Document of The World Bank FOR OFFICIAL USE ONLY Report No.: 63857 - MD PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF SDR 6.6 MILLION (US$10.2 MILLION EQUIVALENT) TO THE REPUBLIC OF MOLDOVA FOR A HEALTH SERVICES AND SOCIAL ASSISTANCE PROJECT November 9, 2011 Human Development Sector Unit Europe and Central Asia Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization CURRENCY EQUIVALENTS (Exchange Rate Effective: August 2011) Currency Unit = Moldova Leu (MDL) MDL 11.44 = US$1 USD 1.561619 = SDR 1 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AF Additional Financing HSSAP Health Services and Social Assistance Project CIS Commonwealth of Independent IDA International Development States Association CNAM Compania Nationala de Asigurari in IP Implementation Progress Medicina CPS Country Partnership Strategy KPI Key Performance Indicators DP Development Partners MoF Ministry of Finance DPO Development Policy Operation MoH Ministry of Health EC European Community MoLSPF Ministry of Labor, Social Protection, and Family EMP Environmental Management Plan PDO Project Development Objective ECA Europe and Central Asia PHC Primary Health Care EU European Union POM Project Operational Manual FD Family Doctor RHC Rural Health Center FM Financial Management SAAIS Social Assistance Automated Information System FMR Financial Monitoring Report SIL Specific Investment Loan GFPCRG Global Food Price Crisis Response SP Social Protection Grant GoM Government of Moldova SWAp Sector Wide Approach HCWM Health Care Waste Management WHO World Health Organization HMIS Health Management Information System Vice President: Philippe Le Houérou Country Director: Martin Raiser Sector Director: Ana Revenga Sector Manager: Daniel Dulitzky Task Team Leader: Paolo Belli i REPUBLIC OF MOLDOVA ADDITIONAL FINANCING FOR HEALTH SERVICES AND SOCIAL ASSISTANCE PROJECT CONTENTS DATA SHEET ............................................................................................................................... iii I. Introduction ......................................................................................................................... 1 II. Background and rationale for Additional Financing in the amount of USD 10.2 million equivalent ............................................................................................................................ 1 III. Proposed Changes ............................................................................................................... 8 IV. Appraisal Summary of Proposed Additional Financing ................................................... 10 V. Operational Risk Assessment Framework ........................................................................ 15 VI. Financial Terms ................................................................................................................ 16 Annex 1: Results Framework and Monitoring ....................................................................... 17 Annex 2: Operational Risk Assessment Framework (ORAF) ............................................... 26 Annex 3: List of the selected 35 RHC facilities to be constructed/renovated under the AF ........................................................................................................... 30 Annex 4: Technical Assistance Activities to Support Primary Health Care and Hospital Reforms .................................................................................................... 33 Annex 5: Procurement Plan ................................................................................................... 35 Map IBRD 33448 ii REPUBLIC OF MOLDOVA ADDITIONAL FINANCING FOR HEALTH SERVICES AND SOCIAL ASSISTANCE PROJECT DATA SHEET Basic Information - Additional Financing (AF) Country Director: Martin Raiser Sectors: Health (78%); Other social services Acting Sector Director: Ana Revenga (22%) Sector Manager: Daniel Dulitzky Themes: Health system performance (P); Social Team Leader: Paolo Carlo Belli safety nets (P); Social risk mitigation (S) Project ID: P125719 Environmental category: B Expected Effectiveness Date: February 2012 Expected Closing Date: August 31, 2013 Lending Instrument: SIL Joint IFC: N/A Additional Financing Type: Scale-up Joint Level: N/A Basic Information - Original Project Project ID: P095250 Environmental category: B Project Name: Health Services and Social Expected Closing Date: August 31, 2013 Assistance Lending Instrument: SIL Joint IFC: N/A Joint Level: N/A AF Project Financing Data [ ] Loan [ X ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: with 25 years maturity, including 5 years of grace period AF Financing Plan (USD million) Source Total Amount (US $m) Total Project Cost: 10.2 Cofinancing: Borrower: Total Bank Financing: IBRD IDA 10.2 New Recommitted Client Information Recipient: Republic of Moldova Responsible Agency: Ministry of Health; Ministry of Labor, Social Protection and Family Contact Person: Viorel Soltan/Valentina Buliga Telephone No.: 373 22 268883/269387 Fax No.: 373 22 738781/269310 Email: viorel.soltan@ms.gov.md/valentina.buliga@mmpsf.gov.md iii AF Estimated Disbursements (Bank FY/USD million) FY 2012 2013 2014 Annual 3.7 6.4 0.1 Cumulative 3.7 10.1 10.2 Project Development Objective and Description Original Project development objective: The Project Development Objectives are to increase access to quality and efficient health services, with the aim of reducing premature mortality and disability for the local population, and to improve targeting of social transfers and services to the poor. Revised Project development objective: Not applicable Project description: Component 1: Health System Modernization. This component supports the reform and further development of four key blocks of the health care system, following the Healthcare System Development Strategy for period 2008-2017. Component 1.1: Capacity Development and Sector Regulation. This component contributes to spearhead new policy developments in the areas of Public Private Partnership, monitoring of health financing flows in the healthcare sector (with the preparation of National Health Accounts (NHAs), and human resources’ management development and reform. Component 1.2: Health Care Financing and Provider Payment. This component contributes to reform the way healthcare services are ―paid‖ by government, with a change in the payment system for hospitals, as well as to design strategies to progressively expand health insurance coverage in a fiscally sustainable manner. Component 1.3: Primary Health Care Development. This component supports the: (i) rehabilitation of primary health care facilities in rural areas (Rural Health Facilities, or RHAs); and (ii) updating the curriculum of Family Doctors, and providing training opportunities for them. Component 1.4: Hospital Capacity Assessment and modernization. This component contributes to the: (i) modernization of the Republican Clinical Hospital (RCH), the largest referral facility in the country; (ii) finalization of a new Hospital Master Plan with further hospital optimizations; and (iii) strategy to modernize the Oncologic Institute in Chisinau, and reform the way cancer treatment services are organized. Component 2: Social Assistance and Welfare Component. This component supports the first implementation steps of a new targeted social assistance program, called Ajutor Social, to strengthen government’s capacity to identify the poor, and to efficiently collect and process information for appropriate decision-making. Activities under this Component establish a hardware and software infrastructure supportive to further rolling out Ajutor Social. iv Component 3: Institutional Support. This component supports operating costs of the Project, both in Ministry of Health (MoH), as well as in Ministry of Labor, Social Protection, and Family (MoLSPF). Component 4: Protecting Health and Nutritional Status. This component was introduced as part of the Global Food Price Crisis Response Grant approved in August 2008 and closed on August 28, 2011. The component provided cash support to selected social institutions (mainly kinder-gardens, orphanages, and long-term care institutions), and in-kind nutrition supplement to at-risk pregnant women, lactating mothers, and infants/young children. Safeguard and Exception to Policies Safeguard policies triggered: Environmental Assessment (OP/BP 4.01) [X] Yes [ ] No Natural Habitats (OP/BP 4.04) [ ] Yes [X] No Forests (OP/BP 4.36) [ ] Yes [X] No Pest Management (OP 4.09) [ ] Yes [X] No Physical Cultural Resources (OP/BP 4.11) [ ] Yes [X] No Indigenous Peoples (OP/BP 4.10) [ ] Yes [X] No Involuntary Resettlement (OP/BP 4.12) [ ] Yes [X] No Safety of Dams (OP/BP 4.37) [ ] Yes [X] No Projects on International Waterways (OP/BP 7.50) [ ] Yes [X] No Projects in Disputed Areas (OP/BP 7.60) [ ] Yes [X] No Does the Project require any waivers of Bank policies? [ ] Yes [X] No Have these been endorsed or approved by Bank management? [ ] Yes [ ] No v I. INTRODUCTION 1. This Project Paper seeks the approval of the Executive Directors to provide an additional credit in an amount of SDR 6.6 million (USD 10.2 million equivalent) to the Moldova Health Services and Social Assistance Project (HSSAP, P095250). 2. The additional funds under this second Additional Financing (AF) would help finance the costs for the rehabilitation of primary Rural Health Centers (RHCs) and expand activities that scale-up the Project’s impact and the development effectiveness of this complex, but well- performing Project. In addition, the main changes that are being introduced to the Project through this Project Paper include: (a) a revision of the results framework to adjust the key performance indicators (KPIs) towards outcomes that are measurable and more closely aligned with Project activities; and (b) a modification of the Project description to include the new activities. II. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING IN THE AMOUNT OF USD 10.2 MILLION EQUIVALENT A. Background 3. The original Credit (Cr. 4320-MD) in the amount of SDR 11.3 million (USD 17 million equivalent) was approved by the Board on June 7, 2007, and became effective on September 5, 2007. In addition in 2008, the Government of Moldova (GoM) received a Grant from the Global Food Price Crisis Response Grant (GFPCRG, TF092641), which was processed as an AF for an amount of USD 7.0 million equivalent. The Grant was approved by the Board on August 8, 2008, and closed on August 28, 2011 fully disbursed. 4. The original Project Development Objectives (PDOs), which remain relevant, are to increase access to quality and efficient health services, with the aim of reducing premature mortality and disability for the local population, and to improve targeting of social transfers and services to the poor. 5. The Government of the Republic of Moldova (GOM) has formally requested on May 20, 2011, the Bank to provide an additional financing to cover a financing gap and complete the activities initiated under the original Credit, as well as to scale-up implementation of a few new activities in support of the healthcare and social assistance services’ reform. Specifically, the AF would be used to (more details are provided in Section II.C): (a) fill in the financing gap for the rehabilitation of primary Rural Health Centers (RHCs); (b) support, together with the European Union (EU) and the World Health Organization (WHO), some key technical assistance (TA) activities to respond to the Government embarking upon hospital and primary health care reforms. These TA activities would specifically focus on increasing efficiency and quality of hospital and primary services (in line with the PDOs); and (c) provide a small but necessary extension of the business functionalities being developed as part of the new automated management information system for social assistance services, 1 under Component 2: ―Social Assistance and Welfare Component‖, which is implemented by the Ministry of Labor, Social Protection, and Family (MoLSPF). 6. The original Project would also require some adjustments in the Results Framework. Specifically, these corrections would include some changes to the Key Performance Indicators (KPIs) and intermediate outcome indicators. The savings in the current Project will also be used to finance a new round of Household Budget Survey to be conducted by the National Bureau of Statistics in 2012. Annex 1 details the proposed changes to the Results Framework, which narrow the set of indicators to ensure that they can be measured, traced over time, and linked to Project-supported activities. 7. The proposed scaled-up activities are strategically aligned and operationally consistent1 with the Country Partnership Strategy, FY09-FY13. The ongoing HSSAP also meets the criteria and conditions of OP/BP 13.20 for AF that require that: (a) the Project objectives continue to be achievable; (b) the performance of the Borrower and implementing agencies be satisfactory; (c) the implementing agencies have an action plan satisfactory to the Bank for the completion of the original Project; and (d) there be no outstanding audit reports and audit reports have been unqualified. B. Project Progress to Date 8. Overall Implementation Progress (IP) and progress toward achieving PDOs for the original Project have been consistently rated as Satisfactory or Moderately Satisfactory.2 Implementation pace has picked up momentum over FY11, and, at present, 70.3 percent of the total allocation is disbursed,3 and more than 80 percent of the available credit is already committed with contracts signed and under implementation. Figure 1 presents the status of disbursement by component under the original Credit and the first AF from the Global Food Price Crisis Response Grant (GFPCRG). The Project does not have any unresolved fiduciary, environmental, social or other safeguard issues. The audit reports of the Project are current and the Borrower is in compliance with the legal covenants. 