Actual Project Name : Social Insurance. US$9.7 US$9.4 Technical Assistance Project (SITAP) Country: Bosnia and US$M): Project Costs (US$M

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1 IEG ICR Review Independent Evaluation Group 1. Project Data: Date Posted : 10/22/2008 Report Number : ICRR12969 PROJ ID : P Appraisal Actual Project Name : Social Insurance Project Costs (US$M US$M): US$9.7 US$9.4 Technical Assistance Project (SITAP) Country: Bosnia and Loan/Credit (US$M US$M): US$7.0 US$6.3 Herzegovina Sector Board : HE Cofinancing (US$M US$M): US$1.7 US$2.1 Sector(s): Health (65%) Compulsory pension and unemployment insurance (35%) Theme(s): Health system performance (33% - P) Social risk mitigation (33% - P) Administrative and civil service reform (17% - S) Tax policy and administration (17% - S) L/C Number: C3778 Partners involved : DFID Evaluator : Panel Reviewer : Group Manager : Group: Gayle Martin Roy Gilbert Monika Huppi IEGSG Board Approval Date : 06/10/2003 Closing Date : 12/31/ /31/ Project Objectives and Components: a. Objectives: The objective was to strengthen the effectiveness and efficiency of health insurance systems and pension systems by provision of high quality technical assistance (TA) and training to help implement existing reforms and to help design options for future social insurance reforms (PAD, p3; DCA, p17). b.were the project objectives/key associated outcome targets revised during implementation? No c. Components (or Key Conditions in the case of DPLs, as appropriate): A. Developing a policy framework for social insurance (appraisal estimate: US$4.2 million/43% of estimated cost; actual cost: US$4.7 million/50% of actual cost). In the two entities, Federation of Bosnia-Herzegovina (FBH) and Republika Srpska (RS), this component financed goods, technical and advisory services to : (a) develop options and mechanisms for expanding the coverage and contribution base for health insurance and pensions among farmers, self-employed and uninsured, and increase the portability of health care and pension benefits; (b) assess the systems for collection, reporting, enforcement of contributions for pension, health and unemployment insurance and payroll tax obligations, and the development of new mechanisms and procedures; (c) identify options for improved

2 risk pooling and to develop a master plan for utilization of health services; (d) define, design, test, evaluate and plan for national roll-out of a new insurance provider payment system; (e) assess options for medium term systemic reforms of pension system, and identify the necessary preconditions for introduction of private pension funds. B. Organizational Management (appraisal estimate: US$3.9 million/41% of estimated cost; actual cost: US$2.6 million/28% of actual cost). This component financed technical and advisory services as well as study tours to : (a) develop strategic goals, institutional mandates, business and financial planning for the health and pension sectors, including human resources planning and management, public communications, customer service standards, and stakeholder participation in the development of health and pension policies and priorities; (b) strengthen information technology capacity of relevant agencies, through the provision of goods, consultants services and training. C. Project Implementation Support (appraisal estimate: US$1.1 million/11% of estimated cost; actual cost: US$2.1 million/23% of actual cost). This component financed: strengthening of the institutional capacity of various agencies through the provision of technical assistance, goods and training for project implementation, monitoring and evaluation; and support for project coordination and implementation, including fiduciary responsibilities by the Project Implementation Unit (PIU) in the FBH and the Project Coordination Unit (PCU) in the RS. d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: Dates. The project became effective as planned (10/03/2003). The MTR occurred roughly as planned (March 2006). During the MTR in March 2006, 5 technical assistance packages under components A and B were cancelled. The results framework was revised and 4 indicators were added around the time of the MTR. The project closed as planned (12/31/2007). Cost. Actual project cost was similar to the appraisal estimate. Component A (Developing a policy framework for social insurance) accounted for half of the actual project costs, a slightly larger share than anticipated at appraisal. Financing. At closing the IDA credit was 90% disbursed (actual: US$6.3 million). Actual borrower contribution was close to the appraisal estimate, and the co -financier (DFID) contribution was US$2.1million, 123% of appraisal estimate. 3. Relevance of Objectives & Design: Objectives. The project supported the country's endeavor to reform public institutions, and was generally consistent with the 2000 CAS objective to improve the sustainability, effectiveness and equity of social services and safety nets, as well as with the 2005 CAS, where the strengthening of institutions continued to be strongly emphasized. Design. It was envisaged that the technical assistance project design would complement the adjustment lending under the Economic Management Structural Adjustment Credit (EMSAC) and Social Sector Adjustment Credit (SOSAC2) by shaping the policy framework and building the institutional capacity of the two main elements of the country's social insurance system (pension and health insurance) necessary to implement these credits. (The SOSAC2 was subsequently dropped). Given the size of the operation, the project was quite ambitious in the activities it undertook (reflected in the 5 sub-components of Component A). Similar concerns were raised in the Quality Enhancement Review (QER) in March Consistent with the recommendations of the QER, the components were simplified and some activities under the sub -components were dropped. Relevance is rated substantial. 4. Achievement of Objectives (Efficacy): The objective was to strengthen the effectiveness and efficiency of pension systems and health insurance systems. In the area of health insurance reform, the project sought to address 5 key issues that affected the efficiency and effectiveness of health insurance, and these are discussed separately : expanding coverage to the uninsured; portability of benefits; reforming the revenue collection system; rationalization of health service provision; and health provider payment systems (PAD, p12-13). An external evaluation concluded that the project had made progress toward achieving the development objective and, as discussed below, the technical assistance and analytical work provided the basis for some legal reforms, the development of various reform strategies and action plans, the consolidation of revenue collection systems, and the development of a new provider payment system. (The ICR does not provide information on who conducted the external evaluation nor on its methodology ). While it appears that the outputs and processes noted below will likely contribute to improved efficiency and effectiveness, some of the anticipated outcomes were not realized, and as the external evaluation concluded, the quantification of improvements in efficacy and efficiency was not possible (ICR, p16). On this basis efficacy is rated modest. The outputs and intermediate outcomes are : Reforming health insurance systems : Expanding coverage. Policy options were developed for the expansion of health and pension insurance coverage to include farmers and the self-employed. Recommendations were reviewed by the implementing agencies concerned and were subsequently used to modify the Law on Health Insurance, the Law on Contributions, and the Law on

