The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Romania Health Program for Results (P169927) EUROPE AND CENTRAL ASIA | Romania | Health, Nutrition & Population Global Practice | Requesting Unit: ECCEU | Responsible Unit: HECHN IBRD/IDA | Program-for-Results Financing | FY 2020 | Team Leader(s): Dorothee Chen, Adanna Deborah Ugochi Chukwuma Seq No: 4 | ARCHIVED on 21-Jul-2021 | ISR47697 | Created by: Dorothee Chen on 16-Jul-2021 | Modified by: Dorothee Chen on 21-Jul-2021 Program Development Objectives PDO Table Program Development Objective (from Program Appraisal Document) The Program Development Objective (PDO) is to increase the coverage of primary health care for underserved populations and improve the efficiency of health spending by addressing underlying institutional challenges. 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 Romania Health Program-for-Results (PforR) was approved by the World Bank Board on September 17, 2019 and the Loan Agreement was signed by the Government of Romania and the Bank on September 23, 2019. Following changes in Government in November 2019 and March 2020 and the start of the COVID-19 epidemic, the PforR was restructured on July 30, 2020 to address changes in Government’s approach to some health sector reforms and the need to prioritize actions to respond to the public health emergency. The operation was finally declared effective on January 12, 2021. Implementation progress of the PforR has been affected by changes in leadership of the Ministry of Health (MoH), which delayed the establishment of the required institutional arrangement. The Minister of Health changed in December 2020 and again in April 2021. Similarly, the Bank's portfolio was assigned to a State Secretary in March 2021, who was also replaced in May 2021. A coordinator for the Program-for-Results (PforR) and health sector reforms supported under the ongoing Romania Health Sector Reform Project (P145174) was finally hired on June 23. 2021. The establishment of a Steering Committee chaired by the MoH and comprising representatives of the MoH, the Ministry of Finance (MoF) and the National Health Insurance House (NHIH) is yet to be completed, as well as the appointment of focal points from implementing institutions and the appointment of the Agency for Quality Management in Health Care (ANMCS), which is required to confirm that COVID-related disbursement-linked results have been fully achieved. The COVID-related DLRs that have already been achieved according to the implementing institutions and which are pending verification by ANMCS are:  Under DLI 4 on the strengthening of primary healthcare (PHC) to respond to the COVID-19 outbreak: DLR 4.1, which is formulated as follows: “Regulations adopted to: (i) introduce in the benefits package for the uninsured population COVID-19-related services delivered at all levels of care including PHC; (ii) introduce remote consultations and prescriptions in the scope of services delivered by PHC providers; (iii) expand prescribing rights for PHC providers; and (iv) increase hourly caps on the number of consultations by PHC providers from 4 to 8.”; and  Under DLI 7 on the implementation of centralized procurement: DLR 7.1, which is formulated as follows: “Framework agreements between the National Office for Centralized Procurement (ONAC) and suppliers signed for 10 priority products to address the COVID-19 outbreak.” Data on Financial Performance Disbursements (by loan) 7/21/2021 Page 1 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P169927 IBRD-90050 Effective USD 557.20 557.20 0.00 0.00 557.20 0% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P169927 IBRD-90050 Effective 17-Sep-2019 23-Sep-2019 12-Jan-2021 31-Dec-2023 31-Dec-2023 DLI Disbursement Achievement Disbursed amount in Disbursement % for DLI ID DLI Type Description Coc DLI Amount Status Coc DLI Loan: IBRD90050-001 Health Reform Law 1.1 Regular EUR 20,000,000.00 Not Achieved 0.00 95/2006 amended Ann.budg.law and 1.2 Regular EUR 20,000,000.00 Not Achieved 0.00 med.exp.fram.reflect HR Min 2 mil people registered 1.3 Regular EUR 35,000,000.00 Not Achieved 0.00 at PHC Meth.guid.and 2.1 Regular EUR 15,000,000.00 Not Achieved 0.00 hous.mon.instr.delevoped Progress report on 1st Y 2.2 Regular EUR 25,000,000.00 Not Achieved 0.00 impl.of hc tool Min 300 2.3 Regular underserv.comm.providing EUR 50,000,000.00 Not Achieved 0.00 pch in Fram.Contr.modif to 3.1 Regular EUR 20,000,000.00 Not Achieved 0.00 increase eff of PHC NHIH budget for PHC min 3.2 Regular EUR 20,000,000.00 Not Achieved 0.00 8% NHIH budget for PHC min 3.3 Regular EUR 35,000,000.00 Not Achieved 0.00 10% Regulat adopted for 4.1 Regular EUR 50,000,000.00 Not Achieved 0.00 (i),(ii),(iii),(iv) (a)10%Metformin;(b)10%c 5.1 Regular EUR 20,000,000.00 Not Achieved 0.00 heckups (a)20%Metformin;(b)20%c 5.2 Regular EUR 30,000,000.00 Not Achieved 0.00 heckups (a)strategy 6.1 Regular EUR 25,000,000.00 Not Achieved 0.00 approved;(b)NHIH updated (a)system data 6.2 Regular EUR 25,000,000.00 Not Achieved 0.00 connection;(b)eff.increas Fr.Agr between 7.1 Regular EUR 25,000,000.00 Not Achieved 0.00 ONAC&suppliers COVID 7/21/2021 Page 2 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Fr.Agr between 7.2 Regular EUR 35,000,000.00 Not Achieved 0.00 Proc.Ag.and suppliers (a)MOH approved 8.1 Regular EUR 30,000,000.00 Not Achieved 0.00 HTA;(b)recalc.prices Managed entry agreement 8.2 Regular EUR 20,000,000.00 Not Achieved 0.00 signed Program Action Plan Action Description Sufficient allocation of Program funding in the budget and timely remittance of financing to implementing