The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) EUROPE AND CENTRAL ASIA | Kazakhstan | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2016 | Seq No: 8 | ARCHIVED on 22-Oct-2019 | ISR38223 | Implementing Agencies: Ministry of Health, Ministry of Health, Republic of Kazakhstan Key Dates Key Project Dates Bank Approval Date: 27-Apr-2016 Effectiveness Date: 27-Jun-2017 Planned Mid Term Review Date: 30-Mar-2020 Actual Mid-Term Review Date: Original Closing Date: 30-Jun-2021 Revised Closing Date: 30-Jun-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The proposed Project Development Objective is to improve accessibility, quality, and efficiency of health service delivery, and reduce financial risks to the population that are caused by serious health problems. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Component 1. Supporting implementation of the national mandatory Social Health Insurance system:(Cost $16.63 M) Component 2. Strengthening of health service delivery to support implementation of the national mandatory Social Health Insurance system:(Cost $62.94 M) Component 3. Project management, monitoring and evaluation, and communications strategy:(Cost $10.43 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO ►Moderately Satisfactory ►Moderately Satisfactory Overall Implementation Progress (IP) ►Moderately Satisfactory ►Moderately Satisfactory Overall Risk Rating ►Substantial ►Substantial Implementation Status and Key Decisions 10/22/2019 Page 1 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Health reform implementation. Implementation of the health sector reform has continued to advance, with good progress demonstrated to date. More specifically (i) As a single payer and purchaser of health services, the Social Health Insurance Fund (SHIF) now manages 95% of health sector budget, including for health services under the State Guaranteed Benefits Package (SGBP) and Mandatory Social Health Insurance (MSHI); (ii) As of September 1, 2019, the Ministry of Health (MoH) launched the pilot implementation of MSHI in Karaganda oblast, based on which necessary adjustments are being made to various aspects of the MSHI system; (ii) As a financial institution, the SHIF should have more autonomy in flexibly managing its funds, and it is gradually learning to exercise more autonomy; (iv) Since July 1, 2017, the amount of insurance contributions collected from formal sector employers and individual entrepreneurs has exceeded KZT 207 billion (~ US$531 million), which will provide a financial buffer for health provider payments under the health insurance scheme as of January 2020; (v) In line with the objective to increase the level of health facilities’ autonomy, the legal status of hospitals and other qualified health sector organizations are being transformed from “public institutions” into “state economical enterprises” and corporate management elements are being introduced, such as boards of trustees, to provide health organizations with the necessary autonomy to implement changes to better respond to the new demands of the single payer system. This transformation allows health facilities to expand or reduce existing services or create new services to become more competitive when the SHIF expands the use of strategic purchasing function; (vi) The MoH has intensified the outreach and communication campaign to prepare the population and health providers for the implementation of the MSHI system. Current status of the activities under each of the Project components is as follows: Component 1. Supporting implementation of the national mandatory Social Health Insurance system: The implementation of this component has moved ahead with a pilot implementation of MSHI in Karaganda oblast. Feedback from providers in Karaganda is overall positive, with the system appearing to have all of the needed functionality and good interaction with SHIF provider payment functionality. Activities under this Component on supporting implementation of MSHI system and improvement of the MoH information technology systems are under implementation and on schedule. Key legal acts, necessary for the MSHI implementation, were adopted; three-level model of health care was approved; and the lists of medical services within the State Guarantied Benefit Package and MSHI package were accepted by the Decrees of the Government. Component 2. Strengthening of health service delivery to support implementation of the national mandatory Social Health Insurance system: Activities on supporting the development of the health facility network, managing the quality of health care services, and strengthening human resources for health care are being implemented satisfactorily. All strategic partnerships with international medical universities (Finland, Sweden, Turkey, Lithuania, Poland) are launched. Procurement process for medical/simulation training equipment is delayed. Procurement process for medical equipment has been launched in September, which will result in significant increase of disbursement once the procurement process is completed. Component 3. Project management, monitoring and evaluation, and communications strategy: In accordance with the renewed MSHI communication strategy, the MoH/PMU are implementing activities on comprehensive media/public relations, awareness raising/communication outreach, social media marketing, social surveys/reputation audit as well as handling/analyzing incoming complaints. Support will also be provided to the following activities, which are in the procurement process: (i) design and implementation of an informed community monitoring and dialogue mechanism in health facilities; (ii) regional conflict management workshops to train health workers in health facilities to competently handle dialogue with citizens/patients; and (iii) continuation of support to the Medical Informational and Analytical Contact Center following its current pilot implementation. As part of the Capacity Building Plan for 2018-2019, a total of 1,335 health sector workers were covered with various training activities under all Project components, including 785 in 2018 and 350 in first six months of 2019. