online patient
management system
3. Patients are informed about the system
No specific social risk associated to
these activities. 37. Awareness and knowledge to
access patients record and at an
appropriate time needs attention.
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Table (32): Inclusion Matrix
Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
as per DLI2 through SMS
4. Information education activities are
undertaken for raising public awareness
Indicator 4: Increase in
the number of
empanelled private
pharmacies able to
dispense state financed
drugs to patients
1. Policy decision
2. Contracts with private providers
3. Information education activities are
undertaken for raising public awareness
While this will be help patients for
easy access to drugs, adequate
attention to be put in for ensuring ma
practice of any kind.
38. Adequate safeguard clause to be
built into empaneling pharmacies
from any malpractice.
39. Adequate monitoring mechanism
to be built towards this.
Indicator 5: Hospital
Development Society
(HDS) provide regular
monitoring and
undertake actions to
improve quality
1. Administrative effort by the staff to
communicate with the communities and
functional operation of the Hospital
Development Societies
2. Increase in monthly conducting of Hospital
Development Society (HDS) meetings
3. HDS members review patient experience
feedback, funds availability and activities to be
undertaken to fill the gaps identified during
meetings
4. Minutes of meetings are recorded
As per existing norms, HDS should
also have representation from
community and should include
women representation and members
of tribal and vulnerable groups.
40. HDS formation should be
instructed with respect to inclusion
of women and vulnerable group
population including tribal
population where applicable.
Indicator 6: System
developed and rolled
out to measure and
report patient report
experience in a
1. Service contract with the provider of the
integrated online patient management system,
Kiosks installed and operated
2. Information on patient reported experience
Awareness and knowledge towards
importance of feedback and how to
operate these kiosks will be
important.
41. Creation of a central, project level
Grievance Redressal Mechanism
to a) consolidate different
complaint numbers used by
hospitals b)to monitor the nature
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Project Indicator Main Activities Risks/ Impacts Potential Mitigation Measures
standardized and
confidential way. collected in a credible way
3. Administrative effort by the DoHFW staff to
analyze and share analysis through health
bulletins
4. IEC activities undertaken
and pattern of complaints across
districts.
42. Adapting the IEC material
received under NHM to a)make it
available in local dialect b) using
audio-visuals to create awareness
and disseminate information.
104
9 CITIZEN ENGAGEMENT AND GRIEVANCE REDRESS MECHANISM
9.1 Citizen Engagement and Outreach Strategies
154. The Government of Andhra Pradesh has continuously over the years have launched various
programmes and care schemes focussed to meet the social inclusion norms for the citizens of the state.
With the presence of SC, ST and tribal population along with the existence of “Fifth Scheduled
Areas” in the state, it becomes imperative for the Government to ensure that the care services are
extended to those communities and areas. The main objectives of the programmes and schemes
launched till date were to create awareness among the communities regarding health-related matters
and extend the reach of care services to the underserved and tribal communities.
155. In lines with the objective to reach the underserved and village communities, the state
government of Andhra Pradesh has customized the national Village Health Nutrition Day (VHND)
guideline as per the state specific needs and practices. It is presently conducting two Village Health
Nutrition Days (VHNDs) in every village in convergence with Women and Child Welfare
Department. One Village Health Nutrition day (VHND) is conducted in an Anganwadi Centre(AWC)
on 7th of every month i.e., the day of release of Monthly Health Bulletin which includes precautions
to be followed during the month, non-communicable diseases to be focused in the village, disease
profile of the village, health message of the month and Health Service Profile of that village. It
mainly focuses to cover pregnant women, lactating mothers, children below 5 years and adolescent
girls as the primary beneficiaries of the programme.
156. The second Village Health and Nutrition Day (VHND) is conducted presently on the day of
visit of ChandrannaSancharaChikitsa (CSC) to that particular village which is defined as “Primary
Health Centre (PHC) on wheels”. The CSC services are assisted by a Medical Officer, Staff Nurse,
Pharmacist, Lab Technician etc., which also coincides with visit of two students from Medical
Colleges to that village who will be imparting awareness to the villagers on preventive aspects.
157. The VHND services are mainly focussed on pregnant women, ANC tracking for registered
pregnant women and drop-out pregnant women, vaccination to eligible children below one-year,
provision of Anti-TB drugs, contraceptive services to all eligible couples, and supplementary nutrition
to underweight children. The collection of data pertaining to the SCs, the STs, the minorities, weaker
sections of society that needs services and the number of children with special needs are all recorded
as part of the VHND programme. On the VHND day, ASHAs (Accredited Social Health Activist),
AWWs (Anganwadi Worker), and others will mobilize the villagers, especially women and children,
to assemble at the nearest AWC. During the VHND day, the villagers are encouraged to interact
freely with the health personnel and obtain basic care services and information. The preventive and
promotive aspects of health care are being imparted to the community which will encourage them to
seek health care at proper facilities. As per the data from October to December 2018, 48,624 VHND -
I were held as against 51,738 VHNDs planned and 44,245 VHND – II were held as against 51,738
VHNDs planned.
158. The second initiative by the Government includes the outreach immunization programme
aimed to reach out to the population living in remote areas with limited access to fixed services,
underserved or hard to reach area groups. Routine Immunization (RI) is being made complementary
to other Primary Health Care (PHC) services in orders to reduce morbidity, mortality and disability
from the vaccine preventable diseases of childhood in the state. The RIs are generally conducted
through fixed-post site (within health facilities) . Additionally, the state has initiated RI outreach
sessions conducted by regular and periodic single day visits by qualified staffs from a health facility
to population located 5-15 Km from the facility. As on date, 75,280 outreach sessions were conducted
in High Risk Areas (HRAs) and 4,67,856 sessions were conducted in other areas.
159. The state also follows adherence to the National Immunization Schedule while preparing the
Universal Immunization Programme (UIP) based on the guidelines of Immunization Handbook for
105
Health Workers 2018 published by the Ministry of Health & Family Welfare, GoI. The state UIP
aims to reach-out to pregnant women and infants and children for full immunization at birth, before
age of 1 year and 2 years of the child. The RI micro plan is prepared to enlist all villages, wards, tolas,
HRAs across the state and the ANM coordinate activities with ASHA & AWW at least 2 days before
RI session. The RIs are planned once in a year, every six months and quarterly based on the analysis
done from house-to-house survey and head counting activities by ASHAs, ANMs and Integrated
Child Development Services (ICDS) partners. Every pregnant women and child are provided with
Mother and Child Protection (MCP) card which gives information on the immunization schedule and
the doses of Vitamin A to be given to the child during the first five years. The MCP card is the first
step to ensure that the families start learning, understand and follow positive practices for achieving
good health. The RI sessions are generally aimed to achieve higher success rates through IEC
activities backed by continuous advance information notice to the communities. Till December 2018,
the state in its immunization effort has achieved 101% coverage under the indicator of “Infants (0 to 1
Years) receiving Full Immunization” and 113% coverage under the indicator of “Infants (1 to 5
Years) receiving Full Immunization”.
160. The current outreach strategies being conducted by the state at the village and community
level have led to a significant growth in the proportion of the state population accessing health care
from public health facilities. It has overall lifted the health index of the state supported by the
continuous interventions and efforts from the government and DoHFW to strengthen its current
outreach programmes.
9.1.1 Hospital Development Societies (HDS)
161. The conducting of Rogi Kalyan Samithi's (HDS meetings) is a crucial indicator for effective
functioning of the Hospital administration and participative Governance in the Government Hospitals.
The GoAP through the G.O.Rt.No.48 of HM&FW (D1) Dept., dated 13.05.2015 have issued
guidelines for constitution and organization of Hospital/Primary Health Centre Development Societies
(HDS), in all Teaching Hospitals, District Headquarters Hospitals, Area Hospitals, Community Health
Centres, Primary Health Centres and other Government Hospitals and AYUSH hospitals in the State.
The HDS meetings shall be conducted once in every month.
162. The HDS meetings are conducted to review the day-to-day functioning of the institution, its
cleanliness, the regular attendance of the staff, and delivery of quality healthcare services by the staff
to the general public. It also includes review of compliance to Standards, treatment and other
protocols issued by the
163. Government/other professional bodies in the treatment and other protocols issued by the
Government / other professional bodies in the treatment of patients. In respect of Primary Health
Centre-Hospital Development Societies, review of the outreach work performed during the last three
months and outreach work schedule for the next quarter are reviewed.
164. Additionally, the review of implementation of various health schemes under the State and
Central Governments, including NRHM, RCH-II, Disease Control Programmes, Immunization,
Family Welfare Programmes, etc., are being discussed in HDS. The Hospital / Primary Health Centre
Development Societies regularly submits (1) copies of minutes of every meeting; (2) Abstract of
progress reports as prescribed; (3) Annual audit Reports and (4) any other reports as prescribed to the
concerned Head of Department through the District Controlling Officer (where applicable) on any
matter concerning the functioning of the hospital for suitable action by the Government within one
month of the last date of the Quarter. Recently, the Government through G.O.Rt.No.653 of HM&FW
(D1) Dept., dated 20.12.2018 issued an instruction of abolishing the HDS committee if HDS meeting
is not conducted for two months successively for any health institution.
106
Total No of Institutions -1403
Improvement in the conduct of RKS Meetings (%) month-wise in 2018
Months JAN FEB MAR APR MAY JUNE JULY AUG SEP OCT NOV DEC
RKS
Meetings
%
23% 32% 31% 49% 70% 74% 91% 90% 90% 91% 90% 92%
165. All the Hospitals in the state from PHCs to Teaching Hospitals are presently conducting HDS
Committee meetings every month. To track the conduct of meetings, on time, a tracker is developed
(URL: http://hmfw.ap.gov.in) and the Hospital superintendents ensures that HDS monthly meetings
minutes and details are uploaded in the tracker on real time basis. The report of the number of
Hospitals where meeting is conducted is generated on 1st of every month and shared with all District
and State Level Authorities through an auto-generated mail.
9.2 Grievance Redress Mechanism
166. The Government of Andhra Pradesh in its continuous effort to strengthen the healthcare
delivery system has placed special emphasis in making the Grievances Redressal Mechanism (GRM)
system transparent and inclusive. The same will also be applicable for the project as well. The
qualitative healthcare delivery aspect in the public Health Care Facilities (HCFs) is generally ensured
by the services of administrative staffs including doctors, nurses etc. at the public HCFs. In the
receiving end, the patient feedback on care services at the public HCFs forms a crucial factor for the
improvement of services. The Government of AP has presently established GRM system for
registering all grievances known as Chief Ministers “ParishkaraVedika” an online grievance redressal
program run by CRDA GOAP for urban and the District Collectorate Grievance Cell at the district
level, percolating down the chain of command to the Village Panchayati Raj Institutions(PRI).
167. The governmental website www.meekosam.ap.gov.in allows any citizen of the state to seek
grievance redressal. The grievance can be uploaded into the website, and has six stages of processing
Signing in, Sending the application, reaching the concerned government officer, “receipt” from the
government officer being sent to the applicant, sending the message to the concerned government
department, Grievance Resolution, communication to the applicant that the grievance has been
resolved. However, there is a gap in demand and supply due to the Turn-Around-Time of the
concerned Government Departments in responding and resolving a grievance. Another platform under
the aegis of the commissioner and director of municipal administration for grievance redressal is
http://www.cdma.ap.gov.in/grievance-redressal .
