The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) Project Information Document (PID) Concept Stage | Date Prepared/Updated: 29-Mar-2023 | Report No: PIDC35590 Mar 22, 2023 Page 1 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) BASIC INFORMATION A. Basic Project Data OPS TABLE Country Project ID Parent Project ID (if any) Project Name Serbia P180619 Serbia Noncommunicable Diseases Prevention and Control Project (P180619) Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) EUROPE AND CENTRAL ASIA Sep 11, 2023 Feb 27, 2024 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Investment Project Financing Serbia Ministry of Health Proposed Development Objective(s) The PDO is to contribute to improving health system effectiveness in addressing noncommunicable diseases in Serbia. PROJECT FINANCING DATA (US$, Millions) SUMMARY-NewFin1 Total Project Cost 75.00 Total Financing 75.00 of which IBRD/IDA 75.00 Financing Gap 0.00 DETAILS -NewFinEnh1 World Bank Group Financing International Bank for Reconstruction and Development (IBRD) 75.00 Environmental and Social Risk Classification Concept Review Decision Moderate Track I-The review did authorize the preparation to continue Mar 22, 2023 Page 2 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) Other Decision (as needed) B. Introduction and Context Country Context 1. Serbia is an upper-middle-income economy with a gross domestic product (GDP) per capita of US$9,230 (2021).1 With a population of around 6.7 million, it is the most populous country in the Western Balkans.2 Serbia saw its first democratic governments elected in the early 2000s. After making substantial gains in political stability and institution building, in 2014 Serbia started its accession to the European Union (EU), which is ongoing. In addition, fiscal consolidation and other reforms implemented since 2014 helped restore macroeconomic stability and pave the way for the economic recovery, improvement in living standards, and reduction in poverty. 2. An early and robust response to COVID-19 was key to limiting the economic impact of the pandemic. As the economy entered a recession in 2020, the Government approved a robust fiscal stimulus in 2020. The stimulus allowed a quick recovery in 2021 (GDP grew by 7.5 percent in 2021).3 However, due to a significant increase in spending on pandemic-related goods and services, transfers to households, and subsidies provided as part of a stimulus package to mitigate pandemic impacts, the fiscal deficit significantly expanded to 8 percent of GDP in 20204 and 4.1 percent in 2021.5 3. Although Serbia managed to sustain previous progress in reducing poverty through the pandemic, poverty and inequality remain significantly higher than in comparator countries. Almost one-third (30.7 percent) of Serbia’s population lives on an income between US$6.85 to US$13.7 per day (in 2017 PPP) and is vulnerable to falling into poverty in the event of a shock.6 Moreover, inequality in Serbia, though declining, remains high. The country’s Gini coefficient of income dropped from 39.5 in 2013 to 34.5 in 2019,7 which still places Serbia among the three countries with the highest Gini coefficient when compared to Central and Eastern Europe and the Baltics. 4. Vulnerability to the impacts of climate change pose significant challenges to Serbia’s population and e conomy. According to official statistics, extreme weather events in recent years have cost the country more than €5 billion, with droughts and extreme temperatures accounting for 70 percent of the losses. The number of people affected by flooding is estimated at about 200,000 on average per year, at an estimated cost of US$1 billion in GDP.8 Significant additional risk comes from an increased frequency of droughts which, according to government estimates, have caused damages of over €3.5 billion since 2000. 5. These vulnerabilities have been compounded by the war in Ukraine. The breakdown of two of Serbia’s largest coal plants in late 2021 and early 2022, combined with the 2022 drought that substantially reduced domestic 1 2021 value. Source: World Bank, World Development Indicators. 2 The 2022 Census of Population, Households and Dwellings. Statistical Office of the Republic of Serbia, 2022. https://popis2022.stat.gov.rs/en-US 3 2021 value. Source: World Bank, World Development Indicators. 4 Compared to a pre-crisis projection of 0.5 percent. 5 Basic Macroeconomic Indicators. Ministry of Finance of the Republic of Serbia, March 2023. https://www.mfin.gov.rs/en/documents2- 2/macroeconomic-and-fiscal-data2 6 World Bank staff calculations. 7 2021 value. Source: World Bank, World Development Indicators. 