The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Moldova Health Transformation Project (P144892) EUROPE AND CENTRAL ASIA | Moldova | Health, Nutrition & Population Global Practice | Requesting Unit: ECCEE | Responsible Unit: GHN03 IBRD/IDA | Program-for-Results Financing | FY 2014 | Team Leader(s): Volkan Cetinkaya Seq No: 11 | ARCHIVED on 08-Jan-2019 | ISR34971 | Created by: Irina Guban on 20-Nov-2018 | Modified by: Maya Razat on 03-Jan-2019 Program Development Objectives Program Development Objective (from Program Appraisal Document) The Program Development Objective is to contribute to reducing key risks for non-communicable diseases and improving efficiency ofhealth services in Moldova. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Implementation Status and Key Decisions The Project has achieved progress towards key indicators and recorded improvements in the disbursement level reaching 50% for the Program part and 54.4% for the technical assistance part of the Operation. However, due to evolving country and sector circumstances, the operation was recently restructured to address the country's changing context, to fine-tune the results framework and to extend the closing date to allow enough time for achievement of Program expected results. A further improvement in the implementation of the hospital sector reforms is foreseen over the coming year. So far, the Program part of this operation has disbursed four out of the ten Disbursement-linked Indicators entirely, while other indicators have demonstrated good progress (partially achieved). The Ministry of Health, Labor and Social Protection (MoHLSP) has expressed its commitment to improve efficiency of hospital sector and quality of services provided to the population. The Ministry is currently fine-tuning its vision and intends to engage in a consultative process with all the stakeholders in the upcoming months. The Bank team proposed to provide immediate technical assistance (TA) to support the development of consensus among stakeholders on the vision and the implementation of the regionalization of hospital care based on international best practices. To increase the percentage of people with cardiovascular diseases benefitting from compensated medications for treatment, the MoHLSP and the CNAM are increasing their efforts. Together with the Bank team, they reached an agreement on the methodology for new Disbursement-linked indicators (DLI) DLI #2 (definition and data sources), the frequency of measurement and the responsibilities of each institutions in terms of data collection. This DLI will monitor the number of adult patients who benefited from one or more compensated drugs for cardiovascular diseases (CVDs) prevention and/or treatment. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P144892 IDA-54690 Effective USD 28.70 28.70 0.00 12.90 12.89 50% P144892 IDA-54700 Effective USD 2.10 2.10 0.00 1.06 0.88 55% 1/8/2019 Page 1 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P144892 IDA-54690 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Dec-2020 P144892 IDA-54700 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Dec-2020 Program Action Plan Action Description 6. Adoption of sanction mechanisms against hospitals with confirmed informal payment cases Source DLI# Responsibility Timing Timing Value Status Client Completed Completion There is a regulatory framework in place that allows non-payment by CNAM of inpatient case treated by hospital if Measurement there is a proof of out-of-pocket payments for drugs or medical services. The number of such cases decreasing. Comments Action Description 7. Implementation of annual audit of Diagnosis Related Group (DRG) payment for hospitals Source DLI# Responsibility Timing Timing Value Status Client Completed CNAM is conducting verification of DRG coding by means of IT application which helps cross-check and identify Completion suspicious cases, after which more detailed verification takes place. The DRG audit report is submitted to the Bank Measurement by April each year. Comments Action Description 2. Annual tobacco excise duty increase as per the roadmap in the tobacco control legislation Source DLI# Responsibility Timing Timing Value Status Client In Progress Completion The GoM adopts 3-year (rolling) fiscal policy framework based on which tobacco excise taxes are being defined. In Measurement 2018 the 3% ad valorem tax was added to the non-filter cigarettes, however a greater tax unification is needed. Comments Action Description 3. Filling the vacancies in the MOH Policy Analysis and Monitoring Unit Source DLI# Responsibility Timing Timing Value Status Client Completed 1/8/2019 Page 2 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Completion completed early during project implementation and maintained since then. Measurement Comments Action Description 4. Completion of stakeholder analysis related to key health reforms supported by the Program Source DLI# Responsibility Timing Timing Value Status Client Completed Completion completed early during project implementation. Measurement Comments 5. Annual public awareness and communication campaigns on health reforms on the basis of the completed Action Description stakeholder analysis under Action 4 Source DLI# Responsibility Timing Timing Value Status Client