The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) Emergency Medical Services Project (P159544) EUROPE AND CENTRAL ASIA | Uzbekistan | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2018 | Seq No: 6 | ARCHIVED on 09-Jun-2021 | ISR45875 | Implementing Agencies: Republic of Uzbekistan, Ministry of Health Key Dates Key Project Dates Bank Approval Date: 25-Apr-2018 Effectiveness Date: 12-Sep-2018 Planned Mid Term Review Date: 25-Oct-2021 Actual Mid-Term Review Date: Original Closing Date: 31-Aug-2024 Revised Closing Date: 31-Aug-2024 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The Project Development Objective (PDO) is to increase the effectiveness and efficiency of the emergency medical services (EMS) system. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Component 1: EMS Enabling Environment, System Management and Quality Improvement:(Cost $3.16 M) Component 2: Dispatch, Communications and Information Systems:(Cost $13.96 M) Component 3: Emergency Care System Improvement:(Cost $81.19 M) Component 4: Project Management:(Cost $1.69 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Satisfactory Overall Risk Rating Moderate Moderate Implementation Status and Key Decisions This ISR builds on the February 2021 virtual implementation support mission findings, the progress reports received from the PIU, and weekly meetings with the PIU. Project Development Objectives are on track and are achievable by the current closing date; progress towards the achievement of the PDO is Satisfactory. In light of substantial progress in procurement of goods, the ratings for Overall Implementation Progress and Component 3 have been upgraded to Moderately Satisfactory. However, while the likelihood of achieving end targets remains strong, the overall PDO rating will continue to be reassessed in future ISRs to ensure that they remain feasible given the scope of impact of COVID-19. 6/9/2021 Page 1 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Substantial Substantial Substantial Macroeconomic Moderate Moderate Moderate Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Moderate Moderate Moderate Sustainability Fiduciary Substantial Moderate Moderate Environment and Social Moderate Moderate Moderate Stakeholders Moderate Moderate Moderate Other -- -- -- Overall Moderate Moderate Moderate Results PDO Indicators by Objectives / Outcomes Increase effectiveness and efficiency of the Emergency Medical Services system IN00966238 ►Percentage of heart attack cases surviving through hospital discharge (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 83.70 84.30 100.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The reported at this and previous ISR period are the estimates for the national EMS hospitals for 2020. Processes for manual extraction and transformation of the existing data to compute this indicator is in place in all regional EMS hospitals. The reported at this ISR period are the estimates for the national and regional EMS hospitals. Comments: A little improvement noted since the last ISR is expected, as key factors that help improve in-hospital survival, such as angiography systems and in-service training, still has not happened. Due to the pandemic, the start of procurement of angiography systems was put off until early 2022, which would further delay improvements given the lengthy procurement processes. In light of this, the procurement plan for 2021 will be revised to include angiography system with the aim to have them installed and operational in most of regional EMS hospitals by Summer 2022. 6/9/2021 Page 2 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) An in-service training plan for myocardial infarction and angiography systems has been drafted, but not implemented pending the MoH decision on designation of the Center for Postgraduate Medical Education as the main training agency for the project in-service activities. The training plan is advised to be revised to involve an international partner from a well-performing health system to aid in skills and knowledge development. To improve sustainability and cost-effectiveness, online learning methods will be prioritized. The preparation for implementation of training activities should start immediately. Routine collection of quality care data beyond in-hospital mortality should be initiated. End target: In the absence of the baseline data, the end target set for this indicator at the project design was tentative and unrealistic; it will be revised at the mid-term review, considering the baseline value and in-hospital mortality rates for acute myocardial infarction reported in other comparable well-performing health systems. IN00966239 ►Share of hospitalized patients coming to EMS wards by ambulance (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 25.00 23.60 27.10 30.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The reported at this and previous ISR period are the estimates for the national EMS hospitals for 2020. The current reporting period coincides with the next COVID-19 pandemic wave and hence conclusions Comments: need to be drawn with care. For example, the reported value for the first quarter of 2021 is at 12.17%. The team will continue monitoring with care the targets during the pandemic. IN00966240 ►Average response time for ambulance calls (Minutes, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 27.60 22.00 15.