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): Adrien Arnoux Dozol, Volkan Cetinkaya Seq No: 18 | ARCHIVED on 29-Aug-2022 | ISR52743 | Created by: Gabriel C. Francis on 22-Aug-2022 | Modified by: Olena Doroshenko on 28-Aug- 2022 Program Development Objectives PDO Table 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 of health services in Moldova. Board Approved Revised Program Development Objective (If program is formally restructured) The Program Development Objective is to contribute to reducing key risks for non-communicable and infectious diseases, including COVID-19, and improving efficiency of health 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 Program has made significant progress towards its objectives of contributing to reductions in key risks for non-communicable and infectious diseases, including COVID-19, and improving the efficiency of health services in Moldova. Through its implementation, the Program has supported tobacco control activities, implementation of performance-based incentive scheme at the primary care level, improved access to compensated medications for the treatment of cardiovascular diseases, and helped rationalize inpatient care. The Program has also supported the COVID-19 response by strengthening communication activities. Specifically, the PforR has also significantly contributed to the national communication strategy by delivering over forty communication activities. Most of the Program’s key indicators have been achieved, with ten of eleven disbursement-linked indicators supporting Program implementation fully achieved and respective allocations disbursed and one indicator partially achieved and disbursed. 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 24.25 1.17 95% P144892 IDA-54700 Effective USD 2.10 2.10 0.00 1.94 0.00 100% Key Dates (by loan) 8/29/2022 Page 1 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) 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-Aug-2022 P144892 IDA-54700 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Aug-2022 Program Action Plan Action Description 1. Provision of sufficient Program annual budget Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems Client Recurrent Yearly Completed Completion Measurement Not defined during Project design. Comments At the time of monitoring, there was no information on the lack of budget allocated to PforR-related activities. 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 Completed Completion Measurement The GoM adopts a 3-year (rolling) fiscal policy framework based on which tobacco excise taxes are being defined. 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 Measurement Not defined during Project design. Comments Completed early during project implementation (2016) and maintained since then. 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 Yearly Completed Completion Measurement Not defined during Project design. Comments Completed early during project implementation (2016). 8/29/2022 Page 2 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) 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 Completed Not defined during Project design. Completion Measurement For 2019, the Mass Media Information and Communication Service proposed to include several actions related to the Comments communication campaigns. The National Communication Strategy for COVID-19 was revised and activities were implemented. 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 Measurement Not defined during Project design. There is a regulatory framework in place that allows non-payment by CNAM of inpatient cases treated by the hospital Comments if there is proof of out-of-pocket payments for drugs or medical services. The number of such cases decreasing. 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 Completion Measurement Not defined during Project design. CNAM is conducting verification of DRG coding by means of an IT application that helps cross-check and identify Comments suspicious cases, after which more detailed verification takes place. The DRG audit report is submitted to the Bank by April each year. 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 Completed Completion Measurement Not designed during Project design. The firm responsible for the assignment revised the content of the report in line with Ministry of Health and Labour Comments and Social Protection (MoHLSP)’s comments and accordingly the training was conducted. 