8 Serbia - Systematic Country Diagnostic Update. World Bank Group, 2020. https://documents1.worldbank.org/curated/en/941541588367005122/pdf/Serbia-Systematic-Country-Diagnostic-Update.pdf Mar 22, 2023 Page 3 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) hydroelectric power production, necessitated the large-scale import of electricity, coal and gas. On top of domestic pressures, Russia’s invasion of Ukraine and the resulting depleted inventory of energy sources caused energy prices to rise, requiring Serbia to import energy at exceptionally high prices. As a consequence, the current account deficit expanded to 6.9 percent of GDP in 2022 from 4.2 percent in 2021.9 Inflation increased to average 11.9 percent in 2022 and continued increasing into 2023, peaking in February at 16.1 percent year on year.10 6. On top of these challenges, Serbia’s population is aging and declining, with significant implications for growth and shared prosperity. The fertility rate has remained at 1.5 births per woman since 2015,11 and the population shrinks by about 38,000 people each year, or 0.5 percent of the total population. The latest census data reveal a drop in population to an estimated 6.7 million from 7.2 million in 2011.12 Given the low fertility rate and high out-migration, the population is expected to continue declining until 2050, and the labor force could decline by up to 20 percent by 2050. Sectoral and Institutional Context 7. Serbia’s health financing is based on the principle of universal health coverage. Virtually all population is covered through the social health insurance managed by a single purchaser – the National Health Insurance Fund - a favorable setup for financial protection and efficiency gains. Total health spending between 2008-2018 accounted for an appreciable 8.6-10 percent of GDP. However, the long-term trend in government health spending shows a remarkable decline, from 6.2 percent of GDP in 2008 to 5.1 percent in 2018. 8. Despite improvements in recent decades, Serbia does not compare well with peers and aspirational peers in health outcomes.13 Life expectancy at birth is lower than in several Western Balkan countries. Serbia ranks second highest on mortality per 100,000 population among comparator countries, performing better than only Bulgaria. At 12 per 100,000 live births, maternal mortality ratio in 2017 is more than double the average among countries in the European Union (EU). Subjectively, 16 percent of the population perceived their health as ‘bad’ or ‘very bad’ in 2018, higher than in nearly all comparator countries. Although a majority of the population thinks that public health services are accessible, dissatisfaction remains regarding waiting time, facility conditions, patient communication and privacy, and the practice of ’asking for favors’.14 9. The health system in Serbia faces significant challenges arising from the large and increasing burden of noncommunicable diseases (NCDs). Key NCDs such as cardiovascular diseases and cancer are responsible for more than three-quarters of all deaths in the country. The risk of premature death between 30 and 70 years due to NCDs 9 Macroeconomic Developments in Serbia. National Bank of Serbia, March 2023. https://www.nbs.rs/export/sites/NBS_site/documents- eng/finansijska-stabilnost/presentation_invest.pdf 10 Consumer price indices by COICOP. Statistical Office of the Republic of Serbia, February 2023. https://www.stat.gov.rs/en- us/oblasti/cene/potrosacke-cene/ 11 2021 value. Source: World Bank, World Development Indicators. 12 The 2022 Census of Population, Households and Dwellings. Statistical Office of the Republic of Serbia, 2022. https://popis2022.stat.gov.rs/en-US 13 Peers and aspirational peers (comparators) for Serbia include: (i) other countries in the Western Balkans (WB5); (ii) countries in the European Union with or without the United Kingdom (EU28 or EU27), especially the 13 New Member States (NMS13) – Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovak Republic and Slovenia; and (iii) Seven Small Transition Economies of Europe (STEE7): Bulgaria, Croatia, Estonia, Latvia, Lithuania, Slovak Republic and Slovenia. Data may not be available for all comparators for certain indicators. 14 The World Bank (2023) Serbia – Toward a More Effective, Efficient, Equitable and Resilient Health System. https://documents1.worldbank.org/en/publication/documents-reports/documentdetail/099171502282316990 Mar 22, 2023 Page 4 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) in 2016 was 25% for males and 14% for females in Serbia, a trend that has continuously increased over the last two decades.15 10. Serbia compares unfavorably with peers and aspirational peers in the prevalence of smoking and alcohol consumption. More importantly, heavy smoking (defined as smoking more than 20 cigarettes per day) is almost three times higher than most comparable countries and the EU28 average. Around one in ten Serbians report binge drinking (drinking more than six alcoholic drinks on one occasion) at least once a month in 2019. The figure is higher among men, with more than 15 percent reporting binge drinking at least once a month compared to 4.5 percent of women in 2019. 