entities Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoPF Recurrent Continuous Not Yet Due Completion Measurement Program funding consistent with annual workplans. Comments Strengthen the enforcement of the existing regulations for medical waste management to handle, collect, record, Action Description store, decontaminate, transport and disposal of waste by developing/updating/revising internal procedures and guidelines at PHC Source DLI# Responsibility Timing Timing Value Status First 2 years of Environmental and Social MoH Other Program Not Yet Due Systems implementation Analysis of MoH internal regulations norms for implementing the procedures for reactive and preventive identified Completion Measurement priorities for medical waste management confirmed Comments Strengthen the capacity to adapt, prevent and react to extreme weather events by developing/updating/revising Action Description internal procedures and guidelines at PHC Source DLI# Responsibility Timing Timing Value Status First 2 years of Environmental and Social MoH Other Program Not Yet Due Systems implementation Analysis of MoH internal regulations/norms for implementing the procedures for reactive and preventive identified Completion Measurement priorities for adaptation to climate change effects confirmed Comments Develop and implement existing communication tools, as may be relevant, to increase public awareness of Program Action Description initiatives in consultation with the World Bank Source DLI# Responsibility Timing Timing Value Status 7/21/2021 Page 3 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Second and third years Environmental and Social MoH, NIPH, CSO, Other of Program Not Yet Due Systems other implementation Completion Measurement Findings on the level of public awareness regarding access to basic services package for uninsured Comments Strengthening a unit of the MoH to ensure integration at the institutional level of strategic planning for primary and Action Description community health care services Source DLI# Responsibility Timing Timing Value Status Technical MoH Due Date 31-Dec-2020 Delayed A ministerial order will be issued to specify the unit staffing, job descriptions and qualifications, overall institutional Completion Measurement mandate, and operational budget. Leadership instability at the MoH has delayed the implementation of this reform, which is expected within the coming Comments weeks. Action Description Determining the benefit package for PHC, including the currently uninsured Source DLI# Responsibility Timing Timing Value Status Technical MoH, NHIH, MoPF Due Date 30-Jun-2021 Delayed Completion Measurement Benefit package for PHC determined and incorporated in the Health Care Law 95/2006. Leadership instability at the MoH has delayed this reform, which requires legal changes and therefore leadership from Comments the MoH. It is expected that this action will be completed by June 30, 2022. Action Description Conducting public expenditure review based on defined scope of work Source DLI# Responsibility Timing Timing Value Status At least 2 times during Technical MoPF Other Not Yet Due Program period Completion Measurement PER conducted and results analyzed and used for decision making Comments Maintain records of and track the number of patients, on a sample basis, whom community health workers have Action Description referred to acquire IDs for their registration with family physicians Source DLI# Responsibility Timing Timing Value Status Environmental and Social NHIH, MoH, MoSPJ Recurrent Yearly Not Yet Due Systems 7/21/2021 Page 4 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Reporting by community health workers on the number of patients who have been referred by community health Completion Measurement workers to acquire an ID for their registration with family physicians Comments Adequate arrangements and technical capacity to prepare Program financial statements and have them timely Action Description audited Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoH Recurrent Continuous Not Yet Due Completion Measurement Timely preparation and audit of Program financial statements. Comments Technical assistance for the establishment of centralized procurement of medical supplies – including systems and Action Description staffing Source DLI# Responsibility Timing Timing Value Status First year of Program Fiduciary Systems MoH/MoPF/ONAC Other Not Yet Due implementation Completion Measurement Report on completed review and implementation of report's recommendations – included in annual progress report Comments Technical assistance for the establishment and maintenance of electronic platforms for collation of procurement Action Description needs of implementing entities to support timely centralized procurement Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoH/MoPF/ONAC Due Date 30-Dec-2022 Not Yet Due Report on system functionalities and roll-out data, including information on capacity building of actual and potential Completion Measurement users – included in annual progress report. Comments Conducting training of community nurses and Roma mediators on public community health care in collaboration with Action Description PHC providers Source DLI# Responsibility Timing Timing Value Status Year 2 of Program Technical MoH Other Not Yet Due implementation Completion Measurement Training conducted and evaluation report from training participants available. 