1 IDA, Country Partnership Strategy Progress Report for Republic of Moldova for the Period FY09-FY13, May 2011, p. 11, Table 2. 2 The Project has been rated ―moderately satisfactory‖ with respect to IP/DO, with ―satisfactory‖ ratings for procurement and financial management in the latest ISR (approved on December 29, 2010). 3 To date, total disbursements in the Project equal to USD 9.9 million (58.1 percent of total Project funds) of which 74.3 percent for Component 1 (or USD 8.9 million), implemented by the Ministry of Health (MoH), and 19 percent for Component 2 (or USD 1.0 million), implemented by the Ministry of Labor, Social Protection, and Family (MoLSPF). In addition, a Grant of USD 7.0 million from the Global Food Price Crisis Response Trust Fund (TF092641) received in 2008 and closed on August 28, 2011, is fully disbursed. This brings total disbursements for the Project to USD 16.9 million (or 70.3 percent of the total allocation). 2 Figure 1: Amount allocated and disbursed in HSSAP, by Component (August 2011) 1. Health System Modernization Component (74,3%) $8.921.239 (MoH) $12,000,000 2. Social Assistance and Welfare Component (19%) $950.000 (MoLSPF) $5,000,000 Credit: Health Services and Social Assistance (58,1%) $9.871.239 Project $17,000,000 4. Additional Financing Grant (MoLSPF & MoH) (100%) $7.000.000 $7,000,000 TOTAL for Health Services and Social (70,3%) $16.871.239 Assistance Project $24,000,000 $0 $15,000,000 $30,000,000 Disbursed amount Credit/Grant Amount Note: The top bar represents disbursed amount while the lower bar represents total credit/grant amount allocated to each component and or source of funding. 9. The Ministry of Health (MoH) new leadership since January 2011 is highly committed to the Project and has reinvigorated government’s initiative towards health reforms. The MoLSPF has started a new targeted cash support program, Ajutor Social, and is committed to improving benefits’ administration and reducing categorical benefits. The MoLSPF’s commitment is reaffirmed through approval by the Parliament on July 28, 2011, of the new World Bank Results- Based Project ―Strengthening of Social Safety Net‖ (Board approval on June 9, 2011). C. Rationale for Additional Financing 10. The AF would be used to: (a) fill in the financing gap for the rehabilitation of RHCs; (b) support, together with the EU and WHO, some key TA activities to underpin the new government initiative on health care reforms. These TA activities would specifically focus on increasing efficiency and quality of hospital and primary care services (in line with the original PDOs); and (c) provide a small but necessary extension of the business functionalities being developed as part of the new automated management information system for social assistance services, under Component 2: ―Social Assistance and Welfare Component‖, implemented by the MoLSPF. (a) Fill in the financing gap for the rehabilitation of RHCs 11. Background: According to the Project Appraisal Document (PAD, Report No. 38277- MD) of May 8, 2007, 65 RHCs were planned to be constructed/reconstructed in rural areas for an estimated amount of USD 5.2 million (construction part of Component 1.3). During 2008, when the first tenders for contracting construction companies were organized, it appeared that unit costs estimated during Project preparation (approximately USD 80,000 per RHC) had grossly underestimated the real costs. The first 15 RHCs were constructed/reconstructed for an amount of over MDL 26.1 million (over USD 2.1 million equivalent, which represents a unit cost of USD 140,000 per RHC). 3 12. Reasons for costs overrun: There were several reasons which can explain this gross underestimation of unit costs per RHC during Project preparation:  When the unit costs were computed, the task team took as a reference the works performed under the previous Health Investment Fund Project (HIFP), 2001-2006. However, under the latter, only partial renovations were carried out, in several cases limited to internal works such as repainting, substituting bathroom tiles, or substitution of windows, whereas the health centres selected for renovation under HSSAP were for the most part extremely dilapidated, old, or excessively large. Thus, the RHCs needed more radical renovation work.  A detailed technical survey of all RHCs planned for renovation under the first three batches revealed that 20 of those were in such poor condition that solitary interventions to repair or replace particular building elements would not produce functioning health facilities and, thus, would not be cost efficient. Shortcomings were multiple: poor functionality caused by too many and often dysfunctional rooms, and too large overall floor areas for present and future use of the facility; structural failures of the buildings’ superstructure (i.e., roof structure, load bearing walls, foundation); non-existing or non- functioning utilities (i.e., sewer system, sanitary facilities, and power supply). Therefore, for those 20 of the 36 RHCs completed to date, the MoH decided to build new ones, rather than to renovate existing facilities, with investment costs higher than costs of renovating existing facilities, but with more durable and significant impact (more details are presented in Annex 3).  The PAD was finalized in May of 2007. However, cost calculations are based on 2005 prices. During implementation of civil work activities, construction costs have progressed unfavorably, with a near doubling of labor wages and very significant increases of the cost of key primary building materials and plant rentals.4 Though costs decreased after the 2008 crisis, they have recently raised again to pre-crisis level.  According to seismic activity the Republic of Moldova is divided into three seismic zones: so called ―eight-nine degrees‖, ―seven degrees‖, and a small one of ―six degrees‖, where concrete and steel columns are not necessary. The main territory is the seven degrees zone and the eight-nine degrees in the south. Accordingly, there are very strict requirements for seismic norms and building regulations, which need to be respected any time a new building is raised. These costs were not taken into account during Project preparation. 13. Current situation: Currently, the total contract value for the 38 RHCs already renovated/built, or still under renovation, is approximately 72 million MDL (or USD 6.45 4 For example, services for renting concrete mixer and bulldozer services increased by 87 percent and 92 percent, respectively. At the time tenders started in 2008, cement was 3.5 times more expensive than in 2006, concrete’s unit price had increased by 45 percent, mortar by 82 percent, brick by 66 percent, timber by 24 percent, steel bars by 72 percent, etc. Costs for transportation of building materials to the site amounts to 10 percent of the total value of building material; hence, the more expensive are the materials, the more expensive is the transportation of these materials. 4 million – as Table 1 below indicates), which means approximately USD 170,000 per RCH renovated/rebuilt, or more than twice the unit cost originally estimated. Table 1. Total estimated cost overrun for construction of first 38 RHCs Activities Amount in USD Budget initially planned in Procurement Plan 5,215,373 Amount contracted for the first 38 RHCs 6,450,113 (1) Deficit -1,234,740 14. By end of July 2011, disbursements were at approximately 97 percent of the initial budget planned in the Procurement Plan for renovation of RHCs, while commitments were already at 107 percent of the original planned amount. 15. Overall assessment: In the fall of 2010, a World Bank infrastructure specialist carried out an in-depth assessment of the reasons for the costs overrun, found the justifications provided by MoH to be solid,5 and concluded that an additional financing of USD 8.45 million would allow the Project to complete all the 39 RHCs planned for construction/renovation to date,6 with an additional 35 RHCs which could be completed over a two-year period7 (the list of RHCs, approved based on MoH Order No. 492 dated July 16, 2011, and estimated unit cost per square meter for new construction, are presented in Annex 3). Table 2 presents details on the additional financing needed to complete the RHCs as prepared by the MoH. Table 2. Breakdown of additional financing request from the Ministry of Health Primary Rural Health Centers Item Amount in USD (1) Deficit -1,234,740 Designing of the next 348 RHCs’ batch 300,000 Construction of 35 RHCs (approximate unit costs = USD 194,300) 6,800,000 Services provided by the consultants / engineers in civil works 115,000 (2) Cost estimates for redevelopment of the next 35 RHCs by August 31, 2013 7,215,000 Total Component 1.3 INFRASTRUCTURE (1+2) 8,449,740 5 The consultant also concluded that the process of selection of the RHCs planned for renovation/reconstruction is technically sound. RHCs to be reconstructed/renovated are selected by a specific working group of the MoH according to sound technical criteria, including: RHCs catchment area, current activity levels, nearest referral facilities, level of deprivation of the communities where the RHCs are located. Selection criteria are also in line with the recommendations of the 2007 study: ―Feasibility Study and Plan for Infrastructure and Human Resources in Primary Health Care System‖. 6 Only for one RHC works are lagging behind, because the contract with the first company selected had to be rescinded for lack of performance, and a new contract was recently advertised. 7 Since during the winter months construction comes to a halt, even with additional staff in the engineering unit, it would be difficult to reduce implementation time. 8 One of the RHC was already designed by the Agroind Project Company (contracted in the framework of HSSAP) from the local public authorities funds in accordance with the standards and requirements approved by the Ministry of Health. 5 16. In addition, the consultant concluded that, since the preparation for rehabilitation of the first batch of RHCs in 2008, there has been a positive and continuous effort to improve RHCs’ functionality, and reduce size and running costs of renovated facilities. Efforts in most of these areas have been backed by the MoH’s leadership with significant achievements. New and rehabilitated RHCs have improved functionality, space economy, comfort for patients and staff, and energy efficiency. Because of the smaller floor area, they are generating savings on recurrent costs. 17. The MoH has continued to improve the design of new RHCs and on October 2010, through MoH Order no. 695, a new surface standard for RHCs was approved, and it will be used for the design of the planned new 35 RHCs under this proposed AF. Therefore, the planned 35 RHCs would use once-again-revised standard designs, with multi functional rooms, and smaller space allocation to maximize space economy and functionality in rural health facilities. Construction techniques with higher levels of thermal insulation and modern heating systems would contribute to improved comfort for patients and staff, and help offset the impact of continuously increasing costs of energy. Entrance and sanitary facilities would be adjusted to persons with disabilities. Improvement of the solid and medical waste disposal would be extended to the new batch of RHCs, with an environmental protection plan attached to every contract with the construction company. 18. Conclusion and recommendation: The HSSAP has played an important role in setting in motion a complex process of improving the rural health services in the country. One major component of this process is the rehabilitation of derelict physical infrastructure. The MoH has accepted the challenge of defining and implementing new concepts for the provision of health services in the rural areas, and has actively supported the efforts made to improve efficiency by modernizing the normative framework guiding the development of physical infrastructure for health facilities. This process is now more than half way to the goal, but could still collapse if left at its current stage. In addition, RHCs represent a key tool in the MoH’s strategy focused of non-communicable disease prevention, and they are more cost-effective and pro-poor than hospitals as a first point of contact for patients seeking care for common ailments. It is in this context that the AF proposes to continue and further expand RHCs reconstruction. (b) Support, together with the EU and WHO, key technical assistance activities in support of the healthcare reforms under the Ministry of Health, specifically focusing on increasing efficiency and quality of primary and hospital services at decentralized level (outside Chisinau) 19. Investments in ―brick and mortar‖ need to be accompanied by continuous investments in capacity and skills in order to maximize impact. In addition, the renewed push for health reforms under the government that formed in January 2011 needs to be nurtured, and informed by better evidence base, including continuous exposure of senior MoH officers to international best practices. 