The contents of  ‘Second State Health Systems Development’ were to enhance the role of private and voluntary sectors in delivery and management of health services by strengthening the capacity of implementing the sector analysis and increasing finance and improving resource allocation of health sector.

The investments in the project were as following :

I. Management development and Institutional Strengthening :

a. Improving the Institutional Framework for Policy Development by creation of Strategic Planning Cell.

b.Strengthening Management and Implementation capacity:PHSC has been able to attract qualified technical staff in the areas of civil works, financial management, taxation & law, system management, economics, equipment & transport management, procurement, quality assurance, training.  Organization structure and Category wise information regarding manpower is available at Annexure II. In order to ensure the focus approach for management of secondary level health care services, additional programme officers in the field of Quality Assurance, HMIS, Waste Management, Surveillance, Referral, Training, IEC, Hospital Services, Blood Bank have been positioned at H.Q. level and also separate offices were set-up for Deputy Medical Commissioners (DMC). Apart from this, in order to enhance the data collection and analysis capabilities, the office of DMCs have been strengthened by providing manpower in the field of accounts and HMIS which support the hospitals in proper recordkeeping and monitoring.  In 50 hospitals and 17 districts H.Q.s, capacity has been developed for computerized recordkeeping with the help of HMIS software which cover records of HMIS, Accounts, OPD/IPD, Blood Banks, and Diagnostic Services. For this purpose, the concerned staff has been trained and computer operators have been provided in-house capabilities have been developed for commercially negotiating with the private partners for outsourcing. Slowly this capacity is being decentralized for effective implementation.  Two full-fledged training centers have been established under the project to provide in-house training to the doctors and paramedics viz. State Institute of Health and Family Welfare, Mohali, Distt. Ropar and State Institute of Nursing and Paramedical Sciences, Badal, Distt. Mukatsar.
(c)Developing Surveillance Capacity for Major Communicable Diseases: - 22 communicable and 12 non-communicable diseases prevalent were identified. In order to strengthen identification of diseases;
(i) TOT trainings were got done from NICD, New Delhi. 
(ii) 7460 paramedic’s staff in all the Blocks in all the districts has been trained.
(iii) 17 special disease surveillance vehicles one for each district has been provided.
(iv) Awareness campaigns for community have been initiated through special IEC component.
For indexing of the cases or isolation of cases and treatment, following steps have been taken;
(i) Rapid Response Team headed by Nodal Coordinator (Epidemiologist/DHO/DIO) has been constituted in all the districts consisting of DHO, Medical Specialist, Pediatrician, Pathologist/Microbiologist, Entomologist, and 2 NGO’s / Health workers.
(ii) Air Conditioning, Isolation Rooms/Wards have been identified in all the district hospitals equipped to tackle emergencies.
(iii) Hospitals have been authorized to purchase required medicines in case of outbreaks (out of user charges) to be recouped by H.Q.
For tracing of contacts for monitoring and evaluation
(i) MDRR a standard format for data collection developed and distributed to all health institutions.
(ii) Data is critically analyzed to find: Disease Burden, Trends, Special Trends, Prevalence, Epidemic and reports are prepared with Charts, Graphs & Mapping on GIS.  (iii) Feed back is given for corrective measures to reduce incidence of disease. For integrating the programme, secondary level data is being transmitted to Directorate. Necessary infrastructure at Directorate level has been upgraded under the project. 

II. Improving Service Quality and Effectiveness at District, Sub divisional and Community/Rural Hospitals.

(a)        Renovating/Extending District, Sub divisional and Community/Rural Hospitals:-

Civil Works:- As per the SAR 13 district, 2 special, 46 sub-divisional and 91 community hospitals were to be renovated/extended and about 2140 new beds were to be added in the bed strength of 5822 (4378 functional). In 34 hospitals additional facilities for patient’s attendants have been augmented.
 

