Environmental and Social Management Framework for the Andhra...

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

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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

ix

Table E1: Type of Health Care Facilities in Andhra Pradesh


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

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Table (E2): World Bank Policies


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


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



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


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.


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


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


SPIU to ensure


included in the

contract document

HCF in charge/

Hospital

Administrator

and District Level

Safeguard In

charge i.e. DQM

xvi



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


SPIU to ensure


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


SPIU to ensure


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


SPIU to ensure


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



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



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



(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



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



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.


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.


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


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.

http://qi.nhsrcindia.org/national-quality-assurance-standards


xxii



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.


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



the project.


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.


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.



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



staff for operating the patient management system)


the percentage of creation

of EMR for IPD and

chronic OPD cases

registered in the facilities

indicated in DLI 1



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.


the percentage of patients

accessing information

(web-based, application-

based) through PHRMS

for which the EMR has

been created as per DLI2



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.


the number of empanelled

private pharmacies able

to dispense state financed

drugs to patients

1. Policy decision

2. Contracts with private providers



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



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.


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%


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%

5

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%


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

7

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


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

9

Table 5: Type of Health Care Facilities in Andhra Pradesh


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.

10

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

11

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


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


3. Fill HR gaps


5. Minor furniture, equipment, other goods procured

6. Service contract to establish and maintain Quality

Tracking Dashboard System




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.






Indicator 4: Improved pharmaceutical

stock management system at the

PHCs and CHCs.

1. Upgrading/ replacing of the supply chain software

with modern functionality


3. Facility pharmacists incentivized to enter information

into the supply chain software



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



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




subcentres with trained mid-level

service providers (BSC nurses)



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






Indicator 4: Increase in the percentage

of women screened in target age

group for cervical cancer at

subcentres or PHC facilities


2. VIA testing





of women that are registered in the

first trimester receive full ANC

care

1. ASHA identify the women and ANM registers the

pregnant women



4. Conducting of the Village Health Nutrition Days by

ANMs

Result Area 3: Enabling patient-centreed care


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)


of creation of EMR for IPD and

chronic OPD cases registered in the

facilities indicated in DLI 1


online patient management system executed

2. Staff at the facilities are entering and using the EMR

3. Facilities identify nodal officers for implementation


of patients accessing information

(web-based, application-based)

through PHRMS for which the

EMR has been created as per DLI2


online patient management system executed


management system

3. Patients are informed about the system through SMS

4. Information education activities are undertaken for

16



raising public awareness


empaneled private pharmacies able

to dispense state financed drugs to

patients

1. Policy decision


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



3. HDS members review patient experience feedback,

funds availability and activities to be undertaken to

fill the gaps identified during meetings


Indicator 6: System developed and

rolled out to measure and report

patient report experience in a

standardized and confidential way.


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


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.

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


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.

21

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


Andhra Pradesh


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


Andhra Pradesh


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


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


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


Andhra Pradesh


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.


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.


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


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


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



Sl.

No.

Name of CBMWTF,

and Districts

Covered

Total quantity of

BMW collected

from member HCFs

(in kg/day)


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



Sl.

No.

Name of CBMWTF,

and Districts

Covered

Total quantity of

BMW collected

from member HCFs

(in kg/day)


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


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.


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.


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


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


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



S




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



S




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


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


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


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


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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;


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:


Employment, GoI;


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


Employment, GoI;


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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


Sl.

No.

Applicable Act/

Regulation/ Policy


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



primary health care

services.

49


Sl.

No.

Applicable Act/

Regulation/ Policy


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.



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.



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


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



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

http://www.ifc.org/ehsguidelines

51



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



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


Consultation at Prakasam

Stakeholder consultation at Guntur


Consultation at Guntur

Stakeholder consultation at Nellore


Consultation at Nellore

61

6 ENVIRONMENTAL AND SOCIAL ASSESSMENT

6.1 Environmental Risks and Impact

Table (23): Environment Risks and Impacts




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


3. Fill HR gaps


5. Minor furniture, equipment, other goods

procured

6. Service contract to establish and maintain

Quality Tracking Dashboard System






*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



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



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



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



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.


number of CHCs

and PHCs NQAS

certified


the national authorities


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


coverage of core

services provided

through

performance -






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

66



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


pharmaceutical

stock management

system at the PHCs

and CHCs.

1. Upgrading/ replacing of the supply chain

software with modern functionality




Mechanism for disposal of expired

medicine requires standard protocol to

be followed.

1. SOP for notification and

disposal of expired medicine



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



centres





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.

67



for battery requires proper planning as

well for environmental safety.


the number of

subcentres with

trained mid-level

service providers

(BSC nurses)


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.


