Component 1: Activities

Community Action for Health and Nutrition : This component is designed to empower communities to oversee, manage, and improve Health, Nutrition, and Population (HNP) services and their utilization.

An incentive strategy will be used whereby funding will be provided to communities on the basis of progress on defined indicators of improved health and nutrition-related services and practices. In turn, communities will use the incentives for activities and investments that are important to them and have potential impacts on health and nutrition.

The component will have a major focus on knowledge and skill building of Village Health Committees and other stakeholders at the community level, including women’s groups and Village Councils. Village Health Committees will be supported in identifying existing gaps, determining the most suitable approaches to address these gaps, developing action plans, and operationalizing those plans. Funding will be provided to targeted committees that meet preconditions reflecting a minimum level of capacity and interest, including having a woman cochair of the committee and a health and nutrition action plan with agreed targets. An Incentive Agreement will be signed between the Village Health Committee and the Department of Health and Family Welfare.

Subsequently, financial incentives will be provided to committees on achievement of agreed targets as laid out in their action plans, following verification by the Department of Health and Family Welfare. In addition, contracted consultants will independently assess reported results as well as the use of financial incentives by the committees. Indicators chosen for the first phase of implementation relate to antenatal care, postnatal care, delivery services, birth registration, child health and nutrition services, behavior change communication efforts, and support to health service delivery. Indicators and targets will be revised based on implementation experience.

Committees will be empowered to use these incentives for health and nutrition-related activities that are priorities to them, including investments designed to improve performance in future rounds. Examples could include improving health facility infrastructure; incentivizing health staff; contracting additional staff; filling gaps in supplies and equipment; and encouraging behavior change in areas of health, nutrition, and hygiene. These activities will be consistent with existing policies and systems of Government of India.

The first phase of implementation will focus on 1 Community Health Center in each of 2 selected districts, including, in their catchment areas, 1 Primary Health Center, 3 Sub Centers, and 17 Village Health Committees. Experience from this will inform subsequent phased scale-up to all facilities and communities targeted by the project.

Health System Development: This component will support improvements in the management and delivery of health services, including both facility-specific and system-wide investments.

Subcomponent 2.1: Investments to Improve Service Delivery Conditions at Targeted Health Facilities

The project will finance investments to improve conditions for staff and patients in targeted health facilities, with the intention of contributing to improved staff motivation, better quality services, and greater demand for services. For example, reliable lighting and functional and clean toilets in health facilities can help reduce barriers to access to health services, in particular for women and girls. Indeed, health facilities should stand as best-practice examples to the community for safety, cleanliness, and hygiene.

Reliable electricity supply:

The project will invest in off-grid electrical power solutions that will be adapted to the needs of each targeted health facility to ensure a basic level of functioning (that is, for lighting and high-priority equipment), acting as a backup when grid power is not available. In larger facilities, solar energy technology will be installed, while smaller facilities will require battery and inverter systems that can be charged by the grid when it is available. Sunlight, altitude, and temperature conditions in Nagaland make solar energy a cost effective option. The project will also support installation of solar water pumps and water heaters in targeted health facilities. During the first phase of implementation, investments will be made in 14 health facilities for which detailed technical requirements have been assessed. The second phase will cover the approximately 160 remaining targeted facilities.

Improved water supply and sanitation:

Investment in improved water supply in targeted health facilities will entail repair and upgrading of piping and storage facilities linked to existing water supplies, as well as installation of roof water harvesting systems. This work will include ensuring water supply to washbasins and toilets. Sanitation improvements will include upgrading septic tanks, including anaerobic filter installations. The first phase of implementation will involve water supply and sanitation investments in 27 health facilities for which technical requirements have been assessed. The second phase will cover the approximately 150 remaining targeted facilities. It is well understood that investment in infrastructure is not enough to ensure better hygienic conditions. The project will support behavior change communication to encourage effective maintenance and cleaning.

Subcomponent 2.2. Development of Health System Components

The project will support development of key components of the health system intended to improve the management and effectiveness of government health services in Nagaland.

Supply chain management system:

The project will support development and implementation of systems and processes, including defining roles and responsibilities, establishing procurement procedures, putting in place a planning and ordering system, developing a quality assurance system, and developing an inventory management and distribution system. National guidelines under the National Health Mission will provide the basis for strengthening procedures and systems.

Information and communication technology:

The project will support the development of an interoperable information and communication technology (ICT) platform, to which several high-priority applications will be linked, including (a) supply chain management; (b) financial management; (c) human resource management; (d) health management information system (including reducing the reporting burden on frontline health staff); and (e) mobile applications for behavior change communication. Implementation will be contracted out to a single service provider to ensure coherence of the systems and applications.

Health human resource strategy:

Based on a situation analysis done during project preparation, during the first phase the project will support the development of a medium-term health human resource strategy for the state. The strategy will address key constraints, including improved human resource management systems. Once adopted by the state government, the project will finance implementation of relevant components of the strategy. In addition, the project will provide technical support (through consultancy services) for development of a medical college in the state capital of Kohima. There is currently no medical college in the state, which has contributed in particular to a lack of specialist physicians. The state government's parallel funding in support of the project will support, for an initial period, higher-level human resources necessary for development and accreditation of the medical college.

Other investment requirements:

Flexibility will be retained for the project to support other priority investments to improve health service delivery that cannot be met from other sources, including at the level of District Hospitals. Technical assessment and World Bank concurrence will be required for such activities to be included in the project's annual budget and work plan. During initial implementation, detailed technical assessments of health facilities to define bills of quantities for procurement of energy and water and sanitation investments under Subcomponent 2.1 will also identify other gaps in health service capacity. These will include minor repairs and rehabilitation and medical equipment and supplies necessary for effective delivery of health services necessary for achievement of the PDO. The state government's parallel funding in support of the project will be used to fill such gaps.

Monitoring and evaluation:

Health facility and household surveys will be done at the project start, mid-project, and near the end of the project. These will provide a basis for impact evaluation of the project and will also improve knowledge of health and nutrition services and factors influencing HNP outcomes more broadly in the state. The project will support punctual evaluations and studies as needs arise.

Project management:

Under this component, the project will finance the costs of the Project Management Unit, district coordinators, a contracted firm to provide technical and management support, and other consultants as needed.