The World Bank Report No: ISR8378 Implementation Status & Results Montenegro Healthcare System Improvement Project (Montenegro) (P082223) Public Disclosure Copy Operation Name: Healthcare System Improvement Project (Montenegro) Project Stage: Implementation Seq.No: 17 Status: ARCHIVED Archive Date: 25-Dec-2012 (P082223) Country: Montenegro Approval FY: 2004 Product Line: IBRD/IDA Region: EUROPE AND CENTRAL ASIA Lending Instrument: Specific Investment Loan Implementing Agency(ies): Ministry of Health Key Dates Board Approval Date 08-Jun-2004 Original Closing Date 28-Feb-2009 Planned Mid Term Review Date 12-Feb-2007 Last Archived ISR Date 08-May-2012 Effectiveness Date 01-Dec-2004 Revised Closing Date 31-Dec-2012 Actual Mid Term Review Date 12-Feb-2007 Project Development Objectives Project Development Objective (from Project Appraisal Document) The objective of the proposed Health System Improvement Project is to put in place the first phase of steps towards reform of the health system in the Republic of Montenegro, giving priority to increasing capacity for policy, planning and regulation; stabilizing health financing and improving primary health care service delivery. Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost 1. SUPPORT FOR HEALTH REFORM PROGRAM 5.13 2. PHASED IMPLEMENTATION OF PRIMARY HEALTH CARE DEVELOPMENT 14.18 3. PROJECT MANAGEMENT 1.26 Overall Ratings Public Disclosure Copy Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Satisfactory Overall Risk Rating Implementation Status Overview All Project activities have been fully implemented. The original credit for the project, approved by the Board in June 2004 (for US$7 million equivalent) closed in December 2009; but activities continued to be supported by an Additional Financing (AF) with same Project Development Objectives (PDOs), which was approved on November 3, 2009 (for US$7.2 million equivalent). Page 1 of 12 The World Bank Report No: ISR8378 The project is achieving its PDOs. 7 out of 10 PDO indicators were fully achieved (PDOs 1, 2, 3, 4, 5, 7 and 9), 3 PDOs indicators were partially achieved (6, 8 and 10 - in the case of indicator 10 the Public Health Institute will adjust the denominator to exclude children with residence outside Montenegro). Ministry of Health stewardship of the health system improved and adopted: i) a Health Development Master Plan 2010-2013, and ii) a new Law on Record Keeping in Health adopted, in addition the Law on Health Care and the Law on Health Insurance were amended. A new Strategy for Quality Assurance approved in Feb 2012 and 11 Clinical Protocols and Public Disclosure Copy Guidelines being implemented. The health service delivery have improved increasing utilization, reducing waiting time and increasing patient satisfaction. and the expenditures in the sector were stabilized. The original credit disbursed 98 percent of Credit proceeds, while the Additional Financing portion of the loan has disbursed 54 percent, with 96 percent of the remaining balance of the loan committed. Of these commitments, many activities are completed and the remaining activities will be completed by project closing. With the support of Project activities, the Ministry of Health has introduced several primary health care reforms, supported by the Montenegro Health System Improvement Project. These reforms have included the introduction of a “Chosen Doctor� model where primary care patients are registered with a particular primary physician, who acts as a gatekeeper to reduce over-reliance on specialists and hospital care. The capacity building plan for the Medical faculty is completed and the Family Medicine additional specialization program is fully implemented with the first cohort ready to get certified. Mentors and educators have been trained in additional specialization and the Medical Faculty already has the tools and material to launch basic specialization. The new residents who are supposed to start residency (basic specialization) during school year 2012/13 school year are being enrolled. At the same time, the financing of primary care doctors has changed from salaried to a combination of capitation and fee-for-service. During the original credit, 10 primary health care centers (PHC) were rehabilitated and equipped and an additional PHC reconstructed in Bijelo Polje with the AF. At the secondary and tertiary levels, the project has supported the implementation of several instruments and tools to improve performance and efficiency, including a new basic package of services based on the epidemiological profile of Montenegro, the development of 10 new clinical guidelines, the implementation of a National Drug Agency and the introduction of a Health Technology Assessment