20. All TA activities under the proposed AF estimated at USD 960,000 (see Annex 4 for a detailed description of all TA activities planned under AF) would share two common denominators: (a) they would build upon previous studies financed under HSSAP, or other donor-sponsored, programs; and (b) they would have a ―nuts-and-bolts‖, operational and 6 practical focus. Their objective is to support the reform process by clarifying the ―how‖ of reforms, and produce detailed cost plans rather than highlighting broad strategic reform directions. (c) Provide an extension of the modules being developed as part of the new automated management system for social assistance services under Component 2: “Social Assistance and Welfare Component�. 21. Component 2 of the HSSAP is supporting two sets of activities: (a) the development of a consolidated database for all social assistance benefits, with relative capacity building and operational support activities; and (b) the provision of computers, followed by training for social workers in charge of data intake. 22. On January 24, 2011, the MoLSPF launched the development and implementation of a new Social Assistance Automated Information System (SAAIS), followed by an Inception Report and implementation plan on software development. The Inception Report recommended the extension of functionalities within SAAIS beyond what was originally envisaged in the software development contract, in order to: (a) strengthen monitoring of family income for the means-tested benefits; (b) integrate functions related to social inspection to reduce fraud and corruption; (c) facilitate the accreditation process of social services providers; and (d) facilitate the work of social assistants with individual case management for special category cases (for example, individuals with disability), which require continuous exchange of data with other Ministries. 23. An information technology (IT) expert hired by the World Bank concluded that it would be more efficient to allow an expansion of the SAAIS functionalities at this stage of software development, rather than in a subsequent phase, for the following reasons:  The immediate expansion of the system functions would allow better system design in terms of integration of its functions.  Extension of functionalities at this stage would eliminate the need for separate procurement of additional functionalities, and will eliminate the risk of incompatibility and delays.  In addition, with the extension under the current contract, significant savings may be obtained, as compared to a separate contract in the future. 24. Hence, the MoLSPF requested from the World Bank an additional financing in the amount of USD 240,000 to expand the current contract with the software developer to include the development of the additional functionalities described above. 25. Overall, this AF, which has strong support of the Moldovan authorities, is a better mechanism to maximize development impact and results than a repeater project, a completely new operation, or non-lending instruments. This is mainly because this second AF will use a well performing HSSAP implementation and institutional arrangements as an instrument to maximize outcomes, while at the same time bringing additional funds from IDA fairly quickly, which would be particularly important in view of the launch of a new phase of health care reforms and the need to implement the new SAAIS as soon as possible. 7 III. PROPOSED CHANGES A. Results Framework and Project Development Objectives (PDOs) 26. The Results Framework and specific KPIs for the Project require fine-tuning. The original HSSAP PDOs are to increase access to quality and efficient health services, with the aim of reducing premature mortality and disability for the local population, and to improve targeting of social transfers and services to the poor. The PDOs are still relevant, and will not be changed. By contrast, the results framework and specific KPIs would require fine-tuning, to link it more directly to the activities supported under the Project, and to reflect the proposed scaled-up and new activities under the AF both in time and scope (see Annex 1). B. Proposed Components for Additional Financing 27. The investments and activities proposed under the proposed 2nd AF would be placed within four separate components of the current Project: Sub-component 1.3: Primary Health Care Development (AF equal to USD 8,739,740 equivalent). This sub-component supports: (a) the rehabilitation of RHCs; and (b) the development of standardized work place protocols for Family Doctors (FDs) and the provision of training opportunities for them, specifically in rural facilities’ management. 28. The AF would allow the Project to complete the 39 RHCs already planned for construction/renovation and largely completed to date, as well as an additional 35 RHCs (see Annex 3). In addition, under the same sub-component 1.3, the AF would support two technical assistance activities (detail justification is provided in Annex 4):  Technical assistance to improve quality of primary health care by developing and implementing of at least 60 standardized protocols for FDs to diagnose and treat most commonly encountered pathologies.  Technical assistance to strengthen the role of primary care through training of FDs, managers, and accountants in primary health care facilities’ management, in support to promotion of their direct contracting by the social health insurance company (Compania Nationala de Asigurari in Medicina, or CNAM). 29. Sub-component 1.4: Hospital Capacity Assessment and Modernization (AF equal to USD 670,000 equivalent). This sub-component contributes to the: (i) piloting regionalization of hospitals in line with the developed Hospital Master Plan; (ii) re-profiling the excessive acute hospital beds into long-term care beds; (iii) development of strategy to modernize the Oncologic Institute in Chisinau, and reform the way cancer treatment services are organized; and (iv) implementation of PPPs for diagnostic labs and rehabilitation services. 30. The AF would be used to carry out some key technical assistance activities necessary to operationally specify current plans of hospital reforms, including regionalization of hospital services. The proposed TA activities are explained in Annex 4. 8 31. Component 2: Social Assistance and Welfare (USD 240,000 equivalent). This component is meant to strengthen the Government’s capacity to monitor the poor, and to collect information for appropriate decision-making. Over the last couple of years, it has been supporting the first implementation steps of a new targeted social assistance program referred to as Ajutor Social. 32. The AF would allow the extension of the functionalities of the new software being developed (SAAIS) to: (a) enhance the system’s capability to ascertain family income by integrating functions related to social inspection, in order to reduce fraud and corruption; (b) facilitate the accreditation process of social services providers; and (c) facilitate the work of social assistants with individual case management where integration of different data sets kept by different Ministries is required. 33. Component 3: Institutional Support (USD 550,261 equivalent). This component supports operating costs of the Project, both in MoH, as well as in MoLSPF. 34. The additional financing would be utilized to support the current institutional arrangements until the new closing date of the Project (August 31, 2013), as follows: Table 3. Additional Project management costs (USD equivalent) Item Amount in USD Services provided by the driver 17,250 Services provided by the procurement consultant 65,000 Services provided by the procurement assistant 46,000 Services provided by the financial management consultant 60,000 Services provided by the assistant in financial management 46,000 Services provided by the coordination consultant 80,000 Services provided by the assistant /translator 60,000 Operating costs / Audit 128,411 (1) Total demand of AF (Component 3), MoH 502,661 (2) Total demand of AF (Component 3), MoLSPF, including for incremental operating and staff costs 47,600 Total additional Costs- Component 3 550,261 C. Extension of the Closing Date 35. The closing date for the 2nd Additional Financing will be August 31, 2013. At the request of the Government, the same closing date of the original Credit was recently extended from August 31, 2011 to August 31, 2013. D. Project Costs and Financing Plan 36. Table 4 shows the Project costs and financing plan by component and sub-component under: (i) the original Project; (ii) the first Additional Financing; and (iii) the second Additional Financing. 9 Table 4. Project Costs by Component (USD equivalent) Name of Component Credit 4320- 1st AF Proposed Total MD Allocation 2nd AF Proposed (TF092641) Allocation Allocation Component 1: Health System 11.57 0.00 9.41 20.98 Modernization Sub-component 1.1: Capacity 0.48 0.00 0.00 0.48 Development and Sector Regulation Sub-component 1.2: Health Care 1.02 0.00 0.00 1.02 Financing and Provider Payment Sub-component 1.3: Primary 5.75 0.00 8.74 14.49 Health Care Development Sub-component 1.4: Hospital 4.32 0.00 0.67 4.99 Capacity Assessment and Modernization Component 2: Social Assistance 4.73 0.00 0.24 4.97 and Welfare Component 3: Institutional 0.70 0.00 0.55 1.25 Support Component 4: Protecting Health 0.00 7.00 0.00 7.00 and Nutritional Status Total 17.00 7.00 10.20 34.20 IV. APPRAISAL SUMMARY OF PROPOSED ADDITIONAL FINANCING A. Technical 37. The technical design and the fiduciary arrangements remain the same as under the original operation. Experience has shown that the technical basis of the Project is sound. Investment priorities will continue to focus on quality and efficiency of primary and hospital care, on strengthening and augmenting the primary health care service delivery system, and contributing to further develop the stewardship functions of MoH. B. Economic and Financial Analysis 38. Economic Analysis. The economic analysis both looks at the rationale for the overall Project, and in addition reviews the fiscal implications of government spending in health. 39. The economic rationale that underpins the proposed AF and related activities is the same as that for the original Project, namely to: (i) improve quality and efficiency of service provision, and mitigate allocative and technical inefficiencies in the sector; (ii) improve targeting of resources for the social assistance programs; (iii) contribute to fiscal sustainability of healthcare expenditure; and (iv) continue health services’ modernization and quality improvement. All HSSAP components and activities can be ―mapped‖ to one or more of the above objectives. The following few paragraphs outline the situation analysis in the health care sector that justifies the above objectives and economic rationale for the Project. 10 40. Government spending on health as a percent of total government recurrent spending has consistently increased since 2004 (Table 5). In absolute terms, GoM spends on health care approximately USD 113 per capita (EU average is USD 2,400 per capita), and an almost equivalent amount (45 percent of total health expenditure) is still paid on an out-of pocket basis by patients. Table 5. Total government health expenditure, million lei, 2005–2009 2010 2005 2006 2007 2008 2009 (revised allocations) Actual 1,572.4 2,152 2,628.6 3,391.4 3,846.8 3,996.5 % of government expenditure 11.3 11,7 11.73 12.97 14.1 % of GDP 4.2 4.8 4.92 5.39 6.41 5.6 Source: GoM. 41. In the first decade of the 2000s, the country implemented important reforms in the health sector, including:  The creation of a social health insurance-based health financing system, with an independent Compania Nationala de Asigurari in Medicina (CNAM) managing allocations in the sector;  Rationalization of the hospital network (reduction of number of hospitals from over 300 to 85, and reduction in half of hospital beds, following the 1998 crisis);  Separation of primary and secondary care financing (from 2008), and gradual introduction of capitation payment for primary care and output-based payment system for hospitals; and  Initial steps (from 2008) towards development of Public-Private Partnerships, and of accreditation and quality standards. 42. However, some of the above critical reform processes progressed slowly, and stalled when the crisis hit the country in late 2008, and political uncertainty followed. Reforms to improve hospital and primary care efficiency and quality have been slow to take root. 43. Moving forward, the Government needs to complete the process of reforms on the health care delivery front, while stabilizing health financing. At the same time, the MoH needs to develop its stewardship functions (monitoring and evaluation, evidence based health planning, control of financial flows, regulatory framework for medicines, minimal quality standards, regulation of the private sector, etc.) and step back from direct service provision. The ongoing Project and the AF are supporting the Government in this effort to complete the reforms initiated a decade ago. 44. On the health care delivery front, the priority should be to improve quality of care, and value for money/efficiency. In order to do so, CNAM needs to be empowered to do selective and performance-based contracting with hospitals (71 hospitals currently have contractual 11 arrangements with CNAM), and primary RHCs (at present 95 RHCs have direct contractual arrangements with CNAM). The Project is supporting CNAM in assuming this role of strategic purchaser by investing in a new more transparent payment system (PS) for hospitals, based on Diagnostic-related Groups (HSSAP is financing a pilot in seven hospitals of the new DRG-based PS). 