The World Bank Emergency Medical Services Project (P159544) REPORT NO.: RES52587 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF EMERGENCY MEDICAL SERVICES PROJECT APPROVED ON APRIL 25, 2018 TO THE REPUBLIC OF UZBEKISTAN HEALTH, NUTRITION & POPULATION EUROPE AND CENTRAL ASIA Regional Vice President: Anna M. Bjerde Country Director: Tatiana A. Proskuryakova Regional Director: Fadia M. Saadah Practice Manager/Manager: Tania Dmytraczenko Task Team Leader(s): Elvira Anadolu, Mohirjon Ahmedov The World Bank Emergency Medical Services Project (P159544) ABBREVIATIONS AND ACRONYMS COVID-19 Coronavirus disease CDPQMW Center for the Development of Professional Qualifications of Medical Workers CT Computed Tomography EMC Emergency Medical Care EMS Emergency Medical Services EMSP Emergency Medical Services Project ESS Environmental and Social Standards FM Financial management IDA International Development Association IMIS Integrated Medical Information System IT Information Technology M&E Monitoring and evaluation MIIT Ministry of Investments, Industry and Trade MoF Ministry of Finance MoH Ministry of Health MPA Multiphase Programmatic Approach MU Moderately Unsatisfactory PDO Project Development Objective PIU Project Implementation Unit PP Procurement Plan PPSD Project Procurement Strategy for Development RSCEMC Republican Scientific Center of Emergency Medical Care TOR Terms of Reference WB World Bank The World Bank Emergency Medical Services Project (P159544) BASIC DATA Product Information Project ID Financing Instrument P159544 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 25-Apr-2018 31-Aug-2024 Organizations Borrower Responsible Agency Republic of Uzbekistan Project Development Objective (PDO) Original PDO The Project Development Objective (PDO) is to increase the effectiveness and efficiency of the emergency medical services (EMS) system. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing (US$, Millions) Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-62100 25-Apr-2018 17-May-2018 12-Sep-2018 31-Aug-2024 100.00 47.24 52.76 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Emergency Medical Services Project (P159544) I. PROJECT STATUS 1. The Project Development Objective (PDO) – to increase the effectiveness and efficiency of the emergency medical services (EMS) system – remains relevant and achievable with the effort made through this restructuring to revise the PDO and intermediate result indicators (IRIs). To date, out of 17 IRIs, five have met their end targets, ten are on track to achieving their targets, with proposed limited revisions to five of them aiming to better align with the current context, including the Ministry of Health’s priorities. Specifically, two IRIs are proposed to be dropped (due to the inability to obtain accurate data in the absence of rigorous hospital information systems), and three IRI indicators are proposed for revision to update baseline and target values. 2. Overall implementation progress has been downgraded to Moderately Unsatisfactory in February 2023 due to delays in procurement and slow disbursements. The procurement delays are driven by lengthy government processes that are systemic in nature. The long decision-making process by the counterpart also contributes to the delays, of which specific examples include those on approving the computer-aided dispatch system equipment list and angiography machines. 3. To date, 12,068 units (104 types) of various medical and diagnostic equipment totaling US$ 44.517 million have been delivered to 191 project-supported health facilities. These include equipment critical to the operation of emergency services such as stationary and mobile X-rays, ultrasound machines, mechanical ventilators, patient monitors, and surgical instruments. Procurement of additional medical equipment at an estimated cost of US$ 19.15 million is in the advanced processing stages, with contract signing expected by June 2023. 4. Procurement. As of April 27, 2023, total disbursement (US$ 46.67 million (or 47 percent)) and commitments amount to US$ 56.7 million of the total credit. Of the remaining US$ 43.25 million, contracts for US$ 13.8 million are at the bidding stage. During the most recent (February 2023) mission, the Bank team, and the counterpart have agreed on a new expedited timeline for a set of actions to ensure that all pending procurement packages are launched over the coming three months. All the activities which were not launched prior to May 31, 2023, and would require long bidding processes will be canceled. 5. Financial Management (FM). The FM arrangements, including accounting, budgeting, planning, reporting, internal controls, external audits, funds flow, organization, and staffing are found adequate as of the February 2023 mission. Given the substantial progress, the FM rating has been upgraded to Satisfactory. 6. Environmental and Social Standards (ESS). The overall environmental and social safeguards rating is Satisfactory. The Project’s Environmental and Social Specialist conducts regular visits to the regions to review and monitor compliance in the Project-supported medical institutions with infection control requirements specified in the Environmental and Social Management Plans. Grievance uptake channels are established and functional through the dedicated national hotline number, PIU’s and RSCEMC’s phone numbers, email addresses, and special boxes installed in each regional EMS hospital. The World Bank Emergency Medical Services Project (P159544) 7. Legal Covenants. The Project is in compliance with all legal covenants. II. RATIONALE FOR RESTRUCTURING 8. By letter of December 20, 2022, the Ministry of Finance has requested the revisions of three PDO indicators’ baseline and end-target values and several intermediate results indicators to better reflect the current state of implementation and priorities for the remaining implementation period. 