8/29/2022 Page 3 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) 9. The MoHLSP will revise the technical guidelines and sanitary regulation for health care waste management to Action Description address the potential impact of COVID-19 Source DLI# Responsibility Timing Timing Value Status Environmental and Social Client Due Date 30-Jun-2021 Completed Systems Completion Measurement This action was reformulated as part of a restructuring in November 2020. The regulation framework on health-care waste management has been approved by Government Decision No.696 of 11.07.2018. The National Agency for Public Health also developed requested technical guidelines. Comments 10. The MoHLSP will set up an efficient mechanism for close cooperation among the key institutions that have attributions in health care waste management. The cooperation will include plans for dealing with the medical waste Action Description generated by COVID-19. Source DLI# Responsibility Timing Timing Value Status Environmental and Social Client Due Date 31-May-2021 Completed Systems Completion Measurement This action was reformulated as part of a restructuring in November 2020. The MoH has set up an efficient mechanism for close cooperation among the key institutions that have attributions in Comments Health Care Waste Management. Ministry of Agriculture, Regional Development and Environment is receiving necessary support. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Moderate Moderate Macroeconomic -- Substantial Moderate Sector Strategies and Policies -- Moderate Moderate Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and -- Moderate Moderate Sustainability Fiduciary Moderate Moderate Moderate Environment and Social Moderate Moderate Moderate Stakeholders -- Substantial Moderate Other Moderate Moderate Moderate 8/29/2022 Page 4 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Overall Moderate Substantial Moderate RiskComments Comments The macroeconomic, stakeholders, and overall risk ratings are updated to reflect residual risks to PDO achievement in the very final stage of project impleemntation. Results PDO Indicators by Objectives / Outcomes Reducing key risks for non-communicable and infectious diseases IN01180756 ►PDO Indicator 1: Smoking prevalence among adults (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 16.10 15.10 14.70 14.10 Date 02-Dec-2013 29-Dec-2017 23-Aug-2022 31-Aug-2022 The baseline reflects the value from the 2013 STEPS survey data, and the actual (previous) data is taken from the 2017 STEPS survey. Comments The data used for the actual current value is from “Population access to health services” - the additional module to Research Household Budgets. IN01180759 Smoking prevalence among adults, Male (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 33.00 30.00 28.00 29.00 Date 02-Dec-2013 29-Dec-2017 23-Aug-2022 31-Aug-2022 IN01180761 Smoking prevalence among adults, Female (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 3.40 3.30 3.70 2.90 Date 02-Dec-2013 29-Dec-2017 29-Dec-2017 31-Aug-2022 IN01180762 ►PDO Indicator 2: Increase in the number of people with CVDs benefitting from compensated medications for treatment of CVDs (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 414,744.00 439,421.00 459,686.00 456,218.00 Date 29-Dec-2017 31-Dec-2020 23-Aug-2022 31-Dec-2021 Overachieved. Comments Data for 2021 from CNAM. IN01180763 8/29/2022 Page 5 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) ►PDO Indicator 6: Revise the national communication strategy for COVID-19 (based on the results of the survey and the Vaccines Readiness Assessment) and implement six activities of the revised strategy (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 44.00 45.00 6.00 Date 17-Dec-2020 28-Feb-2022 23-Aug-2022 31-Aug-2022 Overachieved. Comments 45 activities from the revised strategy were implemented compared to the end target of 6 activities. Improving efficiency of health services IN01180757 ►PDO Indicator 3: Annual acute care hospital discharges per 100 persons (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17.60 9.33 12.42 15.60 Date 27-May-2014 31-Dec-2020 23-Aug-2022 31-Dec-2020 Overachieved. Data was calculated according to the Annual CNAM Report for 2020, using the indicator of a stable population of 3,545,124 according to NPHA. Annual acute care hospital discharges were calculated based Comments on CNAM data provided (the data include a number of treated, reported, and validated acute cases, the year 2021. A number of discharged and reported acute treated cases: General Program, Novel Coronavirus Infection, and Special Programs. IN01180758 ►PDO Indicator 4: Acute care hospital beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 17,586.00 11,853.00 12,893.00 15,000.00 Date 