47816 DATA SHEET TEMPLATEFOR PROJECTPAPER GEORGIA: PRIMARY HEALTH CARE DEVELOPMENT PROJECT (Credit No.3702) Borrower:Republicof Georgia Responsibleagency: Ministry of Labor, Healthand Social Affairs Revisedestimateddisbursements(Bank FY/US$m) -based on current US/SDR exchangerate FY 1 2003 1 2004 1 2005 1 2006 1 2007 1 I P 2008 2009/2010 Current closingdate: 12/31/2009 Revisedclosingdate: proposedto extenduntil 12/31/2010 Indicateifthe restructuringis: Boardapproved -a RVP approved - Does the restructuredprojectrequire any exceptions to Bank policies? -Yes WNo Havethese beenapprovedby Bankmanagement? Yes -No I s approval for any policy exceptionsought from the Board? Yes H N o Revisedprojectdevelopmentobjective/outcomes: (i) to improvecoverage, utilization and quality of healthcare services, and; (ii) to strengthenGovernmentstewardshipfunctions inthe health sector Doesthe restructuredprojecttrigger any new safeguardpolicies? NO RevisedFinancingPlan(US$m.) Source Local Foreign Total Borrower 4.46 0 4.46 IBRD/IDA 14.40 9.1 23.5 Total 18.86 9.1 27.96 2 PROJECT PAPER PROPOSALTO RESTRUCTURE GEORGIA PRIMARY HEALTHCARE DEVELOPMENT PROJECT (Project ID P040555) A. IntroductoryStatement 1. This Project Paper seeks Board approval to introduce changes in the Georgia Primary Health Care Development Project (PHCD), Credit No.3702, Project ID PO40555 and the related amendmentsto the project's Development Credit Agreement. The proposed changes include: (i) changing the project development objectives and key performance indicators to better reflect priorities o f Georgia's current health sector reform program; (ii)revision o f project components, with added emphasis on sector stewardship activities; (iii) changing the project name to "Health Sector Development Project" to better reflect the nature o f the proposed project restructuring; (iv) amending Schedule 1 o f the Development Credit Agreement to allow the percentage of expenditures to be financed at 100 percent under a single new category combining works, goods, technical assistance, training, and incremental operating costs; (v) reallocationo f Credit proceeds among the current expenditure categories to accommodate the proposed changes; (vi) changing the project procurement plan and prior review thresholds to reflect the October 2006 updated World Bank Procurement and Consultant Guidelines; and (vii) extending the project Closing Date by 12 months to December 31,2010. B. Backgroundand Reasons for Restructuring 2. The SDR 16 million Credit (US$20.34) for this Project was approved on August 1, 2002 and became effective on May 6, 2003. The Project Development Objective, as stated in the Development Credit Agreement, i s "to improve coverage and utilization o f quality primary health care (PHC), in the territory o f the Borrower, based on a model o f Family Medicine/General Practice." The Project includes three components: + Component I (US$16.2 million total costs): PHC Service Delivery: the overall objective o f the component was to support development o f PHC services in urban and rural areas of Georgia through rehabilitation o f the facilities and provision o f basic medical and office equipment. This component has three sub-components: (i) establishing PHC clinics and referral laboratories; (ii) Referral Pilot at Kutaisi M C H PHC Center; and (iii) Community-based Information, Education and Communication (IEC). + Component I1(US$7.10 million total costs): Institutional Development: the objective of this component was to support institutional development and the capacity building in Family Medicine for the sustainable delivery o f the PHC services through: (i)Capacity building for PHC Training; (ii) Capacity building in the management o f PHC services; (iii)StrengtheningHealthManagementInformationSystems forPHC;and(iv) Support for PHC FinancingReforms. 3 + Component I11 (USU.5 million total costs): Project Management Support. The objective o f this component i s to support project implementation by supporting the development and functioning of the Health and Social ImplementationCenter. 3. Progress to date: After initial delays, the implementationaccelerated in 2006. Sixty one percent o f IDA funds (SDR9.87 million or US$14.68 million) have been disbursed and an additional US$l.l million (4 percent) i s committed. In terms o f activities, the project has financed the rehabilitation o f 103 primary health care centers, regional family medicine training centers, as well as the Kutaisi M C H Center under Component 1. Training o f family medicine staff has also been supported. Under Component 2, an informatiodcommunication strategy has been developed and a Master plan for the PHC has been prepared. Inaddition, the capacity of the Health Policy Unit and the Center for Medical Statistics and Information has been strengthened. The project has made progress towards the achievement o f its development objectives as measured by key performance indicators. About 71 percent o f rural population have access to the PHC clinic within 15 minutes in project target areas (Imereti, Adjara, Shida Kartli regions) and national average utilization of PHC services increased from 1.4 (2003) to 1.85 (2006) visitskapita (3/capita target). A ten percent increase nationwide inthe proportion of infants that receive timely immunization (DPT3) was observed amounting to an 86.8 percent coverage rate (2006). There has beena 7.5 percent increase (30 percent increase targeted) inthe proportion o f pregnant women to have had at least 4 perinatalvisits compared to the baseline. 