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Comments: The reported at this ISR period are the data from the automated dispatch center in Tashkent for 2020. The reported average response time in the previous ISR was only for one district in Tashkent (Shayhontohur), where the new dispatch software had initially been installed and piloted. The reported period covers from September-December 2020 and allows comparison with the data reported in the previous ISR. The dispatch software became fully operational in all districts of Tashkent at the end of August 2020. The current reported average response time captures both the time that it takes a dispatch center to process a call and the time it takes for a vehicle to arrive at the scene from when it received a request. However, given that the rollout of activities to support faster repsonse times coincided with the onset of the COVID-19 pandemic, and in the context of a lack of data/analysis on how the pandemic is affecting population behavior regardng the use of ambulance services, more detailed analysis is needed. Specifically, a more granular data available for analysis in Tashkent needs to be connected to data warehouses and an analytics platform to ensure routine use of data for policy and decision making to reduce ambulance average response times. The ToR for data warehouses and an analytics platform supported by the project has now been finalized and beng prepared for tendering. Baseline and end target: Typically, an average response time measure captures both the time that it takes a dispatch center to process a call and the time it takes for a vehicle to arrive at the scene from when it received a request from a dispatch center. At the project design, official reporting included only the latter; hence the baseline is only reflective of a part of the entire response time reported in the current ISR. However, the end target includes both the dispatch processing and vehicle arrival times. The current ISR 6/9/2021 Page 3 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) reports an average response time that includes both the dispatch processing time (approx. 2 minutes) and the time from when a request is communicated and to an arrival of a vehicle at the scene (approx.22 minutes) in Tashkent. Also, the baseline data was collected from paper reports, which are prone to data quality issues, while the current data comes from the software is highly accurate. IN00966261 ►Percent of pre-hospital EMS patients hospitalized (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.30 13.40 10.20 20.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The reported at this ISR period are the national data for 2020. The first quarter data for 2021 from Tashkent is 16.86%. The typical values might be driven upwards or downwards during the times of crisis such as the current Comments: pandemic. While the values for 2020 were at 10.2%, the data for first quarter of 2021 in Tashkent indicates some improvements (16.86%). The team will continue to monitor the targets during the pandemic period. IN00966262 ►Percentage of poly-trauma cases surviving through hospital discharge (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 65.00 90.10 100.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The reported at this ISR period is the national data for 2020. Polytrauma is not part of the standard clinical case definitions used in the country; hence it requires multiple steps to define and adopt the definition and use medical records data to identify cases and capture outcomes. Due to the pandemic, adoption of the new definition of poly-trauma has been delayed, thus the current reporting provides data on combined trauma that is the closest coded value to poly- Comments: trauma in the existing data reporting system. In the absence of the baseline data, the end target set at the project design was tentative. The end target will be revised at the mid-term review/restructuring, considering the baseline value and in-hospital polytrauma mortality rates in other comparable well-performing health systems. Intermediate Results Indicators by Components Component 3: Emergency Care System Improvement IN00966265 ►Number of the departments of emergency and urgent medical care furnished per the approved list of equipment (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 190.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Comments: The first target is set at 50 departments, to be achieved by December 2021. 6/9/2021 Page 4 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) The indicator may need to be revisited at the mid-term review/restructuring to clarify the definition of "furnished per approved list of equipment." The procurement plan includes approximately 130 types of equipment that will go to 14 EMS hospitals and 177 general hospital EMS departments. Given the scale of the procurement activities required, the equipment is being procured in batches/lots. Hence, the EMS hospitals and departments will not be fully equipped per the approved list until all equipment is procured. The procurement of equipment is likely to span over the project's life, with critical life-saving equipment being prioritized in the early years of the project. Given the indicator's current definition, the indicator targets are unlikely to be met until the project's final years. To date, 29.8% of planned equipment has been delivered to all regional and district branches of EMS system. IN00966269 ►Number of clinical protocols developed and/or updated for the departments of emergency and urgent medical care under the project (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2.00 2.00 15.