168. An integrated portal-based citizen help desk and GRM is under development, wherein citizens
can send their complaints/suggestions/grievances to the municipalities through post or phone or
Fax/E-mail. The Grievances shall be forwarded to the concerned Department/Section of the respective
ULB depending on the nature of Grievance for further action. The Corresponding sections staff will
attend the complaints in given time period and send a reply back to the citizen helpdesk. The reply
sent from the corresponding department/Section to the Integrated Citizen helpdesk will be sent to the
complainant. The complainant who uses internet can also check the status of his grievance through the
web. This proposed system provides periodical reports on status-wise complaint list, department-wise
pending complaints, etc. to the higher authorities for monitoring the efficiency and progress of
grievance redressal.
169. At the district level, the judicial and executive powers in the district are currently exercised by
the District Collector in the Grievance Cell held every Monday, aided by the concerned department
heads. However, at the village level, it is the PRI and the Village councils that resolve grievances.
107
Considering the legacy of the deeply entrenched socio-economic divisions, justice is not always
served.
170. The current patient satisfaction survey on care services is solicited through Real-Time
Governance System (RTGS) which is a common platform for all satisfaction survey of any
government schemes or programmes implemented in the state. The RTGS extracts the beneficiaries
data of a specific programme and solicits feedback through outbound calls and Interactive Voice
Response (IVR) routed to the beneficiary mobile number. The set of questionnaires on the services
indicators of the programme are being administered which are later analysed for satisfaction report.
Every month the reports are generated for each programme and uploaded in RTGS website. The
dissatisfaction results are being reviewed by the departmental HODs both at state and district level.
The corrective measures are being discussed in monthly review meetings with district heads and
service providers and are proposed as action points.
171. The proposed patient satisfaction survey under the citizen-centric approach of the APHSSP
project would ensure that there is a continuous feedback mechanism system established for its
activities to sustain the changes being instituted. The development of the feedback system at all the
public HCFs would bring the community closer to the concerned authorities while addressing any gap
or dissatisfaction of services. It is envisaged that a robust system will be in place that will sustain the
improvement and quality of services post project for posterity.
108
10 INSTIUTIONAL AND IMPELEMENTATION ARRANGEMENTS
172. The project follows the existing DoHFW governance and management structure for
implementation of the proposed project. This includes: (i) an Executive Committee (EC) under the
Chairmanship of the Principal Secretary, DoHFW; and (ii) the Strategic Planning and Innovations
Unit (SPIU) designated as Project Management Unit (PMU) under the leadership of the Mission
Director (MD), National Health Mission (NHM), to plan, coordinate, implement and monitor project
activities, and (iii) district quality assurance teams.
173. An EC has been established under the Chairmanship of the Principal Secretary, Government of
Andhra Pradesh to provide overall direction, reviewing and approving workplans and budgets,
staffing and financial and legal sanctions required for project implementation. The MD, NHM is the
Convener of EC with members representing the following: Department of Municipal Administration
and Urban Development; Mission for Elimination of Poverty in Municipal Areas (MEPMA); Andhra
Pradesh Health and Medical Housing Infrastructure Development Corporation (APHMHIDC);
Andhra Pradesh Vaidya Vidhan Parishad (APVVP); NTR Trust; Medical Education; Ayush; Institute
of Preventive Medicine; Commissionerate of Health and Family Welfare; and Drugs Control
Administration.
174. The EC will ensure coordination at the state level with other relevant departments such as
municipalities, Pollution Control Boards, Public works departments, water departments, SC/ST
welfare departments, officers of the Tribal Reforms Yardstick, etc.
174. The Strategic Planning and Innovations Unit (SPIU) has been designated as the PMU for the
project. The SPIU will report to the MD, NHM and will coordinate with the relevant departmental
heads, specifically the APVVP that manages secondary care hospitals and the Department of Public
Health and Family Welfare that manages primary health care, towards the implementation of the
project. The PMU will consist of staff specialized in areas relevant to the core needs of the project
including a dedicated, full-time environment and social safeguards specialist.
175. An Environment and Social safeguards specialist will be hired at the SPIU level. The E&S
specialist will oversee, monitor and report back on implementation of ESMF activities. S/he will be
assisted by District level safeguard specialists (full time) which will be placed in each district of the
State ( these specialists are already part of the District Quality management teams). Further, at the
HCF level, the administrative coordinator will support monitoring of E&S activities, as well as
completing the screening checklist, and implementing environment and social mitigation measures at
the facility level.
176. PMU safeguards specialist and District level staff engaged in safeguards management will be
provided with orientation training on environment and social safeguards management, along with
continued and refresher training programs on specific areas such as (i) worker health and safety (ii)
ESMP monitoring and (iii) medical waste management.
177. The monitoring of ESMF implementation will also be done as per the parameters set under EMP
and SMP and will be integrated into the regular monitoring of the project will be by the responsible
agencies/bodies/units for each of the key result areas. Data will be collected by the health care facility
in charge and collected at district level by District safeguards officer. A monitoring report for the
ESMF implementation will also be part of quarterly, six monthly and annual review by the SPIU
specialist. This will comprise of all trainings, contracts, equipment, EMPs implemented at the HCF
level.
109
181. The monitoring of ESMF implementation will also be done as per the parameters set under
EMP and SMP and will be integrated into the regular monitoring of the project will be by the
responsible agencies/bodies/units for each of the key result areas.A monitoring report for the ESMF
implementation will also be part of quarterly, six monthly and annual review.
182. The establishment of institutional arrangements and operational systems for environment and
social management is a key prerequisite for systematic and standardized implementation across all of
the health services. The NHM, IPHS and National Accreditation Board for Hospitals, provides a
framework of the standards to be implemented by public health-care facilities. The institutional
capacity assessment carried out as part of the ESMF indicates there is sufficient manpower and
technical capacity within the existing system of DoHFW for management of environment and social
issues and ESMF implementation. DPMU safeguards staff will need to be trained in the requirements
of Banks safeguard policies and the ESMF, such that day to day supervision is carried out in
accordance with the ESMPs. Capacity of HCF level staff will need to be augmented to manage
environment and social risks. This will be assessed on a case to case basis, and preparation of capacity
building plan for different cadre of HCF staffs and will be part of the regular training calendar being
used by the project.
183. There are also numerous guidelines as part of the existing government framework (such as
IMEP) which provide information and guidance on infection control and worker health and safety
issues, along with training modules and awareness methodologies, which are critical components for
bringing about behavioral change. The project will ensure that trainings provided will be
complimentary, and coordinate with NHM on allocations for procurement of consumables and
awareness materials.
184. The project will also leverage learnings from previous Bank funded projects in India on scaling
up trainings on key environment and social issues.
Executive Committee - Principal Secretary,
DoHFWStrategic Lead
Commissioner, AP Vaidya Vidhan
ParishadQuality of Care Lead
Director, Public Health & Family
WelfareIntegrated Primary Health Care Lead
Director, SPIU
Patient-centred care Lead
Project Director,
MD, NHM
State Project Implementation Unit (designated as PMU)
Consultant Environmental and Social Safeguard, SPIU
District Level In- charge for safeguards – i.e. District Quality
Manager
110
185. Proposed trainings under the project include the following areas, these will be integrated with the
proposed project level capacity building. These training plans, needs assessments, awareness
programs, occupational safety issues and monitoring plans will be included in project budget.
(1) Training of HCF in-charge and DQMs on screening checklist as per ESMF
(2) Training and capacity building of HCF staffs and other departmental staff for implementation
of Environmental Management Plan and Social Management Plan.
(3) Training of contractors who will carry out refurbishment works in the HCFs
(4) Training to biomedical waste and sanitation workers on worker health and safety
186. Broadly, the trainings will cover
1) Medical staff: doctors, nurses, sanitary staff and hospital maintenance personnel
2) Workers in support services linked to health-care facilities such as laundries, waste handling
3) and transportation services; medical equipment servicing
4) Short term contractors engaged in carrying out renovation works in HCFs
111
11 ESTIMATED BUDGET FOR IMPLEMENTING ESMF
187. Necessary budgetary provisions must be made for implementing environmental and social
mitigation measures as per EMP and SMP for the various project activities as part of the ESMF. This
enables preparedness for financial requirements and allows early planning and appropriate budgeting.
The indicative budget for ESMF will be integrated into the component budget for implementation as
per the activities planned. Certain project activities include the requirement of environmental
mitigation measures costs like setting up of Effluent Treatment Plant (ETP), Sewage Treatment Plant
(STP) , costs relating to on site wastewater management such as septic tanks and soak pits etc. at the
Health Care Facilities (HCFs).The other cost components for the ESMF implementation includes the
training costs for Bio-medical waste management.
188. It is estimated that a total of rupees ninety-three crores and seventy-seven lakhs equivalent to
USD thirteen million five hundred and twenty thousand will be needed to accomplish the below tasks.
11.1 TRAINING COSTS
Table 34: Training Cost
S/N Training
Program/
Awareness
Activities
Target
Audience
Type of
Training/
Activities
Duration Estimated Costs
(INR)
Estimated Costs
(USD)
1 Biomedical Waste
Management
SPIU, Hospital
staffs,ASHAs,A
NMs, Field
Workers,Volunt
ary
Organisations,
SHG in the
community
Workshops 10 sessions (1
session per
day)
₹ 1,500,000 $21,428
2 Behaviour change
and communication
(BCC) strategy on
awareness on NCD
Village Health
Communities,
ASHAs,ANMs,
Field Workers,
Voluntary
Organisations,
SHG in the
community
Workshops Project period Included as part
of the project
implementation
costs
Included as part
of the project
implementation
costs
3 IEC awareness
about the central,
project level
Grievance
Redressal
Mechanism(GRM)
in local dialect
using audio-visuals
to create awareness
Citizens of AP IEC activities Project period Included as part
of the project
implementation
costs
Included as part
of the project
implementation
costs
5 Awareness and
knowledge to
access patients
record in the online
patient
management
system
Patients
registered with
the system
availing care
services at
public HCFs
IEC activities Project period Included as part
of the project
implementation
costs
Included as part
of the project
implementation
costs
112
11.2 TECHNICAL COSTS FOR STP AND ETP
Table 35: Technical Costs for STP and ETP
Activity Quantity Estimated Total
Cost (INR)
USD
Conversion
Set-up of Effluent Treatment Plan (ETP)
1. District Hospitals (DH) 13 ₹ 70,800,000 $1,011,428
2. Area Hospitals (AH) 28 ₹ 104,200,000 $1,540,000
3. Community Health Center (CHC) 100 ₹ 102,900,000 $1,470,000
4. Primary Health Center(PHC) 150 ₹ 150,000,000 $2,142,857
TOTAL ₹ 427,900,000 $6,164,285
Set-up of Sewage Treatment Plan (STP)
1. District Hospitals (DH) 13 ₹ 184,600,000 $2,637,142
2. Area Hospitals (AH) 28 ₹ 184,800,000 $2,734,285
3. Community Health Center (CHC) 100 ₹ 138,960,000 $1,985,142
TOTAL ₹ 508,360,000 $7,356,571
TOTAL TECHNICAL MEASURES COST ₹ 936,260,000 $13,520,857
11.3 CONSOLIDATED TOTAL COSTS
Table 36: Consolidated Total Costs
Measures Actions Estimated Costs
(INR) Estimated Costs
(USD)
Technical
Measures 1. Set-up of Effluent Treatment Plant (ETP) ₹ 936,260,000 $13,520,000.00
2. Set-up of Sewage Treatment Plant (STP)
Training &
Awareness
Measures
1. Biomedical Waste Management ₹ 1,500,000 $21,428
2. Behaviour change and communication
(BCC) strategy on awareness on NCD
3. IEC awareness about the central, project
level Grievance Redressal Mechanism (GRM)
4. Awareness and knowledge to access
patients record in the online patient
management system
General Estimated Total ₹ 937,760,000 $ 13,520,000
*This is a gross estimate for all the facilities regardless of current status of BMW and EM.