9. PDO Indicators: three out of five PDO indicators are being revised to update baseline and end target values. For all three indicators, data to estimate baseline and realistic end target values was either not or partially available at the time of the project design. While baseline data became available early in the project implementation, the data collected during the pandemic was not best suited to estimate realistic end targets, given the way in which the COVID-19 pandemic significantly impacted care delivery both in hospitals and ambulance services. 10. IRIs need to be revised to support the achievement of the revised PDO indicators and to better reflect a shift in the MoH priorities and implementation progress. III. DESCRIPTION OF PROPOSED CHANGES 11. This is the first Level II restructuring of the Project, which entails revisions to the PDO-level and IRIs as follows: Out of five PDO Indicators, three are being revised for their baseline and end-target values. (i) Percentage of heart attack cases surviving through hospital discharge. Original: baseline 0 – end-target 100 Revised: baseline 80 – end-target 85. Justification: The current end-target value of 100 percent is unachievable even in the highest-performance hospitals in the world. The revised end target is based on expert opinion considering data quality issues, regional variation, and what is feasible within the current politico-economic and health system context. An indication of poor data quality is, for instance, evident in the in-hospital heart attack survival rate, which was at 95 percent in Andijan and Ferghana regional EMS hospitals (2022) - a better rate than that observed at the National EMS hospital (83 percent) and comparable to the best-performing hospitals in the world. The proposed end target takes into account the impact of ongoing activities to improve the quality of the data collected such as those implementing clinical data reporting forms and automated data collection and analysis. (ii) Percentage of polytrauma cases surviving through hospital discharge. Original: baseline 0 – end-target 100 Revised: baseline 92 (in 2017) – end-target 95. Justification: The definition of polytrauma is not part of a common clinical and statistical reporting practice in Uzbekistan, therefore it will be revised to reflect the realities of local clinical practice, where combined trauma (which is similar but not the same as polytrauma) is used in everyday clinical practice and reporting. Also, the current end-target value of 100 percent is unachievable even in the highest-performance hospitals in the world. Therefore, it will be revised based on expert opinion considering data quality issues, regional variation, and what is feasible within the current politico-economic and health system context. The baseline value is also updated using available data. The World Bank Emergency Medical Services Project (P159544) (iii) Average response time for ambulance calls. Original: baseline 20 – end-target 15 Revised: baseline 30 (in 2020) – end-target 20. Justification: The baseline value is revised to account for the official reporting practice used at the time of project design that only included the time it takes for a vehicle to arrive at the scene from the time it was dispatched, providing a partial and more optimistic view of the ambulance system’s performance. The proposed revised target accounts for the processing time of the call by the dispatch center prior to sending a vehicle to the location. Revised end targets are based on expert opinion considering what is feasible within the current politico-economic and health system context. Intermediate Results Indicators: four IRIs are being revised for titles/end-target values, three are being dropped, and one is being added, as follows. 1) Number of ambulances furnished according to the approved list of equipment (in number): - title of the indicator is being revised to Number of procured ambulances (in number). Justification: to reflect the change in the MoH’s decision regarding the procurement of ambulances, which shifted from not furnishing ambulances to procuring furnished ambulances. 2) Number of regional EMS training departments created and/or equipped under the project (in number) – end target value is being revised from 4 to 1. Justification: The allocated budget is insufficient to finance four training centers given the MoH’s priority to build and maintain competencies in high-end technology-based complex procedures. Furthermore, given the limited number of physician positions that operate high-end equipment and deliver these procedures in EMS hospitals, maintaining one high-quality national training center makes sound economic sense. 3) Number of trainers trained for EMS training departments (in number): - end-target value to be revised from 0 to 50. Justification: The revised end-target value is proposed based on the expert opinion given the downsizing of the training center end target and the focus on high-end technology-based complex procedures. 4) Percent of patients satisfied with the EMS system (as measured by patient satisfaction surveys), (in percentage): - title of the indicator is being revised to Percent of patients reporting a positive experience with the EMS system (in percentage). Justification: Patients’ perspective about the care received is an important component of the quality of care. Earlier efforts to measure patient satisfaction have now been largely replaced by patient experience measures. This shift has been driven by patient satisfaction being a less objective measure as it is influenced by individuals’ expectations. The patient experience on the other hand focuses on objective and actionable measures such as what happened during the care encounter and how it happened. Patient experience will be measured by communication composite of hospital patient experience survey in selected regional EMS hospitals. 