The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) EUROPE AND CENTRAL ASIA | Kazakhstan | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2016 | Seq No: 10 | ARCHIVED on 28-Oct-2020 | ISR43757 | Implementing Agencies: Ministry of Health, Ministry of Health, Republic of Kazakhstan Key Dates Key Project Dates Bank Approval Date: 27-Apr-2016 Effectiveness Date: 27-Jun-2017 Planned Mid Term Review Date: 22-Jun-2020 Actual Mid-Term Review Date: 15-Jun-2020 Original Closing Date: 30-Jun-2021 Revised Closing Date: 30-Jun-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The proposed Project Development Objective is to improve accessibility, quality, and efficiency of health service delivery, and reduce financial risks to the population that are caused by serious health problems. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Component 1. Supporting implementation of the national mandatory Social Health Insurance system:(Cost $16.63 M) Component 2. Strengthening of health service delivery to support implementation of the national mandatory Social Health Insurance system:(Cost $62.94 M) Component 3. Project management, monitoring and evaluation, and communications strategy:(Cost $10.43 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions Health reform implementation has continued with significant progress demonstrated to date. The entire financing mechanism of health services has changed. Starting on January 1, 2018, budget proceeds for State Guaranteed Benefits Package, from flowing directly to health providers in amounts based on historic budget, were channeled through the Social Health Insurance Fund, which started conducting strategic purchasing and contracting services from public and private providers. Payments followed different mechanisms including: (i) per capita financing and a list of fees for services in case of primary health care, (ii) the use of Diagnoses Related Groups to finance hospital admissions, and (iii) fee-for-service for some specific ambulatory hospital and other health services. In addition, health care providers got autonomy to use part of the received funds to implement adjustments in service delivery and provide incentives to their staff. 10/28/2020 Page 1 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Implementation of the second phase of the Mandatory Social Health Insurance began on January 1, 2020, following the 4-month pilot carried out between September-December 2019 in Karaganda oblast. The pilot triggered some adjustments to the legal and institutional aspects, claim processes, and tools related to Mandatory Social Health Insurance implementation. Several measures were also introduced by the Government to facilitate and enforce population enrollment in Mandatory Social Health Insurance and provision of health services, including implementation of the ‘Unified Bundled Payment’ scheme. COVID-19 emergency response. The Project has supported Kazakhstan’s response to the COVID-19 pandemic enabling the Ministry of Health to procure ventilators and other equipment necessary to treat COVID-19 patients. Efforts are underway to procure additional equipment to prepare for a potential second wave of COVID-19. Mid-term review and Project restructuring. The project mid-term review was conducted jointly by the World Bank and Ministry of Health between June 15-17, 2020. It was agreed that the following adjustments to the Project would be made: (a) modifications to some of the existing activities and formulation of new activities in line with the emerging health sector priorities; (b) corresponding revisions to the Project performance indicators; and (c) extension of the Project closing date to complete all Project activities. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate Moderate Moderate Macroeconomic Substantial Substantial Substantial Sector Strategies and Policies Substantial Moderate Moderate Technical Design of Project or Program Substantial Moderate Moderate Institutional Capacity for Implementation and Substantial Moderate Moderate Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Substantial Substantial Substantial Other Substantial Substantial Substantial Overall Substantial Substantial Substantial Results PDO Indicators by Objectives / Outcomes Improve accessibility, quality, and effeciency of health service delivery and reduce financial risk IN00901642 ►Increase public expenditure share for PHC + consultation and diagnostic care + outpatient drugs (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 35.00 40.80 40.80 40.00 10/28/2020 Page 2 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has been achieved ahead of schedule. The data reflected in PMU/MoH's MTR report are based on annual National Health Accounts report for Comments: 2018. The data for 2019 will be available in Q4 of 2020. IN00901643 ►Percent of all surgeries included in the “outpatient elective surgeries” list performed as outpatient surgeries in project-supported hospitals and outpatient facilities (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 31.90 38.00 40.00 Date 18-Sep-2015 15-Apr-2020 14-Aug-2020 30-Jun-2021 Indicator is on track. The 2020 target value for this indicator (30%) is achieved based on data reflected in PMU/MoH's progress Comments: report for Q2 of 2020 (31.9% in 2019 and 38% in Q2 of 2020). IN00901644 ►Percent of all contracted inpatient services subject to technical audit (annually) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 26.60 14.00 30.00 Date 18-Sep-2015 15-Apr-2020 14-Aug-2020 30-Jun-2021 On track overall, though based on data reflected in PMU/MoH's progress report, the value for Q2 of 2020 Comments: has understandably dropped amidst the health crisis caused by the COVID-19 pandemic. IN00901645 ►SHIF is fully functional based on predefined criteria (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 18-Sep-2015 15-Apr-2020 14-Aug-2020 30-Jun-2021 This indicator is achieved based on data reflected in PMU/MoH's progress report for Q2 of 2020. The second phase of MSHI reform began implementation in January 2020. All six criteria of the SHIF have been satisfied: (i) the Law on MSHI has