4. Reasonsfor Restructuring: Inthe mid-l990s, Georgia embarked on a series of reforms in the healthcare sector. These sought to improve the mobilization, allocation, and management o f public funds and to shift the healthcare delivery system away from the heavy emphasis on tertiary care to primary health care. Most recently, in 2006, the government launched a further major reform o f the health sector, which composes four main areas: (i) increasing the private sector role in health financing and service provision by privatizing public health facilities; (ii) prioritizing public funds to finance health care for the poor and other vulnerable groups; (iii) channeling public health financing through private health insurance companies; and (iv) strengthening the regulatory role of the Ministry o f Labor, Health and Social Affairs (MOLHSA). Given these policy changes, the Government requested that Bank support under the Primary Health Care Development Project be revised to reflect the new priorities. The government has decided not to continue to rehabilitate primary health care clinics, because these would be privatized, but rather to increase funds for additional training on family medicine, to revise family medicine guidelines, to strengthen the stewardship functions o f the MOLHSA, and to develop a modernized public health information management system covering the entire health system rather than just PHC as was originally envisaged. To meet the new reform requirements in a dynamic policy environment in Georgia, the Bank agreed to restructure the project. It should be notedthat this project was a core project under the 2003 Country Assistance Strategy and the key element under the Country Partnership Strategy Progress Report for FY2006-2009. This Project also complements the Poverty Reduction Support Operation (PRSO), which provided policy-based credits to the Government for a range o f policy reforms including the reform inthe health sector. Inparallel to the PRSO, this Project finances a health management information system and provides technical assistance to the Government for better monitoring service provision by the private sector. The Project is conducting an impact evaluation o f the Medical Assistance Program for the Poor, which is a key program under the 4 health sector reform. This kind o f support i s very critical to the success o f the health reform in Georgia. C. ProposedChanges 5. During the restructuring mission in July 2008, the project was re-appraised and re-costed in order to reflect changes in Government priorities. As a result of the restructuring mission, it was proposed to revise the original project objectives, the project name, project components, and key indicators in the Results Framework. It should be noted that following the restructuring mission, the process was interruptedby the Russo-Georgia military conflict inAugust 2008. As a result, the project lost time for the implementation. In the letter to the Bank on October 20, 2008, the Government o f Georgia requested formally project restructuring as well as the second extension o f the project Closing Date from December 31,2009 to December 31,2010 inorder to fully utilize the IDA credit and achieve the revised project development objectives. This letter reconfirms the proposed restructuring inorder to meet the changing needs under the health sector reform program. The proposed changes are as follows: 6. RevisedPDO, project name, and outcome indicators: The proposed revisedPDO includes a new objective relating to the strengthening o f the stewardship functions o f the MOLHSA. The revised PDOs are to: (i) improve coverage, utilization and quality of health care services in the territory o f the Recipient, and (ii)strengthen the Government's stewardship functions in the health sector. In order to better reflect the revised objectives, the project name would change to the Health Sector Development Project. In line with the proposed revisions in the PDO, the results framework i s revised. During the course o f the implementation, some indicators in the results framework became irrelevant and have been modified informally. A thorough assessment was made of all outcome and output indicators inthe results framework during the restructuring mission and a set o f new indicators have been proposed to ensure that the results framework more closely reflects the project activities. Intotal, 9 out o f 17 indicators were modified, 7 were dropped and another 17 indicators were added. This restructuring allows indicators under the results framework to be formally changed (see Annex 1 for details on the original outcome and intermediate outcome indicators inthe Project Appraisal Document and the proposed