Primary Health Care Improvement Project (RRP UZB 50190-002) RISK ASSESSMENT AND RISK MANAGEMENT PLAN 1. This Risk Assessment and Risk Management Plan (RAMP) for the Primary Health Care Improvement Project summarizes the risks and key mitigation measures identified during due diligence. The change of scope undertaken for the project confirmed it to be a low risk, having met all low-risk categorization criteria. 1 2. Country governance risks. The World Bank conducted a Country Integrated Fiduciary Assessment (CIFA) of the Republic of Uzbekistan (Uzbekistan) in March 2011. 2 Prior to this report, a Public Expenditure Review was conducted in 2005. 3 The CIFA has benefits for the government, the Asian Development Bank (ADB), and other development partners. It provides an update on all the various studies conducted by the development partners and the government since 2005. It also details the progress made by the government in implementing key reforms in several critical public financial management (PFM) areas. 3. The CIFA was designed to provide information on the public sector s financial accountability and fiduciary arrangements in Uzbekistan; identify and document the most significant fiduciary risks in the government s PFM and procurement systems; document the existing program of reforms and capacity building to improve transparency and accountability aspects of PFM, and make proposals for actions that can bring positive change; and provide a road map for using the country PFM system in investment projects along with adequate fiduciary safeguards. The report recommended to the government (i) to strengthen the role of the investment committee, (ii) to improve financial reporting and internal audits, and (iii) to continuously strengthen procurement capacities and regulations. 4. Project risks. Project-related risks were identified in the following areas: (i) technical; (ii) economic and financial; (iii) governance in financial management, procurement, and anticorruption measures, as well as capacity and institutional governance; and (iv) poverty, social, and gender. 4 No civil works are being undertaken by the project and no safeguards risks were identified. Risks are rated high, substantial, moderate, or low. The proposed mitigation measures were discussed and agreed with the government and built into the design of the project. The risks, rating, mitigation measures, and responsible agencies are summarized in the table below. 1 Change of Scope memo; Project Number 50190-002 and TA9148-UZB: Electronic Healthcare Development Project Change in Project and Transaction Technical Assistance (TRTA) Scope and Implementation Arrangements, signed 4 April 2017Manila. 2 Republic of Uzbekistan Country Integrated Fiduciary Assessment, The World Bank. Operations Services and Quality Department Europe and Central Asia Region. Report 60713-UZ. March 2011. 3 World Bank. 2005. Uzbekistan: Public Expenditure Review. Public expenditure review. Washington, DC. World Bank. https://openknowledge.worldbank.org/handle/10986/8528 License: CC BY 3.0 IGO. 4 Detailed analyses are included in the project s Economic Analysis (Linked Document 6), Financial Analysis (Linked Document 7), Summary Poverty Reduction and Social Strategy (Linked Document 8) and Gender Action Plan (Linked Document 9).
2 Table 1: Risks and Mitigating Measures Risk Description Rating Mitigation Measures Responsibility 1. Technical 1.1 Unreliable power supply. Rural areas in Uzbekistan suffer from unreliable availability of electricity and face regular power outages. A substantial number of facilities do not have the required equipment (generators) to maintain stable and reliable power supply to maintain basic service levels. 1.2 Weak maintenance logistics and/or allocated financing. The large amount of equipment spread over 793 facilities requires substantial efforts and resources for preventive and standard maintenance. Lack of maintenance logistics and/or allocated financing for maintenance (post-warranty) may lead to premature deterioration of equipment. 1.3 Limited technical capacity for equipment installation and commission. Limited implementation capacities at the oblast (region) level to meet all ADB and project requirements (training, installation, commission). 1.4 Limited clinical experience of staff using advanced diagnostic technology. There is a high number of staff (across many different positions) who require training to utilize modern equipment. High staff turnover jeopardizes the training needs. 1.5 Weak health information data collection and reporting. Data reported through the routine health information system are inaccurate and not up to date. Government and have assured that measures are being taken to improve the situation and that power supply equipment will be provided to affected facilities prior or in tandem with the supply of project equipment. Government and have assured that measures are being taken to improve the situation regarding maintenance logistics and allocated financing. 5 They are expanding a maintenance center to cover nationwide maintenance of medical equipment. Capacity building measures are part of the project (user training through suppliers). The government has experience in nationwide supply of equipment and a traditionally coherent framework for nationalto-regional dissemination. In addition, the PIU will be supported by international and national medical equipment logistics experts. The government and are taking steps to recruit and retain the staff required for the operation of the family polyclinics including providing housing and other incentives. The government and are taking steps to standardize and improve health information and reporting. Capacity building measures and the pilot of digital reporting are part of the project. Government and MOF,, polyclinics, PIU, regional government authorities, and polyclinics, PIU 5 order 127. 2017. About the Decree of the President of the Republic of Uzbekistan No. DP-2857 of March 29, 2017 On measures of further improving organization of activities of primary medico-sanitary care institutions in the Republic of Uzbekistan ; and order 175. 2017. On organization of activities of Primary medico-sanitary care institutions provide specific guidance on the allocation of funds for consumables and reagents used by the family polyclinics and states they will be procured centrally by.