been adopted and relevant by-laws have been updated; ii) SHIF has signed contracts with providers for specific sets of services; (iii) the insurance package has been approved (Government Decree No.421 dated June 20, 2019) and is under implementation; (iv) SHIF regularly commissions annual external financial audits for each past year; (v) SHIF has maintained a Comments: positive balance between revenues and expenses; and (vi) health facilities have received payments for services contracted by SHIF in accordance with payment schedules specified in their contracts. However, with respect to facility paments, the COVID-19 pandemic and the related lockdown measures resulted in underutilization of health services (and corresponding lack of payments) in the first half of 2020. This has been addressed through various measures, including increased amounts of advance payments to health facilities and shifting of unutilized amounts of health services to the second half of 2020. IN00901681 ►Proportion of the bottom 40% of households spending 10% and more on health services and non-food goods in the health sector out of total expenditure on paid services and non-food goods (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.50 13.70 10.70 12.80 10/28/2020 Page 3 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Date 30-Jun-2016 15-Apr-2020 14-Aug-2020 30-Jun-2021 Based on data for 2019 from the Statistics Committee, this indicator has achieved its revised end-target of 12.8%. The out-of-pocket expenditures of the bottom 40% of households demonstrated an increase from Comments: the baseline value of 10.5% in 2016 to 13.7% in 2018 and a decrease to 10.7% in 2019. The 2020 data for this indicator will become available in Q3 of 2021. Overall Comments PDO Three PDO-level indicators have achieved their end-targets ahead of schedule and two indicators are on track to be achieved. Intermediate Results Indicators by Components Component 1. Supporting implementation of the National Mandatory Social Health Insurance System IN00901682 ►Percent of population for whom SHIF received SHI contributions/subsidies (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 30.80 83.90 83.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has achieved its end-target value based on data for first three months of 2020 reflected in Comments: PMU/MoH's MTR report. The achievement will be verified based on data for full year 2020. IN00901685 ►Achievement of key benchmarks for functioning social health insurance system (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Partial Partial Yes Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator is on track (partial achievement of key benchmarks, as planned). The Road Map for MSHI implementation was approved through MoH Order No.764 dated October 16, 2017. Following the 4-month MSHI pilot (September-December 2019), implementation of the second-phase of the MSHI reform began in January 2020. The whole population of the country was assigned the status of Comments: 'conditionally insured' until April 1, 2020 to ensure uninterrupted provision of services included in the MSHI package and a smooth transition period for payment of insurance contributions. Given the state of emergency announced in relation to the spread of COVID-19, the transition period was subsequently extended until July 1, 2020. IN00901686 ►Key adjustments in the contracting methods are adopted to include incentives for providers to improve quality (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 10/28/2020 Page 4 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) This indicator is on track. Contracts with key adjustments to improve quality are already being implemented as part of the second- phase of the MSHI reform as of January 2020 (based on MoH Order dated March 16, 2020). Some such adjustments include: (a) Provider selection stage - selection takes into account: availability of a higher-category accreditation status; past history of services provision retrieved from various information systems, including records of justified complaints on accessibility and quality; results of performance monitoring of previous contractual obligations; for highly technological services, certified availability of qualified and experienced specialists, Comments: and confirmed availability of medical equipment and devices relevant to the scope of contractual services. (b) Contract execution stage - payments under concluded contracts made are based on outcomes of recurrent, special-purpose, off-schedule monitoring of quantity and quality of services done both automatically based IT technologies and through site visits involving independent experts. (c) Payment of primary health care and outpatient care services - payments based on ‘comprehensive per capita rate’ is made based on a set of performance indicators, which include avoidable cases of maternal deaths, availability of recorded complaints from among the catchment population, etc. Component 2. Strengthening of health service delivery to support implementation of the national mand IN00901683 ►Number of fully functional regional PHC excellence centers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 17.00 16.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has been achieved. 16 regional PHC excellence centers have been identified through the MoH Order No.239 dated May 5, 2018. Following the establishment of the new Turkestan oblast on June 19, 2018, this number has Comments: increased to 17. As of the MTR, all the 17 PHC excellence centers have achieved the criteria of their full functionality. IN00901684 ►Number of regions implementing disease management programs with evidence-based effectiveness, including incentives for health providers and patients (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 16.00 17.00 16.