5) Percent of hospital EMS cases that are emergency and urgent (in percentage): - indicator is being dropped. Justification: All EMS hospitals in Uzbekistan are mandated to admit only patients that meet emergency and urgency requirements. Therefore, in the absence of a rigorous hospital information system that can help identify inappropriate cases, 100 percent of hospital EMS cases are considered emergency and urgent in all reporting forms. The World Bank Emergency Medical Services Project (P159544) 6) Percent of in‐hospital EMS patients treated within the clinically recommended time, (in percentage): - indicator is being dropped. Justification: reliable tracking of whether specific clinical activities were undertaken within recommended time would require fully deployed sophisticated hospital information systems in EMS hospitals, which is unlikely to happen within the Project life. 7) Number of departments of emergency and urgent medical care furnished per the approved list of equipment (in number): - indicator is being dropped. Justification: Equipment is purchased in batches in a phased approach, each batch comprised of a specific type of equipment (e.g., ultrasound, mechanical ventilator, or X-ray machines) for simultaneous distribution to all pre- defined EMS hospitals. This process makes it difficult to measure progress given the way the indicator is currently formulated, as no emergency department will meet the requirement of being furnished per the approved list until all equipment in the list is procured. 8) Medical equipment procured to Project financed hospitals as a share of all equipment in the approved list, (in percent). - A new indicator is being added to replace the above indicator (7). 12. End-target date: The end-target date for all PDOs and IRIs is revised from March 31, 2023, to August 31, 2024, to align with the actual Project closing date. IV. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ PBCs ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ The World Bank Emergency Medical Services Project (P159544) EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) . The World Bank Emergency Medical Services Project (P159544) . Results framework COUNTRY: Uzbekistan Emergency Medical Services Project Project Development Objectives(s) The Project Development Objective (PDO) is to increase the effectiveness and efficiency of the emergency medical services (EMS) system. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Increase effectiveness and efficiency of the Emergency Medical Services system Percentage of heart attack cases surviving through 80.00 85.00 hospital discharge (Percentage) Rationale: The current end-target value of 100 percent is unachievable even in the highest-performance hospitals in the world. Revised end targets are based on expert Action: This indicator has opinion taking into account the quality of data (massive underreporting of mortality) and what is feasible within the current politico-economic and health been Revised system context. The baseline is updated with data from 2018. Share of hospitalized patients coming to EMS 25.00 25.00 25.00 26.00 27.00 28.00 30.00 wards by ambulance (Percentage) Average response time for 30.00 20.00 ambulance calls (Minutes) Action: This indicator has Rationale: been Revised The World Bank Emergency Medical Services Project (P159544) RESULT_FRAME_TBL_PDO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 At the time of project design, official reporting only included the time it took for a vehicle to arrive at the scene from when it was dispatched, thus providing a partial (optimistic) picture of the ambulance system's performance. The updated baseline of 30 minutes (2020) is received from a computer-aided dispatch system and reflects the entire ambulance response time (from a call to a patient's door). The proposed revised end target of 20 minutes is based on an expert opinion considering what is feasible within the current politico-economic and health system context. The current definition of the indicator is broad. It includes all calls making tracking the progress in ambulance response times to life-threatening conditions such as heart attack and major trauma (that benefit from shorter ambulance response times the most) quite challenging. The definition of ambulance calls will be revised to include only capturing ambulance response times to two life-threatening conditions ( heart attack and polytrauma). Percent of pre-hospital EMS patients hospitalized 10.30 10.30 10.30 13.00 15.00 17.00 20.00 (Percentage) Percentage of polytrauma cases surviving through 92.00 95.00 hospital discharge (Percentage) Rationale: The current end-target value of 100 percent is unachievable even in the best-performing hospitals in the world. Revised end targets are based on expert opinion considering the quality of care (underreporting of deaths), the potential impact of remedial actions being undertaken to improve data quality, and what is Action: This indicator has feasible within the current politico-economic and health system context. The baseline is updated with data from 2017. been Revised Polytrauma is not part of a standard clinical case definition used in the country; hence the data on combined trauma, the closest coded value to polytrauma in the existing data reporting system, is reported. PDO Table SPACE The World Bank Emergency Medical Services Project (P159544) Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Component 