3 Pensions and Disability Insurance in the RS. However, the targets for decreasing the percentage of the uninsured in RS and FBH were not met. Portability of benefits. Contracts were signed with health care providers in FBH (in Mostar, Sarajevo, Tuzla and Brcko) to enable patients from the RS to receive health care in the FBH. In addition to the contracts, the administrative and financial mechanisms were put in place for facilitating the portability of health care benefits between the two entities. Reforming the revenue collection system. Detailed analyses of the problems facing social insurance revenue collection system (including reporting, control and enforcement ) were conducted. According to the borrower's ICR this analytical work formed a solid base for the development of mechanisms to consolidate the revenue collection system in a manner consistent with the broader directions of tax administration reform. An important outcome was consensus on future reforms among 11 implementing agencies and other stakeholders. An action plan was developed for a unified collection gateway under the RS Tax Administration, and the Action Plan is currently being implemented under USAID's ELMO project. In RS a control department in the Health Insurance Fund was introduced and is said to have contributed to increased revenue collection. In FBH IT equipment and software for the financial information system for the Health Insurance Fund in the FBH was procured. A draft Law on Tax Collections is being developed in FBH. Both entities reported having increased the level of reserve funds on hold in their Health Insurance Fund, but in RS the reserves fell short of the target. Reserves in RS were 1% compared to the targeted 4%, and in FBH reserves were 5% exceeding the target of 4%. Rationalization of health service provision. Functional assessments, utilization reviews of the secondary and tertiary health care facilities and a situation analysis of hospitals (in RS only) contributed toward the drafting of a Health Service Rationalization Plan in both entities. In RS the plan did not provide sufficient detail to develop facility -level plans. Additional hospital-level data were collected and together with the Rationalization Plan informed the development of the Secondary and Tertiary Healthcare Strategy in RS. The Rationalization Plan also informed used the development of a Human Resource Plan for the RS public hospital system. In FBH the Rationalization Plan is awaiting implementation, according to the ICR. In support of the Secondary and Tertiary Healthcare Strategy in RS additional activities were undertaken: At 3 pilot health centers work plans for 3 specialties and productivity benchmarks for medical doctors were defined; a database on hospital staff and related IT infrastructure was developed; and staff planning based on the scope of work was done and the accuracy of hospital staff records was improved. Discussion are ongoing in FBH on ways to improve risk pooling across the cantonal health insurance funds. According to the borrower's ICR, following the work on the rationalization plans the RS Ministry of Health and the Health Insurance Fund initiated a multiyear project on the introduction of management and quality improvement systems in the RS hospital sector. Health provider payment systems. Existing payment mechanisms were analyzed and options developed for revising the payment system. A capitation provider reimbursement method was developed for use in health centers and an output-based methodology (using diagnostic-related groups -- DRGs) was developed for hospitals. The DRG manuals were developed and officially disseminated at the State and Entity levels. Training was provided to hospital and Health Insurance Fund staff in purchasing and contracting under the new system, and in hospital performance monitoring using a newly defined list of indicators. The analytical work informed strategic decisions reflected in the RS Secondary and Tertiary Healthcare Strategy and the Primary Healthcare Strategy. The new purchasing mechanisms were to be piloted in selected hospitals and health centers. According to the borrower's ICR the pilots were not implemented (ICR, p33), but according to Indicator 13 in the results framework analysis "pilot testing of new pilot mechanisms were completed" (ICR, pvi). Reforming pension policies : 17 reports were produced for each of the Entities addressing : situational analysis of different categories of pensioners; simulation of revenue and expenditure projects associated with expanding coverage of farmers and self-employed under the current system and various reform options; and a review of international and regional best practices in the design and implementation of pension reform. Training was provided for Pension Fund staff in actuarial mathematics and modeling, and study tours to European countries. By project closing the strategy for pension reform was drafted and the draft strategy was being considered by the Entity governments. Pension Reform Working groups were established to oversee the reform process. An action plan on improved policy making, coordination and more effective pension administration within and between the Entities was also developed and approved by the governments. 5. Efficiency (not applicable to DPLs): Cost-benefit analysis or cost-effectiveness analysis is not required for technical assistance projects, and on this basis efficiency cannot be rated for this project. a. If available, enter the Economic Rate of Return (ERR ERR)/Financial Rate of Return (FRR FRR) at appraisal and the re-estimated estimated value at evaluation : Rate Available? Point Value Coverage/Scope*