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance ►Moderate ►Moderate ►Moderate Macroeconomic ►Substantial ►Substantial ►Substantial Sector Strategies and Policies ►Substantial ►Substantial ►Substantial Technical Design of Project or Program ►Substantial ►Substantial ►Substantial Institutional Capacity for Implementation and Sustainability ►Substantial ►Substantial ►Substantial Fiduciary ►Substantial ►High ►High 10/22/2019 Page 2 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Environment and Social ►Moderate ►Moderate ►Moderate Stakeholders ►Substantial ►Substantial ►Substantial Other ►Substantial ►Substantial ►Substantial Overall ►Substantial ►Substantial ►Substantial Results PDO Indicators by Objectives / Outcomes Improve accessibility, quality, and effeciency of health service delivery and reduce financial risk IN00733920 ►Increase public expenditure share for PHC + consultation and diagnostic care + outpatient drugs (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 35.00 38.00 38.00 40.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track based on data from Implementation Progress Report for the first half of 2019. The data is for 2017. Comments: The data for 2018 will be provided in Q4 of 2019. IN00733971 ►Percent of all surgeries included in the “outpatient elective surgeries” list performed as outpatient surgeries in project-supported hospitals and outpatient facilities (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 35.00 33.00 40.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track based on data from Implementation Progress Report for the first half of 2019. According to the revised RF, a specific target for 2018 is defined as the “List of “elective outpatient surgeries” defined”. The list of “outpatient elective surgeries” recommended to be performed as outpatient surgeries was approved in 2018 and Comments: includes the following 5 manipulations from ICD-9: (i) Hernioplasty of umbilical hernia; (ii) Local excision of the disease site of mammary gland; (iii) Reposition of nasal bone; (iv) Surgery to remove hydrocele of tunica vaginalis; (v) Drainage of soft tissue abscess. IN00733972 ►Percent of all contracted inpatient services subject to technical audit (annually) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 20.00 20.00 30.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track based on data from Implementation Progress Report for the first half of 2019. Comments: IN00733973 10/22/2019 Page 3 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) ►SHIF is fully functional based on predefined criteria (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track based on data from Implementation Progress Report for the first half of 2019. The first phase of MSHI reform is under implementation, with four out of six criteria of the SHIF full functionality satisfied as part of its current functioning as the purchaser of health services under in the State Guaranteed Benefits Package (SGBP): (i) the Law on MSHI adopted and relevant by-laws updated; ii) SHIF signs contracts with providers for specific Comments: sets of services; (iv) SHIF completed annual external financial audits; and (vi) health facilities receive payments for services contracted by SHIF in accordance with payment schedules specified in their contracts. In addition, (iii) the insurance package has also been defined and approved. It will be updated and re-approved based on the findings of the MSHI pilot implementation. IN00733974 ►Proportion of the bottom 40% of households spending 10% and more on health services and non-food goods in the health sector out of total expenditure on paid services and non-food goods (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.50 11.70 13.70 12.80 Date 30-Jun-2016 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track in the sense that, although the out-of-pocket expenditures of the bottom 40% of households in 2017 demonstrated an increase from the baseline value of 10.5% in 2016 (based on data for 2018 from the Statistics Agency), this increase was anticipated based on the tendency of increased out-of-pocket health expenditures of the Comments: population in recent years, which is projected to start gradually decreasing with full MSHI implementation, beginning in 2020. The data is for 2018. The data for 2019 will be provided in Q3 of 2020. Overall Comments PDO The progress being achieved in health sector reforms supported by the Project is reflected in the PDO-level indicators, with four out of five indicators showing improvements, as reported in the MoH/PMU implementation progress report for the first half of 2019. Intermediate Results Indicators by Components Component 1. Supporting implementation of the National Mandatory Social Health Insurance System IN00733975 ►Percent of population for whom SHIF received SHI contributions/subsidies (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 26.00 26.60 83.