3 2. Economic and Financial 2.1 Poor linkage between health care policies and budgeting. This brings the risk of inadequate prioritization of allocation for expenditures and investments in the primary, secondary, and tertiary health care service sectors and may impact sustainability of project measures. will engage in policy dialogue with primary health care stakeholders to ensure that financing and budgetary measures are part of the UHC initiatives. 2.2 Insufficient sector capacities for planning, forecasting, and cost benefit analysis. Health care planning is not indicator-based, which leads to suboptimal use of resources. The government will initiate development of a health care indicator framework to enable better and results-oriented health care planning and analysis. 3. Governance (Financial Management, Procurement, Anticorruption Measures, Capacity, and Institutional) 3.1 Weakness in the country financial management system. While the government s PFM system functions well in some areas (e.g., budget credibility and comprehensiveness, tax administration, and the treasury function) there are weaknesses in medium-term budgeting, the appropriation system, accounting, payroll-related internal controls, procurement, and internal and external audits. 3.2 Lack of clarity in the roles of regulatory or supervisory agencies. The role delineation between the States Investment Committee and the Ministry of Finance for regulation and supervision of IFI loans is not clearly defined. 3.3 Incomplete financial reporting and monitoring. Financial reporting of income and expenditure is not produced automatically, and cannot be easily verified for completeness and accuracy by management. 3.4 Immature internal audit system. The government put in place a resolution for the financial control and restructure of the The government has taken steps to mitigate and reduce risks, including the update of detailed accounting standards by the Ministry of Finance and a very recent presidential resolution (No. RP-3231 of 21 August 2017) on financial control and restructuring of the accounting and internal audit in budget organizations. The government is taking steps to clearly outline the role for the States Investment Committee and its decision-making responsibilities within this project. Under new internal audit procedures and recently revised accounting standards, the government will put in place specific financial reporting steps to ensure accurate accounting. With adoption of an upgraded 1C (version 8) accounting software, the degree of automation will be increased. Internal audit and financial control services were created in the structure of the and other relevant ministries. The Government and and MOF MOF
4 accounting and internal audit in budget organizations on 1 September 2017. 3.5 Limited data capture and management capability., data are managed in spreadsheets, which can lead to data entry and management errors. 3.6 Limited familiarity of with ADB s recent procurement procedures and practices. While and PIU have experienced staff to undertake procurement, there is less knowledge available on recent ADB procurement procedures because the last ADBfunded project was completed in 2012. 4. Poverty, Social, and Gender 4.1 Lack of awareness. Especially in remote and/or economically disadvantaged areas, a lack of awareness of improved primary health care services through family polyclinics may have a detrimental effect on the polyclinic s utilization. This is especially notable in services related to prenatal and pediatric care. 4.2 Lack of sex-disaggregated data. A paucity of sexdisaggregated data makes it difficult to analyze genderdifferentiated patterns of access to health care and social protection measures, and acts as a critical impediment to targeted and gender-sensitive social policies and health services for the poor. new subdivisions will manage prevention and detection of cases of illegal consumption and theft of budget funds Internal auditors will be hired to strengthen financial controls, including development of an internal audit manual and adoption of annual work plans. a Data capture will be carefully managed by staff, and an emphasis will be put on strengthening the relationship between Excel and the 1C software applied under the PIU. Risk monitoring recommended: (a) annual procurement plan to be prepared and schedule of procurement timeline to be followed strictly; (b) an international consulting company to assist in the procurement process; (c) frequent training to be provided to procurement staff on national and ADB guidelines on procurement of goods, works, and services; and (d) Uzbekistan s guidelines, the procurement of donor-funded projects to follow strictly the guidelines of the donor. The government is continually updating the population on development and improvements in health care service provision through the print media, which is available and affordable in all areas. Family polyclinic patronage nurses are communicating new services in remote areas through family visits. The project will ensure monitoring of gender indicators in the health system performance monitoring database. Gender indicators are institutionalized in the monitoring database. Gender analysis based on the system will be conducted. The PIU will be supported by a dedicated gender expert throughout the project and PIU, PIU, and PHC facilities PIU
5 implementation. 4.3 Poor social perception. Poor social perception of the capabilities of (especially rural) primary health facilities may continue to divert patients directly to secondary or tertiary care facilities. Overall The government is implementing and increasingly enforcing referral requirements and an appropriate policy framework for care escalation. Family polyclinics and regional governments are continually updating the population (local media, town meetings, community committee meetings) on improved services and availability of specialists on primary care level., regional government authorities, and PHC facilities ADB = Asian Development Bank, IFI = international financial institution, MOF = Ministry of Finance, = Ministry of Health; PFM = public financial management, PHC = primary health care, PIU = project implementation unit, UHC = universal health coverage. a Government of Uzbekistan 2017. On further improvement of the mechanism of financing educational and medical institutions and the system of the state financial control Presidential decree No. RP-3231 Tashkent (21 August). Source: Asian Development Bank.