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: HECHN IBRD/IDA | Program-for-Results Financing | FY 2014 | Team Leader(s): Volkan Cetinkaya Seq No: 12 | ARCHIVED on 13-Jul-2019 | ISR37950 | Created by: Volkan Cetinkaya on 28-Jun-2019 | Modified by: Volkan Cetinkaya on 10-Jul-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, including PDO Indicator 5, “average length of stay in acute care hospitals”, and recorded improvements in the disbursement level reaching 53.5% for the Program part and 80% for the technical assistance part of the Operation. 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). A further improvement in the implementation of the hospital sector reforms is foreseen over the coming year. The Ministry of Health, Labor and Social Protection has expressed its commitment to improve efficiency of hospital sector and quality of services provided to the population. The Bank team will continue providing immediate technical assistance 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. 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 13.80 12.02 53% P144892 IDA-54700 Effective USD 2.10 2.10 0.00 1.55 0.40 80% 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 7/13/2019 Page 1 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Program Action Plan Action Description 6. Adoption of sanction mechanisms against hospitals with confirmed informal payment cases Source DLI# Responsibility Timing Timing Value Status Technical Client Recurrent Continuous 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 Technical Client Recurrent Yearly 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 Technical Client Recurrent Yearly 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. For 2017 – 2019 period of time and in compliance with the Association Agreement between the Republic of Moldova Comments and European Union, the Government has approved the gradual annual growth of the excise duty on tobacco products. Action Description 3. Filling the vacancies in the MOH Policy Analysis and Monitoring Unit Source DLI# Responsibility Timing Timing Value Status Technical Client Other 2016 Completed Completion completed early during project implementation and maintained since then. Measurement Comments 7/13/2019 Page 2 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Action Description 4. Completion of stakeholder analysis related to key health reforms supported by the Program Source DLI# Responsibility Timing Timing Value Status Technical Client Other 2016 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 Technical Client Due Date 31-Dec-2020 In Progress For 2019, the Mass Media Information and Communication Service has proposed to include several actions related to Completion the communication campaigns. Above mentioned Service is going to develop the Communication Strategy of the Measurement MHLSP for 2019-2021. Comments Action Description 1. Provision of sufficient Program annual budget Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems Client Recurrent Yearly 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 Technical Client Due Date 31-Dec-2020 In Progress Completion Firm responsible for the assignment is revising the content of the report in light with MoHLSP’s comments. Measurement Comments 7/13/2019 Page 3 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Action Description 9. Development of technical guidelines and sanitary regulation for Healthcare Waste Management (HCWM) Source DLI# Responsibility Timing Timing Value Status Environmental and Social Client Due Date 31-Dec-2020 In Progress Systems Completion This action was reformulated as part of restructuring completed in November, 2018. Measurement No technical guidelines developed yet. The regulation framework on health-care waste management, "Sanitary regulation on health-care waste Comments management", has been approved by the Government Decision no.696 of 11.07.2018. 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 Environmental and Social Client Due Date 31-Dec-2020 In Progress Systems 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 Moderate Macroeconomic -- Substantial Substantial Sector Strategies and Policies -- Substantial Substantial Technical Design of Project or Program -- Substantial Moderate Institutional Capacity for Implementation and Sustainability -- Substantial Substantial Fiduciary -- Moderate Moderate Environment and Social -- Moderate Moderate Stakeholders -- Substantial Substantial Other -- -- -- Overall -- Substantial Substantial 7/13/2019 Page 4 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) RiskComments Comments The "Political Governance" risk is lowered from "Substantial" to "Moderate" since a new government was established in June, 2019 after the last parliamentary election. The "Technical Design of Project" risk is lowered from "Substantial" to "Moderate" since the project implementation has been progressing well after the completion of restructuring. Results PDO Indicators by Objectives / Outcomes Reducing key risks for NCDs IN00725674 ►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 19-Oct-2018 05-Jul-2019 31-Dec-2020 The current value reflects 2013 STEPS survey data due to the fact that there was no other STEPS survey Comments conducted in the meantime. It will be updated after 2019 STEPS survey is completed. IN00725747 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 19-Oct-2018 05-Jul-2019 31-Dec-2020 IN00725749 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 19-Oct-2018 05-Jul-2019 31-Dec-2020 IN00725750 ►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 19-Oct-2018 05-Jul-2019 31-Dec-2020 The current value reflects 2013 STEPS survey data due to the fact that there was no other STEPS survey Comments conducted in the meantime. It will be updated after 2019 STEPS survey is completed. IN00725751 Adults with hypertension whose blood pressure is under control, Female (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target 7/13/2019 Page 5 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Value 7.00 7.00 7.00 11.30 Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020 IN00725752 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 19-Oct-2018 05-Jul-2019 31-Dec-2020 Improving efficiency of health services IN00725675 ►PDO Indicator 3: Annual acute care hospital discharges per 100 persons (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17.60 13.70 13.60 15.60 Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020 Comments IN00725746 ►PDO Indicator 4: Acute care hospital beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17,586.00 13,632.00 13,206.00 15,000.00 Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020 Comments IN00725748 ►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 6.90 7.20 Date 27-May-2014 20-Nov-2018 05-Jul-2019 31-Dec-2020 Comments Intermediate Results Indicators by Results Areas Intermediate Results Area 1: Reducing NCD risks IN00725753 ►Intermediate Results Indicator 1: Approval of the new tobacco control legislation (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes 7/13/2019 Page 6 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Date 27-May-2014 23-Nov-2018 23-Nov-2018 31-Dec-2020 Comments IN00725754 ►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 Yes Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020 Starting February 1, 2019, citizens can request free of charge medications (only one from each INN, the cost of which falls within the compensated amounts established quarterly by CNAM), according to Order No. Comments 96/20A dated January 24th, 2019 signed by the Ministry of Health, Labor and Social Protection and the National Health Insurance Company (CNAM). IN00725756 ►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 32.40 39.00 Date 31-Mar-2015 19-Oct-2018 05-Jul-2019 31-Dec-2020 This indicator was revised as part of restructuring process completed in November, 2018. Actual of 23.80% is measurement of previous indicator before the revision. The current value reflects 2013 STEPS survey data due to the fact that there was no other STEPS survey Comments conducted in the meantime. It will be updated after 2019 STEPS survey is completed. IN00725759 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 19-Oct-2018 19-Oct-2018 31-Dec-2020 IN00725761 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 19-Oct-2018 19-Oct-2018 31-Dec-2020 Intermediate Results Area 2: Improved efficiency of health services IN00725760 ►Intermediate Results Indicator 4: 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 7/13/2019 Page 7 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Date 27-May-2014 19-Oct-2018 19-Oct-2018 31-Dec-2020 Comments IN00725764 ►Intermediate Results Indicator 5: 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 19-Oct-2018 05-Jul-2019 31-Dec-2020 Comments IN00725765 ►Intermediate Results Indicator 6: Consolidation of departmental hospitals under the MoHLSP authority (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 19-Oct-2018 19-Oct-2018 05-Jul-2019 31-Dec-2020 Comments IN00725766 ►Intermediate Results Indicator 7: Percentage of citizen satisfied with quality of health services (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 62.60 62.60 62.60 70.00 Date 19-Oct-2018 19-Oct-2018 05-Jul-2019 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 23-Nov-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. ►DLI 2 Increase in the percentage of people with CVDs benefitting from compensated medications for treatment of CVDs (Outcome, 3,217,500.00, 0%) 7/13/2019 Page 8 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) 2019 Value 48.50 48.50 48.50 58.50 Date 22-May-2014 23-Nov-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 13.60 15.60 Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- Comments ►DLI 4 Acute care hospital beds (Output, 4,700,000.00, 91%) Baseline Actual (Previous) Actual (Current) 2019 Value 17,586.00 16.50 13,206.00 15,000.00 Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- 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 23-Nov-2018 05-Jul-2019 -- 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 Performancebased incentive Revision of the agreements signed Value performance-based In progress. Achieved with all primary care incentive scheme centers contracted by CNAM in Year 4: Yes 7/13/2019 Page 9 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- The Pay-for-Performance scheme was amended based on recommendations of the TA consultancy financed under IPF component. The mid-term review showed the new P4P scheme needs further significant improvement. The MoHLSP abolished Pay-for-Performance scheme recommended by TA consultancy and Comments proposed new set of indicators. The Bank approved the revised scheme and agreed to disburse the DLI entirely. If needed, the Bank team will provide technical support for further revisions in the scheme in the future. ►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 contracts signed Value In progress In progress hospitals with all multiple- profile hospitals Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- 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 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. Advance payment made in 2015 which was accounted for upon the completion of P4P report under the IPF component. Comments To achieve the DLI target, the following shall be urgently completed: 1. Design and development of IT application necessary for processing of large data required for P4P scheme; 2. Simulation of P4P scheme for 2018; 3. Adjustment of performance indicators; ►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 In progress In progress payment by CNAM to country data public hospitals Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- DLI#8.1, DLI#8.2, and DLI#8.3 have been accomplished. DLI #8.4 is not yet achieved due to delay in the TA supporting the DLI. The contract with the EuroHealth consulting company expired on February 28, 2019. The report no-3 with methodology for DRG cost calculation was included in this report and approved. Currently, the report no-4 is Comments being discussed within the working group and is expected to be approved by end August 2019. Application of new DRG costs simulation was conducted. ►DLI 9 Consolidation of departmental hospitals under the MoHLSP authority (Process, 4,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) 2019 7/13/2019 Page 10 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Value 0.00 0.00 0.00 50.00 Date 22-May-2014 23-Nov-2018 05-Jul-2019 -- The DLI #9.1 was disbursed as advance payment. The draft Government 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 Government brought under the MoHLSP few departmental hospitals (namely, Comments Railway hospitals) in 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. ►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 Achieved Achieved -- revised and approved Date 22-May-2014 23-Nov-2018 23-Nov-2018 -- DLI # 10 achieved and accounted. Comments 7/13/2019 Page 11 of 11