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)


staff



subcenter or PHC staff



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


the percentage of

women screened in

target age group

for cervical cancer

at subcentres or


2. VIA testing




Other than the risk already mentioned

above from diagnostic and laboratory

services, there are no additional

environmental risk.

1. As mentioned above

68



PHC facilities


the percentage of

women that are

registered in the

first trimester

receive full ANC

care


the pregnant women




by ANMs

No major environmental risk

associated with this activity.



the number of

facilities actively

using an integrated

online patient

management

system





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.


the percentage of

creation of EMR

for IPD and

chronic OPD cases

registered in the

facilities indicated

in DLI 1



executed


EMR


implementation




the percentage of

patients accessing



executed



69



information (web-

based, application-

based) through

PHRMS for which

the EMR has been

created as per

DLI2


management system


SMS




the number of

empaneled private

pharmacies able to

dispense state

financed drugs to

patients

1. Policy decision




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.


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






meetings



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






associated with this activity. Health

bulletins should also cover

implementation review of

1. Disclosure of adherence to

various SOP to be made public.

70



patient report

experience in a

standardized and

confidential way.



analyze and share analysis through health

bulletins


environmental and health safety

measures.

6.2 Social Risk and Impact

Table (24): Social Risks and Impacts




the number of

PHCs and CHCs

have more than 70

percent quality


seeking national

certification,

supported to

improve quality

and monitor sustain

quality.




3. Fill HR gaps



procured









and modifications


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.



adverse impacts related to

involuntary resettlement of

squatters and non-title holders

on government land.

3. Implementation of ESMP as per

the ESMF wherever

71



renovations/civil works are

planned.


number of CHCs

and PHCs NQAS

certified


the national authorities


improvement in overall infrastructure

and services including sanitation

facilities for both men and women.



22. In line with existing DoHFW

policy, a targeted approach to

certify PHCs located in tribal

districts will be adopted.


coverage of core

services provided

through

performance -

based contracts at

CHCs and the

performance of

those services.






The service contracts will help

improve services. However, it is

important to ensure that it is inclusive


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.


pharmaceutical

stock management

system at the PHCs

and CHCs.







this activity, however building

capacity of personnel at geographically

difficult to reach PHCs (located in

tribal/rural areas) needs to be

prioritized.


72




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






centres





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





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.


the number of

subcentres with

trained mid-level

service providers

(BSC nurses)



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.


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.


citizens screened,

an increase in the

number of patients

at high-risk* for

NCDs

(hypertension and

diabetes) who are


staff







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.

73



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.,


the percentage of

women screened in

target age group

for cervical cancer

at subcentres or

PHC facilities


2. VIA testing




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.


the percentage of

women that are

registered in the

first trimester

receive full ANC

care


the pregnant women




by ANMs

There is a possibility that women from

tribal/rural areas do-not access full

ANC care.

1. Mapping of low performing

areas.


delivery of full ANC care in


Result Area 3: Enabling patient-centered care

74




the number of

facilities actively

using an integrated

online patient

management

system








system)


issue if not given priority.

1. Adequate data security to be

ensured to safeguard the privacy

of the patient data.


the percentage of

creation of EMR

for IPD and

chronic OPD cases

registered in the

facilities indicated

in DLI 1



executed


EMR


implementation

This will help enhance proper follow-

up care with patient records. It has no


activities.


the percentage of

patients accessing

information (web-

based, application-

based) through

PHRMS for which

the EMR has been

created as per

DLI2



executed


management system


SMS



No specific social risk associated to

these activities.

1. Awareness and knowledge to

access patients record and at an

appropriate time needs attention.


the number of

empaneled private

1. Policy decision



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

75



pharmacies able to

dispense state

financed drugs to

patients


practice of any kind. malpractice.

2. Adequate monitoring

mechanism to be built towards

this.


Development

Society (HDS)

provide regular

monitoring and

undertake actions

to improve quality










meetings


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.








bulletins




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



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


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.


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


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


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


SPIU to ensure


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


HCF in charge/

Hospital

80



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


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


SPIU to ensure


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


SPIU to ensure


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


SPIU to ensure


included in the

HCF in charge/

Hospital

Administrator

and District Level

Safeguard In

charge i.e. DQM

81



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



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



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



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.


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


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.


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


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.


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.


(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).


(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.


(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.


(2018-19)

6 PPP based sub-centres in

telemedicine mode


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.


(2018-19)

7 Select non- 24X7 PHCs

into 24X7 PHCs


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.


