Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467)

Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467)

EUROPE AND CENTRAL ASIA | | Health, Nutrition & Population Global Practice | Public Disclosure Authorized IBRD/IDA | Adaptable Program Loan | FY 2007 | Seq No: 17 | ARCHIVED on 04-Sep-2015 | ISR19907 |

Implementing Agencies: Ministry of Health, HSMP-PIU

Key Dates

Key Project Dates

Board Approval date:08-Mar-2007 Effectiveness Date:06-Jun-2007 Planned Mid Term Review Date:-- Actual Mid-Term Review Date:17-May-2010 Original Closing Date:31-Dec-2012 Revised Closing Date:29-Feb-2016 Public Disclosure Authorized

Project Development Objectives

Project Development Objective (from Project Appraisal Document) The overall objective of the HSRP Program remains unchanged: to improve the organization of the health care system in order to provide more accessible, quality and sustainable health care services to the population, in particular to the most vulnerable groups, and to better manage public health threats. This Project aims at: (i) scaling up family medicine based primary health care reform by expanding the renovation of primary health care facilities and upgrading of the medical equipment in the remaining marzes; (ii) optimizing and upgrading hospital networks in the remaining marzes; (iii) strengthening Government's capacity to develop and monitor effective health sector policies in the area of health financing, resource allocation and provider payments; and (iii) expanding investment in human resources to include formal and continuous education in health (medical, nursing, auxiliary health professionals).

Public Disclosure Authorized Has the Project Development Objective been changed since Board Approval of the Project Objective? No

PHRPDODEL

Components

Name COMPONENT A: FAMILY MEDICINE DEVELOPMENT:(Cost $10.15 M) COMPONENT B: HOSPITAL NETWORK OPTIMIZATION:(Cost $37.77 M) COMPONENT C: INSTITUTIONAL STRENGTHENING:(Cost $4.82 M) COMPONENT D: PROJECT MANAGEMENT:(Cost $2.20 M) Public Disclosure Authorized

Overall Ratings

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Name Previous Rating Current Rating

Progress towards achievement of PDO  Satisfactory  Moderately Satisfactory Overall Implementation Progress (IP)  Satisfactory  Satisfactory Overall Risk Rating  Low  Low

Implementation Status and Key Decisions

Progress towards achieving project objectives is on track and implementation of project activities is proceeding as planned. All activities are expected to be completed by the closing date of February 29, 2016. Specifically, Component A (Family Medicine Development): Civil works of ambulatories in all communities of (, , Voskevan and Berdavan), Lori (Lernapat), Ararat (Qaxcrashen) and Armavir (Aknalich) marzes were completed in December 2014 and ambulatory in Voskevan community of Tavush marz was completed in May 2015. Ten renovated ambulances were provided to Marz health facilities in December 2014. Renovation of Metsamor MC Polyclinic was completed in January 2015, and medical equipment and furniture were provided in May 2015. Savings under the AF has made it possible to construct an additional 5 rural ambulatories in the communities of Ararat (Lanjazat and Mkhchian), Vayots Dzor (Shatin), Aragacotn (Byurakan) and Lori (Urut) marzes. Component B (Hospital Network Optimization and Modernization): Contracts for medical equipment and furniture for MC and Kapan MC are ongoing. All civil works are expected to be completed before the Project closing date. The last MCs benefitting from the project where civil works are still ongoing are: Meghri regional center (64% completed), Kapan MC (82%), Berd MC (completed), and Chambarak MC (43%). Based on updated information from September 4th, 90% of works at Chambarak are completed, with all works expected to complete by the end of September. Provision of equipment to Chambarak will be completed by mid-October. Component C (Strengthening Government capacity: National Health Sector Performance Assessment Report (HSPA) – Technical Assistance (TA) for Diagnosis Related Groups system development (AP-DRG).The HPIU has prepared TOR for International Consultancy for the revision of current hospital reimbursement system and development of recommendations for introduction and implementation of reimbursement mechanisms based on a “case mixed” approach.

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Risks

Systematic Operations Risk-rating Tool

Risk Category Rating at Approval Previous Rating Current Rating

Political and Governance  --  Low  Low Macroeconomic  --  Low  Low Sector Strategies and Policies  --  Low  Low Technical Design of Project or Program  --  Low  Low Institutional Capacity for Implementation and -- Low Low Sustainability    Fiduciary  --  Low  Low Environment and Social  --  Low  Low Stakeholders  --  Low  Low Other  --  --  -- Overall  --  Low  Low

Results

Project Development Objective Indicators

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PHINDPDOTBL

 Proportion of Armenian Population covered by qualified family medicine practices (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 47% 91% 91% 95%

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This PDO indicator will fall short of being met by the closing date of February 29, 2016. The mission was informed that the State budget will not finance further training of family medicine providers, therefore the actual target of 91% will remain (end of project target is 95%).