11. Over half of adults in Serbia are overweight or obese, while obesity in children is widely prevalent . The prevalence of overweight and obesity among adults has been constantly increasing since 2000. Children are also considerably affected. In 2016, around a quarter (23.1 percent) of children in Serbia were classified as overweight or obese,16 increasing their risk for NCDs in their adulthood. Consumption of sugar-sweetened beverages is higher than NMS13 countries. Compared to NMS13 countries, Serbia reported one of the lowest figures of people that are not consuming or that are occasionally consuming sugar-sweetened beverages, at 51.9 percent, only behind Bulgaria (47.8 percent). 12. While early cancer detection is critical to ensure a better prognosis, cancer screening is low in Serbia. In 2019, roughly 30 percent of women aged 50-69 were screened for breast cancer, less than half the national target of 75 percent. More importantly, the progress has not been equally distributed as people from the lowest income and least educated access screening twice less frequently than the most educated. Only 10.9 percent of adults aged 50 to 74 were screened for colorectal cancer in the same year.17 13. Utilization of preventive services in the public sector for NCDs in Serbia is scarce , especially at the primary health care (PHC) level. Similar to cancer, screening for diabetes and hypertension is fundamental to reduce morbidity and premature mortality. However, results from a phone survey conducted by the World Bank in 2021 demonstrated that only two out of ten Serbians reported using screening services for cancer, diabetes, blood pressure, and heart and liver disease in the public health care sector. 14. Serbia lacks a well-functioning system of planning, organizing and coordinating care for patients with chronic conditions and ensuring a smooth transition between different treatments and stages of care. In particular, case management by PHC is highly ineffective. In 2021, among all patients of type 2 diabetes, only eight percent underwent testing for glycolyzing hemoglobin (HbA1C) and 15 percent for low-density lipoprotein (LDL) cholesterol in the preceding year by their chosen PHC doctor. For foot exam, which is also supposed to take place annually, the percentage is as low as four percent. The situation is similar with other routine check-up essential for patients with hypertension. 15World Health Organization. Noncommunicable diseases Country Profiles 2018 (2018). Page 180. https://www.who.int/publications/i/item/ncd- country-profiles-2018 16 Marković L, Ä?orÄ‘ić V, Trajković N, Božić P, HalaÅ¡i S, Cvejić D, Ostojić SM. Childhood Obesity in Serbia on the Rise. Children (Basel). 20 21 May 18;8(5):409. doi: 10.3390/children8050409. PMID: 34070022; PMCID: PMC8157883. 17 Serbia Health Survey 2019 (2021). Belgrade: Statistical Office of the Republic of Serbia, Ministry of Health Republic of Serbia, and Institute of public health of Serbia “Dr Milan Jovanovic Batut.â€? Available at: https://www.batut.org.rs/download/publikacije/ZdravljeStanovnistva2019.pdf. Mar 22, 2023 Page 5 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) 15. There is substantial room for improvement when it comes to treatment of critical NCDs. In 2017, Serbia’s cancer death rate was 301 per 100,000 population. This is substantially higher than countries that have higher cancer incidence, such as Estonia, Slovakia, and Poland, pointing to weakness in treatment and management of cancers (Figure 8). 16. While addressing risk factors for NCDs requires participation of multiple sectors, for detection, case management, and treatment of NCDs, root cause problems largely derive from shortcomings in health system performance . In particular, there are constraints in provider’s competence and accountability of healthcare providers, availability of and access to services, and quality of both public health measures and clinical care that affect health system effectiveness in addressing NCDs, as elaborated below. Relationship to CPF 17. The Project seeks to address the binding constraints identified in the 2020 update to the Systematic Country Diagnostic Update and is aligned with the Country Partnership Framework (CPF) for FY22–26 (Report No. 166496- YF).18 Specifically, the Project is responsive to the updated