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The two are compendium of protocols for various prevalent diseases. Clinical protocols for myocardial Comments: infraction and poly-trauma management are to be updated by the end of 2021. IN00966271 ►Number of ambulances furnished according to the approved list of equipment (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 60.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Since 2018, the Government has procured over 2,000 ambulances using other sources of financing. In light of these developments, the indicator will have to be revisited/removed at the mid-term Comments: review/restructuring. IN00966273 ►Percent of in-hospital EMS patients treated within the clinically recommended time (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 20.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 This indicator is not part of routine reporting in the health system, thus it is not readily available for reporting. A routine collection of data for monitoring would require a functional hospital information system. The EMS hospitals with operational hospital information systems will be explored for opportunity Comments: to collect data during the next physical missions. If not feasible, the indicator will be removed during the restructuring. IN00966275 ►Number of EMS (pre-hospital) related medical and other personnel who underwent training under the Project (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 300.00 300.00 13,000.00 6/9/2021 Page 5 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Approximately 300 dispatch workers have been trained to support the new dispatch software Comments: implementation in Tashkent. Training needs are being identified for other regions. IN00966276 ►Number of regional EMS training departments created and/or equipped under the project (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 4.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Four existing training centers have been identified for strengthening. A market analysis has been carried out for select high-end technology skills simulation equipment. Next steps are for the PIU to prepare ToR Comments: and initiate procurement processes for the selected simulation equipment. The ToRs are expected to be finalized by the end of July 2021. IN00966277 ►Number of trainers trained for EMS training departments (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 0.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 Training of trainers is expected to start in late 2021- early 2022. A training plan has been prepared on the management of myocardial infarction, including training on angiography procedures. The PIU is advised to partner with a well-performing academic hospital in the development of the training, with a particular focus on online and hybrid learning to ensure scaling and sustainability. Preparation activities should start in the Comments: Summer of 2021. The end target will be revised at the mid-term review/restructuring. IN00966278 ►Percent of personnel satisfied with trainings by EMS training departments (male/female) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 70.00 0.00 0.00 90.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 A training evaluation survey is under development. Evaluation reports are due after four training centers are equipent and learning activities are initiated. Comments: Note: At the project design, average training satisfaction rates for other similar training activities had been used as a baseline. IN00966279 ►Reduced variation in ambulance teams per capita (ratio) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 18.10 4.90 4.90 12.10 6/9/2021 Page 6 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The end target is met. Since 2018, some 2,000 new ambulances, including 450 ALS vehicles, have been purchased. The new ambulances have been distributed across all regions to ensure compliance with the Government standard Comments: on ambulance care delivery (one vehicle per 13,000 population). In response to the pandemic, regional authorities have initiated purchases of additional 230 ambulances and another 1,000 ambulances are expected to be supplied in 2021-2022. Component 1: EMS Enabling Environment, System Management and Quality Improvement IN00966263 ►Percent of hospital EMS cases that are emergency and urgent (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 60.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 This indicator is not part of routine reporting in the health system, thus it is not readily available for reporting. Patients will have to meet locally specified urgency and emergency criteria to be admitted to EMS Comments: hospitals/departments. Work is in progress to reconcile local and international definitions of urgency and emergency and establish processes for extraction and transformation of the existing data to compute this indicator. If reconciliation is unsuccessful or data extraction is not feasible, the indicator will be revisited at the mid-term review/restructuring. IN00966267 ►Law has been amended to allow redirecting of non-urgent case (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 A local consultant prepared a draft Law "On the Emergency Medical Service". The draft has been Comments: submitted to the Ministry of Health for review. IN00966270 ►Severity scoring system developed and implemented in pre-hospital level (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 A pre-hospital severity scoring system has been developed. The pre-hospital scoring system consists of two elements – call prioritization and advising over the phone Comments: until the arrival of the ambulance crew. Based on the severity scoring system, the calls can be grouped into five