PHINDPDOTBL

 Increased utilization of a) out-patient services; and b) in-patient services by the poorest income quintile (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Increased Value a) 3.9%; b) 3.1% a) 2,9%; b) 4.0% a) 2,9%; b) 4.0% Utilization

Date 22-Nov-2011 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDPDOTBL

 Health Sector Performance Report issued once every two years (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

HSPA for 2012 HSPA for 2012 HSPA HSPA for 2006 year published in Dec. 2013; published in Dec. 2013; Value published every published new survey planned for new survey planned for two year 2015 2015

Date 01-Sep-2007 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDPDOTBL

 Perceived quality of care in marzes increased (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

a) PHC: urban: 64.1%; a) PHC: urban: 64.1%; rural: 73.2%; b) rural: 73.2%; b) hospital: Value 64.3% 75% hospital: urban: 73.7%; urban: 73.7%; rural: rural: 66.8% 66.8%

Date 30-Dec-2007 23-Mar-2015 09-Jul-2015 29-Feb-2016

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PHINDPDOTBL

 ALOS in marz hospitals decreased close to OECD average (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 7.7 6.4 6.6 6.5

Date 01-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDPDOTBL

 National Health Accounts report published annually (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

NHA for 2012 published 2006 NHA report NHA for 2012 Value in Dec. 2013, new Annual distributed 2007 published in Dec. 2013 survey planned for 2015

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDPDOTBL

 Public hospitals in project sites that have published financial audit reports from independent audits (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 0 2 4 13

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This PDO indicator will fall short of being met by the closing date of February 29, 2016. Only 4 public hospitals in project sites were able to finance and publish financial audit reports due to lack of funds in other public hospitals (22 hospitals).

PHINDPDOTBL

 Proportion of patients with a) hypertension who had at least one ECG annually; b) ischemic heart disease who had at least one totalcholesterol test annually (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value a) 42%; b) 33% a) 49.5%; b) 46.4% a) 55.2%; b) 53.7% Increased

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Overall Comments

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Intermediate Results Indicators

PHINDIRITBL

 Number of certified FDs trained (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 633 1676 1676 1750

Date 01-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This indicator on the number of certified family doctors will not meet the target of 1750 given that no State budget funds have been allocated in 2015 for re-training. This also slightly impacts on the achievement of PDO indicator number 1 (population covered by family medicine).

PHINDIRITBL

 Number of certified FNs trained (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 568 1804 1804 1950

Date 01-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This indicator on the number of certified family nurses will not meet the target of 1950 given that no State budget funds have been allocated in 2015 for re-training. This also slightly impacts on the achievement of PDO indicator number 1 (population covered by family medicine).

PHINDIRITBL

 Reduction of sq. meters of hospital space (percent of original) in all marzes (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 0% 85% 85% 85%

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 31-Dec-2014

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PHINDIRITBL

 Health personnel receiving training (number) (Number, Core)

Baseline Actual (Previous) Actual (Current) End Target

Value 1201.00 3480.00 3480.00 3700.00

Date 01-Jan-2009 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDIRITBL

 Health facilities constructed, renovated, and/or equipped (number) (Number, Core)

Baseline Actual (Previous) Actual (Current) End Target

Value 0.00 101.00 109.00 100.00

Date 01-Jan-2008 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDIRITBL

 Proportion of health budget allocated to PHC (Percentage, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 35.50 34.60 34.60 43.00

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This indicator is unlikely to be met with the current approved budget of 34.5% for 2015 against a target of 43%.

PHINDIRITBL

 All project hospitals apply updated environmental management guidelines (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value No Yes Yes Yes

Date 01-Jan-2007 23-Mar-2015 09-Jul-2015 29-Feb-2016

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PHINDIRITBL

 State Medical University has a revised students examination system in line with EU countries (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value No revision has been done No No Yes

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This indicator will not be met given the lack of interest of the Head of the Yerevan State Medical University in carrying out a situation analysis of the current examination system, despite repeated efforts by the team to engage on this issue.

PHINDIRITBL

 Increased number of admission in project hospitals (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

Value 29,668 46,966 46,966 40,000

Date 01-May-2009 23-Mar-2015 09-Jul-2015 29-Feb-2016

PHINDIRITBL

 Proportion of key management staff in project hospitals trained on financial management after the results of performed independent audits (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

39 key 1:39 key management 1:39 key management Value 0 management staff staff staff or 100%

Date 31-Dec-2006 23-Mar-2015 09-Jul-2015 29-Feb-2016

Comments This indicator will not meet the target of 39 given that very few project hospitals are able to finance independent audits, currently only staff of four hospitals have been able to complete the audits. Thus far only the Hrazdan MC Chief Doctor was trained for 1.5- 2 months on financial management in the last trimester of year 2013.

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PHINDIRITBL

 Reduction in out-of-pocket payments for essential health services (Text, Custom)

Baseline Actual (Previous) Actual (Current) End Target

a) 33.2% (out-patient); a) 33.2% (out-patient); a) 35.4% (out-patient); b) Value b) 36.1% (in-patient) b) 36.1% (in-patient) Reduction 47.1% (in-patient) (2013 ISLS) (2013 ISLS)

Date 31-Dec-2009 23-Mar-2015 09-Jul-2015 29-Feb-2016

Overall Comments

Data on Financial Performance

Disbursements (by loan)

Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed

P104467 IBRD-79870 Effective USD 19.00 19.00 0.00 18.33 0.67 96%

P104467 IDA-42670 Closed USD 22.00 21.96 0.04 22.87 0.00 104%

Key Dates (by loan)

Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date

P104467 IBRD-79870 Effective 20-Dec-2010 26-Jan-2011 08-Jun-2011 31-Dec-2014 29-Feb-2016 P104467 IDA-42670 Closed 08-Mar-2007 09-Mar-2007 06-Jun-2007 31-Dec-2012 31-Dec-2012

Cumulative Disbursements

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Restructuring History

Level Approved on 11-Mar-2010 ,Level Approved on 19-Mar-2010 ,Level 2 Approved on 26-Mar-2014

Related Project(s)

P121728-Additional Financing for the 2nd Health System Modernization Project (APL2) in Support of the 2nd Phase of the Health Sector

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