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 10/22/2019 Page 4 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) This indicator is on track based on data from MoH/PMU Implementation Progress Report for the first half of 2019. Comments: IN00733978 ►Achievement of key benchmarks for functioning social health insurance system (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Partial Partial Yes Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track (partial achievement of key benchmarks, as planned). The Road Map for MSHI implementation was approved through MoH Order No.764 dated October 16, 2017. Since January 1, 2018, budget proceeds under the State Guaranteed Benefits Package are channeled through the Social Comments: Health Insurance Fund (SHIF), which conducts strategic purchasing and contracts services from public and private providers. IN00733979 ►Key adjustments in the contracting methods are adopted to include incentives for providers to improve quality (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No Yes Yes Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track (partial progress towards achievement, as planned). The related MoH Order No.138 on incentivizing quality of health services rendered as part of the SGBP was signed on Comments: March 29, 2018. Contracts with key adjustments to improve quality are already being implemented as part of MSHI pilot. Component 2. Strengthening of health service delivery to support implementation of the national mand IN00733976 ►Number of fully functional regional PHC excellence centers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 16.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 This indicator is on track for achievement as scheduled. 16 regional PHC excellence centers have been identified through the MoH Order No.239 dated May 5, 2018. The process Comments: to ensure their full functionality--including procurement of the necessary equipment, training, etc.--is underway. IN00733977 ►Number of regions implementing disease management programs with evidence-based effectiveness, including incentives for health providers and patients (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 16.00 16.00 16.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 10/22/2019 Page 5 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Activities measured by this indicator are being implemented ahead of schedule. All 16 regions have launched activities for implementation of disease management programs for the three piloted conditions (arterial hypertension, diabetes, and Comments: chronic heart failure) based on the MoH Order No. 348 dated June 11, 2018. IN00733980 ►Number of educational programs developed and implemented in medical education institutions based on competence-based approach and professional standards through strategic partnerships (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 6.00 6.00 5.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 Activities measured by this indicator are implemented ahead of schedule. Six educational programs (nursing at technical and vocational, academic bachelor's, master's, and PhD levels as well as educational programs on public health (bachelor's level) and biomedicine (master's level)) have been developed or updated in 2018, with five of them to be implemented as of Comments: the new academic year in September 2019. Educational programs for neurology and anesthesiology, traumatology, medical radiology (residency), public health (bachelor's, master's and PhD levels) are currently being developed. IN00733981 ►Unified register of human resources for health implemented (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 On track. Acceptance of the Health Information and Interoperability Platform, which includes a module on human resources for health, has been completed. Development of an information model (Data Mart) for "Business Analytics" Comments: component of the Platform, through which analytical and reporting information on human resources would be provided, is currently underway. IN00733982 ►Health personnel receiving training (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 983.00 1,135.00 3,400.00 Date 18-Sep-2015 31-Mar-2019 20-Sep-2019 30-Jun-2021 This indicator is on track. 1135 health workers have been trained with Project support as of June 30, 2019. Comments: IN00733983 ►Health facilities constructed, renovated, and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1.00 1.00 50.00 Date 18-Sep-2015 05-Apr-2019 20-Sep-2019 30-Jun-2021 Procurement process for simulation equipment for 20 pre-hospital emergency medical care stations has started. Comments: IN00733984 ►Percentage of patients reporting improved health services (Text, Custom) 10/22/2019 Page 6 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Baseline Actual (Previous) Actual (Current) End Target Value n/a 22.5% 37.8% +10% over baseline Date 18-Sep-2015 31-Mar-2019 30-Apr-2019 30-Jun-2021 This indicator is on track. Based on findings of the semi-annual sociological survey conducted in December 2018, on average, 22.5% of patients across all the regions have reported improvements in health services provision. This value will Comments: serve as the baseline value for subsequent measurements of this indicator. IN00733985 ►Increase in transparency, credibility, and effectiveness of the complaints handling system (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 57.00 57.00 60.00 Date 18-Sep-2015 31-Mar-2019 31-Mar-2019 30-Jun-2021 This indicator is on track. Based on findings of the semi-annual sociological survey conducted in December 2018, on average, 57% of the population across all the regions have rated the transparency, credibility, and effectiveness of the Comments: existing complaints handling system as High. The findings from the next survey to be carried out will be reported in next ISR. Overall Comments IR All 11 intermediate results indicators (IRI) are on track to achieve their end-of-Project targets, with activities measured by three of the indicators (IRI 3, IRI 5 and IRI 6) being implemented ahead of schedule. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P152625 IBRD-86170 Effective USD 80.00 80.00 0.00 7.60 72.40 9.5% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P152625 IBRD-86170 Effective 27-Apr-2016 01-Nov-2016 27-Jun-2017 30-Jun-2021 30-Jun-2021 Cumulative Disbursements 10/22/2019 Page 7 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Restructuring History Level 2 Approved on 11-Dec-2018 Related Project(s) There are no related projects. 10/22/2019 Page 8 of 8