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has been achieved. Following the establishment of the new Turkestan oblast on June 19, 2018, this number has increased to 17. As of the MTR, all the 17 regions are implementing disease Comments: management programs for the three conditions (arterial hypertension, diabetes, and chronic heart failure) based on the MoH Order No.348 dated June 11, 2018. IN00901687 ►Number of educational programs developed and implemented in medical education institutions based on competence-based approach and professional standards through strategic partnerships (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 6.00 16.00 5.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 Activities measured by this indicator have been implemented ahead of schedule and on a much larger Comments: scale. 16 educational programs were developed and have been implemented since 2018: one in General Practice (Bachelor), one in Pediatrics (Residency), three in Public Health (Bachelor, Master, doctorate), 10/28/2020 Page 5 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) one in Traumatology and Orthopedics (Residency), one in Nuclear Medicine (Residency), one in Emergency Care (Residency), one in Anesthesia and Rehabilitation (Residency), one in Neurology (Residency), three in Nursing Care (vocational, Master, doctorate), one in Healthcare Management (Master), one in Bioengineering (Master), one in Medical Laboratory Technician specialty (Master). Two more programs were developed and registered in 2020, but are yet to be implemented: one in Paramedical specialty and one in Medical Physics specialty. Three more programs are planned to be developed and implemented in 2021. IN00901688 ►Unified register of human resources for health implemented (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 Methodology and module for planning and forecasting human resources for health have been developed. However, completion of the unified register of human resources for health is not feasible due to several factors. Comments: This indicator will be revised as part of the project restructuring, with the rationale for the revision to be reflected in the Restructuring Paper. IN00901689 ►Health personnel receiving training (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 8,022.00 8,527.00 3,400.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has been exceeded, with 8,527 health workers trained with Project support as of June 17, Comments: 2020. IN00901690 ►Health facilities constructed, renovated, and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1.00 56.00 50.00 Date 18-Sep-2015 15-Apr-2020 17-Jun-2020 30-Jun-2021 This indicator has been achieved due to an increased number of health facilities equipped with COVID-19 Comments: related equipment. IN00901691 ►Percentage of patients reporting improved health services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value n/a 36.8% 36.8% +10% over baseline Date 18-Sep-2015 15-Apr-2020 15-Apr-2020 30-Jun-2021 Comments: This indicator uses semi-annual surveys as the basis for patient feedback. Baseline: The December 2018 (baseline) survey found that, on average, 22.5% of patients across all the regions have reported improvements in health services provision. 10/28/2020 Page 6 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) 2019: In a follow-up survey conducted in August 2019, 36.8% reported improvements in provision of health services during the last six months, 46.1% reported no improvements, 5.9% reported worsening of health services provision, and 11.2% had difficulty answering the question. 2020: Another follow-up survey was conducted in July 2020. The preliminary results of this survey showed a considerable decrease in citizens' perception of improvements in health services provision. Given the timing of the survey during the ongoing COVID-19 pandemic, these results are not surprising, but may not be a true reflection of improvements in health services provision. As a result, the findings will be verified/triangulated through data from a smaller-scale survey conducted at a later period in Q3 of 2020. In the meantime, increased demand from citizens for health services financed by the SHIF as of January 2020 (some of which used to be underfunded, such as expensive diagnostic services, elective surgeries, medical rehabilitation, etc.) indirectly points to certain improvements in health services delivery. IN00901692 ►Increase in transparency, credibility, and effectiveness of the complaints handling system (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 54.80 54.80 60.00 Date 18-Sep-2015 15-Apr-2020 15-Apr-2020 30-Jun-2021 This indicator uses semi-annual surveys as the basis for citizen feedback. 2018: Based on findings from December 2018, on average, 57% of the population across all the regions rated the transparency, credibility, and effectiveness of the existing complaints handling system as High. 2019: In follow-up survey conducted in August 2019, 54.8% of those who used the existing complaints handling system rated its transparency, credibility, and effectiveness as High, and 45.2% rated it as Low. 2020: Another follow-up survey was conducted in July 2020. The results of this survey showed a Comments: considerable decrease in citizens' perception of seffectiveness of the complaints handling system. Given the timing of the survey during the ongoing COVID-19 pandemic, these results are not surprising, but may not be a true reflection of transparency, credibility, and effectiveness in handling complaints. As a result, the findings will be verified/triangulated through data from a smaller-scale survey conducted at a later period in Q3 of 2020. Overall Comments IR Eight out of eleven intermediate result indicators have achieved or exceeded their end-target values. Performance-Based Conditions Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P152625 IBRD-86170 Effective USD 80.00 80.00 0.00 20.91 59.09 26% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P152625 IBRD-86170 Effective 27-Apr-2016 01-Nov-2016 27-Jun-2017 30-Jun-2021 30-Jun-2021 10/28/2020 Page 7 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Cumulative Disbursements PBC Disbursement Achievement Disbursed amount in Disbursement % PBC ID PBC Type Description Coc PBC Amount Status Coc for PBC Restructuring History Level 2 Approved on 11-Dec-2018 Related Project(s) There are no related projects. 10/28/2020 Page 8 of 8