changes to the original indicators and the targets as well as the new indicators). Annex 2 provides the revised Results Framework with the baseline data and targets. The main outcome indicators to measure the success o f the restructuredproject are as follows: Project Development Objective Revised PDO Indicators Improve Access % o fpopulation covered with re-trained family medicine providers Percentage o f rural population with access to a PHC clinic within 30 minutes of transportation/ walking Increased immunization rate of (DPT3). Increase Utilization Increased health care service utilization as measuredby number of out- patient visits per capita (by poor and by general population) (threshold score for accessing M A P - 70,000) Enhance Quality Increased satisfaction of population with PHC services intarget areas, as measured by the utilization survey % of trained rural physicians who manage cases according to nationally approved treatment guidelines inproject target areas Proportion of TB patients managed at the PHC level according to the 5 Project Development Objective RevisedPDOIndicators DOT stratew, Strengthen Stewardship Functions IIII% o fhealth budget earmarkedto program for poor Key health laws revised & passed (health care, medical practice) I I Increasedawareness o f population on health care reforms I 7. Revised project components: The project design would be changed as follows: (i) the original sub-components 1.1 and 1.2 would be merged; (ii) sub-component 2.1 would be moved under Component 1,now renamed "Strengthening the PHC System". This would consolidate all PHC related activities under Component 1, Additionally, Component 2 would be renamed "Support for Health Sector Reform" and the original sub-component 1.3 would be moved under this component. Also, the original sub-components 2.2 and 2.4 would be mergedunder a new sub-component 2.2. Component 3 on Project Management would remain unchanged. The table below shows comparisons o fthe original and revisedproject structure. Component 2: Institutional Development Component 2: Support for Health Sector Reform Sub-component 2.1: Capacity Buildingfor PHC Sub-component2.1: Information and Training Communication Campaign Sub-component2.2: Capacity Buildinginthe Sub-component 2.2: Capacity Buildingfor Management o fPHC Services MOLHSA inPolicy, Regulation, Financing and M&E Sub-component2.3: Strengthening Health Sub-component 2.3: Strengthening Health Management Information Systems for PHC Management Information Systems Sub-component2.4: Support for PHC Health Care I I Financing Reforms Component 3: Project Management IComponent 3: Project Management 8. The total estimated costs in US$ are based on the current SDWUS$ exchange rate o f SDRl/US$1.48 (February 17, 2009). Hence the total Bank financing i s estimated at US$23.5 million, The revisedproject descriptionwould be as follows: COMPONENT 1: StrengtheningPHC System (US$17.8 millionBankfinancing) + Sub-component 1.1: Upgrading Health Clinics: The objective o f this sub-component i s to increase access to critical primary health care services. This sub-component would finance the following activities: (i) rehabilitation of health clinics, including 1 reference laboratory; (ii) provision o f equipment for clinics and family doctors; (iii) rehabilitation 6 and equipment o f Kutaisi M C H Center; and (iv) equipment for Avian flu resuscitation units andanti-viraldrugs for avian flu. + Sub-component 1.2: PHC Training: The objective o f this sub-component i s to strengthen capacity in PHC and improve the quality of care, through the: (i) rehabilitation and equipment o f 5 regional Family Medicine Training Centers; (ii) establishment o f Family Medicine Faculty; (iii) development of clinical guidelines and undergraduate nursing education curriculum; (iv) provision o f training for PHC providers in family medicine, on clinical guidelines, and contract negotiatiodmanagement skills; and (v) provision o f training on maternal and child care and health management to health practitioners and managers. COMPONENT 2: Supportfor HealthSector Reform(US$4.1 millionBankfinancing) + Sub-component 2.1: Information and Communication (IC): The objective o f this sub- component i s to increase awareness and understanding by the population o f the Government's health reform program. Specifically, this includes information on programs for the poor, privatization o f health facilities, contracting with private insurance, content of the benefit package, etc. The sub-component would finance the design and implementation of the IC campaign throughout Georgia. + Sub-component 2.2: Capacity Building in MOLHSA in Policy. Regulation, Financing and Monitoring and Evaluation. The objective is to support the development o f capacity o f the MOLHSA to analyze, monitor the sector as a basis for `steering' rather than `rowing' stewardship role. This sub-component would finance the following activities: (i)Strengthening the capacity of Health Policy Division in MOLHSA; (ii) institutionalization o f M&E; (iii) support for development o f regulatory capacity; (iv) the development and institutionalization o f