In Progress There is no strategy for public awareness on health reforms. It is expected that the MoHLSP shall consolidate its Completion communication capacity on priority reforms upon new long-term MoHLSP management is established (after PM Measurement elections in February 2019). Comments Action Description 1. Provision of sufficient Program annual budget Source DLI# Responsibility Timing Timing Value Status Client Completed Completion At the time of monitoring, there was no information on the lack of budget allocated to PforR-related activities. Measurement Comments 8. Training conducted by hospital management consultants for all managers of hospitals under common management Action Description structures on reengineered business processes and workflows Source DLI# Responsibility Timing Timing Value Status Client In Progress 1/8/2019 Page 3 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Completion Firm responsible for the assignment is revising the content of the report in light with MoHLSP’s comments. Measurement Comments Action Description 9. Development of technical guidelines and sanitary regulation for Healthcare Waste Management (HCWM) Source DLI# Responsibility Timing Timing Value Status Client In Progress Completion This action was reformulated as part of restructuring completed in November, 2018. Measurement Comments 10. Setting up of an efficient mechanism for close cooperation among key institutions that have attributions in HCWM, Action Description including, but not limited to, the Ministry of Environment, Academy of Science, UNDP Source DLI# Responsibility Timing Timing Value Status Client In Progress This action was reformulated. The MoHLSP will set up an efficient mechanism for close cooperation among the key Completion institutions that have attributions in HCWM, including, but not limited to, the Ministry of Environment, Academy of Measurement Science, UNDP. Comments Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Substantial Substantial Macroeconomic -- Moderate Substantial Sector Strategies and Policies -- Substantial Substantial Technical Design of Project or Program -- Substantial Substantial Institutional Capacity for Implementation and Sustainability -- High Substantial Fiduciary -- Moderate Moderate Environment and Social -- Moderate Moderate Stakeholders -- Substantial Substantial 1/8/2019 Page 4 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Other -- -- -- Overall -- Substantial Substantial RiskComments Comments The project keeps its overall rating as substantial due to persisting political and governance concerns, however the risks related to capacity for implementation and sustainability are being downgraded from high to substantial as a result of significant improvements in program implementation by the Client. Political and macroeconomic country context also brought down the macroeconomic risk to substantial. Despite the fact that there has been improvement, there remain the risk that delays may occurred as a result of parliamentary elections and change in the Government. Results PDO Indicators by Objectives / Outcomes Reducing key risks for NCDs IN00649095 ►PDO Indicator 1: Smoking prevalence among adults (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 25.40 25.40 25.40 23.40 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 Comments IN00649153 Smoking prevalence among adults, Male (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 43.70 43.70 43.70 42.00 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 IN00649155 Smoking prevalence among adults, Female (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 5.70 5.70 5.70 5.20 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 IN00649156 ►PDO Indicator 2: Adults (age 45-59) with hypertension whose blood pressure is under control because of antihypertensive medications (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.10 5.10 5.10 10.00 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 Comments IN00649157 Adults with hypertension whose blood pressure is under control, Female (Percentage, Custom Breakdown) 1/8/2019 Page 5 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) End Target Value 7.00 7.00 7.00 11.30 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 IN00649158 Adults with hypertension whose blood pressure is under control, Male (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 2.90 2.90 2.90 7.10 Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 Improving efficiency of health services IN00649151 ►PDO Indicator 3: Annual acute care hospital discharges per 100 persons (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17.60 16.50 13.70 15.60 Date 27-May-2014 20-Jun-2018 20-Dec-2018 31-Dec-2020 Comments IN00649152 ►PDO Indicator 4: Acute care hospital beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17,586.00 16,500.00 13,632.00 15,000.00 Date 27-May-2014 20-Jun-2018 20-Dec-2018 31-Dec-2020 Comments IN00649154 ►PDO Indicator 5: Average length of stay in acute care hospitals (Days, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 8.00 7.60 7.60 7.20 Date 27-May-2014 20-Jun-2018 20-Nov-2018 31-Dec-2020 Comments Intermediate Results Indicators by Results Areas Intermediate Results Area 1: Reducing NCD risks IN00649159 ►Intermediate Results Indicator 1: Approval of the new