Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) EUROPE AND CENTRAL ASIA | Armenia | Health, Nutrition & Population Global Practice | IBRD/IDA | Adaptable Program Loan | FY 2007 | Seq No: 18 | ARCHIVED on 12-Feb-2016 | ISR22661 | Implementing Agencies: Ministry of Health, HSMP-PIU Key Dates Key Project Dates Bank Approval Date:08-Mar-2007 Effectiveness Date:06-Jun-2007 Planned Mid Term Review Date:-- Actual Mid-Term Review Date:17-May-2010 Original Closing Date:31-Dec-2012 Revised Closing Date:29-Feb-2016 Project Development Objectives Project Development Objective (from Project Appraisal Document) The overall objective of the HSRP Program remains unchanged: to improve the organization of the health care system in order to provide more accessible, quality and sustainable health care services to the population, in particular to the most vulnerable groups, and to better manage public health threats. This Project aims at: (i) scaling up family medicine based primary health care reform by expanding the renovation of primary health care facilities and upgrading of the medical equipment in the remaining marzes; (ii) optimizing and upgrading hospital networks in the remaining marzes; (iii) strengthening Government's capacity to develop and monitor effective health sector policies in the area of health financing, resource allocation and provider payments; and (iii) expanding investment in human resources to include formal and continuous education in health (medical, nursing, auxiliary health professionals). Has the Project Development Objective been changed since Board Approval of the Project Objective? No PHRPDODEL Components Name COMPONENT A: FAMILY MEDICINE DEVELOPMENT:(Cost $10.15 M) COMPONENT B: HOSPITAL NETWORK OPTIMIZATION:(Cost $37.77 M) COMPONENT C: INSTITUTIONAL STRENGTHENING:(Cost $4.82 M) COMPONENT D: PROJECT MANAGEMENT:(Cost $2.20 M) Overall Ratings 2/12/2016 Page 1 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) Name Previous Rating Current Rating Progress towards achievement of PDO  Moderately Satisfactory  Moderately Satisfactory Overall Implementation Progress (IP)  Satisfactory  Satisfactory Overall Risk Rating  Low  Low Implementation Status and Key Decisions The Project will be fully disbursed by the closing date of the Additional Financing (AF) Loan (February 29, 2016), and all activities are expected to be completed and the project development objectives met. Specifically, the original Project has been successfully implemented with the following major achievements: a) restructuring of the primary health care system based on the Family Medicine (FM) model; b) optimizing the hospital network nationwide by reducing average length of stay (ALOS) and space; c) building management capacity through the training of Ministry of Health professionals and health providers in health and financial management; and d) building capacity for monitoring and evaluating progress in the health sector and supporting decision making. Based on these achievements, the Government of Armenia requested an Additional Financing (Loan) in 2010 to scale up project activities to enhance the development impact of the Project. With the support of the Loan, the Project delivered a complex set of interventions to improve the conditions of the primary health care facilities and hospital network, updated the medical equipment of these facilities, trained FM teams (doctors and nurses), develop protocols, developed and implemented quality standards and quality control mechanisms. Capacity was also built towards improving health sector management and statistics (data collection, analysis, and publication of results). The Government has now institutionalized the carrying out of surveys and publications of Health System Performance Assessment and National Health Accounts to improve and support decision making and monitor progress in the sector. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance  --  Low  Low Macroeconomic  --  Low  Low Sector Strategies and Policies  --  Low  Low Technical Design of Project or Program  --  Low  Low Institutional Capacity for Implementation and Sustainability  --  Low  Low Fiduciary  --  Low  Low Environment and Social  --  Low  Low Stakeholders  --  Low  Low Other  --  --  -- Overall  --  Low  Low Results 2/12/2016 Page 2 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) Project Development Objective Indicators PHINDPDOTBL  Proportion of Armenian Population covered by qualified family medicine practices (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 47% 91% 91% 95% Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Substantially achieved. All rural population is covered by retrained family physicians and nurses. Target not reached due to age of and retirement of a number of family physicians (14). Overall, family physicians are accessible for 85% of the urban population (polyclinics) and 100% of the rural population. PHINDPDOTBL  Increased utilization of a) out-patient services; and b) in-patient services by the poorest income quintile (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Increased Value a) 3.9%; b) 3.1% a) 2,9%; b) 4.0% a) 5.3%; b) 9.7% Utilization Date 22-Nov-2011 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Achieved. Percentage of respondents in the poorest quintile a) who apply for out-patient services within the last month; and b) who apply for in-patient services within the last year. PHINDPDOTBL  Health Sector Performance Report issued once every two years (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target HSPA for 2012 HSPA 2014 developed HSPA HSPA for 2006 year published in Dec. 2013; Value and in the process of published every published new survey planned for being published. two year 2015 Date 01-Sep-2007 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Overachieved. Originally planned once every two years, now published every year. HSPA 2015 survey in progress and will be published by end of CY2016. 2/12/2016 Page 3 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) PHINDPDOTBL  Perceived quality of care in marzes increased (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target a) PHC: urban: 64.1%; rural: 73.2%; b) Value 64.3% not available 75% hospital: urban: 73.7%; rural: 66.8% Date 30-Dec-2007 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments To be confirmed in ICR. Survey results to be made available by March 2016. PHINDPDOTBL  ALOS in marz hospitals decreased close to OECD average (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 7.7 6.6 5.8 6.5 Date 01-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Overachieved. PHINDPDOTBL  National Health Accounts report published annually (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target NHA for 2012 2006 NHA report published in Dec. 2013, NHA 2014 in process of Value Annual distributed 2007 new survey planned for being published 2015 Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Achieved. NHA 2015: survey ongoing and report expected to be published by end of CY2016. 