7/21/2021 Page 5 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Comments Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Substantial Substantial Substantial Macroeconomic Substantial Substantial Substantial Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program Substantial Substantial Substantial Institutional Capacity for Implementation and High High High Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Substantial Moderate Moderate Stakeholders Moderate Moderate Moderate Other -- -- -- Overall Substantial Substantial Substantial Results PDO Indicators by Objectives / Outcomes To increase the coverage of primary health care for underserved populations IN01022354 ►Number of the uninsured in Romania who are registered with family physicians and entitled to receive the minimum PHC package, which is aligned with the basic PHC package (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 2,000,000.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022356 ►Percentage of adults (40 years old and above) receiving annual medical check-ups from family physicians (disaggregated by gender) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 1.00 0.00 20.00 Date 01-May-2019 15-Jun-2020 15-Jun-2020 31-Dec-2023 7/21/2021 Page 6 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Comments To improve the efficiency of health spending IN01022355 ►Percentage of National Health Insurance House’s annual budget allocated to PHC (Percentage, Custom) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 6.50 6.50 6.50 10.00 Date 01-May-2019 15-Jun-2020 15-Jun-2020 31-Dec-2023 Comments IN01022357 ►Proportion of supplies and devices for emergency medical services (in value) procured under framework agreements (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 50.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments Intermediate Results Indicators by Results Areas Improving coverage for underserved population IN01022358 ►Number of underserved communities covered by community health care in collaboration with PHC (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 300.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022361 ►Difference between the counties with the highest and lowest coverages of children who have received one dose of measles vaccination at 12 months old (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 48.6% Highest coverage: 100% Value 48.6% 48.6% 41% Lowest coverage: 51.4% Date 01-May-2019 15-Jun-2020 15-Jun-2020 31-Dec-2023 Comments IN01022363 ►Percentage of uninsured who are aware they are entitled to receive an improved PHC benefit package (aligned with the basic benefits package for the insured) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 7/21/2021 Page 7 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Not applicable because Value Not applicable Not applicable 90% they are not entitled yet Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022365 ►Number of community health care workers (community health nurses and Roma health mediators) trained (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 2,000.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022368 ►Percentage of women living in communities covered by community health care receiving at least one annual visit from a community health care provider (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 70.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments Hospital-centric health system rebalanced towards effective primary care IN01022359 ►Percentage of metformin prescriptions initiated at the PHC level (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 30.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022366 ►Number of communication tools applied for universal access to PHC and framework contract modification (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 12.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022369 ►Number of public expenditure reviews conducted (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 3.00 7/21/2021 Page 8 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments Improving fiscal efficiency by addressing cristical cost drivers IN01022360 ►Percentage change in claims detected as unacceptable (unnecessary care, non-optimized laboratory tests, intentional or unintentional errors, …) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 0.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022362 PHC claims (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 20.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 IN01022364 Hospital claims (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 20.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 IN01022367 Laboratory tests (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 30.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 IN01022370 ►Percentage of healthcare providers that automatically share data to the central EHR (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 0.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022371 PHC practices (Percentage, Custom Breakdown) 7/21/2021 Page 9 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 90.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 IN01022372 Hospitals (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 60.