tobacco control legislation (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target 1/8/2019 Page 6 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Value No Yes Yes Yes Date 27-May-2014 21-Jun-2018 23-Nov-2018 31-Dec-2020 Comments IN00658118 ►Intermediate Restults Indicator 2: Revision of the outpatient drug benefit package with regard to antihypertensive drugs (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No -- Yes Yes Date 27-May-2014 -- 19-Oct-2018 31-Dec-2020 Comments IN00649161 ►Intermediate Results Indicator 3: Rate of registered patients with hypertension on antihypertensive treatment with value of arterial tension of <140/90 mm Hg (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 32.40 23.80 23.80 39.00 Date 31-Mar-2015 21-Jun-2018 19-Oct-2018 31-Dec-2020 This indicator was revised as part of restructuring process completed in November, 2018. Actual of 23.80% Comments is measurement of previous indicator before the revision. IN00649164 Adults with hypertension receiving treatment, Male (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 15.90 15.90 15.90 23.00 Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 IN00649166 Adults with hypertension receiving treatment, Female (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 32.50 32.50 32.50 37.60 Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 Intermediate Results Area 2: Improved efficiency of health services IN00649162 ►Intermediate Results Indicator 4: Revision and implementation of the performance-based incentive scheme in family medicine (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target On-going Performance based No revision of On-going implementation implementation of incentive performance based of revised performance revised performance agreements signed Value incentives in family based incentives scheme based incentives with medicine in family medicine scheme in family all primary care medicine centers 1/8/2019 Page 7 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) contracted by CNAM in Year 4 Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 This Intermediate Results Indcator was dropped as part of the restructuring completed in November, 2018. Comments IN00649163 ►Intermediate Results Indicator 5: Introduction of performance-based incentives to improve (i) efficiency; and (ii) quality of care in hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Proposed incentive Proposed incentive Performance-based scheme for hospitals (DLI scheme for hospitals No performance based incentive agreements Value 7.1) was reviewed by the (DLI 7.1) was reviewed incentives for hospitals signed with all multiple Bank and found by the Bank and found profile hospitals satisfactory. satisfactory. Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 This Intermediate Results Indicator was dropped as part of Restructuring completed in November, 2018. Comments IN00649165 ►Intermediate Results Indicator 6: Use of updated DRG prices for payment by CNAM to acute care public hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target DRG accounting for less DRG accounting for 60% DRG accounting for DRG updated using than 40% of total payment of total payment by 60% of total payment by Value country by CNAM to acute care CNAM to acute care CNAM to acute care data public hospitals public hospitals public hospitals Date 27-May-2014 20-Jun-2018 19-Oct-2018 31-Dec-2020 This Intermediate Results Indicator was dropped as part of Restructuring process completed in November, Comments 2018. IN00649167 ►Intermediate Results Indicator 7: Approval of the revised national health strategy which includes hospital rationalization measures (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 Comments IN00649168 ►Intermediate Results Indicator 8: Public hospitals in Chisinau which are under common management (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 50.00 Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 This Intermediate Results Indicator was dropped as part of Restructuring Process completed in November, Comments 2018. IN00649169 ►Intermediate Results Indicator 9: Establishment of university hospital (Yes/No, Custom) 1/8/2019 Page 8 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 27-May-2014 21-Jun-2018 19-Oct-2018 31-Dec-2020 This Intermediate Results Indicator was dropped as part of Restructuring completed in November, 2018. Comments IN00649170 ►Intermediate Results Indicator10: Annual hospitalizations through referrals by family medicine providers (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 36.00 40.00 40.00 44.00 Date 31-Dec-2011 21-Jun-2018 19-Oct-2018 31-Dec-2020 Comments IN00655232 ►Intermediate Results Indicator 11: Consolidation of departmental hospitals under the MoHLSP authority (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No -- No Yes Date 19-Oct-2018 -- 19-Oct-2018 31-Dec-2020 Comments IN00655233 ►Intermediate Results Indicator 12: Percentage of citizen satisfied with quality of health services (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 62.60 -- 62.60 70.00 Date 19-Oct-2018 -- 19-Oct-2018 31-Dec-2020 Comments Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 Smoking prevalence among (age between 18 and 69); a) men; b) women (Output, 3,941,000.00, 0%) Baseline Actual (Previous) Actual (Current) 2019 Value 25.40 25.40 25.40 23.40 Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- The baseline was originally 28% in the PAD. However, the baseline was updated to 25.40% once the results of the 2013 STEP survey became available. Comments The current value reflects 2013 STEPS data due to the fact that there was no other STEPS survey conducted in the meantime. 