National Health Accounts; (v) carrying out a Health Sector Performance Assessment; (vi) technical assistance on health financing reforms; and (vii) conducting the Impact Evaluation o f the Medical Assistance Program for the Poor. + Sub-component 2.3: Strengthening o f Health Management Information System (HMIS): The objective is support the development of the HMIS. Specifically, this includes (i) the rehabilitation and equipping o f the Center for Medical Statistics, which has been merged with the National Center for Disease Control; (ii)technical assistance to analyze the existing flows of health related information and to develop a conceptual framework, conduct a bankable feasibility study including an implementation plan for a future system o f health informationmanagement at a national level; and (iii) design o f the HMIS. the COMPONENT 3: ProjectManagement(US$1.60 millionBankfinancing) + This component would continue to support effective administration and coordination o f the project. This includes managing the resources.of the project, procuring goods and services under the project, operating the financial management system, and ensuring timely and appropriate reporting. 7 Other relatedproposedchanges: 9. Inorder to reflect changes made inthe project, as outlined above, the following additional changes are proposed: a new single expenditure category entitled, "Provision o f Civil works, Goods, Consultant Services and Training, and Incremental Operating Costs," with an allocation o f SDR 6.6 million added to the Allocation o f Credit Proceeds in Schedule 1. This category would be financed at 100 percent in line with the 2005 Country FinancingParameters, which allow for such financing. reallocations between expenditure categories to accommodate the proposed changes. The reallocations proposed are as follows: Allocationof CreditProceeds (SDR) The project Closing Date would be extended by12 months to December 31, 2010 because the implementation o f the new activities under the restructured project requires a longer project time period. The procurement thresholds under the restructured project would be based on the updated Procurement and Consultant Guidelines (2004) as revised in October 2006. The procurement plan will specify those contracts which are subject to the Bank's prior review. D. Analysis I O . The government of Georgia has taken a radical approach to change both the financing and provision o f health care services in Georgia. This approach has the potential to increase financing to the health sector through private investment and to improve management o f health 8 service provision. However, the approach also bears substantial risks. One o f the major risks i s whether the government would have the capacity to regulate and monitor the provision of health service by the private sector as well as the purchasing function performed by private insurance companies. This risk i s addressed by the proposed changes under the project by increasing support to capacity buildingfor the Ministry o f Health to enhance its stewardship functions. 1 1. Another risk i s that a large proportion o f population who are poor are not eligible for the government's Medical Assistance Program for the Poor, which covers the extremely poor, and who will have difficulties to access health care after the privatization o f the health facilities. The project supports an evaluation to assess the impact o f the government's reform programs on the access to and utilization o f health services and will provide hard evidence to policy makers on the feasibility ofthe approach beingtaken. 12. The proposed changes, however, do not have a major effect on the original economic, technical, institutional, environmental, and social aspects o f the project. In terms of project implementation and financial arrangements, these would continue to be used under the restructured project. Also, the existing procurement procedures would apply for all project activities. A revised procurement plan for the restructured project has been prepared and reviewed by the Bank team. Lastly, the proposed changes to the project do not affect the environmental category o f the project or trigger new safeguard policies. The restructuring does not involve any exceptions to Bankpolicies. E. ExpectedOutcomes 13. The proposed changes inthe project's development objectives and its designare reflected inarevisedset ofoutcome andintermediate outcome indicators oftheprojectthat are attachedto this Project Paper (see Annex 1 and Annex 2). The revisedresults framework, which includes ten outcome indicators as well as a set of component-related indicators, has been discussed and agreed on with all relevant project agencies. F. BenefitsandRisks 14. The project is expected to yield benefits in support of Georgia's health sector reform to improve the health status o f its population. As a result of the project: (i)relevant health facilities would be rehabilitated and equipment provided; (ii) health staff would be trained and certified to provide family medicine on the basis o f new family medicine guidelines; (iii) the capacity of the MOLHSA and related agencies would be strengthened in policy analysis, monitoring and evaluation, and inregulation. Importantly, it i s expected that the main benefit of the restructured project would be that it provides the support to the government at this critical time to be able to monitor and evaluate its health reform program and to ensure that the most vulnerable groups o f the population have access to good quality healthcare services. 