Procurement of Equipment, Repair & Maintenance:-  Under the Rs. 450 Crores World bank assisted Second State Health Systems Development project Punjab Health systems Corporation has streamlined procurement process to enable equipment, Drugs, Consumable items and other Medical and Non- Medical; Supply reach the right place at the right tome cost effective. All the 157 Secondary Level health institutions i.e. District Hospital, Sub-Divisional Hospital and Block level Community Health Centres have been provided with requisite Modern Medical and other Equipment according to norms finalized for different level of Hospitals. Equipments i.e. X-ray Machines, Ultra Sound Scanners, Cardiac Monitors, Defibrillators, Eye & ENT equipment, Laparoscopes, Operation Tables, Autoclaves, Laboratory equipment, Laundry Units, Mortuary Refrigerators, Blood bank Refrigerators etc. have been provided. 133 new additional Ambulances and 17 Surveillance Vehicles have been  provided. The Total plan outlay under World bank project for procurement under various components was Rs.124.64  crores  for Major/Minor Other Equipment, Hospital furniture and other Supplies Rs. 83.24 crores, Medicines and Lab. Supplies Rs. 22.45 Crores, MIS/IEC Material Rs. 9.85 Crore and vehicles Rs. 9.10 Crores. Out of the above Plan out lay procurement worth Rs. 118.28 Crores has been done by PHSC which comprise equipment valuing Rs. 63.53 Crores, 17.96 on drugs, 11.04 cr. on hospital furniture, 7.65 cr. on supplies 8.20 cr. on vehicles, 9.90 cr. on MIS/IEC .Equipment status survey was got done to identify the availability of the equipments (repairable and non-repairable) against the norms. By spending around Rs. 7.00 M on repair of the 32 types of existing equipment, equipment worth Rs. 250.00 M was put in order.
                Subsequent to the completion of World Bank Project, PHSC got the budget from State Govt. for procurement of Medicine and Supplies for PHSC hospitals during the year 2004-05. The procurement of Medicine and supplies from the State Govt. Budget is under process.

(b)       Upgrading the effectiveness of clinical and support services and quality of services: All the renovated/upgraded hospitals have been operationalized along with two training centres. A set of clinical and staffing norms have been adopted.
Quality Assurance Programme: As per SAR there was a plan for establishment of Quality Assurance Committee and Working Groups to take care of quality assessment evaluation, improvements and criteria and medical audit. Initially, State level committees along with working groups were constituted. A set of Core Quality Indicators taking into consideration dimensions of   Access to the services;   Continuity;   Technical Competence;   Interpersonal Relations;   Efficiency & Effectiveness;   Safety;  Amenities;  Waste Management; Cleanliness; Referral Systems; Vital Drugs; and Swab Tests have been finalized and monthly grading of all the hospitals is being done on the basis of such indictors.  External Quality Assurance Programme has been introduced by tying up the CMC Vellore to check the quality of clinical laboratories. Presently, some of the laboratories of the PHSC hospitals are among the first ten in the India. Medical Record Keeping: Checklists and protocols have been introduced in all the hospitals for medical record keeping and ICD coding. Special trainings have been given to doctors and paramedics. Prescription Audit to ascertain prescribing practices based on ICD coding was got done. Patient’s Satisfaction:  Five rounds of patient’s satisfaction surveys have been got conducted, out of which four surveys have been conducted through external   agencies. Regular analysis and feed backs are being given to hospitals for better services to be imparted to patients.

Waste Management:   Guidelines as regard to segregation, storage, disinfection, disposal, sharp management, as per the Biomedical Waste (Management & Handling) Rules, 1998 were issued. 955 doctors, 2032 paramedics and 2142 class-IV employees were got trained. On the basis of recommendations and action plan finalized by the consultants hired for preparing a comprehensive plan, protective aids and requisite material like; Needle Syringe Destroyers( a total no. of 800 NSD have been supplied by PHSC) , Shredders (at 28 hospitals) and Autoclaves ( at 32 hospitals) have been supplied. Deep burial pits for human anatomical waste have been constructed in all the hospitals and as per the requirements of the law, for some hospitals, arrangements have been made with the private operators for incineration. Continuous monitoring is being done and special inputs for improving the systems are being provided through specially created programme of Quality Circles. Manual on standard operative procedures for biomedical waste have been circulated. Developing quality circles and its monitoring can be helpful in implementing the program in a sustainable manner. 

Training: Based on Training Need Assessment done, areas were identified for the training and training curriculums were finalized. Following different 23396 trainings were organized as against the targeted number of 10000;     

Trainings have been organized in prestigious institutions like; PGIMER Chandigarh, CMC Ludhiana, GMCH Chandigarh, AIIMS New Delhi, LBSNAA Mussoorie, NICD New Delhi, MGSIP Chandigarh, CEDTI Mohali, ASCI Hyderabad, Jaipur and Abraod. Training have been given in the field of clinical skills, managerial skills, hands-on equipment, HMIS, Surveillance, Referrals, Waste Management, Procurement, Computers and Finance. During the course of implementation of training activities, external evaluation was got done. Two State level training centres have been constructed to impart in-job trainings to doctors and paramedics. Apart from this, libraries have been established with internet facility for continuous medical education at H.Q. level as well as in all the district level hospitals.
 