45. Hospital autonomy should be further enhanced, and GoM should envisage some profound changes in hospitals’ governance structure and ownership, including turning them into not-for- profit, fully autonomous, private foundations. In addition, there is a need to invest in management capacity and new transparent, meritocratic selection criteria for hospital managers. Hospital networks’ management needs to be fully in charge of reorganization and of human resources. Finally, it is strategic to establish a meaningful, continuous quality improvement process in all facilities, also using the services' accreditation tool recently developed. The new studies planned under the AF would support the Government in preparing the ground for this second-generation set of reforms in hospital governance and management. 46. On the health financing front in 2010, 56.3 percent of CNAM’s total revenues were from employers and employees’ contributions (payroll tax is set at 7 percent of salaries); the rest (43.7 percent) was from Treasury subsidies. However, out of 2,741,773 citizens with health insurance in 2010, only 908,947 paid contributions through their employers, 33,548 purchased health insurance individually, while for all others (1,799,278) GoM fully subsidized health insurance premium. Moving forward, it is necessary to increase the number of contributory members to CNAM, by implementing policies to reduce informal employment and underreporting of wages, and by subjecting to a means-test those who benefit from full government subsidization of their health insurance contributions (see World Bank and WHO 2010 Report: ―Extending Population Coverage in the CNAM in Republic of Moldova‖). 47. It is also necessary to develop credible strategies to fight against informal payments and corruption. At present, whether they are insured or not, people frequently pay out of their pocket when they seek care (particularly for surgeries, diagnostic tests, and medicines) to ensure treatment with better medicines and technologies, and they may not see any value-added from buying insurance. 48. HSSAP will continue working together with the World Health Organization in policy dialogue with Government to further strengthen health financing policies and capacity, by making health insurance coverage more inclusive, meaningful (reducing OOP expenditure for those insured vis-a-vis others), and fiscally sustainable. 49. Financial Analysis. IDA will provide USD 10.2 million of which USD 8.45 million for investment financing, and the rest to technical assistance and recurrent costs. Generally, recurrent costs for civil works are calculated at 10 percent of the investment cost. Accordingly, the total recurrent cost needs from investments supported under this second AF would be approximately USD 844,000, approximately 0.26 percent of total government health expenditure in 2010, which is not likely to be a fiscal strain. 12 C. Institutional arrangements 50. Institutional arrangements described in the original Project Appraisal Document will remain unchanged, and the two implementing agencies (MoH and MoLSPF) will continue to implement the Project. MoH will be responsible for implementation of all health related activities, while Component 2 of the second AF will be implemented by MoLSPF. 51. A few changes in the implementation arrangements over the last year have led to expedite implementation, including the appointment of a new project coordinator for the health component in the summer of 2010, and a new Deputy Minister of Health in February 2011, who has progressively taken a more active role in Project management. In the MoLSPF, a Project Coordinator in charge of coordinating social assistance component, notably development of software and hardware infrastructure, has been created in February 2011. Strengthening of project activities is also underpinned by the overall reorganization of the MoH, approved by GoM on May 31, 2011. D. Environmental and Social Safeguards 52. The proposed scale-up activities under the AF will not trigger any new safeguard policy not already triggered by the original Project under OP/BP 4.01 Environmental Assessment. The Project AF remains under environmental category B. The AF will support civil works of the same nature and magnitude as the original Project and the environmental procedures outlined in the existing Environmental Management Plan (EMP) will remain applicable. 53. Site specific EMPs or EMP checklists will be developed for individual construction works as required. The AF will support one new relatively large scale construction in the Republican Clinical Hospital. The Borrower indicated that the land allocated for that construction is government owned, free of any settlement, and not used legally and/or illegally. Consequently, there will be no land taken under the Project as user rights to all plots required for construction currently rest with the MoH, or local governments. 54. The recent (May 2011) implementation support mission concluded that overall implementation of the Project environmental requirements has been satisfactory, including medical waste disposal at the site of RHCs supported by the original Credit, and that all construction and rehabilitation activities are being undertaken in a manner consistent with the World Bank rules and procedures and with the existing national environmental and construction requirements and permits. Furthermore, the existing human and institutional capacities to ensure EMP implementation are adequate. E. Fiduciary 55. Procurement. The Guidelines: Procurement of Goods, Works, and Non-Consulting Services under IBRD Loans and IDA Credits and Grants, January 2011, and the Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers, January 2011, will apply to all contracts financed with the proposed AF. 13 56. An assessment of the capacity of the MoH and MoLSPF to carry out Project procurement has been conducted in July, 2011. As part of this assessment, several risks have been identified and mitigation measures have been proposed in order to strengthen the capacity of the two implementing agencies to administer procurement in an effective and transparent manner. The overall procurement risk is rated ―Moderate‖ and ―Low‖ after mitigation. 57. Procurement Plan. A draft Procurement Plan was developed during preparation covering procurement activities under the proposed AF. With support from the Bank team, the Procurement Plan will be refined and agreed during negotiations (Annex 5). Thereafter, the plan will be updated bi-annually or as needed and each update will be subject to Bank prior review. The initial procurement plan plus the subsequent updates will be published on the World Bank’s external website in line with the requirements of Bank Guidelines. 58. Procurement Supervision and Ex-post Review. Routine procurement reviews and supervision will be provided by the Procurement Specialist. In addition, one supervision mission is expected to take place per year during which ex-post reviews will be conducted. Subject to improvement in MoH and MoLSPF capacity to carry out procurement, the Project team recommends to post-review at least 5 percent of the contracts subject to post review. Procurement documents will be kept readily available for Bank’s ex-post review during supervision missions or at any other points in time. A post-review report will be prepared, shared with the respective implementing agency and filed in the procurement post review system. 59. Procurement Thresholds. The thresholds for procurement methods and Bank prior review are indicated in the following table. Table 6. Thresholds for procurement methods and Bank prior review Goods, Works, Non-Consulting Services Procurement Method Threshold Prior Review Threshold 1. ICB (Goods) > USD 200,000 All subject to prior review 2. ICB (Works) > USD 1,000,000 All subject to prior review 3. NCB (Goods and Non-Consulting Services) ≤USD 200,000 First two subject to prior review 4. NCB (Works) ≤USD 1,000,000 First two subject to prior review 3. SH (Goods, Works and Non-Consulting ≤USD100,000 First contract subject to prior Services) review 4. DC* - All subject to prior review 5. Technical Specifications - All subject to prior review * All contracts subject to justification Note: ICB – International Competitive Bidding NCB – National Competitive Bidding DC – Direct Contracting SH – Shopping 14 Consulting Services Selection Method Threshold Prior Review Threshold 1. Competitive Methods (Firms) > USD 100,000 All subject to prior review 2. Single/Sole Source * - All subject to prior review 3. Individual Consultants > USD 50,000 All subject to prior review 4. ToRs for Consulting Assignments (firms - All subject to prior review or individuals) * All contracts subject to justification. 60. Short list comprising entirely of national consultants: Short list of consultants for services, estimated to cost equally or less than USD 100,000 equivalent per contract, may comprise entirely of national consultants. 61. Financial management. The financial management functions of the AF will be handled by the MoH and MoLSPF for their respective parts. Namely, the policy, budget, and finance departments within two Ministries will be responsible for the flow of funds, accounting, reporting, and auditing. The Ministries will open two separate accounts in the Treasury for AF funds for their respective components and will manage them with due diligence. There would be no changes in financial management and disbursement arrangements. 62. The HSSAP financial management arrangements have been reviewed periodically as part of Project supervision, and have been found satisfactory per the latest review (April 2011). The overall FM risk for the Project is moderate. 63. The MoH and MoLSPF are in compliance with the audit covenant: the latest audit report for FY2010 has been received in due course. For the Project financial statements, the auditors have given unqualified opinion mentioning two issues in their Management Letter, which after thorough examination proved to be insignificant. Similar audit arrangements will be adopted for the AF, which will be included in the overall HSSAP audit. The audit of the Project will be conducted by independent private auditors acceptable to the Bank and on agreed Terms of References. The annual audited Project financial statements will be submitted to the Bank within six months of the end of each fiscal year, and also at the closing of the Project. The cost of the audit will be financed from the proceeds of the credit. The additional funds will also be subject to operational review to be conducted by the Court of Account at the end of the Project. 64. Project management-oriented Interim Un-audited Financial Reports (IFRs) will be used for the AF monitoring and supervision. The existing formats of the IFRs will be used and the two ministries will produce a full set of IFRs every semester throughout the life of the Project, and will submit them to the Bank no later than 45 days after the semester end. V. OPERATIONAL RISK ASSESSMENT FRAMEWORK 65. At the time of Board approval of the HSSAP in 2007, the overall risk was rated as Moderate. The attached ORAF (Annex 2) assesses the overall rating of both the HSSAP and AF as Moderate, given Government’s strong commitment to the health sector reform agenda supported by the Project, the MoH demonstrated capacity to fulfill Bank’s fiduciary 15 requirements, the status of progress in achieving PDOs, and in implementing planned activities under HSSAP. That being said, a Moderate risk rating is suggested for preparation and implementation because the Project supports a fairly ambitious reform which requires good coordination across ministries and agencies with structural implementation constraints. 66. However, some key risks remain as there is a risk that the current political majority unravels and that financial and economic growth does not improve as expected. This is mitigated by the fact that the health care reforms were initiated under the current opposition, in power in 2004, and that there is a broad consensus in the country about the directions of health sector reforms. Furthermore, the Bank continues to engage the country in strengthening its private sector environment and improving its fiscal base through reform in the direction of economic liberalization, reform of the social sectors to improve efficiency and value for money, and tax and customs administration reforms through the ongoing Development Policy Operation (DPO) series. The Government has a large Stand-By Agreement with the IMF and which is on track. VI. FINANCIAL TERMS 67. The proposed AF will be an IDA Credit payable in 25 years with a five-year grace period and 1.25 percent interest charge, in addition to the standard service and commitment charges. 