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12 CONSULTATION AND DISCLOSURE
12.1 Consultation during the ESMF Preparation
189. During the preparation of ESMF, consultation was done with:
(a) Various Government departments and institutions including from Department of Health and
Family Welfare (DoHFW), Mission Director National Health Mission, Andhra Pradesh
VadiyaVidhan Parishad, State Quality Cell at DoHFW, Directorate of Medical Education,
APMSIDC, AP Tribal Welfare Department (APTWD), Andhra Pradesh Pollution Control
Board, and other state level institutions.
(b) Consultation and collection of health facility data from a sample of HCF using questionnaire
on (i) Biomedical waste management, (ii) Infection control, and (iii) Social safeguard. This
included collection of data from about 211 HCFs across all 13 districts.
(c) District level consultation was carried out in five districts (East Godavari, Guntur, Prakasam,
Nellore and Kadapa) comprising of a range of stakeholders including (i) Medical staff -
doctors, specialists, nurses, administrative staff, staff in-charge of outreach activities, patient
satisfaction surveys, etc.; (ii) ANMs and ASHAs; (iii) District Medical and Health Officers
(DMHOs), and Deputy DMHOs; (iv) Supervisor in-charge of Area hospitals District hospitals
and CHCs; NQAS -District Quality Manager and District Quality Consultant; (v)
Representatives from at least 5-6 village health communities, including vulnerable groups and
women; (vi) Representatives from service providers of PPP programs; (vii) Officials working
on Tribal Reform Yardstick (TRY); and (viii) Representatives of self-help groups.
12.2 Disclosure
190. The findings of the draft ESMF was shared at the one-day Disclosure Workshop on ESMF for
the Andhra Pradesh Health Systems Strengthening Project (APHSSP)organized by HM&FW
Department on 12th February 2019 at Indian Medical Association (IMA) hall in Vijayawada.A total
of 157 participants from various departments, NGOs and community attended the Workshop. The participants included representative from various Government Departments including various
directorates of the Department of Health and Family Welfare (DoHFW), representatives from
National Health Mission (NHM), Andhra Pradesh Vaidya Vidhana Parishad (APVVP), State Quality
Cell at DoHFW, Directorate of Medical Education (DME), State TB Cell, Integrated Tribal
development Agency (ITDA), various service providers such as for eSC and CTFs, representatives
from various NGOs working on health and/ or tribal welfare,and community representatives. The
departments who could not join the consultations includes Andhra Pradesh Pollution Control Board
(APPCB), Andhra Pradesh Forest Department (APFD), and Department of Archaeology & Museum.
The detail list of participants is included as part of the minutes presented in Annex- 9 of this report.
191. The workshop proceeding included presentation about the proposed project, the need for
ESMF, key findings of environmental and social assessment, and the mitigation measures planned
along with implementation arrangement and monitoring planned. Following the presentation,
comments and suggestions were sought through open discussion. This was further summarised by
addressing the queries raised and how their suggestion will be addressed. The details proceedings of
the workshop is as follows:
The workshop kicked-off with the lighting of the lamp by various dignitaries of the DoHFW. It
was followed with a brief introduction by Mr. Arvind to all the participants regarding the
APHSSP project and the ESMF preparation. Following the short introduction, Director, SPIU
addressed the whole gathering giving a comprehensive and detailed speech on the APHSSP and
the importance of ESMF for the project. The speech captured the prelude to the need for the
APHSSP, focussed on the various activities for the three key result areas of the project – i)
Quality of care, ii) Comprehensive Primary Health care initiative and iii) Patient-centric care
114
approach. The funding for APHSSP by the World Bank through Investment Project Financing
with Disbursement Linked Indicators (DLIs) was also informed. An overview of the various
Disbursement Linked Indicators (DLIs) mapped with the three key results areas was included in
the detailed speech.
The Disclosure Workshop continued after the tea-break with the session on the ESMF preparation
delivered by Mr. Arvind. A presentation on the ESMF preparation, the need for ESMF for the
APHSSP, the various potential environmental and social risks/impacts arising out of the project
activities were being put forward before the audience. The presentation session also highlighted
the various mitigation measures for both environmental and social risks/impacts identified and
included in the Environment Management Plan (EMP) and Social Management Plan (SMP). The
importance of contribution from various concerned agencies and departments in implementing the
mitigation measures were highlighted in the sessions. The whole presentation on ESMF was
continued post lunch and the floor was opened for suggestions and comments.
The comments and suggestions were recorded during the open session is as below:
A participant from PHC Tadepalli, Guntur District raised concern for the non-availability
of segregation and disposal mechanism of biomedical waste at PHC level and suggested
about the inclusion of the appropriate steps to improve the same through the ESMF
project. Another participant from Krishna District asked clarification of the process
involved in conversion of exiting Sub centers to e-Sub Centers under the project. There
was a suggestion regarding the need of IEC in the form of video clippings to improve the
patient information on health care services being provided by the govt. of AP.
The need for strengthening of training to ASHA and ANM staffs was suggested as a
measure to be undertaken in the project. One participant from NGO,
VasavyaMahilaMandali suggested improving the availability of toilets and safe drinking
water facilities at public health facilities. A suggestion to include hygienic sanitation
measures and steps to address malnutrition in the APHSSP was provided.Also, suggestions
for inclusion of a strong monitoring mechanism at the highest level for the APHSSP along
with the ESMF plan was being put forward.
The above suggestions and comments were recorded and addressed by the Director, SPIU and the
workshop was concluded with Vote of Thanks from the department.
192. The final ESMF report is being finalised after incorporating the relevant suggestions from the
stakeholders during the consultation workshop. The final report of the ESMF will be disclosed on the
website of the Department of Health and Family Welfare GoAP and at World Bank‟s external website
prior to appraisal.
115
ANNEXTURES
ANNEX – 1: ENVIRONMENTAL AND SOCIAL SAFEGUARD SCREENING CHECK LIST
ENVIRONMENTAL AND SOCIAL SAFEGUARD SCREENING CHECK LIST
FOR PRELIMINARY ASSESSMENT OF HEALTH CARE FACILITIES
(This screening format needs to be filled under the guidance of health care facility in-charge
(ANM/ MO/ MS as applicable) to rule out any adverse environment and social impacts due to
program intervention.)
Name of the District
Name of the Block
Category of health care facility/
Laboratory
Name of health care facility
Environment Implications
1 Is there nearby protected area/
forest/?
Yes/ No
If yes,10
is there any
risk/impact/disturbance to forests
and/or protected areas?
If yes, any interventions should be
avoided.
2 Are there cultural, historic,
religious site/buildings within 2
kms of the facility?
Yes/ No
If yes,10 is there risk/impact to
known/unknown historical, religious
or cultural sites?
If yes, then activity should be
avoided, where there is no impact,
chance finds procedures would be
applicable and if protected site, ASI
norms would need to be followed
3 Is there civil works/building
rehabilitation envisaged at the
facility?11
Increase in dust and noise
from demolition and/or
construction
Generation of construction
waste
Yes/ No
If yes, follow construction stage
EMP in Chapter-7, Table 28 of this
report.
10
If any of the screening questions identify situations where less than optimum conditions occur (i.e. yes responses to
questions 1 and 2, then the selected HCF and associated interventions may not be suitable for works. In such cases it would
be necessary to reject improvements and refurbishments if doing so would provoke negative environmental impacts that
could not be avoided or mitigated, and the activity must be rejected/excluded. 11
It is expected that the HCFs to be renovated/refurbished will pass the screening criteria with no problem and will be found
suitable for improvements and any small civil works required. In such cases the standard mitigation measures would be all
that is needed to minimize any risk of negative environmental and social impact. The generic Environmental Management Plan (EMP) of this ESMF would apply in these cases.
116
Impacts on accessibility to
the facility
Excavation impacts and soil
erosion
Increase sediment
loads/wastewater discharges
in receiving water
Removal and disposal of
toxic and/or hazardous
substances12
Increase in soil erosion or
changes in local drainage
pattern
7 Does the facility have an
Individual wastewater treatment
system?
Yes/ No/ NA
If yes, ensure that discharges into
receiving waters meeting adequate
water quality standards attached in
Annex-6
These levels should be achieved,
without dilution, at least 95 percent
of the time that the plant or unit is
operating, to be calculated as a
proportion of annual operating hours.
Deviation from these levels in
consideration of specific, local
project conditions should be justified.
8 Is there adequate provision of
clean water and sanitation
services at the facility?
Yes/ No
If no, specify the mitigation measures
to be adopted to provide adequate
supplies of potable drinking water
Water supplied to areas of food
preparation or for the purpose of
personal hygiene (washing or
bathing) should meet drinking water
quality standard.
9
Is there adequate STP-ETP/ Soak
Pit iffacilities are not connected
to the municipal wastewater
scheme?
Yes/ No If no, adequate wastewater treatment
and disposal systems, such as
package
treatment plants and chlorination,
where appropriate for the size,
capacity, and services offered at
the health facilities.
10
Is BMW being suitably
segregated?
(this includes clinical waste,
sharps, pharmaceutical products,
cytoxic and
hazardous chemical waste,
radioactive waste, organic
domestic waste, non-organic
domestic waste)
Yes/ No
If no, then specify the on-site
measures/ equipment needed for
waste segregation and follow CPCB
guidelines on
(i) CPCB Implementation
Guidelines for Management
of Healthcare Waste in
Health Care Facilities as per
Bio Medical Waste
Management Rules, 2016
(ii) Guidelines for Management
of Healthcare Waste as per
12
Toxic / hazardous material includes and is not limited to asbestos, toxic paints, removal of lead paint, etc.
117
Biomedical Waste
Management Rules, 2016
(iii) Guidelines for Bar Code
System for Effective
Management of Bio-medical
Waste
11 Is the HCF connected to an
offsite CBMWTF?
Yes/ No
If no, then specify the on-site
measures for waste disposal
Follow guidance on DBP in Annex-2
12
Is all Biomedical equipment in
good working condition?
Yes/ No
If no, specify how this will be
mitigated
13 Are appropriate colour coded
Bins/ bags provided for bio-
medical waste disposal?