4 Appraisal ICR estimate No No * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome: Based on the substantial relevance and the modest efficacy the project is rated moderately satisfactory. a. Outcome Rating : Moderately 7. Rationale for Risk to Development Outcome Rating: The project financed important TA and advisory services that formed the basis for working groups, strategies action plans and Laws. Many of these outputs and intermediate outcomes are being implemented by the respective entities, by other donors (e.g., USAID) and through related Bank operations (e.g., the Economic Management Structural Adjustment Credit (EMSAC)). Despite a high level of commitment to the social reform agenda, the risk to development outcome is rated moderate in view of the complex political environment, weak institutions, the limited success with capacity building and the lengthy and continued commitment needed for success in the long run. a. Risk to Development Outcome Rating : Moderate 8. Assessment of Bank Performance: Quality-at at-entry entry. The objective was generally consistent with the country's needs and the TA project design complemented the adjustment credits being implemented. The PAD identified several key lessons from previous operations but these were, however, not fully reflected in the project design. While project design may have appeared simple to the Team at appraisal, it was quite complex given the weak institutions. More serious were two shortcomings: the proposed coordination mechanisms were not effective and ownership was lacking in the implementing agencies. Implementing arrangements: The project coordinating mechanisms were: a Steering Committee for state-level oversight ; focal points to support implementation in the implementing agencies, and existing project coordination units in FBH and RS who were familiar with Bank financial management and procu rement requirements. The implementing agency staff were relatively inexperienced and there was a high reliance on consultant inputs. Given this reality, the implementation arrangements could have provided more structure and guidance to the relationship between implementing agency staff and consultants to ensure better transfer of skills and learning. Ownership: There was ownership among senior officials but the Bank -driven and top-down nature of preparation undermined ownership among the mid-level officials who were critical to project implementation. According to the ICR, implementing agency staff felt that their views were not fully taken into account by the Bank team during preparation. Quality of supervision. Initial implementation performed well. Early procurement problems were resolved effectively by the Bank team and there was ownership among senior staff. On this basis QAG rated the project highly satisfactory. Thereafter progress slowed due to the lack of oversight by the Steering Committee, the lack of ownership and weak capacity among implementing agencies. The focal points were overburdened and the capacity of implementing agencies to supervise and effectively utilize contracted consultants was overestimated. The Bank Team did well to address some of these challenges at the MTR and implementation improved significantly. The project was simplified by dropping some sub -components, and re-establishing benchmarks for activities. According to the ICR, these changes generated renewed commitment by government and the Steering Committee, and re-energized the implementing agency staff. Furthermore, the Bank Team organized health insurance and pension flagship courses to improve capacity building. a. Ensuring Quality -at at-entry Entry:Moderately Unsatisfactory b. Quality of Supervision :Moderately c. Overall Bank Performance :Moderately 9. Assessment of Borrower Performance: Government performance. The level of ownership varied over the project's lifespan. Initially, during preparation and at appraisal there was a high level of commitment by senior officials and politicians, but this waned during the first two years, and increased toward the end of the project. The varying ownership and commitment was