priority areas of the SCD, namely the need to strengthen government effectiveness, efficiency and accountability, including through the use of digitalization, and to build relevant skills and provide equitable opportunities to acquire human capital, particularly to counter the adverse impact of Serbia’s aging and declining population and to close reduce inequality and promote inclusion. To this end, the Project activities contribute to the second Higher Level Objective of the CPF to provide More Inclusive Service Delivery and Objective 2.2 (Better access to quality health and education services for the disadvantaged) by supporting ongoing Government reforms to address the persistently high rates of NCDs through increased access to and uptake of preventive, curative, and palliative NCD services. C. Proposed Development Objective(s) 18. The PDO is to contribute to improving health system effectiveness in addressing noncommunicable diseases in Serbia. Key Results (From PCN) 19. The result indicators selected to measure the Project’s contribution to improving health system effectiveness in addressing NCDs include: ï‚· Improvement in the early detection of NCDs, as reflected in the rate of screening for breast and colorectal cancer at the PHC level. ï‚· Improvement in case management of NCDs in PHC, as measured in (a) the percentage of type 2 diabetes patients who underwent testing for HbA1C during the last year; and (b) the percentage of hypertension patients who had their total blood cholesterol level examined within the last year. ï‚· Improvement in treatment of NCDs, proxied by percentage of patients undergoing chemotherapy who receive anti-cancer therapy prepared according to international Quality Standard for the Oncology Pharmacy Service (QUAPOS). 18 FY22-FY26 Serbia Country Partnership Framework, discussed by the Board of Executive Directors on May 26, 2022. Mar 22, 2023 Page 6 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) D. Concept Description 20. The Project seeks to tackle the major risk factors of NCDs and improve prevention, early detection and effective management of chronic diseases. This will require interventions to: (i) improve competence and accountability of health care providers; (ii) increase access to and availability of health services; and (iii) strengthen quality of clinical services and public health measures to improve population’s awareness. Digital solutions will be enablers of such transformation and will be integrated in all components of the Project to facilitate effective delivery of intended outcomes. 21. Component 1: Improving Provider’s Competence and Accountability. This component supports improvement in the competence of general practitioners in prevention and management of NCDs, strengthening capacity of PHC facilities to provide patient management by joint teams of GPs and outpatient specialists, establishment of telemedicine services and further digitalization and integration of medical records, establishment of palliative care capacities for patients with NCDs, and implementation of payment models for outpatient, inpatient and palliative care that improve accountability of health care providers for results. 22. Component 2: Increasing Availability of Services. This component supports upgrading health care infrastructure to improve availability of diagnostic and treatment services, with focus on expanding access to people living in rural areas. The component finances equipment, infrastructure improvements and mobile vehicles. It supports reforms of rationalization of health facilities network proposed by the Masterplan developed under Second Serbia Health Project. It also finances strengthening of health system IT infrastructure, development of digital health platform to improve electronic data exchange for management of NCDs, and data analytics for policy making. 23. Component 3: Strengthening Quality of Public Health and Clinical Services. This component supports development of the national programs for prevention and control of NCDs, implementation of the national Health Care Quality Improvement Plan, good practice guidelines and clinical pathways for NCDs, and improving quality of primary prevention of NCDs through targeted behavior change campaigns. 24. Component 4: Project Management, Monitoring and Evaluation. This component will support overall project administration, including project management, fiduciary functions, environmental and social compliance, and regular monitoring of and reporting on implementation. 