Strengthening of Service Delivery:  
Autonomy to Hospital:  To introduce this concept following steps were taken;

• Higher financial powers to hospital in charge, DMCs and CSs were given;
• Full powers were given to hospital in charge for commercial exploitation for support services for revenue raising, outsourcing of sanitation services, maintenance services of equipment & hospital building and condemnation of unserviceable articles;
• Clear-cut guidelines were given for the procedures to be adopted for retention and utilization of user charges;
• Direct recommendation for recruitment of critical manpower on contractual terms: Higher accountability is possible only when higher autonomy is given to the Institutions.  

Health Management Information Systems (HMIS):    In order to strengthen evaluation and monitoring capacities, managerial training as well as trainings in HMIS was given to the hospitals in charge.

Improvement of Referral Systems: 133 additional ambulances have been provided. 324 existing ambulances were repaired.  Referral manual were prepared containing guidelines that specify ‘what’ ‘when’ and ‘how’ of refer. Colour coded referral cards have been introduced for sub centre level to district level for referring the patients. Trainings to doctors and paramedics for implementation of referral system were given. Incentive for referred patients (queue jump, exemption of OP/Admission Charges, low cost ambulance services) have been introduced, referral routes have been established and displayed in all the hospitals.  On pilot basis feedback reports on emergency obstetrics care are being received and reviewed for timely and justified referrals. This feed back information is being analyzed at H.Q. level and sent to referral institution doctor for taking corrective measures if any. To create awareness among general public regarding facilities available in PHSC hospitals special tie-up has been made at tertiary level facilities for creation of special window for the referred patients thus decreasing load in tertiary level hospitals and providing quality, affordable and easily accessible services to common man. Completion of referral loop is quite vital for the referring institutions and can serve as an incentive to the referring doctor. 
 
Referral of Ischemic Heart patients to PGI: ECG of Patients with acute chest patient visiting the Cardiac Units set up at CH Derabassi and CH Kharar is faxed to the CCU unit, PGI, Chandigarh, the patient is directly admitted to CCU of PGIMER, Chandigarh if IHD is detected without charging any admission fee from the patient. Cardiology department runs a special IHD clinic once a month in the hospitals besides periodic visits by consultants.

Increasing Access to Primary Care Services: To reach poor people of the rural and remote areas for their health needs and to create awareness among general public as regard to medical facilities available 426 nos. of Out Reach Health Camps were organized. Tracking, complete follow-up, incentives of referral and cost effectiveness of the charges were ensured. Six mobile hospitals were launched in backward districts to provide services in the rural deficit areas. Outreach camps give due benefits i.e. understanding the health needs of the people, and awareness and building confidence among them as regard to available services. 

Information, Education & Communication: Three community based studies were done (i) Study to gauge Knowledge, Attitude and Practice level (KAP) of people regarding issues concerning health; (ii) Study to identify “Barriers in accessing health services” specially by women and poor; and (iii) Study to know the psyche of women undergoing female foeticide (Female Foeticide Myth and Reality). A revised focused strategy was developed with the assistance of a professional communication agency on the issues like; Health Seeking Behaviour of the Community, Behaviour of Service Providers, Gender Issues and Water Borne Diseases. Special focus was given by the professional agency in understanding the needs and the areas of emphasize.  Target Groups for each issue were identified. The material produced was pre-tested in the Community in order to assess the acceptability as regard to the message to be disseminated.  Production of the tools to address the target groups was done and launched through a multimedia campaign through specially designed Media Plan.  Approach for handling the IEC issue through professional agency is more effective than in-house handling such issues through traditional approach. Focused approach is quite effective in addressing the core issues and can give more impacts. More emphasis should be given on capacity building and trainings for innovative thinking in IEC.

Evaluation of own Performance:      During the course of project evolution, the State Govt. expeditiously established the PHSC to implement and manage the project, thus not hampering the project processing.  Project start-up was delayed due to continuing debate around the PHSC and constraint in the flow of funds.  These issues were resolved through excellent management and monitoring and time lost was covered. Qualitative designing, construction, meticulous and timely execution of extension works brought a great impact on users, providers and Govt. giving key agency status to the PHSC in health sector. PHSC executed other health project worth Rs.1400.00 M. The availability and quality of furniture, major/minor equipment, drugs and other supplies   brought a new zeal in working environments and professional satisfaction among the providers. Qualitative trainings in prestigious institutions to all levels has improved the clinical, managerial and equipment handling skills. Exemplary work has been done in IEC by focusing special issues by hiring private professional agency, implementation of quality assurance and waste management programme especially monthly grading of the hospitals, introduction of external quality assurance programme in the laboratories and creation of waste management quality circles. Administrative flexibility within the system has given an edge in involving the private sector providers for support & clinical services and brought higher accountability through higher delegations.