16 ANNEX 1: RESULTS FRAMEWORK AND MONITORING COUNTRY: MOLDOVA HEALTH SERVICES AND SOCIAL ASSISTANCE PROJECT Results Framework (list of changes vis-a-vis original PAD, 2007) PDO Current (PAD) Proposed Comments/Rationale for Change The Project Development Continued Objectives are to increase access to quality and efficient health services, with the aim of reducing premature mortality and disability for the local population, and to improve targeting of social transfers and services to the poor. PDO Indicators Current (PAD) Proposed change* Comments/Rationale for Change Population satisfaction with Dropped Due to the fact that this indicator is: ( a) very the health care system sensible and depends of various factors which compared with previous year are not under MoH’s and Project’s control; and (b) the survey was conducted in two only partially overlapping periods in 2008 and 2010, and therefore findings are not clearly comparable; it will be excluded from RF. Number of patients with Dropped This indicator is very relevant, but not confirmed arterial measurable at the moment, since it has not been hypertension under recorded since 2008. In 2009, the MoH decided control/surveillance with to extend free primary care services also to all blood pressure target level up those uninsured. In exchange, to stay within the to 140/80 mmHg achieved budget, it eliminated the performance-based and maintained payment which had been introduced in 2008, linked to achievement of specific treatment indicators, including that for patients with hypertension. As a result, the system stopped recording the above treatment indicator. The Bank team is pressing health authorities to reintroduce incentive payments for primary care. Number of consultation per Revised to: Number of The indicator currently monitored by MoH is person per year by socio- per capital annual visits the total number of visits with Family Doctors, economic group to Family Doctors‖ without disaggregation by socio-economic group. Again, as for indicator 1 above, the Household budget survey information is not comparable over time, and therefore we need to use the information from MoH HMIS. By 17 dividing by the total population of Moldova, we obtain the per capita utilization of Family Doctors. Discharge rate per doctor by Dropped This indicator is not regularly collected, nor is hospital category directly related to Project activities. Share of largest social Dropped Since the HSSA Project’s activities in SA have assistance transfer received been limited to design and implementation of a by the bottom 40 percent of new integrated information system for cash and households in terms of individual services’ management, and income (the largest transfer promotion activities for the new targeted SA is nominal compensation for program Ajutor Social, it is proposed to use heat and utilities) ―upstream‖ PDO indicators for the SA Component of HSSAP, truly reflecting the Project activities. Since June 2011, the Bank is also supporting the MoLSPF through a Results Based-Financing (RBF) operation, which explicitly links disbursements to improving targeting, and where it is therefore appropriate to list as PDO indicators improvements in targeting accuracy. Share of the largest social Dropped Same comment as above assistance transfer that leaks to the top 40 percent of households in terms of income New: ―Share of eligible populations who are tested for arterial blood pressure‖ New: ―Share of eligible populations who are tested for cervical cancer‖ Share of population who has New: ―Share of This indicator is part of the core set of health insurance population who is indicators required for all IDA projects in the covered with mandatory health sector. health insurance ‖ New: ―Average length of This new PDO indicator is relevant for stay reduced‖ in 7 pilotmonitoring the impact on efficiency of the hospitals planned hospital network optimization, and change in payment system towards DRGs implemented under the Project. New: ―Social Assistance Since the Project is focused on the development Automated Information of the social assistance information system, and System developed and expansion of Ajutor Social program, these two introduced‖ new PDO indicators are introduced, the latter with the same Project-end targets as those set for 2013 in the new RBF Project recently approved by the Bank (P120913, June 9, 2011). 18 New: ―Number of Same as above. households benefiting from Ajutor Social� Intermediate Results indicators Current (PAD) Proposed change* Comments/Rationale for Change Component 1: Sub-component 1.1: Capacity Development and Sector Regulation Health expenditures and their Revised to: ―Allocations More directly linked to Project activities, since allocation between different for primary care the Project aims to strengthen the primary care services levels (i.e., primary, maintained (as share of level of delivery. The target is to keep PHC secondary and tertiary) by National health insurance expenditure at a minimum level of 30 percent of facility ownership budget)‖ compulsory health insurance total budget. This indicator is moved to subcomponent 1.2, health financing, where it belongs. Government staff responsible Revised to: ―NHA More directly linked to Project activities. for NHA nominated Reports produced for three years‖ Implementation of Revised to: ―Human Rather than referring generically to three recommendations of at least Resource Strategy, studies, we prefer to list explicitly the actual three policy studies including Action Plan, studies financed by the Project under for the health sector Component 1.1. The study to increase health completed‖. insurance coverage was supported under subcomponent 1.2, and is listed below. The other two studies so far supported under HSSAP, namely: ―Hospital Master Plan‖ and: ―Oncology Institute feasibility study and rehabilitation plan‖, are under subcomponent 1.4. New: ―Number of More directly linked to Project activities. training events sponsored by HSSAP to which MoH officers participate‖ Sub-component 1.2: Health Care Financing and Provider Payment Percent of 15-19 year olds ―Share of population Now a PDO indicator—see comment above. with health insurance who has health coverage insurance‖ At least 12 percent of ―Number of RHCs The original Project presented a target (12 primary care providers (primary Rural Health percent) as an indicator. In the new RF, the contracted directly by Health Centres) directly indicator will be listed correctly, and 40 percent Insurance Company contracted out by the will be the target for this indicator in 2013 (the National Health denominator for calculating this target, i.e., total Insurance Company‖ number of RHCs, has been reduced from 340 to moved as intermediate 250). Project will measure the absolute number indicator of of RHCs directly contracted. This indicator is subcomponent 1.3 moved to subcomponent 1.3, where it belongs. 19 Decreased variance in ALOS Revised to: ―Average Now a PDO indicator—see comment above in selected profiles (surgery, length of stay reduced in internal medicine) by 7 pilot hospitals‖ hospital category New: ―New DRG-based More directly linked to Project activities. payment system for hospitals piloted‖ New: ―Study to increase More directly linked to Project activities health insurance coverage completed‖ New: Three rounds of More directly linked to Project activities. Health Budget Survey with health module conducted and analyzed‖ New: ―Allocations for Moved from subcomponent 1.1 into primary care maintained subcomponent 1.2 (as share of National health insurance budget)‖ Sub-component 1.3: Primary Health Care Development Number of primary care New: ―Number of rural Same indicator will continue to be measured as facilities in line with set health centers in the past. Description of indicator has been norms and standards rehabilitation/constructed made more precise. in line with set norms and standards‖ 65 rural primary care This intermediate indicator in the original PAD facilities rehabilitated and was redundant, because it measures precisely equipped the same indicator as the previous one. Hence, it has been merged with previous one Number of GPs trained in Revised to: ―Enhanced new curriculum curricula/education program for family doctors finalized‖ Percentage of GP vacancies Continued This is the measure regularly tracked by MoH. at PHC facilities New: ―Number of RHCs See comment above. Moved from (health centers, family subcomponent 1.2 to subcomponent 1.3. doctors centers) directly contracted out by the National Health Insurance Company‖ New: ― Number of New intermediate indicator linked to the new standardized protocols of activities financed with AF. family doctors in place and operational (cumulative)‖ 20 Sub-component 1.4: Hospital Capacity Assessment and Modernization National Hospital Master Continued Plan completed and approved by Government New: ―Oncology More directly linked to Project activities. Institute feasibility study and rehabilitation plan completed‖ New: ―Program on New intermediate indicator linked to the new decentralization of activities financed with AF. oncology (chemo and radiotherapy) services developed and adopted by MoH‖ New: ―Public Private More directly linked to Project activities. The Partnership agreements Project has already contributed to finalize a new established (finalized and Legislative Framework for Public Private operational)‖ Partnerships, and with the AF the Project will support two PPP pilots. New: ―Regional New intermediate indicator linked to the new Hospital Action Plan for activities financed with AF. a pilot region (Hincesti, Cimislia, Leova, Basarabeasca) completed‖ New: ―Construction of New intermediate indicator linked to the new Republican Clinical activities financed with AF. Hospital new surgical block initiated‖ Component 2: Unified database for all Moved to PDO indicator. See comment above. social assistance beneficiaries established Number of social workers Revised as: ―Number of More directly linked to Project activities. The recruited, trained and social workers provided Project aims to equip with new computers provided with equipment with IT equipment‖ existing social workers. New: ―Functional More directly linked to Project activities. review of the MoLSPF conducted‖ * Indicate if the indicator is Dropped, Continued, New, Revised, or if there is a change in the end of Project target value. 21 REVISED PROJECT RESULTS FRAMEWORK Project Development Objective (PDO) The Project Development Objectives are to increase access to quality and efficient health services, with the aim of reducing premature mortality and disability for the local population, and to improve targeting of social transfers and services to the poor. Baseline Target end of Data Source/ Resp. for Data Core Indicators UOM Original Project 2008 2009 2010 2011 2012 Frequency Comments Project 2013 Methodology Collection Start (2007) PDO Level Results Indicators9 PDO 1: To increase access to quality and efficient health services, with the aim of reducing premature mortality and disability Annual statistic report 1. Number of per capita At least 3 of the National Center annual visits to family No. 2.74 2.79 2.86 2.87 Annually MoH/NCHM for Health doctors Management. Annual statistic report 2. Share of eligible patients At least 95% of the National Center tested for arterial blood % 81.3 85.4 Annually MoH/NCHM for Health pressure10 Management. Annual statistic report 3. Share of eligible patients At least 75% of the National Center % 56.2 62.4 Annually MoH/NCHM tested for cervical cancer for Health Management. Annual report of National Health 4. Average length of stay No. of Under 9 9.5 Yearly National Health Insurance reduced in 7 pilot hospitals days Insurance Company Company 9 Please indicate whether the indicator is a Core Sector Indicator (for additional guidance – please see http://coreindicators). 10 Share of patients tested for prevention of certain disease is defined as number of examined patients over those who needed such check up. Particularly, the list of those who needed prophylactic check up is defined based on age, risk group, and clinical protocols, which contain a clear description of what kind of screening/lab tests shall be conducted and how often. The MoH orders no. 504 and no. 252 also provide some reference on the frequency and population to be screened for prophylactic purposes. For instance, every Family Doctor who has to prepare annual plan for prophylactic examination for cervical cancer undertakes the following algorithm: takes the list of all registered persons at this particular primary health care centre, selects females, out of which identifies women of age 18+ who have to be examined once in two years as per national clinical protocol (and/or MoH order). Dividing the number of women 18+ by 2 brings the number of patients to be examined during a particular year. Cervical cancer prophylactics consists in a pap smear test that determines cancer cells, which otherwise cannot be identified at an early stage. 