1: EMS Enabling Environment, System Management and Quality Improvement Percent of hospital EMS cases that are emergency 0.00 60.00 and urgent (Percentage) Rationale: All EMS hospitals in Uzbekistan are required to admit only patients that meet emergency and urgency criteria; therefore, in all reporting, the current indicator Action: This indicator has value is reported as 100 percent. Without a functioning sophisticated hospital information system to help identify inappropriately admitted cases, this indicator been Marked for Deletion has little actionable value. Law has been amended to allow redirecting of non- No Yes urgent cases (Yes/No) Severity scoring system developed and No No Yes Yes Yes Yes Yes implemented in pre- hospital level (Yes/No) Percent of pre-hospital EMS cases that are emergency 0.00 0.00 20.00 25.00 30.00 40.00 60.00 and urgent (Percentage) Severity scoring system developed and No No Yes Yes Yes Yes Yes implemented in hospitals (Yes/No) Component 2: Dispatch, Communications and Information Systems Number of newly 0.00 0.00 0.00 3.00 6.00 10.00 14.00 established regional The World Bank Emergency Medical Services Project (P159544) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 dispatch centers with relevant software (Number) Number of dispatch protocols updated under 1.00 1.00 3.00 6.00 10.00 10.00 10.00 the project (Number) Component 3: Emergency Care System Improvement Number of the departments of emergency and urgent medical care furnished per 0.00 0.00 0.00 50.00 100.00 190.00 the approved list of equipment (Number) Rationale: The procurement plan includes approximately 130 types of equipment. The equipment is purchased in batches, comprised of limited types of equipment (e.g., Action: This indicator has ultrasound, mechanical ventilator, or X-ray machines). The purchased set of equipment is then distributed to all pre-defined EMS hospitals. And this cycle been Marked for Deletion repeats until all 130 types of equipment are procured. Given this setup, the current formulation of the indicator does not allow tracking of procurement progress. Therefore, this indicator will be replaced with a new indicator. Number of clinical protocols developed and/or updated for the departments of 0.00 0.00 5.00 10.00 15.00 15.00 15.00 emergency and urgent medical care under the project (Number) Number of procured 0.00 0.00 60.00 60.00 60.00 60.00 60.00 ambulances (Number) Rationale: Action: This indicator has The MoH’s previous decision not to procure or furnish ambulances, and therefore to drop this indicator, has changed lately. In line with the change, the been Revised indicator has been revised from The World Bank Emergency Medical Services Project (P159544) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Number of ambulances furnished according to the approved list of equipment (in number) to Number of procured ambulances (in number). Percent of in-hospital EMS patients treated within the 0.00 20.00 clinically recommended time (Percentage) Rationale: Action: This indicator has Accurate tracking of the delivery time of specific clinical activities/interventions requires fully deployed sophisticated hospital information systems (currently been Marked for Deletion unavailable in EMS hospitals). Number of EMS (pre- hospital) related medical and other personnel who 0.00 13,000.00 underwent training under the Project (Number) Number of regional EMS training departments 0.00 0.00 0.00 0.00 0.00 1.00 1.00 created and/or equipped under the project (Number) Rationale: The MoH has prioritized building and maintaining staff competencies in high-end technology-based complex procedures. Given the high cost of training Action: This indicator has equipment for high-end technologies and a limited number of physician positions that operate high-end equipment in EMS hospitals, maintaining one high- been Revised quality national training center as opposed to four is considered economically appropriate. The World Bank Emergency Medical Services Project (P159544) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Number of trainers trained for EMS training 0.00 50.00 departments (Number) Rationale: Action: This indicator has Given the MoH's priority on high-end technology based complex procedures, the end-target has been revised from 0 to 50. been Revised Percent of personnel satisfied with trainings by 70.00 75.00 80.00 90.00 90.00 EMS training departments (male/female) (Percentage) Reduced variation in ambulance teams per capita 18.10 18.10 18.10 16.10 14.10 13.10 12.10 (ratio) (Number) Medical equipment procured to Project financed hospitals as a 0.00 100.00 share of all equipment in the approved list, (in percent) (Percentage) Rationale: Action: This indicator is A new indicator is added to enable progress monitoring in the procurement of medical equipment to EMS hospitals. New Component 4: Project Management Percent of patients reporting positive 0.00 80.00 experience with the EMS system (Percentage) The World Bank Emergency Medical Services Project (P159544) RESULT_FRAME_TBL_IO Indicator Name PBC Baseline Intermediate Targets End Target 1 2 3 4 5 Rationale: Patients’ perspective about the care received is an important component of the quality of care. Earlier efforts to measure patient satisfaction are now Action: This indicator has internationally being replaced by patient experience measures. In line with the best practices, the title of the indicator is changed from been Revised Percent of patients satisfied with the EMS system (as measured by patient satisfaction surveys), (in percentage) to Percent of patients reporting a positive experience with the EMS system (in percentage). IO Table SPACE The World Bank Emergency Medical Services Project (P159544)