Yes/ No
If no, specify how consumables will
be provided at HCF level, and follow
CPCB Guidelines for Bar Code
System for Effective Management of
Bio-medical Waste
14 Is there SOP to manage
accidents/spills at HCF level
including mercury
Yes/ No/ NA
Develop SOP for accident
management and systems for
reporting and recording:
i. Occupational accidents and
diseases
ii. Dangerous occurrences and
incidents
iii. These systems should
enable workers to report
immediately
iv. Follow CPCB guidelines on
management of mercury. 13
15 Are healthcare and sanitation
workers provided with necessary
and appropriate health screening,
precautionary measures and
immunizations?
Yes/ No
If no, ensure the following practices
are implemented:
i. Yearly health screening of
all HCF and Sanitation staff
ii. Immunization for staff
members as necessary (e.g.
vaccination for hepatitis B
virus, tetanus)
iii. Provisions of gloves, masks,
and gowns
iv. Adequate facilities for hand
washing are available. If
hand washing is not
possible, appropriate
antiseptic hand cleanser and
clean cloths / antiseptic
towelettes should be
provided. v. Adequate procedures and
facilities for handling dirty
linen and contaminated
clothing
13
http://cpcb.nic.in/uploads/hwmd/Guidelines_for_ESM_MercuryW_fromHCFs.pdf
118
16 Does the facility have
appropriate fire safety
Infrastcrture and norms?
Yes/ No/ N. A If N.A, please specify
If no, Fire safety recommendations
applicable to occupational areas are
presented under „Occupational
Health and Safety‟ in the WBG
General EHS Guidelines14
Additional recommendations for fire
safety include:
i. Installation of smoke alarms
and sprinkler systems
ii. Maintenance of all fire
safety systems in proper
working order, including
ventilation ducts, escape
doors.
iii. Training of staff for
operation of fire
extinguishers and
evacuation procedures
iv. Development of facility fire
prevention or emergency
response and evacuation
plans with adequate guest
information (this
information should be
displayed in HCF main
locations and clearly written
in relevant languages).
In-charge of Health care facility (ANM/
MO/ MS)
Name……………………………………….
Designation: …………………………….
Phone No. …………………………………
Signature ………………………………….
Date: …………………………………………
14
https://www.ifc.org/wps/wcm/connect/9aef2880488559a983acd36a6515bb18/2%2BOccupational%2BHealth
%2Band%2BSafety.pdf?MOD=AJPERES
119
ANNEX 2: TECHNICAL SPECIFICATIONS OF DBP AND ETP
(1) Specifications for Deep Burial Pit
Deep burial pits should be constructed as per the Bio Medical Waste Management Rules,
2016 and Amendments (2018). A circular or rectangular pit is dug and lined with brick,
masonry or concrete rings. The pit is covered with a heavy concrete slab that is with an
internal diameter of about 200mm. Needles and scalpel blades (without the syringe body or
drip tubing) are dropped into the pit through the steel pipe. When the pit is full it can be
sealed permanently after another has been prepared.
1. A pit or trench should be dug about 2 meters deep. It should be half-filled with waste,
and then covered with lime up to 50 cm of the surface, before filling the rest of the pit
with soil.
2. Animals should not have any access to the waste burial sites. Covers of galvanized
iron/wire meshes may be used to protect the area from trespassing.
3. On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be
added to cover the wastes.
4. Waste disposal into the pits should be performed under close and dedicated
supervision.
5. The deep burial site should be relatively impermeable, and no shallow well should be
close to the site.
6. The pits should be distant from habitation and sited to ensure that no contamination
occurs of any surface water or ground water. The area should not be prone to flooding
or erosion.
7. The location of the deep burial site should be authorized by the prescribed authority.
8. The institution should maintain weekly/monthly records of the kind of waste sent for
deep burial
9. Only after disinfection, the bio-medical waste can be sent for deep burial.
10. A Record of the size and location of all burial pits needs to be strictly maintained and
displayed at strategic place with due precautions to prevent construction workers,
builders and other from digging in those areas in the future
120
Figure: Layout Specifications for Burial Pit (Source: Mainstreaming Environmental
Management in the Health Care Sector Implementation Experience in India & Tool-Kit for
Managers, The World Bank)
(2) Specifications for Effluent Treatment Plant
The waste water generated from hospital waste contains suspended particles, blood Stains, bacteria,
OT & Labor Block, Mechanized Laundry out lets and other pathogenic organism etc. The basic
principle of operation for ETP while scrubbing emission / flumes generated from high capacity
incinerator plant (100 kg and above approximately) lot of water is used for removing various gases &
particulate matter from the bio medical incineration. This water is required to be treated to be treated
before discharge however by installing ETP plant waste water can be recovered after treatment from
Different stages of ETP plant.
The CPPHEO Manual and as per IS Codes the following characteristic of waste water normally
contains the following parameters.
PH -4.5 TO 6
TSS -400-600 mg/Lts
BOD 300-400 mg/lts
O&G 20-30 MG/Lts
COD 800-1000 mg/Lts
Hospital effluent generated by three steps
Primary treatment
Secondary treatment
Tertiary treatment
Primary Treatment
Primary treatment is the first step of inlet waste water mainly consists of removal of coarse particles
like oil and Greece and mixing co-agents in the water for removal of suspended solids through
sedimentations.
The above primary treatment after the BOD, TSS, COD& O&G levels come down to 25% of initial
levels
Description PH TSS mg/lts BOD mg
/lts O&G mg/lts COD
mg/LTS Inlet water 4.5-6 400-600 300-400 20-30 800-1000 Out let water 8-10 300-450 225-300 15-22.50 600-750
Secondary Treatment
This is second step of waste water treatment. It mainly consist of extensive aeration of the primary
treated water, bacterial growth, addition of oxygen and chemical which help in bacterial growth and
lastly settlement of the biological waste as sludge, normally it is found that the reduction levels in
TSS, BOD, O&G and COD after an efficient secondary treatment will be as under.
Description PH T.S.S
mg/LTS BOD
mg/LTS O&G
mg/LTS COD mg
Inlet water 8-10 300-450 225-300 15-22.5 3000 Outlet water 6.5-9 128-150 96-128 <10 <250
121
Tertiary Treatment
This is final stage of treatment where the effluent after secondary treatment first is mixed with sodium
Hypo Chloride and then effluent will be pass passed through (DMF) DUAL MEDIA FILTER AND
(ACF) activated carbon filter where sand, anthracite and activated carbon will be used as filtration
media.
Description PH T.S.S mg/Lts BOD mg/Lts O&G
mg/LTS COD
mg/LTS Inlet water 6.5-9 128-150 96-128 <10 <250 Outlet water 6.5-9 <100 <30 <10 <250
Treatment of Effluent by the following process
Effluent is initially will passed through Screen chamber and Grit chamber, After the removal of
coarse particles before it enters in to oil and Grease trap. .After this effluent is being stored in an
underground tank where partial aeration is being done to keep the solids into suspension for pumping
ease. The effluent then will be pumped from underground tank to flash mixer where lime, alum and
Polymer solution is being mixed. The capacity for the Reaction chamber/Flash mixture cum
Flocculate is as per requirement. After chemical mixing the effluent will be transferred to primary
lamella clarifiers by gravity where setting of solids takes place. The capacity of the lamella clarifiers
will be as per requirement having minimum retention time for 1 hour. Clarified water will be taken to
aeration tank for biological treatment where necessary chemicals will be mixed for bacterial growth.
After this the primary treated water will be pumped to secondary lamella clarifiers. Clarified water
from clarifier will be taken to supernatant sump where the slurry will be collected in to a slurry tank
below the clarifier. Slurry will further be taken to a series of sludge drying beds for dewatering. After
dewatering the filtrate will be taken back to equalization tank and solids sludge will be disposed to the
site as suggested by Pollution Control board. The filtrate will be taken again back to the equalization
tank for further treatment. The clarifier water from supernatant sump will be dosed optimum quantity
of sodium hypo chloride from chlorine contact .The chlorine contact water from the supernatant sump
will be pumped through dual media filter having sand and anthracite as a filtering medium to control
the quantity of suspended solids .After DMF it will be pumped into an activated carbon filter for
further removed of solids and BOD to achieve the desired results.
122
FTREATMENT FLOW CHART
SCREEN CHAMBER
GRIT CHAMBER
OIL AND GREASE CHAMBERCHAMBER
UNDER GROUND TANK AND GREASE CHAMBER
FLASH
PRIMARY CLARIFIERS
AERATION TANK
SLUDGE DRYING BEDS
EQUALIZATION TANK
SOLID SLUDGE
123
ANNEX – 3: TEAM INVOLVED IN COLLECTION OF PRIMARY DATA FROM FIED
DURING ESMFPREPARATION
A.P. VAIDYA VIDHANA PARISHAD & DCHS
S.No Name of the District Name of the DCHS
1 SRIKAKULAM Dr.B.Suryarao
2 VIZIANAGARAM Dr.Ushasree
3 VISAKHAPATNAM Dr.B.K.Naik
4 EAST GODAVARI Dr.T.Ramesh Kishore
5 WEST GODAVARI Dr.K.Sankara Rao
6 KRISHNA Dr.B.Vijayalaxmi
7 GUNTUR Dr.Ch.Prasannakumar
8 ONGOLE Dr.S.Usha
9 NELLORE Dr.K.Subba Rao
10 CHITTOOR Dr.P.Saralamma
11 KADAPA Dr.Padmaja
12 ANANTAPUR Dr.N.Rameshnath
13 KURNOOL Dr.U.RamaKrishna Rao
DM & HOS'S
1 SRIKAKULAM Dr.M.Chenchaiah
2 VIZIANAGARAM Dr.Vijaya Lakshmi
3 VISAKHAPATNAM Dr.Tirupathirao
4 EAST GODAVARI Dr.T.S.R.Murthy
5 WEST GODAVARI Dr.subramanyaswari
6 KRISHNA Dr.I.Ramesh
7 GUNTUR Dr.J.Yasmin
8 ONGOLE Dr.Rajayalaxmi
9 NELLORE Dr.Varasundaram
10 CHITTOOR Dr.RamaGiddaiah
11 KADAPA Dr.Umasundari
12 ANANTAPUR Dr.S.Prabhudas
13 KURNOOL Dr.U.Raja Subbarao
State Quality Assurance Team
Sl.No. State Name Designation
1 O/o CH&FW Dr.M.Suhasini State Programme Officer (QA&Trgs)
2 O/o CH&FW Dr.G.Narendra Kumar State Consultant (QA)
3 O/o CH&FW Sri.P.Srinivasa Rao State Programme Assistant (QA)
District Quality Assurance Team
Sl.No. District Name Designation
1 Srikakulam Sri.Ravikumar Mantri District Consultant for QA
124
2 Smt.P. Ranjini District Hospital Quality Manager
3 Vizinagaram
Sri.KamalakarBhatu District Consultant for QA
4 Smt.M. Geetha Priya District Hospital Quality Manager
5 Visakhapatnam
Sri.SreenivasKuppili District Consultant for QA
6 Smt.SankeerthanaThalari District Hospital Quality Manager
7 East Godavari
Kmr.Sabbita Sudha Lalitha District Consultant for QA
8 Sri.Atmala Suresh Babu District Hospital Quality Manager
9 West Godavari
Sri.Manoj Kumar Kodi District Consultant for QA
10 Smt.Jhansi Durga Rani District Hospital Quality Manager
11 Krishna
Dr.KrishnaChaitanya.M District Consultant for QA
12 Smt.KranthiSandya . B District Hospital Quality Manager
13 Guntur
Sri.M.Vasudeva Raju District Consultant for QA
14 Sri.VasuBabuAdapa District Hospital Quality Manager
15 Prakasam
Sri.SaiCharan Kumar Pakala District Consultant for QA
16 Sri.Krishna Prasad Neela District Hospital Quality Manager
17 Nellore
Sri.PeddisettyKranthi District Consultant for QA
18 Sri.A. Bharath Bhushan District Hospital Quality Manager
19 Chittoor
Sri.Niranjan Reddy Kamasani District Consultant for QA
20 Kmr.Divya Deepthi Panditi District Hospital Quality Manager
21 Anantapur
Md Murthujavali District Consultant for QA
22 Sri. R. Stephen Paul District Hospital Quality Manager
23 Kurnool
Dr.M. Abdul Khader District Consultant for QA
24 Dr.Roop Kumar Boya District Hospital Quality Manager
25 Kadapa
Dr.Sarala Devi Chebathini District Consultant for QA
26 Sri.Bokke Ramesh Naik District Hospital Quality Manager
125
ANNEX – 4: QUESTIONNAIRE FOR COLLECTION OF BASELINE DATA
1. Checklist for Biomedical Waste Management and Social Safeguards (to be filled by
Health Officers)
Type of HCF: _
PHC CHC
District Hospital RNTCP Laboratory
State: _________________
City/Town: _________________
S. No Questions
Bio- medical waste collection and transport
1. Is the facility operated as per BMWM rules 2016 yes no
2 Does the occupier have authority to set up its own treatment facility or having
any other alternative option
yes no
3. As per the Bio Medical Waste Management Rules, 2016, the healthcare facility is required to submit the Annual Report to the SPCB/PCC. Is the HCF providing
this report?