22 Baseline Target end of Data Source/ Resp. for Data Core Indicators UOM Original Project 2008 2009 2010 2011 2012 Frequency Comments Project 2013 Methodology Collection Start (2007) 5. Share of population At least 80% Annual report of National Health covered with mandatory X % 76.7 75 71.6 80.8 Yearly National Health Insurance health insurance increased Insurance Company Company PDO2: To improve targeting of social transfers and services to the poor Govt. 90% of Social approved Assist. Dept. SAAIS TOR process Ajutor 6. Social Assistance structure SAAIS for Social Benefits Annual activities Automated Information % Consultant SAAIS under Annually MoLSPF (Res. No. developer in new MIS report of the MoLSPF System (SAAIS) developed selected development 1356 of finalized (SAAIS) March 12, 2008) 7. Number of households National Bureau Household Budget benefiting from Ajutor No. 151 30,000 32,000 35,000 50,000 Annually of Statistics/ Survey Social MoLSPF Intermediate Results and Indicators Baseline Intermediate Results Target end of Data Source/ Resp. for Data Core UOM Original Project 2008 2009 2010 2011 2012 Frequency Comments Indicators Project 2013 Methodology Collection Start (2007) Intermediate Result 1: Sub-component 1.1: Capacity Development and Sector Regulation MoU with National Center for Assignment in Reports for 2008 At least three Annual statistic report 1. NHA reports Health process: local produced; reports NHA reports of the National Center No. TA hired Annually MoH/NCHM produced for three years Manageme consultant hired; for 2009 and produced (2008- for Health nt signed; staff maintained 2010 in progress 2010) Management staff employed 2. Human Resource Local and Strategy (including HR strategy Annual MoH activities international Completed Annually MoH Action Plan) for health developed report consultants hired sector completed 3. Number of training All planned events sponsored by Annual MoH activities No. n/a n/a 4/4 4/4 7/7 training each Annually MoH HSSAP to which MoH report year completed officers participate Intermediate Result 2: Sub-component 1.2: Health Care Financing and Provider Payment 4. Allocations for Annual Report of the National Health primary care maintained At least 30% % 30 30.3 31.2% 30.7% Annually National Health Insurance (as share of National and maintained Insurance Company Company/MoH health insurance budget) 23 Baseline Target end of Data Source/ Resp. for Data Core Indicators UOM Original Project 2008 2009 2010 2011 2012 Frequency Comments Project 2013 Methodology Collection Start (2007) 5. New DRG-based Selection of Int’l. consultant DRG-based internationa Annual MoH activity payment system for No. 0 0 l consultant hired; pilot Pilot in progress payment system Annually report MoH/CNAM hospitals piloted initiated piloted in progress 6. Study to increase Assignment in Assignment Annual MoH activity health insurance No. process: selection in process: Completed Annually report MoH coverage completed of TA TA hired 7. Three rounds of MoH/National health budget survey 1st round 2nd round 3rd round Annual MoH activity No. n/a Annually Bureau of with health module completed completed completed report Statistics conducted and analyzed Intermediate Result 3: Sub-component 1.3: Primary Health Care Development 8. Enhanced Selection of the curricula/education Annual MoH activity international TA TA hired Completed MoH program for family report processed doctors finalized 9. Number of RHCs (health centers, family doctors centers) Annual MoH activity X No. 15 21 38 74 Annually MoH rehabilitated/constructed report in line with international norms and standards 10. Percent of vacant Annual statistic report family doctors’ of the National Center % 20 11 12 10 Annually MoH positions at PHC for Health Facilities Management 11. Number of RHCs At least 100 (health centers, family RHCs (40% of total number of Annual report of the doctors centers) directly No. 29 72 73 95 RHCs which is Annually National Health MoH/NHIC contracted out by the equal to 250) Insurance Company National Health Insurance Company 12. Number of At least 107 FD standardized protocols protocols (cumulative), Annual MoH activity of family doctors in No. 0 0 44 47 Annually report MoH including 60 place and operational new protocols (cumulative) Intermediate Result 4: Sub-component 1.4: Hospital Capacity Assessment and Modernization 13. Study on Hospital Government started Annual MoH activity Master Plan completed Selection of Assignment No. TA hired Completed implementing Completed Annually report MoH and approved by international TA in progress study Government recommendations 24 Baseline Target end of Data Source/ Resp. for Data Core Indicators UOM Original Project 2008 2009 2010 2011 2012 Frequency Comments Project 2013 Methodology Collection Start (2007) 14. Oncology Instituted Selection of feasibility study and Assignment Annual MoH activity No. international Completed Completed Annually MoH rehabilitation plan in progress report TA completed 15. Program on Decentralization decentralization of plan completed oncology (chemo, and and adopted by Annual MoH activity No. Ongoing MoH Annually MoH radiotherapy) services report developed and adopted by MoH Legislative Contracting out Annual MoH activity 16. PPP pilots Selection of Framework of diagnostic At least two PPP No. TA hired Annually report MoH established international TA for PPP services of RCH established Completed prepared 17. Regional Hospital Action Plan for a pilot Annual MoH activity region (Hincesti, No. Ongoing Completed Annually report MoH Cimislia, Leova, Basarabeasca) completed 18. Construction of RCH new surgical block Annual MoH activity Republican Clinical Feasibility study Design company No. under Annually report MoH Hospital new surgical completed contracted construction block initiated Intermediate Result 5: Component 2: Social Assistance and Welfare 19. Number of social Procurement of workers provided with Annual report from No. 0 0 0 Training started hardware Completed MoLSF MoLSPF IT equipment finalized 20. Functional review Consultant to of the MoLSPF carry out Annual report from Completed MoLSPF conducted functional review MoLSPF appointed 25 ANNEX 2: OPERATIONAL RISK ASSESSMENT FRAMEWORK (ORAF) Moldova Health Sector and Social Assistance Project Additional Financing Stage: Board Approval Type of Risks Rating: Level of Risk 1. Project Stakeholder Risks Rating: Moderate Description: Risk Management: 1. While the Project is setting the basis for long term improvements, it also invests on initiatives with a short-term, tangible impact on accessibility and quality of care, such 1. Unstable political situation in the country, and as construction of new Rural Health Centers and the renovation of the Republican Clinical disillusionment of the population due to lack of noticeable Hospital. The infrastructure investments are also accompanied by capacity building activities, changes in quality and access to health care services may such as training for family doctors, designated to enhance quality of care, and build consensus for undermine reform efforts. reforms. 2. In social assistance (SA), resistance to the progressive elimination of some categorical benefits may raise. Resp: Client | Stage: Imp | Due Date : Recurrent| Status: NYD Risk Management: 2. The social assistance (SA) component of the HSSA Project supports public communication campaign to make SA program rules transparent and well understood. Resp: Client | Stage: Imp | Due Date : Recurrent| Status: NYD 2. Implementing Agency Risks (including fiduciary) 2.1 Capacity Rating: Moderate Description: The proposed Project could be delayed as a result of Risk Management: In May 2011, the new MoH leadership launched a reorganization of the human resource capacity constraints in MoH and MoLSPF to Ministry in order to put in place more effective and efficient mechanisms for implementation. implement the Project activities, including lack of capacity to absorb funds and staff turnover, challenges of renovating clinics Resp: Client | Stage: Impl | Due Date : | Status: In progress in two years, and lack of procurement capacity in MoLSPF. Risk Management: HSSAP is providing learning opportunities to MoH managerial staff and supporting the continuous upgrading of implementation capacity in MoH and MoLSPF. Resp: Client | Stage: Prep | Due Date | Status: In progress Risk Management: A thorough functional and institutional review of the MoLSPF is planned under the Project in 2011-2012, and will provide a basis for restructuring the Ministry in 2012. Resp: Client | Stage: Prep | Due Date : | Status: Not yet Due Risk Management: The MoH and HSSAP have agreed to recruit two additional civil engineers to coordinate construction of RHCs. In addition, speeding up of new RHC constructions will occur since MoH civil engineers unit has become familiar with the new standard design for construction of facilities developed in 2008-09. 26 Type of Risks Rating: Level of Risk Resp: Client | Stage: Prep | Due Date : | Status: In progress Risk Management: The MoLSPF has agreed to hire additional experts to cover skills gap in procurement, FM, and IT software and infrastructure. In addition, WB local staff in procurement ensures backstopping for Project procurement consultant on a need basis. Resp: Client | Stage: Prep | Due Date : | Status: In progress 2.2 Governance Rating: Moderate Description: Potential for wavering of MoH and MoLSPF Risk Management: The proposed Project would be implemented through existing MoH and commitment to the Program because of leadership changes. MoLSPF departments with clear responsibilities vis-à-vis Program management in the two Ministries’ governance structure. The staff of the two ministries guarantees some continuity to Project implementation even when leadership/managerial staff changes. Resp: Client | Stage: Prep| Due Date : |Status: Not yet Due 3. Project Risks 3.1 Design Rating: Low Description: The initial design of HSSAP with two components and multiple sub-components may have led to Risk Management: Project activities have been reshaped to respond to MoH leadership’s dissipation of efforts into too many directions, while making the priorities, and mechanisms established so that there is coordination of all Project activities as well Project look like a ―Christmas tree‖. Although topping up with as immediate resolution of implementation issues. new additional TA may seem to be complicating rather than simplifying the Project, it ensures continuity and completion of Resp: Client | Stage: Prep | Due Date : | Status: Completed the current HSSA activities, and fits in the overall reform agenda supported by the Government and donor community. Risk Management : Cooperation with donors, specifically WHO and EU, will be further intensify to support scaling up and completion of activities piloted under HSSAP, such as RCH reconstruction, hospital regionalization, and strengthening of MoH stewardship function (M&E, engagement with private sector, close links between planning and budgeting, enhanced HR management, etc.). Resp: Partner| Stage: Impl | Due Date : | Status: Not yet Due Risk Management: Together with other donors, work on improving country fiduciary systems and the MoH monitoring system will be scaled up. Resp: Partner | Stage: Impl| Due Date : | Status: Not yet Due 27 Type of Risks Rating: Level of Risk 3.2 Social & Environmental Rating: Low Description: The proposed AF intends to renovate and, if/where Risk Management: To address environmental issues energy-saving heating systems and necessary, to construct 35 RHCs in rural areas. The main improved waste and sewerage systems will be installed at all renovated RHCs. environment risk is related to the disposal of medical waste. Resp: Client | Stage: Imp | Due Date : | Status: Not yet Due Risk Management: To help improve healthcare waste management, training will be delivered to healthcare personnel and adequate procedures will be enforced. Resp: Client | Stage: Impl | Due Date : | Status: Not yet Due Risk Management: The existing EMP will be updated, and there will be appropriate supervision of the civil works. Resp: Client | Stage: Prep | Due Date : | Status: Not yet Due 3.3 Program & Donor Rating: Low Description: The renewed strong partnership in supporting the reforms with EU/WHO Project may fade out. Risk Management: The Bank team will continuously consult with WHO and other development partners. WHO has started a new TA program that will last for three years and will contribute to the same reforms HSSAP is supporting. Resp: partners | Stage: Impl | Due Date : | Status: Not yet Due 3.4 Implementation & Sustainability Rating: Moderate Description: Constraints in existing monitoring and evaluation systems, and in consultants’ contract management Risk Management: The Bank team will continue to put emphasis on results, and use the revised results framework as a mechanism to regularly review performance and keep the emphasis towards results. Resp: Bank | Stage: Imp | Due Date : | Status: Not yet Due Comments: 4. Project Team Proposed Rating Before Review 4.1. Preparation Risk Rating: Moderate 5.2. Implementation Risk Rating: Moderate Comments: 5. Risk Team 5.1. Preparation Risk Rating: Moderate 6.2. Implementation Risk Rating: Moderate 28 Type of Risks Rating: Level of Risk Comments: (this section will not print if there is no « Risk Team » Review) A Medium-L (moderate) risk rating is suggested for preparation and implementation because the Project supports a fairly ambitious reform which requires good coordination across ministries and agencies with structural implementation constraints. (June 15, 2011) 6. Overall Risk Following Review 6.1. Preparation Risk Rating: 7.2. Implementation Risk Rating: Comments: 29 ANNEX 3: LIST OF THE SELECTED 35 RHC FACILITIES TO BE CONSTRUCTED/RENOVATED UNDER THE AF No. District Title of the primary health care institution 1. Anenii Noi Health Centre Geamăna 2. Cahul Health Centre Colibaşi 3. Cimişlia Health Centre Gura Galbenei 4. Criuleni Health Centre Maşcăuţi 5. Călăraşi Health Centre Vîlcineţ 6. Căuşeni Health Centre Tocuz 7. Donduşeni Health Centre Ţaul 8. Hînceşti Health Centre Bujor 9. Chişinău Health Centre Băcioi 10. Făleşti Health Centre Glinjeni 11. Floreşti Health Centre Prodăneştii Noi 12. Glodeni Health Centre Fundurii Vechi 13. Ialoveni Health Centre Puhoi 14. Leova Health Centre Iargara 15. Nisporeni Health Centre Iurceni 16. Ocniţa Health Centre Clocuşna 17. Orhei Health Centre Ghetlova 18. Nisporeni Health Centre Cioreşti 19. Rîşcani Health Centre Mihăilenii Vechi 20. Sîngerei Health Centre Copăceni 21. Soroca Health Centre Căinarii Vechi 22. Taraclia Health Centre Valea Perjei 23. Teleneşti Health Centre Mîndreşti 24. Hînceşti Health Centre Lăpuşna 25. Hînceşti Health Centre Bozieni 26. Ştefan Vodă Health Centre Talmaza 27. Şoldăneşti Health Centre Zahorna 28. Ungheni Health Centre Năpădeni 29. Ceadîr-Lunga Health Centre Chiriet Lunga 30. Vulcăneşti Health Centre Cişmichioi 31. Anenii Noi Health Centre Varniţa 32. Cantemir Health Centre Ciobalaccia 33. Căuşeni Health Centre Săiţi 34. Dubăsari Health Centre Cocieri 35. Drochia Health Centre Ochiul Alb 30 Unit Costs per Square Meter for New Construction Wether to construct new RHCs or rehabilitate existing ones has been a debated issue since the sub-component was designed. Interesting data have become available on the advantages and disadvantages of new construction versus rehabilitation of existing buildings. Main data for the first batch are shown below. Type of project Outside walls No. Name of Facility Total cost, lei Lei, cost/ m2 New Rehabilitation area, m2 1 Chiperceni, Orhei X 258,64 1,837,505.00 7,104.50 2 Moscovei, Cahul X 290,77 1,243,115.00 4,275.25 3 Baurci, Ceadir Lunga X 340,38 2,196,935.00 6,454.35 4 Satul Nou, Cimislia X 206,48 1,680,930.00 8,140.90 5 Leuseni, Telenesti X 207,22 1,201,202.00 5.796.74 6 Bulboaca, Anenii-Noi X 457,05 1,815,340.00 3,971.90 7 Balabanesti, Criuleni X 253,04 1,679,296.00 6,636.50 8 Raspopeni, Soldanesti X 312,00 1,514,845.00 4,855.30 9 Vascauti, Floresti X 166,58 1,495,987.50 8,980.60 10 Otaci, Ocnita X 306,82 1,913,142.00 6,235.40 11 Corjeuti, Briceni X 552,30 1,655,865.00 2,998.13 12 Recea, Riscani X 393,56 2,191,796,50 5,596.15 13 Costesti, Ialoveni X 464,51 2,241,405.30 4,825.30 14 Zabriceni, Edinet X 206,48 2,097,330.00 10,157.50 15 Iabloana, Glodeni X 247,72 1,205,634.95 4,866.90 Data source: MOH engineering unit, March 27, 2009. As the above table shows, cost per square meter (sq. m.) varies considerably for new construction, as well as for rehabilitation work:  The cost per sq. m. for new construction ranges between Lei 7,104.50 – 10,157.50 (42 percent variation).  