categories, requiring different urgency/time of ambulance response. Both call prioritization and structured advising principles reflected in the new scoring system guidance developed are relatively new concepts for the national ambulance dispatch system and thus may require both behavioral and 6/9/2021 Page 7 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) organizational changes. The required adjustments and changes are perhaps the reasons for the delay in piloting and implementation of the newly developed guidance. To facilitate and support both the adaptation and adoption of the new severity scoring principles, a local consultant will be hired (by the end of June 2021). It is expected to take about two to three months to have an early pilot results on the call prioritization and carry out structured training for pilot on phone advising. Prior to scaling beyond the pilot, the scoring system should also be approved at the Cabinet of Ministers level to safeguard health workers against grievances and legal action (six to nine months after adaptation and adoption). IN00966272 ►Percent of pre-hospital EMS cases that are emergency and urgent (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 69.40 72.00 60.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The reported value exceeds the end target. The reported at this ISR period is the national data for 2020. The steep increase in the share of emergency and urgent cases could be due to the changes in the case Comments: load and population behavior during the COVID-19 pandemic or systemic changes. The team will continue to monitor the targets during the pandemic period. IN00966274 ►Severity scoring system developed and implemented in hospitals (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 A hospital severity scoring system guidance has been developed. A local consultant carried out a proof of concept pilot in two EMS facilities (the national and Samarkand regional EMS hospitals). Based on the findings, a detailed implementation planned for selected two EMS facilities should be developed with follow on implementation. A proof of concept pilots indicated feasibility of the implementation, but with many substantial changes in the way the delivery is organized in the emergency departments. The following steps are needed to get the scoring system to implementation: a) implementation plan (three Comments: weeks) b) endorsement by the EMS Science Committee (one month); c) implementation in the national and Samarkand EMS hospitals (three months); d) the MoH decree/order on scaling (one month); e) scaling to three EMS hospitals (three months); e) the scoring system should also be approved/referenced by the Cabinet of Ministers level document or a Law to safeguard health workers against grievances and legal action (six to nine months from endorsement by the EMS Science Committee). Component 2: Dispatch, Communications and Information Systems IN00966264 ►Number of newly established regional dispatch centers with relevant software (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1.00 1.00 14.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 6/9/2021 Page 8 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) The dispatch center in Tashkent is automated. Procurement packages for regional dispatch centers are being reviewed by the MoH. The first stage of national rollout of the dispatch center automation will start Comments: by the end of 2021 and is expected to cover three regions (Tashkent, Namangan and Syrdarya regions).The completion of dispatch automation in all regions is expected by mid-2023. IN00966268 ►Number of dispatch protocols updated under the project (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 23.00 23.00 10.00 Date 27-Oct-2017 20-Oct-2020 27-May-2021 31-Mar-2024 The end target is met. Dispatch protocols for 23 emergency health states and conditions have been developed. Comments: Component 4: Project Management IN00966266 ►Percent of patients satisfied with the EMS system (as measured by patient satisfaction surveys) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 80.00 Date 30-Sep-2018 20-Oct-2020 27-May-2021 31-Mar-2024 During FY21, a terms of reference has been developed to obtain feedback from patients on the EMS system, and the procurement has been carried out. A local survey vendor firm has now been identified to support implementation of patient experience survey in the EMS hospitals. The firm is currently costing activities to finalize the contract (expected to be signed by the end of June 2021). Findings from the field- test survey are expected by the end of December 2021. The PIU is also considering the approach they Comments: will take (who and how the results will be reviewed) to take account of the feedback and improve the performance of EMS hospitals. The end target might have to be revisited after the survey tool is finalized and first survey results are in. Performance-Based Conditions Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P159544 IDA-62100 Effective USD 100.00 100.00 0.00 22.45 77.55 22% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P159544 IDA-62100 Effective 25-Apr-2018 17-May-2018 12-Sep-2018 31-Aug-2024 31-Aug-2024 6/9/2021 Page 9 of 10 The World Bank Implementation Status & Results Report Emergency Medical Services Project (P159544) Cumulative Disbursements PBC Disbursement Achievement Disbursed amount in Disbursement % PBC ID PBC Type Description Coc PBC Amount Status Coc for PBC Restructuring History There has been no restructuring to date. Related Project(s) There are no related projects. 6/9/2021 Page 10 of 10