yes no
4. Is the segregation of waste being done at the point of generation yes no
5. Is Biomedical waste mixed with other waste yes no
6. Are waste collection containers/bins available and are they in good condition yes no
7. Are needle destroyers available in sufficient number and are they in good
working condition
yes no
8. Are containers colour coded as per the BMWM rules yes no
9. Is there a record of everyday‟s generation of waste available as per the category yes no
10. Does the waste marked for incineration have plastic waste mixed in it yes no
11. Is spill treatment kit available yes no
12. Does the institution have SOP for mercury spill management yes no
15. Is liquid waste being treated before discharge into sewers. yes no
16 Is there proper storage and internal and external transport facility available yes no
17. Is there any accessibility of unauthorised person to waste storage yes no
18. Is there any separate route for the waste transport through the HCF yes no
19. Does the institution have recorded policy on the waste type, collection time and
weighing of waste
yes no
20. Is any waste being stored at the facility for more than 48 hours yes no
21 Is the vehicle which is carrying waste from institution to offsite authorised for
such specialised work
yes no
Worker Health and Safety
22 Do employees wear protective equipment (PPE) while on the job yes no
23 Is there any incidence of occupational injury/ accident 15
yes no
24 Is the record of such injury/ injury/ accident with sufficient details available yes no
15
Needle stick injuries; splash exposure or mercury spills; chemical spillage
126
25 Are Major accidents being reported to SPCB
Toppling of the truck carrying bio-medical waste
Accidental release of bio-medical waste in any water body
Flooding or Erosion of the deep burial pit
yes no
26 Is the BMWM training manual for staff available yes no
27 Is the record of employees training available yes no
28 Is the medical record of waste handlers available yes no
29 Health check-up of all the employees (at least once in a year) yes no
30 Are all staff of the health care facility and involved in handling of BMW is immunized (against the Hepatitis B and Tetanus)
yes no
Any other comments: ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
............................................................
Name of the auditor................................
Date......................Time..............
127
2. Checklist for infection control measures
S.NO Questions
1. Decontamination of instruments
a. Is sterilizer available yes no
b. Is it in good working condition yes no
c. Are clean instruments stored in cupboards under lock yes no
d. Are instruments rust free yes no
2. Handling of sharps
a. Is puncture proof container available yes no
b. Are sharps peeping out of containers yes no
c. Are sharps lying outside containers yes no
d. Is there any recapping of needles/ syringes yes no
e. Is needle cutter available yes no
f. Is it in good working condition yes no
3. Use of Personal Protective Equipment
a. Is PPE (gloves, apron, mask etc.) available? yes no
b. Are staff trained on how to use and dispose of this equipment? yes no
c. Are they of good quality/ good condition yes no
d. Are they being used by staff having high risk of exposure (TB & Chest OPD,
Medicine OPD, Indoor wards, ART Centres, bronchoscopy suites, intensive care
unit (ICU), and operating theatres (OT).
yes no
4. Hand washing practices
a. Is liquid soap and clean water available yes no
b. Is paper towel/ clean towel available yes no
c. Is staff aware of hand washing practices yes no
d. Are staff members washing their hands properly yes no
e. Are list of universal precautions available yes no
5. Solid Waste Management
a. Disposal of the sputum cups and slides into covered containers 5% Sodium
Hypochlorite solution for disinfection
yes no
b. Is there any contaminated waste littered around yes no
c. Are the containers in good condition yes no
d. Does staff handle the waste with bare hands yes no
128
e. Are waste containers colour coded as per rules yes no
Any other comments:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
............................................................
Name of the auditor................................
Date......................Time..............
129
3. Social Safeguards
Heads Type of Details requested:
(Y/N)
Comments, if any, to be
filled in
Infrastructure
Is the facility located on government
land free of encumbrances?
Is the access road to the facility an all-
weather road free of obstacles?
Does the facility require minor civil
works/refurbishments?
Does the facility have a boundary
wall?
Does the facility have adequate seating
space?
Does the facility have separate and
enough toilets for women? (Please list
number of toilets in the comments
section.)
Patient footfall disaggregated by
gender. (approximate)
Does the facility have drinking water
for patients?
IEC material and Awareness
Does the facility display
pictures/hoardings to create awareness
on communicable and non-
communicable diseases prominently?
Does the facility have awareness
material for pregnant and lactating
women?
Does the facility use any kind of videos
for creating awareness in
communities?
Any other comments:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
130
ANNEX – 5: CHECKLIST FOR STAKEHOLDER CONSULTATIONS
Note to the Survey team:
The following questions have been prepared based on the experience of the WB team and
inputs from secondary data. It is suggested that the team members from the state, translate
this questionnaire into telugu for easy communication and documentation.
Considering that the dates currently scheduled are from 20th
to 27th
of December, which
leaves only 4 days for consolidation and completion of the final draft of the report, it is
imperative that the data being captured be as clear and granular as possible so that
compilation and inclusion into the final draft of the project report will be accurate.
Social safeguards:
1. Priority needs:
a. What are some of the priority needs at the community level in your area? (health,
education, water, electricity, communication, transport and connectivity, etc.)
2. Socio economic background:
a. What is the socio-economic background of the patients visiting the health facility?
(Caste, income level, profession, etc.)
b. Do you capture this information in your records?
3. Access:
a. Is your health facility accessible to your target population? What radius do you
serve?
4. Footfall:
a. What is the average patient foot-fall? Average number figure (male and female).
(Will be available in the OP register)
5. Comment on the infrastructure in your facility from a safety and adequacy perspective.
(since AP is a disaster zone).
a. Are there public buildings (Schools, hostels, etc) that can serve as storm shelters?
b. What is the process followed in case of a natural disaster?
6. Disaster management:
a. Do you have a disaster management plan?
b. In case of a disaster what is your role and what is the chain of command?
7. Feedback and Patient Satisfaction
a. Do you gather feedback from patients? (Y/N) and details, if yes.
b. How does the hospital monitor patient satisfaction? Sample, frequency, etc.
8. Does the HCF undertake awareness programs/activities at the community level? Please
give details.
a. Do you conduct programs at the village and tanda level?
b. Do you share preventive, curative and palliative care information with the
community?
c. Do you have IEC material?
9. Committees:
a. Does the HCF have a health monitoring committees/hospital representative
committee?
b. How frequently do they meet?
c. What is their role?
d. How are the members selected? (Please take a note of the minutes.)
131
10. Gender:
a. Based on your observations, do you feel that women come for check-
ups/treatments at advanced stages of the disease compared to men?
b. Do women ignore their health?
11. Please capture details of the functioning medicine dispensing ATMs located in tribal
areas.
Environment Safeguards
1. Is the current waste segregation adequate for infectious wastes and sharps?
2. What could be potential impacts of the incremental increase in waste generated through
the Project?
3. How can the project help manage these risks/impacts?
4. What is the current treatment system of effluents/contaminated wastewater?
5. Can the project help to ensure effluents are suitably treated and disposed so that there are
no risks to the environment (soil and water bodies)?
6. Is Environment Health and Safety performance in larger hospitals being monitored?
(energy use, cleaning schedules, waste generation, effluent treatment, and occupational
safety of medical staff)
7. Is there adequate availability of the consumables i.e. colored bins, bags, PPE gear for
staff, puncture proof containers, needle cutters etc.?
8. How frequently is health checkup and immunization conducted for staff and sanitation
workers?
9. Institutional Arrangements:
a. What are the institutional arrangements for healthcare waste management and
infection control?
b. Are they sufficient to train, guide and implement these activities?
c. Can the project help?
10. What are the current methods of disposal of chemical reagents and disinfectants- is there
impact to water bodies?
11. Present methods of BMW disposal in rural areas (PHCs and the SCs) (where
decentralized treatment facilities are not available) and is there any pollution impacts due
to these systems, can the project support better alternatives?