1/8/2019 Page 9 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) ►DLI 2 Increase in the percentage of people with CVDs benefitting from compensated medications for treatment of CVDs (Outcome, 3,217,500.00, 0%) Baseline Actual (Previous) Actual (Current) 2019 Value 48.50 5.10 48.50 58.50 Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- This DLI was reformulated from “Adults with hypertension whose blood pressure is under control”. Though the strongest risk factor for CVDs, not all risk factors for CVDs are avoidable. The reformulation is cross- Comments supporting and reinforcing DLI 5 (revision of the outpatient drug benefit package with regards to anti- hypertensive drugs). ►DLI 3 Annual acute care hospital discharges per 100 persons (Outcome, 3,000,000.00, 91%) Baseline Actual (Previous) Actual (Current) 2019 Value 17.60 16.50 16.50 15.60 Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- Comments ►DLI 4 Acute care hospital beds (Output, 4,700,000.00, 91%) Baseline Actual (Previous) Actual (Current) 2019 Value 17,586.00 16,500.00 16.50 15,000.00 Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- Comments ►DLI 5 Adoption of a revised outpatient drug benefit package for anti-hypertensive drugs (Process, 2,000,000.00, 92%) Baseline Actual (Previous) Actual (Current) 2019 Value No Yes Yes Yes Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- Comments ►DLI 6 Revision and implementation of performance-based incentive scheme in primary care (Process, 2,000,000.00, 23%) Baseline Actual (Previous) Actual (Current) 2019 Value Revision of the PBI scheme was revised In progress. Performancebased performance-based incentive incentive scheme agreements signed 1/8/2019 Page 10 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) with all primary care centers contracted by CNAM in Year 4: Yes Date 22-May-2014 19-Jun-2018 23-Nov-2018 -- The MoHLSP revised the P4P scheme twice during the project implementation: in 2017 and in 2018. However, after the review of 2017 scheme the Bank team recommended further improvements, while the scheme revision as of 2018 is under examination now. The team will assess whether all of the earlier Comments recommendations were taken into account and reflected in the currently enforced P4P scheme. This will affect DLI confirmation. ►DLI 7 Design, piloting, adoption and implementation of a performance-based incentive scheme for hospitals (Process, 2,000,000.00, 23%) Baseline Actual (Previous) Actual (Current) 2019 Performance based No incentive scheme for Revised scheme under contracts signed Value In progress hospitals implementation with all multiple- profile hospitals Date 22-May-2014 18-Sep-2017 23-Nov-2018 -- This DLI was linked to the technical assistance offered under IPF component. The Report with the proposed scheme developed and approved by the MoHLSP. However, in order to simulate payments under the scheme Comments for hospitals of various level of care, IT application is required. Consequently, while achievement of DLI target 7.1 confirmed, yet attaining of its further targets requires additional work and are scheduled for end 2019. ►DLI 8 Implementation and update of DRG prices for public acute care hospitals (Process, 2,000,000.00, 68%) Baseline Actual (Previous) Actual (Current) 2019 DRG accounting for less than 40 percent of total DRG updated using Value not yet implemented In progress payment by CNAM to country data public hospitals Date 22-May-2014 18-Sep-2017 23-Nov-2018 -- DLI#8.1, DLI#8.2, and DLI#8.3 have been accomplished. DLI #8.4 delayed due to delay in the TA project. It is Comments expected that this target will be accounted within the period of mid-December 2018 through mid-January 2019. ►DLI 9 Consolidation of departmental hospitals under the MoHLSP authority (Process, 4,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) 2019 Value 0.00 0.00 0.00 50.00 Date 22-May-2014 18-Sep-2017 23-Nov-2018 -- The DLI #9.1 was disbursed as advance payment. The draft GoM decision on the merger of three hospitals dd 2016 is still pending. However, given that the hospital reform concept is not yet adopted and taking into account that the GoM brought under the MoHLSP few departmental hospitals (namely, Railway hospitals) in Comments 2018, there is high probability of this indicator to be achieved till project closure. The team is monitoring DLI # 9 status. DLI #9.2, 9.3, 9.4 are restructured to allocate more support for hospital reform design and implementation. 1/8/2019 Page 11 of 12 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) ►DLI 10 Adoption of the revised National Health System Development Strategy which includes hospital rationalization measures (Process, 1,000,000.00, 96%) Baseline Actual (Previous) Actual (Current) 2019 Strategy has not been Value Fulfilled Achieved -- revised and approved Date 22-May-2014 30-Nov-2015 23-Nov-2018 -- DLI # 10 achieved and accounted. Comments 1/8/2019 Page 12 of 12