and cost benefit analysis to update the clinical guidelines. In addition, the sector is piloting a DRG (diagnosis related group) payment system to change from current historic budgets of hospitals to an output-based financing system. The project also supported Hospital information system in 7 general hospitals, and three IT system at the National Drug Agency, the Public Health Institute and the MoH. In addition the Project supported the Secondary and Tertiary Care Reform Strategy, currently approved. This reform includes legislative framework for entering into public private partnerships in health, allowing the Health Insurance Institute to fully implemented throughout the country contracts with private dentists, cardiologists, ophthalmologists, physical medicine and rehabilitation, X-ray diagnostics, ultra sound diagnostics, fertility services, internal medicine, hyperbaric oxygen treatment, cervical cancer screening, opticians, and medical aids. Locations Country First Administrative Division Location Planned Actual Montenegro Not Entered Tuzi Montenegro Not Entered Podgorica Public Disclosure Copy Montenegro Not Entered Golubovci Montenegro Not Entered Konik Montenegro Not Entered Nova Varos Montenegro Not Entered Stara Varos Results Project Development Objective Indicators Page 2 of 12 The World Bank Report No: ISR8378 Indicator Name Core Unit of Measure Baseline Current End Target MoH stewardship of the health system Text Value The Strategy for Health Care nformation available: PHC Secondary and Tertiary Care improves as measured by increases of health Development in Montenegro Operational Review - Reform Strategy developed Public Disclosure Copy related information and development of key until 2020 (2003) approved; Efficiency Study data and approved, including health policies basic health system laws in available. Health System legislative framework for draft; Montenegro inunion Integrity Assessment Report entering into public private with Serbia and not yet with (WHO/UNDP) developed. partnerships in health; Further own country laws and Policy Developments: refine PHC policies; new regulations • Health Development masterplan adopted Master Plan 2010-2013 adopted. • Law on Record Keeping in Health adopted. Law on Health Care amended. Law on Health Insurance amended. • Decision on Network of Health institutions adopted; Secondary and Tertiary HC Strategy adopted by Government and published on the MOH website. • New Strategy for Quality Assurance approved in Feb 2012. • Total of 11 Clinical Protocols and Guidelines developed Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED HIF increases its capacity to perform its Text Value HIF in existence and The MoH procured the AR- HIF has developed the functions of pooling health resources; better developing improved control DRG full version necessary groundwork for allocating health resources; and contracting over pharmaceutical Grouper to be developed from developing hospital budgets Public Disclosure Copy providers towards improved performance expenditures through pricing HIF resources. Hospitals based on output (i.e. DRGs) and information system with started reporting under DRG rather than inputs pharmacists system beginning Sep 2012. includingdefining state- No. of trained hospital staff financed services, developing amounts to approx. 300 (293) the information base, from 7 general, 2 special establishing a system of hospitals and the Clinical coding of diagnoses and Center. The training is on- grouping of diagnoses going and will continue after appropriate for Montenegro, the project closing. and training of hospital staff. • Hospital information Additional contracts with Page 3 of 12 The World Bank Report No: ISR8378 system introduced in 7 private providers signed. general hospitals. • Additional contracts with private providers signed Public Disclosure Copy Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED HIF controls the increasing cost of nationally Text Value Share of HIF expenditures Share of HIF expenditures Over time, the HIF has financed pharmaceuticals and medical spent on drugs: 19.2% Share spent on drugs: 20.0% expanded the list of drugs so materials of HIF expenditures spent on Share of HIF expenditures overall costs may rise even drugs and medical materials: spent on drugs and medical with reductions in drug prices. 28.4% HIF not yet analyzing materials: 28.0% Due to the economic crisis pharmaceutical expenditures Total expenditures: and changes in excha nge 175,357,332.58 eur. rates for imported drugs, reasonable 2012 targets are: Share of HIF expenditures spent on drugs ator below 18.0% Share of HIF expenditures spent on drugs and medical materials at or below 27.5% Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED HIF annual deficit reduced Text Value 0.8 million Euros surplus Formally, zero deficit because Zero deficit (assuming as of 2010, HIF became possible small deficits in budgetary unit under Treasury 2009-2010 and economic recovery 2011-2012). Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments HIF became part of Treasury budget in 2010, so formally there is zero deficits. HIF budget is not linked to the ACHIEVED Public Disclosure Copy HIF revenue. Arrears of health institutions amounted to 30 million in 2010, and 16 million in 2011 Reduced waiting time (from arrival to Text Value Podgorica patients reporting POS survey from 2012: Podgorica patients reporting consultation) in primary care 21 minutes or more: 57% • Podgorica patients 21 minutes or more: 30% reporting 21 minutes or more Patients outside of Podgorica – 30% reporting 21 minutes or more: • Patients outside of (2009 Baseline - 15 %) Podgorica reporting 21 improvement minutesor more - 42% Page 4 of 12 The World Bank Report No: ISR8378 HIF administrative data for 2011: • Average waiting time patients in Podgorica: 4 min, Public Disclosure Copy 43 sec; • Average waiting time patients outside of Podgorica: 34 min. 36 sec HIF administrative data (9 months of 2012 - require revision): • Average waiting time for patients in Podgorica: 23 min, 59 sec; • Average waiting time for patients outside of Podgorica: 29 min. 58 sec Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments To prevent confusion with ACHIEVED baseline dates, additional indicators from HIF admin time for wait time reported in "current". Increased duration of PHC Consultation Text Value Podgorica patients reporting POS survey from 2012: Podgorica patients reporting 21 minutes or more: 34% • Podgorica patients 11 minutes or more: 70% reporting 11 minutes or more Patients outside of Podgorica – 50% reporting 11 minutes or more: • Patients outside (2009 Baseline + 25 %) Podgorica reporting 11 improvement minutes or more – 55% HIF administrative data for 2011: • Average consultation time for patients outside of Public Disclosure Copy Podgorica with prior appointment: 5 min. 58 sec. • Average consultation time for patients in Podgorica with prior appointment: 5 min. 55 sec HIF administrative datafor 9 months of 2012: • Average consultation time for patients outside of Page 5 of 12 The World Bank Report No: ISR8378 Podgorica with prior appointment: 6 min. 00 sec. • Average consultation time for patients in Podgorica Public Disclosure Copy with prior appointment: 5 min. 36 sec Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments To prevent confusion with Partially achieved baseline dates, additional indicators from HIF admin time for wait time reported in "current". Increase utilization rates for primary health Text Value 11.4% of population in NO UPDATED Target groups (population in care for the general population (in Podgorica Podgorica report use of PHC; Podgorica, outside of and outside Podgorica) and the Roma 21% of Roma in Podgorica Podgorica and Roma) report report use of PHC visiting their Chosen Doctor at or close to 40% Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments No updated until survey Increase satisfaction for primary health care of Text Value In Podgorica, 62% of the In Podgorica, 77% satisfied or In Podgorica, 70% of the the general population (in Podgorica and population totally satisfied and higher and 19% partially population totally satisfied and outside of Podgorica) and specifically for the 20% partially satisfied satisfied. 27% partially satisfied; for the Roma Nationally, 70% satisfied or population outside of higher and 24% partially Podgorica, 66% of the satisfied. population totally satisfied and 31% partially satisfied; and Data from Integrity POS. No satisfaction of the Roma updated POS or HH survey population remains high (i.e. data. 87.7% or higher) Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments Partially achieved The general population target should be slightly changed Public Disclosure Copy since based on HH survey, not public opinion survey. Will be discussed during mission in May. Referral rates from PHC to hospitals controlled Text Value Proportion of patients referred Proportion of visits referred to 2009 baseline - 10% increase to specialists = 24.43% specialists = 25.71% for 2011, Proportion of patients referred 22.18% for 9 months of 2012. to hospitals = 1.73% Proportion of visits referred to hospitals = 1.82% for 2011, 1.52% for 9 months of 2012. Page 6 of 12 The World Bank Report No: ISR8378 Date 31-Dec-2009 19-Oct-2012 31-Dec-2012 Comments 2009 data. Achieved Maintain or improve immunization rates (%) for Text Value DPT (initial and