27-May-2014 31-Dec-2021 23-Aug-2022 31-Dec-2020 Overachieved. Comments Data from National Public Health Agency. IN01180760 ►PDO Indicator 5: Average length of stay in acute care hospitals (Days, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 8.00 7.10 6.90 7.20 Date 27-May-2014 31-Dec-2021 23-Aug-2022 31-Dec-2020 Overachieved. Comments Data from National Public Health Agency Intermediate Results Indicators by Results Areas Intermediate Results Area 1: Reducing NCD risks IN01180764 8/29/2022 Page 6 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) ►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 Date 27-May-2014 16-Dec-2019 31-Dec-2020 31-Dec-2020 Achieved. Comments IN01180765 ►Intermediate Results 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 16-Dec-2019 16-Dec-2019 31-Dec-2020 Achieved. Starting February 1, 2019, citizens have been able to request medications free of charge (only one from each INN, the cost of which falls within the compensated amounts established quarterly by CNAM), according to Order No. 96/20A dated January 24th, 2019 signed by the Ministry of Health, Labor and Social Protection and CNAM. Comments Starting with October 1, 2021, the methodology of compensated fixed amount calculation has been changed. Thus, according to the joint Order of MoH and CNAM No. 933/255 from October 8, 2021, for all partially reimbursed medicines (40%, 80%, 90%) have been applied the reimbursement rate of 100% at the median fixed market price. Intermediate Results Area 2: Improved efficiency of health services IN01180766 ►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 Date 27-May-2014 16-Dec-2019 16-Dec-2019 31-Dec-2020 Achieved. Comments IN01180767 ►Intermediate Results Indicator 5: Annual hospitalizations through referrals by family medicine providers (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 36.00 13.10 14.00 44.00 Date 31-Dec-2011 31-Dec-2020 23-Aug-2022 31-Aug-2022 Data on 2020 are based on the annual CNAM report. http://cnam.md/httpdocs/editorDir/file/RapoarteActivitate_anuale/Raport%20privind%20execu tarea%20FAOAM%20in%20anul%202020_rom.pdf Comments According to NAPH data, for 2021 the indicator is 15,3% (based only on Ministry of Health institutions, without private and departmental institutions) IN01180768 ►Intermediate Results Indicator 6: Consolidation of departmental hospitals under the MoHLSP authority (Yes/No, Custom) 8/29/2022 Page 7 of 11 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 19-Oct-2018 23-Dec-2019 23-Aug-2022 31-Aug-2022 IRI 6 is partially achieved, as the MoH has succeeded in bringing two hospitals instead of three under the Comments MoH management. IN01180769 ►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 78.10 78.10 70.00 Date 19-Oct-2018 16-Dec-2019 23-Aug-2022 23-Aug-2022 Overachieved. According to the Health Barometer Survey 2019, conducted by the PAS Center, the percentage of citizens satisfied with the quality of primary health services and hospital services are 78,1%, and 80,1% respectively. Comments Every second person believes that the quality of medical services in 2021 remained the same compared to the previous year (47.2%), according to a study regarding “Population access to health services” - the additional module to Research Household Budgets established by the National Bureau of Statistics. Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 All imported and locally produced cigarettes in the market are in line with the tobacco labelling regulation (Output, 455,634.00, 71%) Baseline Actual (Previous) Actual (Current) 2019 Starting in 2018, all imported and locally produced cigarettes Value N/A. N/A Achieved in the market are in line with the tobacco labelling regulation Date 22-May-2014 25-Nov-2019 25-Nov-2019 -- Achieved. This indicator has been validated by an independent entity, which was contracted in an open Comments tender, in accordance with the methodology jointly approved with the World Bank. ►DLI 2 Increase in the number of people with CVDs benefitting from compensated medications for treatment of CVDs (Output, 4,100,704.00, 87%) Baseline Actual (Previous) Actual (Current) 2019 Value 414,744.00 439,421.00 459,686.00 456,218.00 Date 22-May-2014 31-Dec-2020 23-Aug-2022 -- Achieved. The DLI was assessed by a team of the Court of Accounts (CoA) and approved by Decision no. 22 Comments dated 04.06.2021. ►DLI 3 Annual acute care hospital discharges per 100 persons (Outcome, 3,000,000.00, 91%) 8/29/2022 Page 8 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) 2019 Value 17.60 9.33 12.42 15.60 Date 22-May-2014 31-Dec-2020 23-Aug-2022 -- Achieved. Data on 2020 