The cost per sq. m. for rehabilitation work ranges between Lei 2,998.13 – 6,636.50 (121 percent variation). The gross floor areas of the new and rehabilitated facilities also vary considerably. While the gross floor area of the new facilities is a function of the number of family doctors and their supporting staff, the size of the rehabilitated facilities is largely a result of the size and conditions of the existing buildings, several of which were built according to norms established more than 40 years ago.  The largest new RHC was sq. m. 258,64  The smallest new RHC as sq. m. 166,58  The most expensive (not the largest) new RHC cost Lei 2,097,330.00  The cheapest new RHC (also the smallest) cost Lei 1,495,987.50  The largest rehabilitated RHC was sq.m. 552,30  The smallest rehabilitated RHC was sq. m. 207,22 31  The most expensive (not the largest) rehabilitated RHC cost Lei 2,241,405.30  The cheapest rehabilitated RHC (also the smallest) cost Lei 1,210,202.00 Eight of the rehabilitated RHCs were larger than the biggest new RHC, and three of the rehabilitated RHCs were more expensive than the most expensive of the new-built RHCs. 32 ANNEX 4: TECHNICAL ASSISTANCE ACTIVITIES TO SUPPORT PRIMARY HEALTH CARE AND HOSPITAL REFORMS Estimated Description Budget Rationale (USD) Technical assistance to improve 150,000 This activity will go hand in hand with physical quality of primary health care rehabilitation of RHCs, and would bring value added to through developing and the work of FDs. It would build upon the work carried implementing at least 60 out under: standardized protocols for family (i) Millennium Challenge Corporation Project (2008- doctors (FDs) to diagnose and 2010), which helped develop 128 clinical protocols, and treat most commonly encountered established the National Assessment and Accreditation pathologies. Council; (ii) EU-supported TACIS Project, ―Strengthening Primary Care in Moldova‖, which established a program of systematic training of FDs. The objective of this TA is to progressively expand the number of standardized work place protocols, explicitly focusing on active prevention and early detection of the most common non-communicable diseases (cardiovascular disease and cancer), and provide further training to FDs for the full-implementation of the protocols already established. Training, dissemination, and monitoring initiatives would be integral parts of this activity. Technical assistance to strengthen 140,000 This activity would build upon and scale up the the role of primary care through managerial training provided to FDs under the EU- training of family doctors, supported TACIS Project, ―Strengthening Primary Care managers, and accountants in in Moldova‖, under which 1,100 FDs were trained primary health care facilities’ during 2009-2010 for two weeks on ―Communication management and Practice Management‖, and during three days in ―Management of Primary Health Care‖. Additional training would be delivered over a period of 12 months using material adapted from TACIS Project (―Management of Primary Health Care‖ module), with a focus on HR management. Technical assistance to improve 260,000 Under HSSAP, the GoM already developed a oncology health service document: ―Oncology Services Feasibility study‖, effectiveness through which outlined a vision of more decentralized oncology decentralization of radiotherapy services in Moldova, with creation of Regional and chemotherapy services Oncology Centers in Balti and Cahul Regions. This TA activity will develop detailed, costed, plans for upgrading Balti and Cahul hospitals’ infrastructure in order to enable them to provide chemotherapy and radiotherapy services. It will include a comprehensive plan for training personnel, will identify opportunities for PPPs, based on the ongoing PPP program in the Institute of Oncology, Chisinau. 33 Estimated Description Budget Rationale (USD) Technical assistance to increase 195,000 In 2009-2010 the HSSAP supported a study: ―The cost-effectiveness and quality of Hospital Master Plan‖, which outlined an optimization health services provided by plan for the hospital network, with strengthened regional hospitals by developing regional poles (―hospital districts‖) in order to action plans /activities at regional decentralize services and increase appropriateness of level (Regionalization Plan) for use of higher levels of hospital care in Chisinau. The the three regions of Hincesti, current MoH leadership is committed to expedite Cimislia, Leova and Basarabesca hospital sector regionalization in line with the Master Plan. The operational plan for hospital regionalization of Hincesti, Cimişlia, Leova and Basarabeasca shall include an accurate estimate of bed needs with different profiles, including the long-term care and rehabilitation care; patients’ flows within the referral system within this region; mechanism of cooperation with emergency and primary health care; and a business plan for each hospital. Technical assistance in the 110,000 MoH requests development of a ―business plan‖ for re- context of the need to reduce profiling of some rayon hospitals into long-term care, excess capacity of hospital rehabilitation institutions. This program would include services by developing the accurate cost and savings estimates related to the rehabilitation health services and creation of additional long-term and rehabilitation beds, long-term health care and the reduction of acute care beds, clarify patients’ flows and referral system within these services, and outline new mechanisms of cooperation between health and social assistance services. Technical assistance for the 105,000 In July 2010 MoH signed a cooperation agreement with implementation of public-private the IFC on technical assistance for implementation of partnership (PPP) projects in the PPP projects in tertiary care. Subsequently, the MoH health sector has established a working group led by the Minister of Health, and including the National Health Insurance Company (CNAM), with the purpose of initiating new PPP projects. At present, IFC has embarked upon implementation of PPP projects in two areas: construction, financing, equipping, and operation of radiology centre within Oncology Institute, and diagnostic imaging centre within Republican Clinical Hospital. This activity would contribute to expand PPPs in the areas of acute neurological rehabilitation services, of labs, and of diagnostic imaging services in regional hospitals. Its main objective is to contribute to expand institutional capacity to manage PPPs. 34 ANNEX 5: PROCUREMENT PLAN TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method 1. Health Sector Modernization Component 1.1. Capacity Development and Sector Regulation 1.1.A. National Health Accounts Plan August 2007 September 2007 September 2007 October 2007 October 2007 May30, 2008 1.1.A.1. IT equipment NHA office G/SH Prior Actual August 1, 2007 December 25, 2007 April 2, 2008 May 12, 2008 May 14, 2008 June 16, 2008 Plan October 2007 November 2007 December 2007 December 2007 December 2007 March 31, 2010 1.1.A.2.1. International ITA NHA Development CS/CQ Prior Actual April 10, 2008 April 22, 2008 May 15, 2008 August 5, 2008 August 11, 2008 March 31, 2011 Plan August 2007 September 2007 October 2007 October 2007 October 2007 August 31, 2011 1.1.A.2.2. Local TA NHA Development CS/CQ Prior Actual September 2009 October 2009 November 2009 January 14, 2010 January 15, 2010 Plan January 2008 - - - March 2008 - 1.1.A.3.1 Training courses, conferences T/AP Prior Actual January 2008 - - - 2008-2009 2008-2009 NHA guide translation for NHA Plan 1.1.A.3.2 CS Prior development Actual June 26, 2009 August 6, 2009 September 16, 2009 September 25, 2009 January 31, 2010 Memornadum of Undrstanding for NHA Plan 1.1.A.4.1 CS Prior development Actual April 2009 - - - May 14, 2009 April 30, 2012 Software development and trainings in Plan May 2011 August 2011 September 2011 September 2011 October 2011 February 1, 2012 1.1.A.4.2 use of the software of all medical service NCS Post providers Actual June 2011 August 18, 20-11 September 2, 2011 September 13, 2011 Server, personal computer and printers Plan March 1, 2011 April 1, 2011 April 17, 2011 May 30, 2011 June 30, 2011 August 15, 2011 1.1.A.4.3 G/SH Post for NSHM Actual March 25, 2011 April 21, 2011 May 12, 2011 June 2, 2011 Jun3 3, 2011 1.1.B. Policy development capacity development International TA for HR strategy Plan January 2011 February 2011 March 2011 April 2011 May 2011 May 31, 2011 1.1.B.1.1.a CS/IC Post expertise Actual February 2011 April 2011 April 2011 May 2011 June 2011 June 20, 2011 Plan June 10, 2010 1.1.B.1.1.b Local TA for HR strategy development CS/IC Prior Actual December 2009 January 2010 January 2010 March 2010 June 10, 2010 June 10, 2011 Plan 1.1.B.1.1.c IT equipment for the local consultants G/SH Prior Actual December 2, 2009 December 16, 2009 December 30, 2009 February 10, 2010 March 2010 April 3, 2010 Local TA for review and development Plan October 2007 November 2007 December 2007 December 2007 December 2007 May 2009 for health sector legislative framework 1.1.B.1.2 CS/IC Prior for coherency and international Actual May 26, 2009 May 29, 2009 June 12, 2009 November 10, 2009 June 2010 December 10, 2010 harmonization International TA for development of Plan January 2008 - - - March 2008 February 28, 2009 1.1.B.1.3 policy options for public-private CS/IC Prior partnership Actual April 18, 2008 April 22, 2008 July 5, 2008 August 14, 2008 August 14, 2008 February 28, 2009 Training courses/Workshops/Study Plan 2011 - - - 2011 August 2013 1.1.B.2. T/AP Prior tours/Conferences Actual - - - - 35 - TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method Sub-total 1.1 Health Care Financing and Provider 1.2. Payment 1.2.A. Strategy to expand insurance coverage Plan December 2007 January 2008 January 2008 February 2008 February 2008 May 30, 2008 1.2.A.1. IT equipment G/SH Prior Actual December 7, 2007 December 25, 2008 April 2, 2008 May 12, 2008 May 14, 2008 June 16, 2008 International TA health insurance Plan January 2008 February 2008 March 2008 March 2008 May 2008 1.2.A.2.1. CS/SS Prior management and policy June, 26, 2008 July 1, 2008 - - November 25, 2008 December 16, 2008 Actual Local TA health insurance management Plan November 2007 December 2007 January 2008 January 2008 February 2008 1.2.A.2.2. CS/IC Prior and policy - December 29, 2008 February 5, 2009 August 1, 2009 Actual July 15, 2008 August 7, 2008 Plan July 2010 August 2010 August 2010 - September 2010 1.2.A.2.3. Household survey - Health modul CS/SS Prior Actual July 2010 - November 1, 2010 February 1, 2011 Training courses health insurance Plan May 2008 - - - August 2009 1.2.A.3. T/AP Prior management and policy June 2008 June 2008 June 20, 2008 Actual 1.2.B. Strengthening of Purchasing Function, Provider Payment and Pricing Methodology IT Equipment for test hospitals and Plan December 2010 December 2010 January 2011 February 2011 March 2011 May 20, 2011 1.2.B.1. G/SH Prior CNAM December 2011 March 2011 April 8, 2011 June 7, 2011 Actual February 11, 2011 February 11, 2011 International TA payment systems and Plan December 2007 January 2008 January 2008 February 2008 March 2008 1.2.B.2.1. CS/QCBS Prior case-mix development August 3, 2009 April 22, 2010 July 1, 2010 June 30, 2012 Actual August 7, 2009 October 20, 2009 Training courses/Workshops/Study Plan June 2012 - - - June 2012 June 2012 1.2.B.3. T/AP Prior tours/Conferences Actual Sub-total 1.2 1.3. Primary Health Care Development Design and supervisions of 39 PHC 1.3.A.1 CS/CQ Prior Facilities Plan 31.03.2011; Actual June 2008 July 10, 2008 July 23, 2008 December 8, 2008 October 10, 2008 30.06.2011 Design and supervisions of 34 PHC 1.3.A.2 CS/CQ Prior Facilities Plan February 2011 March 2011 May 2011 Iune 2011 October 2011 August, 2013 Actual March 2011 May 6, 2011 May 20, 2011 August 5, 2011 Prior/Po 1.3.B.1 Construction of 39 PHC facilities CW/NCB st Plan December 2007 February 2008 March 208-08 May 2008 June 2008 30-Jun-11 Actual 2009-2011 2009-2011 2009-2011 2009-2011 2009-2011 1.3.B.2 Construction of 35 PHC