132
ANNEX – 6: APPLICABLE ENVIRONMENTAL STANDARDS
Applicable Standards – CPCB
A. Drinking Water Standard
Drinking water guideline as per IS 10500, 2012 has been presented in table below;
S.No Characteristic Acceptable Limit Permissible Limit
General Parameters
1 Colour, Hazen units, Max 5 15
2 Odour Agreeable Agreeable
3 pH value 6.5-8.5 No Relaxation
4 Turbidity, NTU, Max 1 5
5 Total dissolved solids, mg/l 500 2000
6 Aluminium (as Al), mg/l, Max 0.03 0.2
7 Ammonia (as total ammonia-N)mg/l,
Max 0.5 No relaxation
8 Anionic detergents (as MBAS) mg/l,
Max 0.2 1.0
9 Barium (as Ba), mg/l, Max 0.7 No relaxation
10 Boron (as B), mg/l, Max 0.5 1
11 Calcium (as Ca), mg/l, Max 75 200
12 Chloramines (as Cl2), mg/l, Max 4 No relaxation
13 Chloride (as Cl), mg/l, Max 250 1000
14 Copper (as Cu), mg/l, Max 0.5 1.5
15 Fluoride (as F) mg/l, Max 1.0 1.5
16 Free residual chlorine, mg/l, Min 0.2 1
17 Iron (as Fe), mg/l, Max 0.3 No relaxation
18 Magnesium (as Mg), mg/l, Max 30 100
19 Manganese (as Mn), mg/l, Max 0.1 0.3
20 Mineral oil, mg/l, Max 0.5 No relaxation
21 Nitrate (as NO3), mg/l, Max 45 No relaxation
22 Phenolic compounds (as C6H5OH), mg/l, Max
0.001 0.002
23 Selenium (as Se), mg/l, Max 0.01 No relaxation
24 Silver (as Ag), mg/l, Max 0.1 No relaxation
25 Sulphate (as SO4) mg/l, Max 200 400
26 Sulphide (as H2S), mg/l, Max 0.05 No relaxation
27 Total alkalinity as calcium — carbonate, mg/l, Max
200 600
28 Total hardness (as CaCO3), mg/l,
Max 200 600
29 Zinc (as Zn), mg/l, Max 5 15
Concerning Toxic Substances
30 Cadmium (as Cd), mg/l, Max 0.003 No relaxation
133
S.No Characteristic Acceptable Limit Permissible Limit
31 Cyanide (as CN), mg/l, Max 0.05 No relaxation
32 Lead (as Pb), mg/l, Max 0.01 No relaxation
33 Mercury (as Hg), mg/l, Max 0.001 No relaxation
34 Molybdenum (as Mo), mg/l, Max 0.07
35 Nickel (as Ni), mg/l, Max 0.02
36 Polychlorinated biphenyls, mg/l, *— Max
0.0005 No relaxation
37 Polynuclear aromatic hydro carbons (as PAH), mg/l, Max
- 0.000 1 No relaxation
38 Total arsenic (as As), mg/l, Max 0.01 0.05
39 Total chromium (as Cr), mg/l, Max 0.05 No relaxation
40 Bromoform, mg/l, Max 0.1 No relaxation
41 Dibromochloromethane, — mg/l, Max
0.1 No relaxation
42 Bromodichloromethane, — mg/l, Max
0.06 No relaxation
43 Chloroform, mg/l, Max 0.2 No relaxation
Concerning Radioactive Substances
44 Alpha emitters Bq/l, Max 0.1 No relaxation
45 Beta emitters Bq/l, Max 1.0 No relaxation
Bacteriological Quality of Drinking Water1)
46 All water intended for drinking: a) E. coli or thermotolerant coliform
bacteria2),
Shall not be detectable in any 100 ml sample
47 Treated water entering the
distribution system: a) E. coli or thermotolerant coliform
bacteria2) Shall not be detectable in
any 100 ml sample b) Total coliform bacteria
48 Treated water in the distribution
system: a) E. coli or thermotolerant coliform
bacteria Shall not be detectable in any
100 ml sample b) Total coliform bacteria
B. Surface Water
Surface Water Quality criteria as per CPCB guidelines has been presented in table below
Designated-Best-Use Class Criteria
Drinking Water Source without
conventional treatment but after
disinfection
A Total Coliforms Organism MPN/100ml
shall be 50 or less
pH between 6.5 and 8.5
Dissolved Oxygen 6mg/l or more
Biochemical Oxygen Demand 5 days 20oC
2mg/l or less
134
Outdoor bathing (Organized) B Total Coliforms Organism MPN/100ml
shall be 500 or less
pH between 6.5 and 8.5
Dissolved Oxygen 5mg/l or more
Biochemical Oxygen Demand 5 days 20oC
3mg/l or less
Drinking water source after
conventional treatment and
disinfection
C Total Coliforms Organism MPN/100ml
shall be 5000 or less
pH between 6 to 9
Dissolved Oxygen 4mg/l or more
Biochemical Oxygen Demand 5 days 20oC
3mg/l or less
Propagation of Wildlife and Fisheries D pH between 6.5 to 8.5
Dissolved Oxygen 4mg/l or more
Free Ammonia (as N) 1.2 mg/l or less
Irrigation, Industrial cooling,
Controlled waste disposal
E pH between 6.0 to 8.5
Electrical Conductivity at 25oC micro
mhos/cm Max.2250
Sodium absorption Ratio Max. 26
Boron Max. 2mg/l
Below-
E
Not Meeting A, B, C, D & E Criteria
Source: Central Pollution Control Board
C. DG Set Emission Standards
Emission limits for new diesel engine up to 800 kW for generator set (Gen-set) application has been
presented in table below:
Power Category Emission Limits (g/kW-hr) Smoke Limit (light
absorption
coefficient, m-1) NOx +HC CO PM
Upto 19 KW ≤ 7.5 ≤ 3.5 ≤ 0.3 ≤ 0.7 More than 19
KW upto 75 KW ≤ 4.7 ≤ 3.5 ≤ 0.3 ≤ 0.7
More than 75
KW upto 800
KW
≤ 4.0 ≤ 3.5 ≤ 0.2 ≤ 0.7
D. Noise Levels
The ambient noise quality standard as prescribed by CPCB in the Noise Rules 2000 has been provided
in table below:
Area Code Category of Area /
Zone Limits in dB(A) Leq* Day Time Night Time
A Industrial area 75 70 B Commercial area 65 55 C Residential area 55 45 D Silence Zone 50 40
135
Environmental Quality Standards – WBG EHS Guidelines
E. Air Quality
The ambient air quality guideline as provided in World Bank Group‟s General EHS Guidelines 2007
has been presented in table below:
Parameter Averaging Period Guideline value in µg/m3
Sulfur dioxide (SO2) 24-hour 125 (Interim target-1) 50 (Interim target-2) 20
(guideline) 10 minute 500 (guideline
Nitrogen dioxide
(NO2) 1-year 40 (guideline) 1-hour 200 (guideline)
Particulate Matter
PM10 1-year 70 (Interim target-1)
50 (Interim target-2) 30 (Interim target-3) 20 (guideline)
24-hour 150 (Interim target-1) 100 (Interim target-2) 75 (Interim target-3) 50 (guideline)
Particulate Matter
PM2.5 1-year 35 (Interim target-1)
25 (Interim target-2) 15 (Interim target-3) 10 (guideline
24-hour 75 (Interim target-1) 50 (Interim target-2) 37.5 (Interim target-3) 25 (guideline)
Ozone 8-hour daily maximum 160 (Interim target-1) 100 (guideline)
F. Wastewater
Sanitary wastewater from facilities may include effluents from domestic sewage, food service, and
laundry facilities serving site employees. Miscellaneous wastewater from laboratories, medical
infirmaries, water softening etc. may also be discharged to the sanitary wastewater treatment system.
World Bank Group‟s General EHS Guidelines 2007 for sanitary wastewater quality has been
presented in table below:
Pollutants Pollutants Guideline Value pH pH 6-9 BOD mg/l 30 COD mg/l 125 Total nitrogen mg/l 10 Total phosphorus mg/l 2 Oil and grease mg/l 10 Total suspended solids Mg/l 50 Total coliform bacteria MPN / 100 ml 400
136
G. Noise Level Guideline
As per World Bank Group‟s General EHS Guidelines 2007, noise impacts should not exceed the
levels presented in table or result in a maximum increase in background levels of 3 dB at the nearest
receptor location off-site.
Receptor One Hour LAeq (dBA) Daytime 07:00 - 22:00 Night time 22:00 - 07:00
Residential; institutional; educational 55 45 Industrial; commercial 70 70
137
ANNEX-7: LIST OF MONUMENTS IN ANDHRA PRADESH
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
1. Hill Fort and buildings therein and the
fortifications at the foot of the hill Gooty Anantapur
2. Madhavaraya temple (old Vishnu temple) Gorantla Anantapur
3. Outer wall of the Mahalakshmi temple Goripalli Anantapur
4. Group of sculptures Hemavati Anantapur
5. Group of old temples together with adjacent
land Hemavati Anantapur
6. Large dolmen on a rocky hillock kalyandurg Anantapur
7. Mallikarjuna (siva) temple Kambaduru Anantapur
8. Virabhadra temple Lepakashi Anantapur
9. Basavannah temple Lepakashi Anantapur
10. Hill fort Madakasira Anantapur
11. Large bastion and an old gateway Madakasira Anantapur
12. Extensive hill-fortress with outlying
fortification excluding the fort gate Rayadurg Anantapur
13. Palace and two temples of Rama and Krishna Rayadurg Anantapur
14. Chintalarayaswami temple Tadpatri Anantapur
15. Rameswaraswami temple Tadpatri Anantapur
16. Sitatirtham steeped well with entrance in the
form of a bull Penukonda Anantapur
17. The Hill fort and northern gateway with
inscriptions Penukonda Anantapur
18. The citadel and ruined buildings on the hill Penukonda Anantapur
19. Watch tower known as Rama‟s bastion Penukonda Anantapur
20. Small pavillion Penukonda Anantapur
21. Old gopuram Penukonda Anantapur
22. Old stamba or lamp pillar in the sub
collector‟s office compound Penukonda Anantapur
23. Hill fort and a large wall
Anantapur
24. Lower Fort and structure Chandragiri Chittoor
25. Upper Fort Chandragiri Chittoor
138
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
26. Venkateswara Vishnu temple Mangapuram (hamlet of
Mittapalam) Chittoor
27. Chennakeswaraswami temple Sompalle Chittoor
28. Fort Gurramkonda Chittoor
29. Lower Fort, Centre Fort wall, moat, old fort
gateway, old hanuman temple, old mandapam Gurramkonda Chittoor
30. PalliswaraMudaiyaMadeya temple Kalakada Chittoor
31. Parasuramesvara temple Gudimallam Chittoor
32. Mahal Gurramkonda Chittoor
33. Bhimeshwaraswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
34. Indranadheshwaraswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
35. Kamalasambnashwaraswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
36. Raghaveswaraswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
37. Sivakesavaswamy temple
Pushpagiri,(hamlet of
kotluru) Cuddapah
38. Trikoteswaraswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
39. Vaidhyanadhaswamy temple
Pushpagiri, (hamlet of
kotluru) Cuddapah
40. Ancient Village sites Paddamudiyam Cuddapah
41. Kondarama temple Paddamudiyam Cuddapah
42. Mukundesvara temple with inscriptions Paddamudiyam Cuddapah
43. Narasimha temple Paddamudiyam Cuddapah
44. Vigneswaraswamy temple Chilamakuru Cuddapah
45. Remains of the buried jain temple Danabalapadu Cuddapah
46. Fort with enclosed ancient buildings,
Madhavaperumal temple Gandikota Cuddapah
47. Visvanatha swamy temple Sivalpallu Cuddapah
48. Saumyanatha temple Nandalur Cuddapah
49. Athiralaparasurama temple Poli Cuddapah
139
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
50. SriKodandarmaswamy temple and adjoining
buildings Vontimitta Cuddapah
51. Fort , Moat and buildings Siddhout Cuddapah