2/12/2016 Page 4 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) PHINDPDOTBL  Public hospitals in project sites that have published financial audit reports from independent audits (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0 4 7 13 Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Not achieved. Overestimation of target given that government regulations do not require independent audit in cases when annual revenues are less than 1 billion drams (US$2 million). Only 2 MCs meet this requirement: Hrazdan MC and Gyumri MC. However, by actions from the PIU, the following medical centers (MC) have paid for independent audits: Ararat MC, Aparan MC, Gavar MC, Ijevan MC, Alaverdi MC. Independent audits were to be financed under the AF, but by Government's regulations of 2011, all TA and training were not eligible to be financed out of external funds. PHINDPDOTBL  Proportion of patients with a) hypertension who had at least one ECG annually; b) ischemic heart disease who had at least one totalcholesterol test annually (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target a) 27.3%; 23.3% Value a) 42%; b) 33% a) 55.2%; b) 53.7% (represent the 1st Increased semester of 2015 only) Date 31-Dec-2006 09-Jul-2015 18-Jun-2015 29-Feb-2016 Comments Data for year 2015 will be confirmed by March 2016 for the purpose of the ICR. PHINDPDOTBL  Project beneficiaries (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 550,000 population served 590,000 by renovated/constructed 627,709 (ambulatories); (ambulatories); Value ambulatories; 979,000 -- 2,026,803 (hospitals) 2,000,000 served by renovated (hospitals) hospitals Date 31-Dec-2006 -- 18-Feb-2016 29-Feb-2016 Comments Overachieved. 2/12/2016 Page 5 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) Overall Comments Intermediate Results Indicators PHINDIRITBL  Number of certified FDs trained (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 633 1676 1695 1750 Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Substantially achieved. Only 60 family physicians remain to be re-trained. PHINDIRITBL  Number of certified FNs trained (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 568 1804 1836 1950 Date 01-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Not achieved. 146 family nurses remain to be re-trained. PHINDIRITBL  Reduction of sq. meters of hospital space (percent of original) in all marzes (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0% 85% 85% 85% Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Achieved. 85%. Calculated as percent of reduced sq. meters out of original proposed reduction space. 2/12/2016 Page 6 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) PHINDIRITBL  Health personnel receiving training (number) (Number, Core) Baseline Actual (Previous) Actual (Current) End Target Value 1201.00 3480.00 4118.00 3700.00 Date 01-Jan-2009 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Overachieved. Total actual value includes: family physicians, family nurses, hospitals: 248 low level management, 250 middle level management, 108 top level management. PHINDIRITBL  Health facilities constructed, renovated, and/or equipped (number) (Number, Core) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 109.00 112.00 100.00 Date 01-Jan-2008 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Overachieved. PHINDIRITBL  Proportion of health budget allocated to PHC (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 35.50 34.60 37.20 43.00 Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Not achieved. Actual value represents approved budget for 2015. Percent of PHC experience (without centralized medicine procurement) within State health budget expenditure. 2/12/2016 Page 7 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) PHINDIRITBL  All project hospitals apply updated environmental management guidelines (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 01-Jan-2007 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Achieved. PHINDIRITBL  State Medical University has a revised students examination system in line with EU countries (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No revision has been done No No Yes Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Not achieved. However, State funds were used for a TA on "improving theoretical and practical skills of mars hospital medical specialties (physicians and nurses). The outcome of the study was implemented in departments of Yerevan State Medical University and 7-week training took place for 19 physicians and 5-week for 13 nurses, respectively. PHINDIRITBL  Increased number of admission in project hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 29,668 46,966 49,121 40,000 Date 01-May-2009 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Overachieved. 2/12/2016 Page 8 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) PHINDIRITBL  Proportion of key management staff in project hospitals trained on financial management after the results of performed independent audits (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 39 key 1:39 key management 3:39 key management Value 0 management staff staff staff or 100% Date 31-Dec-2006 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Not achieved. See intermediate outcome indicator on hospitals carrying out independent audits. PHINDIRITBL  Reduction in out-of-pocket payments for essential health services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target a) 33.2% (out-patient); a) 20.6% (out-patient); a) 35.4% (out-patient); b) Value b) 36.1% (in-patient) b) 42.8% (in-patient) Reduction 47.1% (in-patient) (2013 ISLS) (2014 ISLS) Date 31-Dec-2009 09-Jul-2015 18-Feb-2016 29-Feb-2016 Comments Achieved. Overall Comments Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P104467 IBRD-79870 Effective USD 19.00 19.00 0.00 19.00 0.00 100% P104467 IDA-42670 Closed USD 22.00 21.96 0.04 22.87 0.00 104% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P104467 IBRD-79870 Effective 20-Dec-2010 26-Jan-2011 08-Jun-2011 31-Dec-2014 29-Feb-2016 2/12/2016 Page 9 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) P104467 IDA-42670 Closed 08-Mar-2007 09-Mar-2007 06-Jun-2007 31-Dec-2012 31-Dec-2012 Cumulative Disbursements Restructuring History Level Approved on 11-Mar-2010 ,Level Approved on 19-Mar-2010 ,Level 2 Approved on 26-Mar-2014 Related Project(s) P121728-Additional Financing for the 2nd Health System Modernization Project (APL2) in Support of the 2nd Phase of the Health Sector 2/12/2016 Page 10 of 10 Public Disclosure Copy