follow-up): DPT (initial and follow-up): DPT (initial and follow-up): Public Disclosure Copy DPT and measles (already high) following 86% MMR (initial and follow- 94.7% 94% MMR (initial and follow- reform up): 82% up): 92% MMR (initial and follow-up): 90.7% Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments Partially achieved Revision possible - IPH to clarify whether the 2011 data is for Podgorica or nation- wide; IPH also to try to refine the data/change the denominators) Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Adoption of bylaws and administrative Text Value Laws on Health Insurance, 11 new laws adopted or Laws maintained, including documents covering health insurance, health Health Care and amended. 4 new bylaws additional sub-regulations for care and pharmaceuticals Pharmaceuticals in Draft adopted. 434 Pharmaceutical pharmaceuticals drugs approved with 4 new subregulations. New Law on Medicines passed to meet EU regulations. Law on Health Care amended. Law on Health Insurance amended to include supplemental insurance. Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Public Disclosure Copy Revision of policy, benefits, and standards for Text Value Montenegro system of PHC Payment mechanism PHC Policies (particularly the primary care inherited from former continues to be fully payment mechanism and care Yugoslavia operational. 11 Clinical protocols) refined based on protocols and guidelines implementation developed for most frequent and most costly diseases, 10 of which through AF MHSIP activities. Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Page 7 of 12 The World Bank Report No: ISR8378 Development of the reform for revision of Text Value None Master Plan 2010-2013 Masterplan developed and policy, benefits and standards for secondary adopted. Decision on Network adopted; benefit package of and tertiary care of Health institutions adopted; HIF-financed secondary and Secondary and Tertiary HC tertiary care services defined; Public Disclosure Copy Strategy adopted and and the informationbase for published on MOH website. developing an output (i.e. Hospital information system DRG) based financing model introduced in 7 general established hopistals. DRG reporting begun in Sep 2012. BBP work inprogress. 11 Clinical protocols and guidelines developed. Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Drugs Agency developed to better perform its Text Value None Drugs Agency has registered Drugs Agency functional as a functions of regulating and ensuring the quality 44.5% (2011) of total drugs regulatory agency Drugs of drugs in Montenegro available on the market in Agency has registered Montenegro 10-15% of total drugs available on the market Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED PHC Patients are aware of and supportive of Text Value 54% (in Podgorica) 89% (nationally), from 70% or higher (nationally) health reform Integrity POS Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Operational health information systems in HIF, Text Value HIF Pharma and Insuree Information system between Information system between primary health care providers, pharmaceutical Register System Operational HIF, primary health care HIF, primary health care supply chain, to provide timely, accurate data providers and pharmaceutical providers and pharmaceutical on key elements of performance (expenditure, supply chain continues to be supply chain continue to be service utiliza operational. HIF has started operational. IT systemfor elecontric invoicing and drugs includes both public Public Disclosure Copy developed business and private provider information system within prescribed drugs. The general hospitals nationwide. information system Special Hospitals IS under connecting the HIF and development. DRG reporting hospitals, providing among begun in Sep 2012. IS other things information on components for MoH, IPH the coding and costs related and Drug's Agency under necessary to develop out-put development. Only private based financed ie (DRGs), is Page 8 of 12 The World Bank Report No: ISR8378 dentists' practices integrated launched. into the IS. Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Public Disclosure Copy Comments ACHIEVED Increase percentage of patients (adults and Text Value 0% 95.59% (2011) 85% children) in Podgorica with a Chosen primary Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 care doctor (out of total insurees) Comments ACHIEVED Number of facilities renovated/constructed in Text Value 0 of 10 7 of 10 (Blok 5, Stari 7 of 10 (including 2 which are Podgorica Aerodrom, Konik, Tuzi, being financed by the state Golubovci, Stara Varos, Nova budget) Varos) Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Number of facilities equipped with computer Text Value 0 11 of 10 have medical 10 of 10 have medical and medical equipment in Podgorica equipment (including Medical equipment 10 of 10 have Faculty in Podgorica) computer equipment 11 of 10 have computer equipment (including Drugs' Agency in Podgorica) Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Decreasing in the percentage of referrals made Text Value 12.87% (2008) 12.80% (2011) 12% decrease for an injectable drug (ampoule treatment) 12.30% (9 months of 2012) Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments Baseline clarified because ACHIEVED percent is better since the number of visits may increase as utilization increases. 2006-2007 data also unreliable because of new Public Disclosure Copy reporting system Adoption of PHC Guidelines Text Value 0 Total of 11 Clinical Protocols 10 PHC Guidelines Adopted and Guidelines developed (for primary and secondary health care level), 10 of which through AF MHSIP Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Page 9 of 12 The World Bank Report No: ISR8378 Proposal developed for the appropriate quality Text Value No proposal National Strategy for Proposal well developed, assurance system in Montenegro Improvement of Health Care including lessons learned Quality and Safety of Patients from the region and adopted in February 2012. addresses the legal, Public Disclosure Copy institutional, financial and technical aspects of a quality assurance system Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Number of PHC Teams (1 Chosen Doctor + 1 Text Value Preparing Retraining Program Retraining Program Total of Retraining Program Nurse) provided retraining in family Medicine 273 teams and additional 6 Completed with a total of 255 Nationally nurses retrained (of which teams (1 Doctor + 1 Nurse) 248 teams and additional 31 retrained. nurses provided retraining in Family Medicine, and 25 specialists to pass the final/ specialist exam in Family Medicine Additional Specialization Program,in Nov 2012). Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments ACHIEVED Family Medicine specialization established and Text Value Not established Family Medicine Additional Family Medicine operational at Medical Faculty Specialization Program Specialization to be developed, and first cohort of established and initial cohort mentors to pass the final/ of students to be enrolled specialist exam in Nov 2012. Family Medicine Full Specialization Program developed, and the first cohort enrolled in Oct 2012 Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Public Disclosure Copy Comments ACHIEVED Increase percentage of patients (adults and Text Value 0 90.7% 85% children) outside of Podgorica with a Chosen Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 primary care doctor (out of total insurees) Comments ACHIEVED Number of facilities renovated/constructed Text Value 0 1 1 (Bijelo Polje) outside of Podgorica Date 31-Dec-2004 18-Apr-2012 31-Dec-2012 Comments Bijelo Polje. Achieved completed Page 10 of 12 The World Bank Report No: ISR8378 Number of PHC facilities equipped with Text Value 0 20 of 20 equipped with 20 of 20 equipped with computer and medical equipment outside of computer equipment computer equipment 20 of 20 Podgorica equipped with medical equipment Public Disclosure Copy Date 31-Dec-2008 18-Apr-2012 31-Dec-2012 Comments Achieved Health personnel receiving training (number) Number Value 0.00 1700.00 510.00 Date 31-Dec-2004 18-Apr-2012 31-Dec-2012 Comments original and additional 255 Teams (1 Doctor + 1 financing Nurse) ACHIEVED Health facilities constructed, renovated, and/or Number Value 0.00 32.00 8.00 equipped (number) Date 31-Dec-2004 19-Oct-2012 31-Dec-2012 Comments Achieved Data on Financial Performance (as of 03-Dec-2012) Financial Agreement(s) Key Dates Project Ln/Cr/Tf Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P082223 IBRD-78190 Effective 03-Nov-2009 19-Nov-2009 10-Dec-2009 31-Dec-2012 31-Dec-2012 P082223 IDA-39180 Closed 08-Jun-2004 11-Jun-2004 01-Dec-2004 28-Feb-2009 31-Dec-2009 P082223 TF-55474 Closed 25-May-2006 25-May-2006 28-Jun-2007 31-Dec-2007 30-Nov-2008 Disbursements (in Millions) Project Ln/Cr/Tf Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P082223 IBRD-78190 Effective USD 7.20 7.20 0.00 5.11 1.77 71.00 P082223 IDA-39180 Closed USD 7.00 6.85 0.15 7.41 0.00 108.00 P082223 TF-55474 Closed USD 0.31 0.83 0.00 0.83 0.00 100.00 Public Disclosure Copy Disbursement Graph Page 11 of 12 The World Bank Report No: ISR8378 Public Disclosure Copy Key Decisions Regarding Implementation None Restructuring History Level two Approved on 21-Sep-2012 Related Projects P114275-Health System Improvement Additional Financing Public Disclosure Copy Page 12 of 12