52. Old Vishnu temples with inscriptions Peddanudiyam Cuddapah
53. Agatheswar Swami Temple Chilamkur Cuddapah
54. Ruined Buuddhist stupa and other
remains Amaravati Gumtur
55. Inscribed rock to the west of Dharanikota Amaravati Cuddapah
56. Fort in ruins Dharanikota Cuddapah
57. Ancient siva temple with inscription Ayyangaripalam Cuddapah
58. Bhavanarayana temple Bapatla Cuddapah
59. Ruined Buddhist stupa Bhattiprolu Cuddapah
60. Kapoteswara temple with the inscriptional
monuments within the temple site(slabs in the
temple site) Chejerla Cuddapah
61. Mounds with ancient remains Grandhesirl Cuddapah
62. Inscribed marble pillar near the Gopala
temple Ipuru Cuddapah
63. Ancient Buddhist remains and Brahmi
inscriptions on the mound Manchikallu Cuddapah
64. Mounds with ancient remains Velpur Cuddapah
65. Fort-storeyed rock-cut Hindu temple Undavalli Guntur
66. The Sculptures, carvings, images or other like
objects discovered within the revenue limit Buddam Guntur
67. Mound Nagulavaram Guntur
68. Hill of Nagarjunakonda with the ancient
remains Pullareddigudem
(Agarharam) Guntur
69. The Sculptures, carvings, images on the
ancient mound Pullareddigudem Guntur
70. Reconstructed monumets at Anupu and
Nagarjunklonda hilltop Nagarjunakonda Guntur
71. Mounds containing Buddhist remains such as
stupas Adurru EastGodavari
72. Rock-cut caves and cisterns and remains of
Buddhist Stupas, Chatyas and Viharas Kapavaram East Godavari
140
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
(monasteries) on
the hill pandavula or pandavakonda
73. Buddhist remains at Kodavali Kodavali EastGodavari
74. Bhimeswara temple
Samalkot,
Bhimavaram East Godavari
75. Bhimeswara temple Draksharama East Godavari
76. Gollingeswara group of temples Biccavolu East Godavari
77. Monolithic Ganesh Image Biccavolu EastGodavari
78. Ancient site and remains comprised in survey
plot No. 37 Munagacherla Krishna
79. Ancient site with the mound marking the
Buddhist Stupas in it. Alluru Krishna
80. Buddhist remains in a mound Ghantasala Krishna
81. Mound containing Budhist remains and
ancient village site. Gudivada Krishna
82. Hillock containing the mound marking the
ancient remains of Budhist stupas situated on
it Gummadiduru Krishna
83. Bandar Fort (1) Armoury known as Fortand
customs office, Bandar Fort customs office
(2) Belfry Masulipathnam Krishna
84. Dutch cemetry Masulipathnam Krishna
85. Buddhist remains of a Stupa on the hill Jaggayyapeta Krishna
86. Four pillars in the ruined mandapam in
Jammidoddi Vijayawada Krishna
87. Two rock-cut cavetemples on the Indrakila
hill known as Akkanna caves Kiratarjuna
pillar andslab the Indrakilahil Inscribed pillar
and slab in Malleswaraswami temple
Vijayawada Krishna
88. Rock-cut cave temples on
the Hill Mogalrajapuram Krishna
89. Sculptures, carvings, images other like
objects found in the
vicinity of the old Mosque Gudur Krishna
90. Inscribed Pillar and slab in Mallesvarasvami
temple Vijayawada Krishna
91. Kiratharjuna Pillar on the Indrakilla Hill Vijayawada Krishna
141
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
92. Ruined fort and buildings therein except
Ramazan masjid Adoni kurnool
93. Inscribed stone lying to the east of siva
temple Rayachoti kurnool
94. Inscribed boulder bearing Andhra records of
150 A.D. Chinnakadaburu kurnool
95. A prominent granite hillock bearing Asokan
inscriptions Jonnagiri kurnool
96. The One Asokan inscription, Two early
Chalukya inscriptions and One late Chalukya
inscriptions. Rajulamandagiri kurnool
97. Mausaleum known as Abdul Wahab Khan‟s
Tomb and adjoining buildings Kurnool kurnool
98. Gateways and the bastions of the old fort, viz
1) Bastion No.1 Beach GhantkiBuruzu
2) Bastion No. 2 Lal BangalowBuruzu
3) Gateway to Gopala Darwaja
4) Gateway to Panikiddi
Kurnool kurnool
99. Nandavaram Temple including the sculpture
of Subrahamanya Nandavaram kurnool
100. Old Cave Temple Yaganti kurnool
101. Uma-Mahesvaraswami Temple Yaganti kurnool
102. Ancient Mound Kondapur Medak
103.
Mound known as „BodipatiDibba‟
Ramatirtham
(Hamlet
of
Varini)
Nellore
104. Ancient Mound Ramatirtham Nellore
105. Hill Fort with Ancient buildings therein Udayagiri Nellore
106. Krishna Temple in a part of Donka with
Gopuram, Kalyanamandapam and Masonry
built Tank Udayagiri Nellore
107. Ranganayakula Temple Udayagiri Nellore
108. Ancient Mounds Kanuparti Prakasam
109. A group of eight rock-cut temples in
Bhairavakonda hill Kottapalli Prakasam
110. Chola Temple Motupalle Prakasam
142
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
111. Ancient Mound Pedaganjam Prakasam
112. Pitikeswara group of temples including
Approach road Pittikayagulla Prakasam
113. Ancient Site Pusalapadu Prakasam
114. Remalingesvara group of temples Satiavel Prakasam
115. Ancient Buddhist site Kalingapatnam Srikakulam
116. Sri Somesvara temple Mukhalingam Srikakulam
117. Bhimesvara temple, Mukhalingesvara temple Mukhalingesvara Srikakulam
118. Buddhist remains Salihundam Srikakulam
119. Eastern portion of Salihundam hill containing
Buddhist remains (A Chaitya and four stupas) Salihundam Srikakulam
120. Ancient Buddhist Mounds locally known as
„Dhana Dibbalu‟ Kotturu (near Gokivada
forest) Vishakhapatnam
121. Buddhist rock-cut stupas, Dagabas and caves
and the ruins of a
structural Chaitya with its outbuilding and
other Ancient remains on
twoadjoining hills known as Bojjanna Konda.
Sankaram Vishakhapatnam
122. (Durga Bhairavakonda) having an ancient
monument called Durga Nilavati Vizianagaram
123. Ruined Buddhist Monastery at
Gurubhaktulakonda RamatirthaluRamatirtham Vizianagaram
124. The old, Dibbesvarasvamipur temple Sarapalli (Sarapalle) Vizianagaram
125. Mounds containing Buddhist remains Arugolanu WestGodavari
126. Mounds locally known as Bhimalingadibba Denduluru WestGodavari
127. Buddhist monuments
1) Rock-cut temple 2) Large Monastery
3) Small Monastery 4) Brick Chaitya
5) Ruined Mandapa 6) Stone built Stupa and
Large group of stupas.
Guntupalle West Godavari
128. The caves and structural stupa of
Archaeological interest on
Dharmalingesvarasvami hill
Jilakarragudem (Hamlet of
Guntupalle) WestGodavari
129. The mounds of Pedavegi:
Dibba No.1 Dibba No.2, Dibba No. 3,
Dibba No. 4, Dibba No. 5. Pedavegi West Godavari
130. Ancient Mounds Pedavegi West Godavari
143
Alphabetical List of Monuments in Andhra Pradesh by Archaeological Survey of India
SL.No Name of the monument / site Location District
Source: Archaeological Survey of India. Available at http://asi.nic.in/alphabetical-list-of-monuments-
andhra-pradesh/
ANNEX-8: LIST OF PROTECTED MONUMENTS IN ANDHRA PRADESH
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
1 Old Fort (Ranganayanikota) Anantapur
2 Gaganmahal Anantapur
3 Hill Fort known as PallikondaKambam Narasimha Swamy
Konda and Rallagutta
Anantapur
4 Jaina temple Anantapur
5 Sri Kona Ranganatha Swamy temple Anantapur
6 Sri Chennakesava Swamy temple Anantapur
7 Sri Chennakesava Swamy temple Anantapur
8 Akkammavarigudi Anantapur
9 Laxminarsimha Swamy temple Anantapur
10 Pasupathiratha temple Anantapur
11 JainaBasadi Temple Anantapur
12 Chennakesava Swamy temple Anantapur
13 Maheswara Swamy temple Anantapur
14 Kundurti Fort Anantapur
15 Bheemeswaraswamy temple Anantapur
16 Ancient Well Anantapur
17 Chinnakesavaswamy temple Anantapur
18 Sri Lakshmi Narasimha Swamy temple Anantapur
19 Kodandaramaswamy temples Anantapur
20 Narasimhaswamy temple Anantapur
21 Veerabhadraswamy temple Anantapur
144
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
22 Anjaneyaswamy temple Anantapur
23 BallepalliMatam, Kundurpi Fort Anantapur
24 Laxmi Chennakesava Swamy temple Anantapur
25 Anjaneya Swamy temple Anantapur
26 JainaMatha Anantapur
27 Ramaswamy temple Anantapur
28 Ash Mounds Anantapur
29 Malaobula Narsimha Swamy temple Anantapur
30 Mallappakonda site Anantapur
31 Patigadda site Anantapur
32 Megalithic cist burials Anantapur
33 Ancient samadhi of Great Poet Yogi Vemana Anantapur
34 Gangarajulakota Anantapur
35 KalyanaVenkateswara Swamy temple Chittoor
36 Kodandaramaswamy temple (Adityeswara temple) Chittoor
37 Perumallaswamy temple (Prasanna Venkateswara Swamy
temple)
Chittoor
38 KhalabhairavaPrayaga Madhava Swamy temple Chittoor
39 Kangundhi Fort, Kalikamba temple, Venugopalaswamy
temple, Carved image of Hanuman, Virupakshaswamy
temple
Chittoor
40 Neelakanteswara Swamy temple Chittoor
41 (a) Swayambhu Vinayaka Swamy temple
(b)Varadarajaswamy temple, (c) Manikanteswaraswamy
temple
Chittoor
42 Valleswaraswamy temple Chittoor
43 Valmikeswara Swamy temple Chittoor
44 Kodandeswara Swamy temple Chittoor
45 Agasteswaraswamy temple Chittoor
46 Megalithic Burials Chittoor
145
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
47 Late Sri K.Jiddu Krishna Murthy House (VII 160
Raghavendra Rao Street)
Chittoor
48 Sri Venugopalaswamy temple Chittoor
49 Nawab‟s Tower at the Jail Cuddapah
50 Bhogamdanibhavi Cuddapah
51 Syed Ahmed Sahib‟s Tomb Cuddapah
52 Pennapenurkonda Cuddapah
53 Yerraguntalakota Cuddapah
54 Narasimhaswamy temple Cuddapah
55 Siva Temple (Mabbudwalam) Cuddapah
56 Mulasthaneswara Temple Cuddapah
57 LK Gutta site Cuddapah
58 Patigadda Cuddapah
59 Kona Malleswara Swamy temple Cuddapah
60 Mallikarjunaswamy temple Cuddapah
61 Old Mosque East Godavari
62 Pandavula Metta East Godavari
63 Sri Kumara Rama Bheemeswaraswamy temple East Godavari
64 Kunti Madhavaswamy temple, East Godavari
65 Kukkuteswaraswamy temple
66 Sri Bhavanarayanaswamy temple East Godavari
67 Sri Umakoppulinges-wara Swamy temple East Godavari
68 Ranganathaswamy temple East Godavari
69 Sri Lakshminarasimhaswamy temple on the top of hill Sri
Lakshmi-narasimhaswamy temple at the foot of hill. Sri
Pushpa Badraswamy temple on the top of hill
East Godavari
70 Kapoteswaraswamy temple East Godavari
71 Dutch tombs East Godavari
72 Ancient sites East Godavari
73 Cemetery East Godavari
146
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
74 Sri Venugopala Swamy temple East Godavari
75 Residence of Late Sri KandukuriVeerasalingamPantulu East Godavari
76 Prehistoric stone at the Fort of the hill Guntur
