The World Bank Disease Prevention and Control Project (P128442)

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF DISEASE PREVENTION AND CONTROL PROJECT APPROVED ON MARCH 27, 2013 TO REPUBLIC OF ARMENIA REPORT NO.: RES29744 Public Disclosure Authorized HEALTH, NUTRITION & POPULATION EUROPE AND CENTRAL ASIA FEBRUARY 2, 2018 Public Disclosure Authorized Regional Vice President: Country Director: Senior Global Practice Director: Practice Manager/Manager: Task Team Leader: Cyril E Muller Mercy Miyang Tembon Timothy Grant Evans Enis Baris Ana Holt

2 ABBREVIATIONS AND ACRONYMS DA HPIU HRITF PBF PHC MC MCH MTR NCD PDO Designated Account Health Project Implementation Unit Health Results Innovation Trust Fund Performance-based Financing Primary Health Care Medical Center Maternal and Child Health Mid-term Review Non-Communicable Disease Project Development Objective

3 BASIC DATA Product Information Project ID P Original EA Category Partial Assessment (B) Approval Date 27-Mar-2013 Financing Instrument Investment Project Financing Current EA Category Partial Assessment (B) Current Closing Date 15-Dec-2019 Organizations Borrower Republic of Armenia Responsible Agency Ministry of Health, HSMP-PIU Project Development Objective (PDO) Original PDO The Project development objective is to improve (i) Maternal and Child Health(MCH) services and the prevention, early detection, and management of selected Non-Communicable Diseases (NCD) at the Primary Health Care (PHC) level; and (ii) the efficiency and qualityof selected hospitals in Armenia. Summary Status of Financing Ln/Cr/Tf Approval Signing Effectiveness Closing Net Commitment Disbursed Undisbursed IDA Mar May Jul Dec TF Jul Sep Sep Dec Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No

4 I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING Project Status 1. The Credit was approved on March 27, 2013, in the amount of SDR 22,800,000 (US$35 million equivalent) and became effective on July 22, The Project is the continuation of a long-term stable cooperation in the Health Sector between the World Bank and the Republic of Armenia, and builds upon previous support to health sector reforms in health financing, primary health care and hospital modernization and optimization. The Project supports the Government s National Non-Communicable Disease (NCD) strategy that focuses on prevention and control of diseases contributing to high morbidity and mortality. Component 1 of the Project (Performance-based incentives to improve MCH and NCD services in primary care facilities) is co-financed with a Health Results Innovation Trust Funds (HRITF) for an amount of US$1.8 million (TF014138). The Project Development Objective (PDO), which remains relevant, is to improve: (i) Maternal and Child Health (MCH) services and the prevention, early detection, and management of selected non-communicable diseases (NCD) at the Primary Health Care (PHC) level; and (ii) the efficiency and quality of selected hospitals in Armenia. 2. Progress toward achieving the PDO (DO) and Implementation Progress (IP) have been rated no less than moderately satisfactory since effectiveness. 3. Progress towards achievement of the PDO. Three out of five PDO indicators have achieved their 2017 target values, while one indicator on percentage of women screened for cervical cancer (Pap smear tests) at least once during the last 3 years and received results remains behind the current target of 50% (actual is 26.8%). The annual target values for this indicator will be decreased as part of the restructuring based on the trends of the past 3 years (explained by cultural mentality and unprecedented indicator for the country in its volume and coverage). To support the advancement of the indicator, Public Relation campaign will continue to target females to encourage cervical cancer screening. Civil works at the Artashat Medical Center related to the PDO indicator on bed occupancy are in progress. All target values for PDO and intermediate results indicators will be revised to reflect implementation progress and improve measurability of specific indicators, and consistency of data sources. 4. Implementation progress. Component 1: Performance-based financing (PBF) scheme to improve MCH and NCD services in primary care facilities. The PBF scheme launched in January 2015 supported three-year contract with each PHC facility until end of December This Level 2 restructuring would renew these contracts for another three years until end December Despite significant efforts made in carrying out public awareness campaigns on screening activities using various formats, attainment of targets for cervical cancer and diabetes/hypertension for male remain a challenge. Some of the reasons reported for this situation include: (i) seasonal working migration of male population to other countries, when they only return in Armenia during the winter months; (ii) many patients do not return for glucometry test (requiring fasting) as prescribed by family doctors during a first visit to PHC facilities (for prevention and or other reasons) when screening for hypertension (tonometry) is performed. (iii) most households have home devices for self-measurement of blood pressure and glucose levels and perform those tests at home; (iv) male population is involved in agricultural activities and have time constraints in visiting PHC facilities for checkups, which hours of services are on week days between 9:00 am and 5:00 pm. It is also reported that this low participation exists in cities, which could be attributed to working hours and inconvenience. Some further thinking is needed in finding ways to address this issue beyond the continuation of public awareness campaigns (i.e., PHC facilities offering hours of health care services outside regular working hours).