15. The main risk of the project not being able to achieve its development objective is the unstable political environment and the frequent change o f policy makers and policy decisions. The relatively low capacity o f the implementing agency to carry out the project activities in a very dynamic and a complex political environment is another risk. The latter risk i s o f particular 9 concern giventhe project's ambitious nature, a relatively short remaining implementationperiod, and a set o f activities which tend to be highly labor intensive, such as the provision of training to a large number o f medical staff. On the positive side, the project implementation unit i s highly competent with excellent staff and management, which benefits from continued support from high Government levels. Also, to further mitigate this risk, technical assistance will be provided to MOLHSA and other government agencies to assist policy makers in overseeing the reform progress. 16. Policy environment inGeorgia, especially inthe health sector i s very dynamic. It imposes high risk for this operation. However, it also provides opportunities for high gain because it allows the Bank to stay engaged in the health sector to influence important policy development inGeorgia. 10 Annex 1. ProposedChangesinthe ResultsFramework Indicators Original Indicators Revisedor New Indicators Original Revised or (from PAD) (in Project Paper) ProposedChanges (from PAD) New Approximately 50% of YOofrural populationwith This indicatoris the populationwith access to PHC clinic within revisedto add access to a PHC clinic 30 mins of "rural", becausethe within 30 mins of transportatiodwalking projectfinances only walkinglother rural clinics. transportation Populationwith access Increasedhealthcare service Revisedto better 2.6fpclyr for to PHC services utilization as measuredby define the indicator. poor; 2.3lpclyr completingat least three number of out-patient visits for gen. visits per capitaper year per capita (by poor andby population generalpopulation)(threshold score for accessingthe MAP - 70,000) 20% increaseinthe Increasedimmunizationrate Revisedto better 20% increase from 90% of DPT3 proportionof infants in of (DPT3) define the indicator. 78% in2004 coverage the populationthat receive immunization (DPT3) on time At least 50% of YOpopulationcoveredwith Revisedto better 50% populationenrolled with retrainedfamily medicine definethe indicator. certifiedfamily providers medicine practitioners by 2008 90% of providers YOofPHC providers trainedin Revisedto makethis 90% 50% trained in family family medicine(country- indicator medicine actually wide) measurable. practicingfamily medicine 90% of rehabilitated Kept as original. 90% 90% facilities have trained family medicine doctors, nurses and basic equipment Regional Family RegionalFamily Medicine Revisedto better 5 5 MedicineTraining TrainingCentersrehabilitated define the indicator. Centers operational and equipped(operational) PHCnorms and Key healthnorms revisedand Revisedto better Laws passed standards and master passed(healthcare, medical definethe indicator. plantranslated and practice) implementedas laws Basic health information IC campaigndesignedand Revisedto include IC campaign systems for PHC implemented expandedscope of carried out developedand the campaign. implemented 11 Analytical studiesand Analytical studiesand IRevisedto better IStudies and evaluations neededfor evaluationsneededfor define the indicator. analysis developinghealthcare developinghealthcare carriedout financingreforms for financingreforms complete PHC completedand andusedto reviselredefine usedto revisehedefine strategies implementable strategies for healthcare financing Health sector performance HSPE report evaluation completed produced HMISsystemdeveloped System designedand implemented for PHC 30 40 % oftrainedrural physicians New 30 who manage cases according to nationallyapproved treatment guidelines inproject target areas Increasedawareness of New 70 populationonhealthcare Number of new, rehabilitated andequippedhealthclinics Number ofruralpractices New I 98 equipped Increasedsatisfaction of Increased populationwith PHC services satisfaction intarget areas, as measured (70%) by the utilizationsurvey Number ofphysicianstrained 550 innew clinical guidelines Kutaisicenter rehabilitated, New Center equippedand staff trained rehabilitated, equippedand staff trained 12 New Family established, equipped, Medical curriculumdeveloped Facility developed New 40 New 20150 IMaster plandevelopedand New Master plan used developed Laws revised(healthcare, New Laws revised medicalpractice) Policy anddecision-making New Capacity capacity strengthenedas strengthened measuredby number of health policy stafftrained, improved policy analysis, regular reports on healthreform implementation and institutionalizedM&E 30% increasein the This indicator is number of ARI/DD droppedbecauseno cases managedat the disaggregateddata PHC level reportedfor this I indicator. 