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 IN01022373 ►Community health care information system upgraded to share data with the EHR (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022374 ►Annual international price comparisons for all medicines with registered shortages in Romania (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022375 ►Managed Entry Agreement signed for 50% of newly assessed patented drugs with conditional entry decision through HTA methodology (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 50.00 Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022376 ►Clawback tax regulation revised to improve access to cost-effective drugs (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value Clawback tax not revised No revision No revision Clawback tax revised Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments IN01022377 ►Revision of the list of drugs reimbursed by NHIH (Text, Custom) 7/21/2021 Page 10 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Baseline Actual (Previous) Actual (Current) End Target List of drugs reimbursed by HNIH not revised using No revision in HTA List of drugs No revision in HTA/list of Value updated HTA methodology/list of reimbursed by NHIH drugs methodology / HTA drugs revised Methodology not updated Date 01-May-2019 15-Jun-2020 30-Jun-2021 31-Dec-2023 Comments Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 Alignment of the minimum PHC package for the uninsured population with the basic PHC package for the insured population (Outcome, 75,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 At least 2 million uninsured persons registered with PHC providers (family About 2 million uninsured physicians) to Reform yet to be Reform yet to be Value do not have access to the receive the minimum implemented. implemented. basic PHC package PHC package as aligned with the basic PHC package for the insured population Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 2 Number of underserved communities receiving public community health care in collaboration with PHC providers (Outcome, 90,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 300 underserved communities Community health services Reform yet to be Reform yet to be providing public Value not in collaboration with implemented. implemented. community health in PHC services collaboration with PHC providers Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 3 Share of the NHIH budget allocated to primary health care (Output, 75,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 a) Share of the NHIH Share of the NHIF budget allocated to family Reform yet to be Reform yet to be Value budget allocated to medicine is 6.5%; implemented. implemented. PHC is 10% b)Provider payment 7/21/2021 Page 11 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) mechanisms for PHC providers limits effectiveness of PHC provision; c) Limited scope of PHC Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 4 Strengthening of PHC to respond to the COVID-19 outbreak (Process, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Reform has been Reform has been implemented. Results yet implemented. Results yet Limited scope of PHC Value to be verified by to be verified by -- services Independent Verification Independent Verification Agent. Agent. Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 5 Scope and effectiveness of PHC traced through the share of diabetes medication initiated by PHC providers and proportion of adults (40+) receiving annual medical check up (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 a) 20% of metformin prescription (a a) Initiation of diabetes commonly used medication at the PHC level diabetes medication) is 0%; b) Number of adults Reform yet to be Reform yet to be initiated by PHC Value (40+) receiving annual implemented. implemented. providers; b) 20% of medical check-ups is 1% adults (40+) receiving annual medical check ups by PHC providers Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 6 Efficiency of NHIH expenditure improved through data-driven decision making process (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Value 0% (current level of Reform yet to be Reform yet to be a) An inter-operable avoiding unnecessary implemented. implemented. system connects expenditures used as data between PHC baseline) providers, NHIH and MoH, to provide regular data cross- checks and inefficient spending data analytics; b).Efficiency of 7/21/2021 Page 12 of 13 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) health spending increased by avoiding inefficient NHIH expenditures in an amount equivalent to 2.5% of total projected annual NHIH expenditures Date -- 31-Dec-2020 30-Jun-2021 -- Comments ►DLI 7 Efficiency of expenditure improved through implementation of centralized procurement (Outcome, 60,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 First phase of the reform First phase of the reform has been implemented. National Office for has been implemented. First results (DLR 7.1) yet Centralized Procurement First results yet to be to be verified by Value (ONAC) not operational verified by Independent -- Independent Verification and not mandated to work Verification Agent. Agent. Second phase of in health sector Second phase of the the reform (DLR) 7.2 yet reform under preparation. to be implemented. Date -- 31-Dec-2020 31-Dec-2020 -- Comments ►DLI 8 Pharmaceutical measures revised for better efficiency (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Shortcoming of existing pharmaceutical policy: a) External reference pricing for MEA signed by pharmaceutical carried out NHIH and market sporadically authorization b) List of drugs holders for 50% of reimbursed based on Reform yet to be Reform yet to be newly assessed Value outdated health technology implemented. implemented. patented drugs with assessment (HTA) the conditional entry methodology decision using the c) Great potential to new HTA expand use of methodology Management Entry Agreements (MEA) Date -- 31-Dec-2020 30-Jun-2021 -- Comments 7/21/2021 Page 13 of 13