5 5. Component 2: Improving efficiency and quality of selected hospitals. Modernization of the Marz Hospital Network. The reconstruction of Artashat Medical Center (MC) and Sevan MC is progressing well. The provision of medical, diagnostic equipment and training, medical supplies and furniture for Vanadzor MC is also on track. 6. Modernization of the Hematology Centre. Four bone marrow transplants were performed (two with the assistance of German specialists) since the opening of the Centre in early December The accreditation of the Centre is contingent upon performing 5 transplants per year. Latest data indicates that there has been an encouraging trend in the reduction in the number of pediatric patients newly diagnosed with onco-hematology conditions who received treatment overseas (2013 data: 13 patients over 26 total number of patients vs. October 2017 data: 5 patients over 11 total number of patients). The Centre is developing a marketing plan to offer its services to other countries that could help cover essential operating expenditures. Clinical Practice Guidelines. Technical assistance is being provided to the National Institute of Health in the development of 200 clinical guidelines and 100 clinical protocols using existing literature, but adapted to the local context. 7. Modernization of Cancer Treatment Services in Armenia. Architectural design financed under the project for the new Radiotherapy Treatment Center was completed. However, the Government of Armenia has taken the decision to bring in a private investor to finance the construction and equipping of the Center and ensure its management. IFC is supporting the Ministry of Health (MoH) in launching a tender process among potential private operators for the construction and operation of the Radiotherapy Treatment Center. 8. The Financial Management (FM) arrangements, including planning and budgeting, accounting, financial reporting, external audit, internal controls and funds flow at the Health Project Implementation Unit (HPIU) are overall satisfactory and acceptable to the Bank. Therefore, Financial Management requirements under the Project (including audit compliance) as stipulated in the Financing Agreement are satisfactory and complied with. There are no overdue audit reports under the Project. The level and timeliness of government co-financing is satisfactory. 9. The amounts disbursed under the Project as of February, 2018 are as follows: (a) Credit 5222 Around XDR 16.7 million has been disbursed, representing 73.4 percent of the total credit of XDR22.8 million equivalent. Commitment (contracts signed) of around US$4.2 million and around US$1.34 million available in the Designated Account (DA); and (b) Grant TF of the total Grant allocation of US$1.8 million, US$1.2 million have been disbursed (or 64 percent of total allocation) with the remaining funds of US$650,000 committed. 10. Environmental Safeguards. The Project s rating on safeguards compliance is Satisfactory. An Environmental Management Framework developed and adopted for guiding site-specific environmental work is being followed through. Rationale for Restructuring 11. The mid-term review (MTR) of June 2017 has identified a number of areas in the project that require revisions, including: (a) modifications of the Results Framework to adjust target values against recalculation of the baseline, progress and challenges and a proposed first 18.5-month Closing Date extension; (b) reallocation of the Loan proceeds from Category 1 (Goods, works, non-consulting services, operating costs, training and consultants services for the Project, including audits) to Category 2 (Performance-Based Financing Scheme under Component 1) for an amount of US$1.81 million equivalent to reflect the government s decision to bring in a private investor to finance the construction and equipping of the Radiology Treatment Center and ensure its management; (c) 18-month extension of the Closing Date from December 15, 2019 to June 30, 2021 for continued implementation of the PBF scheme until end December 2020 (an additional six months will be necessary to assess/evaluate the results of the PBF scheme) and the completion of two additional marz hospitals as part of the hospital optimization strategy of the government started in 1997; and (d) a reallocation in the amount of US$9.46 million equivalent (from the Radiotherapy Treatment Center