77 Rock cut cave on the hill Guntur
78 Megalithic site Guntur
79 Gopinadhaswamy temple and inscribed pillar Guntur
80 Dharanikota Fort Guntur
81 Hill Fort Guntur
82 Bellamkonda Fort Guntur
83 Veerabhiravaswamy temple Guntur
84 Archaeological site Guntur
85 Nageswaraswamy temple Guntur
86 Veerabhadraswamy temple Guntur
87 Anjaneyaswamy temple Guntur
88 Bheemeswaraswamy temple Guntur
89 Kesavaswamy temple Guntur
90 Parvathi Ammavari temple Guntur
91 Narasimha temple Guntur
92 Chathurmukha Brahma temple Guntur
93 Ruined Fort Guntur
94 Sri Lingodbava-swamivari temple Guntur
95 ChennakesavaSwamyvari temple Guntur
96 Gramadevatha Guntur
97 Siva temple (now in PrakasamDist) Guntur
98 Archaeological sites Guntur
99 Archaeological sites Guntur
100 Veerabhadraswamy temple Guntur
101 Fort walls Guntur
102 GantalaRamalingeswara temple Guntur
147
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
103 Sri Venugopalaswamy temple Guntur
104 Sivunigudi Guntur
105 Sri Kaleswaraswamy temple Guntur
106 Janardhanaswamy temple Guntur
107 Sri Muktheswaraswamy temple Guntur
108 Mud Fort Krishna
109 Hill Fort and Ruined Palace Krishna
110 Nuzvid Fort Gate North and South situated in Sy.No.463 Krishna
111 Archaeological site Krishna
112 Rama‟s temple Kurnool
113 Ruins of Kalkuntha Rayan temple Kurnool
114 Ruins of Gopala Raja‟s Palace Kurnool
115 ShammaKautunMasahiliaBuruz Kurnool
116 Mahanandiswaraswamy temple in Sy.No.227 Kurnool
117 Sri Lakshminarasimhaswamy temple and Kurnool
118 Mandapa in Sy.No.210 Kurnool
119 Sri Narasimhaswami temple in RF Kurnool
120 Sri Rameswaraswamy temple also known as Kurnool
121 Rama-lingeswara Swamy temple Kurnool
122 Panikeswaraswamy temple Kurnool
123 Sri Pandurangaswamy temple Kurnool
124 Sri Sivanandiswara Swamy temple Kurnool
125 Siva temple (locally known as Nagulagudi) Kurnool
126 Sri Panchalingeswara Swamy temple (also Kurnool
127 known as Eswaraswamy temple) Kurnool
128 Bhatalamma temple Kurnool
129 Megalithic Burials at Alluru Kurnool
130 1.Ancient Bastion, 2.Chennakeswavaswamy temple,
3.Basaveswaraswamy temple, 4.Chennasomeswara swamy
temple
Kurnool
148
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
131 Prehistoric rock paintings Kurnool
132 Sri Laxmi Narasimha Swamy temple Kurnool
133 Sri Rajarajeswari temple Kurnool
134 Sri Siddeswara Temple including mural paintings Kurnool
135 Belum Caves Kurnool
136 Sri Mahadevaswamy temple Kurnool
137 (Gopal Dass Bavajmutt) Kurnool
138 Sri Suryanarayana Swamy temple Kurnool
139 Buddhist site at Singarayakonda Prakasam
140 Ancient Buddhist site Prakasam
141 Sri Mahadeswaraswamy temple also known as Siva temple Prakasam
142 Chennakeswaraswamy temple Prakasam
143 Sankaraswamy temple Prakasam
144 Venugopalaswamy temple Prakasam
145 Chennakesavaswamy temple Prakasam
146 Sri Rameshvaraswamy temple Prakasam
147 Sri Anjaneya temple Prakasam
148 Ancient fort of Gajapathis Prakasam
149 Sri Kalyyadri Lakshmi Narasimha Swamy varee temple Prakasam
150 Sri Venugopalaswamy temple Prakasam
151 Sri Madhavaswamy temple Prakasam
152 Siva temple Prakasam
153 Megalithic Burials Prakasam
154 -do- Prakasam
155 -do- Prakasam
156 Stupa Mound Prakasam
157 Megalithic site Prakasam
158 Transfer of land (Poramboku) Prakasam
159 Telugu inscription Srikakulam
149
List of Protected Monuments in Andhra Pradesh
by Archaeological Survey of India
Sl. No. Name of monument(s) District
160 Jumma Masjid Srikakulam
161 Sri Suryanarayana Swamy temple Srikakulam
162 Kurmanandaswamyvari temple Srikakulam
163 Ancient Dutch building Srikakulam
164 Radha Govinda Swamy temple Srikakulam
165 Jaina Caves on Sangamayyakonda Alias Goppakonda Srikakulam
166 Varaha Laxmi Narasimha Swamy temple (Simhachalam) Visakhapatnam
167 Group of temples called- (i) Dharmalingeswara, (ii) Radha
Madhava Swamy, (iii) Visweswara Swamy varu
Visakhapatnam
168 Ancient images of Nilakanteswara, MahishasuraMardhini,
and Nandi situated in Sri Nilakanteswara temple
Visakhapatnam
169 Parvati temple Visakhapatnam
170 Vigneswara temple Visakhapatnam
171 Ancient site Totlakonda (Buddhist complex) Visakhapatnam
172 Buddhist complex Visakhapatnam
173 Someswaraswamy temple Visakhapatnam
174 Memorial monument Vizianagaram
175 Memorial monument Vizianagaram
176 Sri Neelakanteswara temple Vizianagaram
177 KsheeraRamalingeswara Swamy temple West Godavari
178 Sri Nageswaraswamy temple West Godavari
179 Dutch cemetry West Godavari
180 Sri Svarneswara temple also known as Sivaganapati temple
in S.No.244/1
West Godavari
181 Someswaraswamy temple West Godavari
182 Jaina image West Godavari
Source: Archaeological Survey of India. Available at http://asi.nic.in/protected-monuments-in-
andhra-pradesh/
150
ANNEX-9: MINUTES OF THE DISCLOSURE WORKSHOP ON APHSSP
MINUTES OF THE DISCLOSURE WORKSHOP ON AP HEALTH SYSTEM
STRENGTHENNG PROJECT (APHSSSP)
Conducted on 12th
February 2019 at IMA Hall, Vijayawada.
1. Dr. M. Suhasini, PO, QA & Trainings, welcomed the dignitaries and participants, followed by
lightening the lamp by Dignitaries for the Workshop.
2. A brief introduction of the project and the ESMF forAndhra Pradesh Health Systems
Strengthening Project (APHSSP) was presented by Dr. Arvind, NABHCoordinator.
3. Welcome speech and presentation of AP State Healthcare system structure and a brief
description of the 5 (five) new healthcare initiatives taken up by the Govt. of AP in February 2018. A
cumulative summary on all the healthcare initiatives undertaken by the Govt. of AP was presented to
the audience. The need of ESMF for APHSSP as an effort towards safeguarding environmental and
social risks and impacts from project activities, improved quality of care from grass root level through
interventions, integrated primary health care initiatives and enabling patient centered care by Dr. Raja
Sekhar Reddy, Project Director.
4. Dr. Raja Sekhar Reddy briefed about AP Health System Strengthening Project. The launch of
eSubcenter project under the key area of “Comprehensive Primary Healthcare initiative” by upgrading
present Sub centers to eSubCentres was intimated. The eSubcenters provides qualitative services of a
Medical officer to patients in Sub Centers in the form of Tele Consultation with doctors from a Hub,
including facilities like automatic Drug Vending Machines, Multi Para Monitoring Equipments,
Noninvasive haemoglobinometer are provided at the centers. The patient information is captured in
Electronic Medical Record format for future reference in consultations.
5. Dr. Raja Sekhar Reddy explained the need of quality certification being undertaken under the
key area of “Quality of Care” in the form of NQAS and NABH accreditation of Public Health Care
facilities and mentioned the time bound achievements mapped up to 5 years.
6. Dr. Raja Sekhar Reddy briefed on APeRX app, a new initiative in combating non-
communicable diseases like diabetes and hypertension. The patient can avail free drugs for diabetes
and hypertension from any private or public pharmacy stores at free of cost through the application.
7. Dr. Arvind, Coordinator NABH, explained with a presentation on the ESMF framework. The
preparation of the ESMF report executed by the teams at district level & state level and the
methodology adopted for the ESMF was presented to the audience.
8. Followed by Lunch 1.30pm to 2.30pm
9. The post lunch session started with the continuation of the presentation by Dr. Arvind. The
Environmental Management Plan and Social Management Plan were explained to the stakeholders.
10. It was followed by Interactive and open discussion session chaired with Dr. Raja Sekhar
Reddy, Dr. M. Suhasini and Dr, Arvind.
11. Below are the comments and suggestions were recorded during the open session.
(i) A participant from PHC Tadepalli, Guntur District raised concern for the non-availability of
segregation and disposal of biomedical waste at PHC level and asked about the inclusion of any steps
to improve the same through the ESMF.
- To which, Dr. Raja Sekhar Reddy agreed and mentioned that as the project focuses on
quality of services from Primary Health Centers and Community Health Centers level
which includes quality certification in the form of NQAS in which biomedical waste
management as per guidelines is mandatory.
151
(ii) Participant from Krishna District seek clarification of process involved in Sub centers to e-Sub
Centers
- Dr. Raja Sekhar Reddy clarified that refurbishment of all the sub centers with
provision of toilets with running water (whenever necessary), drinking water and
facilities like Telemedicine, internet connectivity, Multipara monitor machine, Non-
invasive Haemoglobinometer, Glucometer, automatic drug vending machine. Also,
the project provides emphasis on the training of ANMs across all Sub Centers for
conducting telemedicine services.
(iii) One of the participants suggested the need of IEC in the form of Video clippings to improve the
patient information on healthcare services being provided by the Govt. of AP.
(iv) The need for strengthening of Training to ASHA and ANM staff was suggested as a measure to
be undertaken in the project.
- Dr. Raja Sekhar Reddy clarified that a training application for ASHA known as ANM
Digi is already introduced in the state and training modules are being given to ANMs.
Also, continuous trainings are conducted to ANMs for strengthening their skills
required for the use of ANM Digi.
(v) One participant from NGO, VasavyaMahilaMandali suggested improving the availability of toilets
and safe drinking water facilities at public health facilities. A suggestion to include hygienic sanitation
measures and steps to address malnutrition in the APHSSP was provided.
(vi) One of the participants suggested that a strong monitoring mechanism at the highest level for the
APHSSP along with the ESMF plan needs to be included.
The above suggestions and comments were recorded and addressed by the Director, SPIU and the
team and the workshop was concluded with Vote of Thanks from the department.
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