5 reflected in the functioning of the Steering Committee. The Steering Committee was supposed to provide high-level oversight for the project, and was particularly important given the Entities' complex institutional arrangement. This structure did, however, not serve its intended purpose. Borrower contribution was consistent with the level expected at appraisal. Implementing agency performance. While there was a high level of ownership among senior officials, the commitment among mid-level officials was weak. Consequently there were initial difficulties in supporting the project activities and the assimilation of consultant outputs in the implementing agencies in both Entities. According to the ICR, the latter half of the project saw improvement in implementing agencies' efforts to support consultants in their activities, and to review and internalize the information generated. The PCU and PIU performance was good in the execution of the project's fiduciary functions and resolution of complex problems with consultants. a. Government Performance :Moderately b. Implementing Agency Performance :Moderately c. Overall Borrower Performance :Moderately 10. M&E Design, Implementation, & Utilization: Design. There were 24 intermediate outcome indicators and 1 outcome indicator. Because of the technical assistance nature of the project, many of the indicators were of necessity qualitative in nature. However, as noted in the QER, closer attention could have been paid to identifying verifiable indicators (whether qualitative or quantitative) against which project performance could be realistically assessed. The results framework was revised to match the changes in the components and activities made at MTR : 3 indicators were added just before the MTR and 1 indicator just after. Implementation and Utilization. The external evaluation proposed in the PAD was conducted in November While an evaluation at the end of the project was helpful, it did not serve the function of informing and guiding decision-making during project implementation. The project emphasized high quality technical assistance and analytical work (as stated in the project objective), yet there appeared to be no systematic way to monitor the quality the technical assistance and analytical work. It is unclear from the ICR what systems were in place to track the performance indicators and what remedial actions were taken during implementation to ensure that the targets were achieved (e.g., the intermediate outcomes indicators 1 and 2 that were not or partially achieved: "percent of target population uninsured through health insurance "; "increased financial sustainability for social insurance, health and pension"). a. M&E Quality Rating : Negligible 11. Other Issues (Safeguards, Fiduciary, Unintended Positive and Negative Impacts): Safeguards. The project had an environmental category C rating, and hence no environmental safeguards were required. Fiduciary. According to the ICR overall performance with respect to procurement activities was satisfactory. The project financial statements were audited annually by independent auditors, and all audit reports had unqualified opinions. 12. Ratings: ICR IEG Review Outcome: Moderately Moderately Risk to Development Moderate Moderate Outcome: Reason for Disagreement /Comments Bank Performance : Moderately Borrower Performance : Moderately Quality of ICR : Moderately Moderately

6 NOTES: - When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate. 13. Lessons: - Technical assistance projects, as with investment projects, have to carefully assess the implementation capacity of the implementing institutions. Specifically, the capacity to oversee and manage the technical assistance, as well as the capacity to absorb the technical assistance have to be carefully assessed. Furthermore, the project's implementing arrangements need to carefully spell out and formalize the working arrangements between the implementing agency staff and the consultants providing the technical assistance. - Buy-in from senior officials is essential but not sufficient for successful implementation. Ownership among mid-level staff is a critical determinant of the whether implementation of the agreed project activities will take place. - Clearly identified and measurable targets or indicators from the start of the project are essential to facilitate measurement of progress towards the project objec tive. - Where the issues are complex flagship -type training courses are more usefully run before project start -up rather than during implementation, as these provide context and background for those involved with implementation of the project. 14. Assessment Recommended? Yes No 15. Comments on Quality of ICR: While the ICR provided a succinct overview of the project's implementation experience, achievements, and weaknesses, there were some shortcomings. The ICR should have provided more information in the area of monitoring and evaluation, particularly on the external evaluation and its methodology. This is particularly important given that both the ICR and borrower's ICR drew extensively upon the findings of the external evaluation. An assessment of the soundness of the findings and recommendations emerging from the TA and analytical work would have been useful. a.quality of ICR Rating :

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