6 under Component 2) is proposed for (i) the continuation of screening activities under the PBF scheme (US$1.81 million equivalent) until end December 2020 as mentioned above; (ii) the financing of two medical centers (civil works and equipment) in Vayots Dzor marz and Gegharkunik marz (US$6.82 million equivalent) to continue the Government s commitment to hospital optimization; and (iii) other priority activity under Project Management, Monitoring and Evaluation to cover the 18-month extension of the Closing Date (US$0.83 million equivalent). II. DESCRIPTION OF PROPOSED CHANGES This Level 2 restructuring seeks to: 12. Revise the Results Framework: All target values for PDO and intermediate results indicators are revised to reflect implementation progress and improve measurability of specific indicators, and consistency of data sources (see section IV on the proposed revisions of the Results Framework). Specifically, the following changes are proposed: PDO Indicators: Percentage of women screened for cervical cancer (Pap smear tests) at least once during the last 3 years and received results remain behind the current target for 2017 of 50% (actual is 26.8%). The annual target value for this indicator is decreased to reflect the trends of the past 3 years (explained by cultural mentality and unprecedented indicator for the country in its volume and coverage). Bed occupancy rate at the new Medical Center (MC) in Artashat : this indicator is replaced by Bed occupancy rate at the new Medical Center in a) Artashat; and b) Sevan. : Sevan MC was added to the list of MCs to be financed under the Project due to savings. Intermediate Results Indicators (IO): Percentage of eligible PHC facilities receiving incentives within two months after the end of every semi-annual period: this indicator is dropped as the newly established e-health system financed by the government and introduced on May 1, 2017 does not provide the tools for calculating semi-annual bonus payments. Level of awareness among adults in key NCD risk factors: a) high blood pressure; b) high cholesterol level; c) high salt intake; d) obesity; e) high glucose level: baseline is adjusted to reflect accurate data from the Health System Performance Assessment (HSPA) of This indicator is also disaggregated by gender. Percentage of pediatric patients newly diagnosed with onco-hematology conditions by the Hematology Center who received treatment overseas in the past year: baseline and target values are revised to reflect accurate data based on absolute number of cases over project implementation period. Percentage of public hospitals at marz level implementing Quality Improvement Program: this indicator is dropped as the program was cancelled. Rather the activities related to quality of care focus on the development of clinical pathways and protocols by the National Institute of Health (NIH). Sevan Medical Union operational: this indicator is replaced by Medical Centers operational: a) Sevan; b) Artashat; c) Vayots Dzor; d) Martuni. 13. Revision of Project components costs and reallocation of Credit proceeds: For the IDA Credit: to reflect the reallocation of the Credit earmarked to the Radiotherapy Treatment Center estimated at US$9.46 million due to government s decision to privatize the construction, equipping and management of the Center and use this amount to construct/rehabilitate two marz hospitals (US$6.82 million equivalent) under Component 2 (Improving efficiency and quality of selected hospitals) or Category 1 and increase the allocation to the PBF scheme under Component 1 (PBF Scheme to improve MCH and NCD) or Category 2 by US$1.81 million equivalent to cover for an additional 3-year contract with Primary Health Care (PHC) facilities. Component 3 (Project Management) is also increased by

7 US$0.83 million from Component 2 to cover for the additional implementation period. However, this does not entail a reallocation between categories of expenditures month extension of the Closing Date: from December 15, 2019 to June 30, 2021 to continue the implementation of the PBF scheme until end December 2020 (an additional six months will be necessary to assess/evaluate the results of the PBF scheme) and the completion of two additional marz hospitals as part of the hospital optimization strategy of the government started in As per BP Paragraph 47 for Extension of Closing Date, the project objectives continue to be achievable; (b) the performance of the Borrower and HPIU is satisfactory; and (c) the Borrower has prepared a specific action plan acceptable to the Bank to complete the Project. III. SUMMARY OF CHANGES Changed Change in Results Framework Not Changed Change in Components and Cost Change in Loan Closing Date(s) Reallocation between Disbursement Categories Change in Disbursement Estimates Change in Implementation Schedule Change in Implementing Agency Change in DDO Status Change in Project's Development Objectives Cancellations Proposed Change in Disbursements Arrangements Change in Overall Risk Rating Change in Safeguard Policies Triggered Change of EA category Change in Legal Covenants Change in Institutional Arrangements Change in Financial Management Change in Procurement Other Change(s) Change in Economic and Financial Analysis Change in Technical Analysis