are based on the annual CNAM report. Comments http://cnam.md/httpdocs/editorDir/file/RapoarteActivitate_anuale/Raport%20privind%20executarea%20FAOA M%20in%20anul%202020_rom.pdf ►DLI 4 Acute care hospital beds (Output, 4,700,000.00, 148%) Baseline Actual (Previous) Actual (Current) 2019 Value 17,586.00 11,853.00 12,893.00 15,000.00 Date 22-May-2014 31-Dec-2021 30-Jun-2016 -- Achieved. The DLI was fully met by the Healthcare Policy Department in the first year of implementation, being Comments verified by the Court of Accounts and approved by the World Bank. ►DLI 5 Adoption of a revised outpatient drug benefit package for anti-hypertensive drugs (Process, 2,000,000.00, 89%) Baseline Actual (Previous) Actual (Current) 2019 Value No Yes Yes Yes Date 22-May-2014 02-Dec-2019 02-Dec-2019 -- Achieved. The adoption of a revised outpatient drug benefit package for anti-hypertensive drugs was carried Comments out in 2015 by the CNAM and the Medicines and Medical Devices Policy Department. ►DLI 6 Revision and implementation of performance-based incentive scheme in primary care (Process, 2,000,000.00, 90%) Baseline Actual (Previous) Actual (Current) 2019 Performancebased incentive Revision of the agreements signed Value performance-based Achieved Achieved with all primary care incentive scheme centers contracted by CNAM in Year 4: Yes Date 22-May-2014 05-Jul-2019 30-Apr-2019 -- Achieved. This DLI was fully achieved and disbursed before the reporting period. In April 2019, the amount of 1,294.000 SDRs was disbursed and distributed in proportion of 10% to the MoHLSP and 90% to the CNAM Comments budgets. ►DLI 7 Design and piloting of the Performance-Based Incentive Scheme for all hospitals (Process, 1,866,900.00, 92%) 8/29/2022 Page 9 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) 2019 No incentive scheme for Value In progress Completed -- hospitals Date 22-May-2014 15-Mar-2022 30-Jun-2022 -- Achieved. The activity has been implemented by CNAM, with the support of international consultants identified by the World Bank and with the participation of the MoHLSP’s working group. Comments ►DLI 8 Implementation and update of DRG prices for public acute care hospitals (Process, 2,000,000.00, 86%) Baseline Actual (Previous) Actual (Current) 2019 DRG accounting for less than 40 percent of total DRG updated using Value Achieved. Achieved. payment by CNAM to country data public hospitals Date 22-May-2014 23-Dec-2019 30-Jun-2022 -- Achieved. The DLI was achieved and the amount of 1.294.000 SDRs was fully disbursed. Comments ►DLI 9 Consolidation of departmental hospitals under the MoHLSP authority (Process, 728,873.00, 47%) Baseline Actual (Previous) Actual (Current) 2019 Three public Two public hospitals in Two public hospitals in hospitals in Chisinau Value N/A Chisinau are under Chisinau are under are under common common management. common management. management Date 22-May-2014 16-Dec-2019 25-Aug-2022 -- Partially achieved. Two of three public hospitals in Chisinau are under common management. The World Bank team confirmed partial achievement in the proportion of 50% for DLI#9. 258 750 SDR equivalent was Comments disbursed to the state budget on August 8, 2022. ►DLI 10 Adoption of the revised National Health System Development Strategy which includes hospital rationalization measures (Process, 1,000,000.00, 95%) Baseline Actual (Previous) Actual (Current) 2019 Strategy has not been Value Achieved Achieved -- revised and approved Date 22-May-2014 23-Nov-2018 30-Oct-2015 -- Achieved. The Policy Analysis, Monitoring and Evaluation Department amended the strategy. Comments ►DLI 11 Incorporate lessons learned in population-based behavior change communication campaigns and vaccine readiness assessment (Output, 4,643,661.00, 95%) 8/29/2022 Page 10 of 11 The World Bank Implementation Status & Results Report Moldova Health Transformation Project (P144892) Baseline Actual (Previous) Actual (Current) 2019 The Borrower has revised the National Communication strategy for COVID- 19, based upon the results of the survey Value N/A. N/A Achieved and vaccine readiness assessment, and has implemented 6 activities of the revised strategy. Date -- 09-Nov-2020 15-Jun-2022 -- Achieved. Under this DLI, 5 rounds of the survey were performed by the World Health Organization (WHO) to assess people’s knowledge, behaviors, and attitudes related to slowing the transmission of COVID-19. Comments Additionally, the World Bank and WHO jointly implemented the COVID-19 Vaccine Readiness Assessment and six (6) activities based on the results of the survey and Vaccine Readiness Assessment. 8/29/2022 Page 11 of 11