25. Component 5: Contingency Emergency Response. The objective of this component is to improve the Government's response capacity in the event of an emergency. The component would support a rapid response to a request for urgent assistance in respect of an event that has caused, or is likely to imminently cause, a major adverse economic and/or social impact in the health sector associated with natural or man-made crises or disasters. In such a case, funds would be reallocated from other components into this one to finance goods and consulting services. It should be noted that this component cannot be used to finance salaries, nor any expenditures that could trigger any of the World Bank's safeguard policies. Legal Operational Policies Triggered? Projects on International Waterways OP 7.50 No Projects in Disputed Areas OP 7.60 No Mar 22, 2023 Page 7 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) Summary of Screening of Environmental and Social Risks and Impacts . The project is not expected to have significant negative environmental impacts, although it entails some potential short- term risks and adverse impacts, mostly related to procurement of medical and laboratory equipment, MRIs, and linear accelerators (LINAC) for radiology centers to replace the depreciated ones, transformation of former COVID-19 hospitals into inpatient facilities for the provision of palliative care (following evaluation of the pilot project, this could be rolled out nationwide). The risks arising out of these activities are related to a small-scale refurbishment and repurposing works in health care facilities envisaged for a setup of a new equipment and/or replacement of the old ones, to the retrofitting works of former COVID-19 hospitals (e.g., occupational health and safety (OHS) issues, improper waste management and impacts on ground and surface water, soil and air contamination (dust and noise), improper waste management), and risk related to usage of procured devices in the operation phase (e.g., life and fire safety in the HCFs that intend to house medical devices, proper grounding at electrical sockets, scheduling calibration and preventive maintenance etc.). These will a be assessed in the ESMF with specific measures and requirements included in the sub- projects ESMPs. One of the main challenges would also be minimizing disruptions to the users of the health care facilities and organizing work around the health care schedules. The list of HCFs and therefore the exact locations of these interventions are yet to be determined, but all small-scale refurbishment and repurposing works will be interior and carried out within the scope of existing facilities. All environmental risks are expected to be low in magnitude, predictable, and temporary if identified, mitigated, and dealt properly. At the concept stage, the relevant social risks are those pertaining to the (ESS2) Labor and working conditions, (ESS4) Community health and safety, and (ESS10) relevant to information disclosure and stakeholder engagement. The risks associated with small rehabilitation works can be mitigated through the development of adequate due diligence in line with the provisions of the ESMF for the overall project. In addition, LMP will be developed to address all concerns regarding working relations and conditions. Ethical concerns around data privacy and security shall be managed by adhering to national legislation and additional measures to be elaborated within ESMF and implemented through ESMP checklists. Considering the nature of the activities strong stakeholder and CE is required for the whole duration of the project. Through SEP and ESMF the project will make sure to integrate and apply the digital inclusion principle and adequately address any issue related to data privacy and security. Assessment of data literacy of vulnerable segments of the population who may have low IT literacy (elderly and disabled persons) will be required prior to the appraisal. This assessment will serve to integrate service activities to reach out to the vulnerable. The Project GM will be established and equipped to receive sensitive and anonymous complaints. The capacity to carry out social activities within the project will be strengthened through the hiring of an experienced social and CE specialist. . CONTACT POINT World Bank Ha Thi Hong Nguyen, Predrag Djukic Senior Economist Borrower/Client/Recipient Serbia Sinisa Mali Minister of Finance Mar 22, 2023 Page 8 of 9 The World Bank Serbia Noncommunicable Diseases Prevention and Control Project (P180619) kabinet@mfin.gov.rs Implementing Agencies Ministry of Health Danijela Urosevic Assistant Minister danijela.urosevic@zdravlje.gov.rs FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects APPROVAL Task Team Leader(s): Ha Thi Hong Nguyen, Predrag Djukic Approved By APPROVALTBL Practice Manager/Manager: Country Director: Xiaoqing Yu 12-Apr-2023 Mar 22, 2023 Page 9 of 9