(2018-19)

8 At least state of art

Area Hospitals in

all ITDAs


1 1

Yerragon-dapalem KR Puram

92

in ITDA Srisailam

area


(2018-19)


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


(2018-19)

11 Mission

Organizations

adoption of ITDAs for

supporting CHCs,

AHs and DHs


RFP to be floated seeking presentations/plans/budgets and

subsequent allotment of all qualified Mission Organizations by

Q2 including CSR funding/Mission Organization support


(2018-19)

12 OT modernization

in 24X7 PHCs,

CHCs & DHs

0 - 24x7 PHCs

0 – CHCs

0 - AHs


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.


(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


(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




the number of PHCs

and CHCs have more

than 70 percent quality


seeking national

certification, supported

to improve quality and

monitor sustain quality.




3. Fill HR gaps



procured




8. Service providers contracted and

incentivized to improve in clinical and non-

clinical gaps




and modifications


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.



adverse impacts related to

involuntary resettlement of

squatters and non-title holders on

government land.


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)


improvement in overall infrastructure

and services including sanitation

facilities for both men and women.



24. In line with existing DoHFW

policy, a targeted approach to



98



certify 13 PHCs (yearly) located

in tribal districts will be adopted.


coverage of core

services provided

through performance -

based contracts at

CHCs and the

performance of those

services.





5. Patient satisfaction/ experience survey

contract

The service contracts will help

improve services. However, it is

important to ensure that it is inclusive


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.


pharmaceutical stock

management system at

the PHCs and CHCs.







this activity, however building

capacity of personnel at

geographically difficult to reach

PHCs (located in tribal/rural areas)

needs to be prioritized.



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





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,


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



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





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.


the number of

subcentres with trained

mid-level service

providers (BSC nurses)



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.


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.


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






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

100



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.


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


4. Follow-up undertaken to ensure referral

happens


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.


the percentage of

women that are

registered in the first

trimester receive full

1. ASHA identify the women and ANM

registers the pregnant women



There is a possibility that women

from tribal/rural areas do-not access

full ANC care.

34. Mapping of low performing areas.


delivery of full ANC care in tribal

and ITDA areas.

101



ANC care 4. Conducting of the Village Health Nutrition

Days by ANMs



the number of facilities

actively using an

integrated online

patient management

system








system)


issue if not given priority. 36. Adequate data security to be

ensured to safeguard the privacy

of the patient data.


the percentage of

creation of EMR for

IPD and chronic OPD

cases registered in the

facilities indicated in

DLI 1



executed

2. Staff at the facilities are entering and using

the EMR


implementation

This will help enhance proper follow-

up care with patient records. It has no


activities.


the percentage of

patients accessing

information (web-

based, application-

based) through

PHRMS for which the

EMR has been created



executed


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.

102



as per DLI2 through SMS

4. Information education activities are

undertaken for raising public awareness


the number of

empanelled private

pharmacies able to

dispense state financed

drugs to patients

1. Policy decision


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.


Development Society

(HDS) provide regular

monitoring and

undertake actions to

improve quality










meetings


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







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

103



standardized and

confidential way. collected in a credible way



bulletins


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.

http://hmfw.ap.gov.in/

http://www.cdma.ap.gov.in/grievance-redressal

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.

113

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


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


(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.

http://cpcb.nic.in/cpcbold/wast/bioimedicalwast/Draft_Guidelines_for_Management_of_Health_Care_Wast(as_on_21.09.2017).pdf






http://cpcb.nic.in/uploads/hwmd/Guidelines_healthcare_June_2018.pdf

http://cpcb.nic.in/uploads/hwmd/Guidelines_healthcare_June_2018.pdf

117

Biomedical Waste


(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

http://cpcb.nic.in/uploads/hwmd/Guidelines_for_Bar_Code_System_for_HCFs_and_CBWTFs.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

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



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



3mg/l or less

Propagation of Wildlife and Fisheries D pH between 6.5 to 8.5


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



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


kotluru) Cuddapah

35. Kamalasambnashwaraswamy temple


kotluru) Cuddapah

36. Raghaveswaraswamy temple


kotluru) Cuddapah

37. Sivakesavaswamy temple

Pushpagiri,(hamlet of

kotluru) Cuddapah

38. Trikoteswaraswamy temple


kotluru) Cuddapah

39. Vaidhyanadhaswamy temple


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



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



(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



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



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



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

http://asi.nic.in/alphabetical-list-of-monuments-andhra-pradesh/

http://asi.nic.in/alphabetical-list-of-monuments-andhra-pradesh/

144




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




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




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




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




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




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/

http://asi.nic.in/protected-monuments-in-andhra-pradesh/

http://asi.nic.in/protected-monuments-in-andhra-pradesh/

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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.

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(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.

Environmental and Social Management Framework for the Andhra...

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