30% increasein the Dropped. The proportionof pregnant projecthas no direct women who havehadat inference on this least 4 prenatalvisits indicator. It is not appropriate indicator to monitor project performance. 50% increasein the Droppeddue to lack proportionof adult of data. patientsseen in refurbishedPHC clinics for whom blood pressureis recordedin patientsmedicalrecords Improvedknowledge Droppeddue to the and practice of practices projectactivities relatedto healthy have beenchanged lifestyles(smoking, diet, and does not directly wellbeingcheck-ups) affect lifestyle changes. 13 20% increase inthe I Dropped. More number of cases appropriate managedaccordingto indicatorshave been internationallyand introducedinthis nationallyapproved area. treatment guidelines I 40% increasein the Dropped.More number of appropriate appropriate referrals (appropriately indicatorshavebeen defined according to the introduced. number of ARI/DD indicatorappeared cases managedat the twice inthe PAD. PHC level 14 Annex 2: ProposedProjectResultsFramework Project PDO Indicators Baseline Proposed Data Development (original Targets sourceskomments Objective (PDO) and new indicators)/ Access ?LOofpopulationcoveredwith re- 0.6 50% MOLHSA Reports trained family medicine providers (2004) Percentageofrural populationwith 20% (2008)' 50% To be measuredby access to a PHC clinic within 30 householdsurvey minutes o ftransportation' walking (total rehab facilities o f 800 rural) Increasedimmunizationrate of 78% 90% I NCDCPublic Health (DPT3). (2004) L'tilization Increasedhealth care service 2lpcly utilizationas measuredby number of for poor for poor householdutilization out-patient visits per capita (by poor 2lpcly survey and by general population)(threshold for G. Pop 2.3lpclyear for (2006) G.DOD Quality 66% Increased As measuredby (2006) satisfaction householdutilization (70%) survey 0% 30% As measuredby (2008) Facility Survey project target areas Proportion of TB patients managedat 3% 40% NationalTB Center the PHC level accordingto the DOT (2004) strategy. Stewardship YOof public healthexpenditure 3.6% 30% MOLHSANHA Data functions earmarkedto programfor poor (2006) Key health laws revisedand passed 0 Laws passed As measuredby (healthcare, medical practice) (2008) number of laws revised andpassed Increasedawareness of populationon 46% 70% As measuredby public healthcare reforms (2006) opinion survey Sub-component 1.1: Number of new, rehabilitatedand 0 120 Actual 103 done Upgrading health equippedhealthclinics (2003) clinics Number ofrural practices equipped 0 98 98 done (2007) Center MCC trainingto be Kutaisicenter rehabilitated, equipped rehabilitated providedin 50 districts and stafftrained equippedand to 120doctors and will trainedstaff include Kutaisi Sub-component 1.2: RegionalFamily MedicineTraining 0 5 I Rehabilitated and PHC Capacity Centersrehabilitatedandequipped (2003) equipped3 centers; Strengthening (operational) trainingin4 FamilyMedicalFacultyestablished, No family Family IIFamilyMedical equipped, curriculumdeveloped medicine Medical Facility established faculty Facility (2003) established IThe 20% is for the total populationandthe data for the rural populationis beencollected. 15 % ofPHC providers trained in family 5yo 50% At the beginningof the medicine (country-wide) (2003) project 105 doctors were trained by DFID. (the total doctors need for trainingincountry i s 2,200 and 1,205 to be trained by project) 90% ofrehabilitatedfacilities have 0 90% HSPIC trained family medicine doctors, (2003) nursesandbasic equipment % ofPHC stafftrained in 40% 404 doctors to be contracting/management (2008) trained out of 1,042 rural doctors 20 family medicine guidelines 0 20150 Printingand developedand adopted, and 50 (2003) distributionwill be guidelines distributed done for all guidelines Number ofphysicianstrained innew 0 550 Ofthe 2,200 in country clinical guidelines (2003) Sub-component 2.1: IC campaigndesignedand No IC IC campaign Information and implemented campaign carriedout Communication (2003) Sub-component 2.2: Master Plandevelopedandused No MP Master plan Master plandeveloped Capacity Building (2003) developed for MOLHSA in Policy, Regulation, Financing and M&E Laws revised(healthcare, medical Laws revised practice) Policy anddecision-making capacity Capacity As measuredby strengthened strengthened number ofhealth policy staff trained, improvedpolicy analysis, regular reports onhealth reform implementation, and institutionalizedM&E. Analytical studies andevaluations Studiesand neededfor developinghealthcare analysis financingreforms completedand carried out usedto revise/redefme strategies. Health sector performanceevaluation HSPEreport (HSPE) completed produced Sub-component 2.3: HMISsystemdeveloped HIMSsystem Consultant assessed Strengthening designed the current systems Health Management Information Systems 16