facilities CW/NCB Post Plan February 2012 March 2012 April 2012 May 2012 June 2012 August, 2013 Actual 1.3.B.3.a Local engineer civil works rural PHC CS/IC Prior Plan March 2008 April 2008 April 2008 May 2008 June 2008 August31, 2011 Actual August 2007 August 2007 August 2007 September 2007 October 1, 2007 May 31, 2011 1.3.B.3.b Local engineer civil works rural PHC CS/IC Prior Plan June 20111 June 2011 July 2011 August 2011 August 2011 August 31, 2013 36 TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method Actual June 2011 June 2011 July 2011 August 2011 September 2011 Vehicle procurement and 1.3.B.3.c G/SH Prior Plan June 2011 maintenance Actual February 23, 2009 February 24, 2009 March 12, 2009 March 20, 2009 April 10, 2009 May 2009 International TA for PHC curricula 1.3.C.1. CS/CQ Prior Plan revision Actual April 18, 2008 April 22, 2008 June, 17, 2008 December 2, 2008 December 5, 2008 September 9, 2009 Trainig for PHC staff on strengthening managerial capacity of 1.3.C.2. CS/CQ Prior Plan October 2011-11 November 2011 November 2011 December 2011 December 2011 PHCs (which are becoming autonomous) December 2012 Actual Local TA for development and implementation of 60 standardized 1.3.C.3 CS/CQ Prior Plan September 2011 October 2011 October 2011 November 2011 November 2011 work place protocols for family doctors August 2013 Actual September 2011 September 2011 September 2011 Training courses/Workshops/Study 1.3.C.4 T/AP Prior Plan January 2008 March 2008 tours/Conferences Actual October 27, 2008 October 31, 2008 Sub-total 1.3 Hospital Capacity Assessment and 1.4. modernisation Rehabilitation of the Republican 1.4.A. Clinical Hospital 1.4.A.1. RCH Feasibility Study CS/CQ Prior Plan September 2007 October 2007 January 2008 January 2008 February 2008 August 5, 2008 Actual November 23, 2007 November 28, 2007 December 21, 2007 January 15, 2008 January 24, 2008 December 15, 2008 1.4.A.2 Design of RCH CS/QCBS Prior Plan May 2009 June 2009 July 2010 September 2010 December 2010 December 2011 Actual February 2, 2010 April 1, 2010 June 17, 2010 October 2010 January 5, 2011 May 31, 2012 Civil works for rehabilitation RCH - 1.4.A.3 CW/ICB Prior Plan February 2011 March 2011 September 15, 2011 October 2011 November 2011 May 2013 new surgical bloc Actual June 2011 August 5, 2011 Technical Assistance Hospital Network Planning and 1.4.B optimisation Plan August 2007 October 2007 November 2007 December 2007 December 31, 2009 1.4.B.1.a National Hospital Masterplan CS/QCBS Prior September 2010, Actual 2008 November 10, 2008 November 20, 2008 March 11, 2008 April 29, 2008 International TA for development of the Plan October 2011 December 2011 December 2011 December 2011 January 2012 December 2012 1.4.B.1.b action plans at regional level for a pilot CS/CQ Prior Actual region (Regionalization plan) International TA for the rehabilitation Plan November 2011 December 2011 January 2012 February 2012 March 2012 October 31, 2012 1.4.B.1.c health care services and long term care CS/CQ Prior development Actual Plan April 2009 1.4.B.2.a Oncology Institute Feasibility Study CS/CQ Prior Actual October 1, 2008 October 1, 2008 December 5, 2008 March 4, 2009 July 14, 2009 April 30, 2010 37 TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method International TA for chemo- and Plan August 2011 October 2011 December 2011 January 2011 February 2011 December 2012 1.4.B.2.b CS/QCBS Prior radiotherapy services decentralization Actual September 2011 September 2011 October 2011 Local TA for Coordination for hospital Plan December 2008 December 2008 December 2008 January 2009 February 2009 August 21, 2011 1.4.B.3.a CS/IC Prior network planning Actual December 2, 2008 December 16, 2008 December 30, 2008 February 10, 2008 March 23, 2009 June 30, 2010 International TA for development the Plan November 2011 December 201111 February 2012 March 2012 April 2012 March 31, 2013 1.4.B.4 CS/CQ Prior PPP projects in health sector Actual Training courses/Workshops/Study Plan December 2007 *- - - January 2008 1.4.B.5. T/AP Prior tours/Conferences Actual 2008-2010 2008-2010 Plan 1.4.B.6 Vaccine procurement SS Prior Actual March 2008 March 2008 December 31, 2008 Sub-total 1.4 TOTAL 1 2. Social Assistance and Welfare Component Development of Social Assistance 2.1. Database Plan March 2011 May 2011 August 2011 September 2011 October 2011 March 2012 2.1.1 Personal Computers for Social Workers G/ICB Prior Actual Personal Computers for Social Workers 2.1.1.a.1 G/SH Prior Actual July 7, 2008 July 8, 2008 July 9, 2008 August 5, 2008 August 20, 2008 October 17, 2008 for training Personal Computers for Social Workers 2.1.1.a.2 G/SH Prior Actual July 2010 August 3, 2010 August 17, 2010 August 18, 2010 19-Sep-10 November 30, 2010 and administration* IT equipment for the MoLSPF and Plan October 1, 2011 2.1.1.a.3 G/SH Post Social Workers Actual Plan March 2008 March 2008 July 2008 March 2008 July 2008 2.1.1.b Printers G/SH Prior Actual June 27, 2008 July 19, 2008 July 19, 2008 October 17, 2008 Plan June 2010 July 2010 October 2010 November 2010 December 2010 October 1, 2012 2.1.1.c Software development inc. upgrade G/ICB Prior Actual June 2010 July 15, 2010 Sept. 9, 2010 November 2010 December 2010 Training for social workers (computer Plan May 2011 June 2011 August 1, 2011 September 1, 2011 October 2011 August 31, 2011 2.1.1.d CS/CQ Prior skills) Actual August 2011 August 2011 September 2011 Study materials and office equipment , Plan 2.1.1.e G/SH Prior printing materials Actual 2008-2009 2008-2009 Local TA for IT development (for Plan August 31, 2011 2.1.1.f CS/IC Prior software) Actual February 1, 2010 February 2, 2010 March 3, 2010 March 2010 April 1, 2010 Plan December 2010 December 2010 December 2010 December 2010 January 2011 August 31, 2011 2.1.1.g Local TA for social benefits CS/SS Prior Actual December 2010 December 2010 December 2010 December 2010 January 2011 2.1.1.h Local TA for social suport CS/IC Prior Plan February 2011 February 2011 March 2011 March 2012 March 2011 August 31, 2011 38 TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method administration Actual December 2010 April 2011 April 2011 April 2011 May 2011 Local TA for IT development Plan February 2011 February 2011 March 2011 March 2012 March 2011 August 31, 2011 2.1.1.i CS/IC Prior (hardware/telecomunication) Actual March 2011 April 2011 April 2011 April 2011 May 2011 Plan October 2011 October 2011 November 2011 November 2011 December 2011 August 31, 2011 2.1.1.j International TA for Social Benefits CS/SS Prior Actual Plan June 2010 July 2010 July 2010 August-10 September 2010 4/30/2010 2.1.2 PR Company for information Campaign CS/CQ Prior Actual October 2010 April-11 Plan December 2010 January 2011 January 2011 February 2011 February 2011 April-11 2.1.3 Printing material for ajutor social G/SH Prior Actual December 2010 January 2011 January 2011 February 2011 February 2011 April-11 Plan April 2011 April 2011 May 2011 June 2011 June 2011 31-Dec-11 2.1.4 Functional review of MLSPF CS/CQ Prior Actual June/11 June/11 July 2011 August 2011 TOTAL 2 3. Institutional Support 3.1. MoH Implementation Team Plan July 2007 July 2007 August 2007 September 2007 September 2007 August 31, 2011 3.1.1.a Procurement Consultant CS/IC Prior Actual July 2007 July 2007 August 2007 September 2007 October 1, 2007 8-Nov-08 Plan August 31, 2011 3.1.1.b Procurement Consultant CS/IC Prior Actual November 1, 2010 November 1, 2010 December 1, 2010 25-Dec-09 19-Jan-09 31-Jan-11 Plan August 31, 2013 3.1.1.c Procurement Consultant CS/SS Prior Actual 1-Feb-11 Plan August 1, 2010 August 1, 2010 September 2010 September 2010 September 2010 August 31, 2011 3.1.1.d Procurement Consultant Assistant CS/IC Prior Actual August 1, 2010 August 1, 2010 September 2010 September 2010 November 1, 2010 31-Jan-11 Plan August 2011 August 2011 September 11 September 11 October 11 August 31, 2013 3.1.1.e Procurement Consultant Assistant CS/IC Prior Actual August 2011 August 2011 September 11 September 11 Plan July 2007 July 2007 August 2007 September 2007 September 2007 August 31, 2013 3.1.2.a Financial Manager CS IC Prior Actual July 2007 July 2007 August 2007 September 2007 October 6, 2009 Plan August 1, 2010 August 1, 2010 September 2010 September 2010 September 2010 August 31, 2013 3.1.2.b Financial Manager Assistant CS/IC Prior Actual August 1, 2010 August 1, 2010 September 10 September 2010 November 1, 2010 Plan July 2007 July 2007 August 2007 September 2007 September 2007 August 31, 2011 3.1.3.a Coordinator/ M&E Consultant CS/IC Prior Actual July 2007 July 2007 August 2007 September 2007 October 1, 2007 June 14, 2010 Plan August 31, 2013 3.1.3.b Coordinator/ Hospital Sector Consultant CS/SS Prior Actual June 14, 2010 - - - July 1, 2010 Plan July 2007 July 2007 August 2007 September 2007 September 2007 August 31, 2013 3.1.4. Project Assistant CS/IC Prior Actual July 2007 July 2007 August 2007 September 2007 October 1, 2007 39 TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method Plan March 2008 April-08 April-08 May-08 June 2008 August 31, 2013 3.1.5 Driver CS/IC Prior Actual 23-Jun-09 2June 5, 2009 November 10, 2009 Plan July 2007 - - - September 2007 August 31, 2013 3.1.6 Training T/AP Prior Actual July 2007 November 2007 Incremental Operating Costs (inc. Plan July 2007 - - - September 2007 August 31, 2013 3.1.7 IOC Communications) Actual July 2007 November 2007 Plan August 31, 2013 3.1.8 Annual Financial Audit CS/LCS Prior Actual TOTAL 1+3.1 3.2. MoLSPF implementation support 3.2.1 Consultants Plan December 2010 December 2010 December 2010 December 2010 January 2011 August 31, 2011 3.2.1.1 Project manager in Social Assistance CS/SS Prior Actual December 2010 December 2010 December 2010 December 2010 January 2011 Plan January 2008 January 2008 February 2008 February 2008 March 3, 2008 August 31, 2011 3.2.1.2 Project Assistant CS/IC Post Actual January 2008 January 2008 February 2008 February 2008 March 3, 2008 Plan August 31, 2011 3.2.1.3 Driver CS/IC Post Actual March 1, 2010 March 10, 2010 April 1, 2010 April 30, 2010 May 6, 2010 Plan September-10 October 2010 January 2011 January 2011 February 2011 August 31, 2011 3.2.1.4 Procurement Consultant CS/IC Prior Actual September-10 October 2010 January 2011 January 2011 February 2011 Plan September-10 October 2010 January 2011 January 2011 February 2011 August 31, 2011 3.2.1.5 Financial Consultant CS/IC Prior Actual September-10 October 2010 January 2011 January 2011 February 2011 Plan July 2007 - - September 2007 August 31, 2011 3.2.2. Training T/AP Prior Actual July 2007 November 2007 Incremental Operating Costs, including Plan July 2007 - - - September 2007 August 31, 2011 3.2.3. IOC vehicle and fuel Actual July 2007 November 2007 TOTAL 3.2 TOTAL 2+3.2 Additional financing 4. GRANT # TF092641 Procurement and distribution of Plan August 2008 August 2008 4.1 G/ DC Prior commodities December 31, 2009 Actual August 2008 February 5, 2009 Plan August 2008 4.2 Cash transfers to institutions AP Prior Actual Plan February 2011 May 2011 July 30, 2011 4.2.1 Cash transfers to MoH institutions AP Prior Actual 40 TYPE Plan vs. (BD/RFP) Bid Invitation/ Bid Contract Item Description Proc. Review Bid opening Contract Signing Actual 1. Preparation GPN/SPN/Local Evaluation Completion Method Plan April 2011 August 2011 4.2.2 Cash transfers to MLSPF institutions AP Prior Actual 4.3 Local TA 4.3.1 E&M/Coordination Consultant CS/IC Prior Actual August 2008 September 1, 2010 September 30, 2010 October 30, 2010 November 12, 2008 January-09 Financial Management and 4.3.2 CS/IC Prior Actual August 2008 September 1, 2010 September 30, 2010 October 30, 2010 November 24, 2008 February-09 Disbursement Consultant 4.3.3 Financial Management Consultant CS/IC Prior Actual August 2008 September 1, 2010 September 30, 2010 October 30, 2010 November 24, 2008 July 31, 2010 4.3.4 Local TA on Monitoring and Evaluation CS/CQ Prior Actual June 5, 2009 June 19, 2009 September 24, 2009 July 5, 2010 November 5, 2010 4.4 Operational costs IOC 4.4.2. Incremental Operating Costs MSPFC IOC - Plan August 2008 4.5 Audit CS/LCS Prior Actual 2009-2011 TOTAL GRANT 41 IBRD 33448R 27°E 28°E 29°E 30°E Dnes tr To Vinnytsya UKRA INE To Chernivtsi Moghiliov- To Vinnytsya Ocnita Podolski Briceni MOLDOVA Donduseni B To Chernivtsi Edinet Soroca e Drochia s s 48°N Camenca 48°N Rîscani s Floresti Nist ru a Costesti Soldanesti ˘ r r Glodeni Balti Rîbnita Rezina Balatina a a Pr Sîngerei ut To Voznesens'k r Falesti ˘ Telenesti 0 10 20 30 40 Kilometers a Chiperceni b Orhei 0 10 20 30 Miles RO MAN I A Sculeni Dubasari ˘ TRANSNISTRIA i i To Pascani Mt. Balanesti Calarasi ˘˘ Criuleni (430 m) a Ungheni Straseni ˘ Grigoriopol Nisporeni ˘ Stauceni To Zhmerynka 47°N ˘ CHISINAU 47°N ˘ Lapusna Ialoveni Anenii Noi Tiraspol Hîncesti Bender Leuseni (Tighina) Slobozia ˘ Cainari Causeni ˘ To Odesa Plain Cimislia c Stefan-Voda N ˘ ist To Birlad ea ru g Leova Bu This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Comrat Basarabeasca Group, any judgment on the legal status of any territory, or any To Birlad endorsement or acceptance of such boundaries. Cantemir 27°E ˘ ˘ GAGAUZIA Ceadîr- To Artsyz UKRA INE Lunga MO LDO VA 46°N 46°N Prut SELECTED CITIES AND TOWNS Cahul Taraclia AUTONOMOUS TERRITORIAL UNIT CAPITALS ˘ ˘ GAGAUZIA RAIONS OR MUNICIPALITIES CAPITALS* ˘ Vulcanesti NATIONAL CAPITAL RIVERS MAIN ROADS RAILROADS To Imayil B l ack AUTONOMOUS TERRITORIAL UNIT BOUNDARIES To Bucharest Sea and Constanta RAIONS OR MUNICIPALITIES BOUNDARIES INTERNATIONAL BOUNDARIES *Names of the raions or municipalities are identical to their capitals. 28°E 29°E 30°E MAY 2007 The original had problem with text extraction. pdftotext Unable to extract text.