8 PDO_IND_TABLE Change in Social Analysis Change in Environmental Analysis IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_RESULTS_TABLE RESULTS FRAMEWORK Project Development Objective Indicators Percentage of antenatal care (ANC) attendees screened for glycosuria, hypertension and proteinuria in at least three antenatal visits Unit of Measure: Percentage Value Revised Percentage of population aged screened for hypertension at least once in the last year a) female; b) male Unit of Measure: Text Value a)22.5 % b)17.8 % a)75.4%; b) 48.3% a) 76% b) 55% Revised Date 31-Dec Feb Jun-2021 Percentage of population aged screened for diabetes mellitus at PHC level at least once during the last 3 years a) female; b)male Unit of Measure: Text Value a)9.8% a) 48% a) 48.1%; b) 30.9% Revised b)7.5% b) 36% Date 31-Dec Feb Jun-2021 Percentage of women aged screened for cervical cancer at least once during the last 3 years and received the results Unit of Measure: Percentage

9 Value Revised Bed occupancy rate at the a) Artashat Medical Center; b) Sevan Medical Center Unit of Measure: Text Value a) 64% b) 51% Civil works ongoing a) 70% b) 70% Revised Intermediate Indicators IO_IND_TABLE Proportion of PHC facilities undergoing enhanced verification of results by the HPIU Unit of Measure: Percentage Value Revised % of eligible PHC facilities receiving incentives within two months after the end of every semi-annual period Unit of Measure: Text Value 70 95%/95% 100 Marked for Deletion Date 23-Jan Jan Dec-2019 Level of awareness among adults in key NCD risk factors a) high blood pressure; b) high cholesterol level; c) high salt intake; d) obesity; e) high glucose level (disaggregated by gender) Unit of Measure: Text Value Male a)45% b) 24% c) Male a) 41% b) 24% c) Male a) 43% b) 26% c) 55% d) 65% e) 33%; 55% d) 64% e) 26%; 57% d) 66% e) 28%; Female a)58% b)32% Female a)58% b)38% Female a)60% b)40% c)64% d)64% e)42% c)68% d)76% e)43% c)70% d)78% e)45% Revised (2012 HSPA data) (2015 HSPA data)

10 Date 31-Dec Feb Jun-2021 Health facilities constructed, renovated, and/or equipped (number) Unit of Measure: Number Value Revised % of pediatric patients newly diagnosed with onco-hematology conditions by the Hematology Center who received treatment overseas inthe past year Unit of Measure: Percentage Value Revised Number of hospital health workers receiving training in a set of new clinical practice guidelines Unit of Measure: Number Value Revised % of public hospitals at marz level implementing Quality Improvement Program Unit of Measure: Percentage Value Marked for Deletion Date 23-Jan Jan Dec-2019 Medical Centers operational a) Sevan MC; b) Artashat MC; c) Vayots Dzor MC; d) Martuni MC Unit of Measure: Text Value No Civil works ongoing All four Medical Centers operational Revised

11 OPS_DETAILEDCHANGES_COMPONENTS_TABLE OPS_DETAILEDCHANGES_LOANCLOSING_TABLE COMPONENTS Current Component Name Performance-based incentives to improve MCH and NCD services in primary care faci Current Cost (US$M) Action 5.03 Revised Proposed Component Name Performance-based incentives to improve MCH and NCD services in primary care faci Proposed Cost (US$M) Hospital Modernization Revised Hospital Modernization Project Management 1.80 Revised Project Management 2.63 TOTAL LOAN CLOSING DATE(S) Ln/Cr/Tf Status Original Closing Revised Closing(s) Proposed Closing Proposed Deadline for Withdrawal Applications IDA Effective 15-Dec Jun Oct-2021 TF Effective 31-Dec Jun Oct-2021 OPS_DETAILEDCHANGES_REALLOCATION _TABLE REALLOCATION BETWEEN DISBURSEMENT CATEGORIES Current Allocation Actuals + Committed Proposed Allocation Financing % (Type Total) Current Proposed IDA Currency: XDR ilap Category Sequence No: 1 Current Expenditure Category: G, CW, non-cs, IOC,TR, CS, AUDIT 20,664, ,366, ,400, ilap Category Sequence No: 2 Current Expenditure Category: Perform.based finan.under Part 1(a)

12 2,136, , ,400, Total 22,800, ,088, ,800, OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed ,756, ,756, ,064, ,064, ,373, ,038, ,800, ,618, ,400, ,057, ,006, ,006, ,600, ,600, ,833.00