ARMENIA Achievements and Challenges in Improving Health Care Utilization A Multiproject Evaluation of the World Bank Support to the Health System Modernization (2004-2016) Report No. 134584 MARCH 20, 2019 © 2019 International Bank for Reconstruction This work is a product of the staff of The World RIGHTS AND PERMISSIONS and Development / The World Bank Bank with external contributions. The findings, The material in this work is subject to copyright. 1818 H Street NW interpretations, and conclusions expressed in Because The World Bank encourages Washington DC 20433 this work do not necessarily reflect the views of dissemination of its knowledge, this work may be Telephone: 202-473-1000 The World Bank, its Board of Executive reproduced, in whole or in part, for Internet: www.worldbank.org Directors, or the governments they represent. noncommercial purposes as long as full attribution to this work is given. Attribution—Please cite the work as follows: The World Bank does not guarantee the World Bank. 2019. Armenia—Achievements accuracy of the data included in this work. The Any queries on rights and licenses, including and Challenges in Improving Health Care boundaries, colors, denominations, and other subsidiary rights, should be addressed to Utilization: A Multi-Project Evaluation of the information shown on any map in this work do World Bank Publications, The World Bank World Bank Support to the Health System not imply any judgment on the part of The Group, 1818 H Street NW, Washington, DC Modernization (2004-2016). Independent World Bank concerning the legal status of any 20433, USA; fax: 202-522-2625; e-mail: Evaluation Group, Project Performance territory or the endorsement or acceptance of [email protected]. Assessment Report 134584. Washington, DC: such boundaries. World Bank. Report No.: 134584 PROJECT PERFORMANCE ASSESSMENT REPORT ARMENIA HEALTH SYSTEM MODERNIZATION PROJECT (APL I) IN SUPPORT OF THE FIRST PHASE OF THE HEALTH SECTOR REFORM PROGRAM IDA CREDIT NO. 39200 HEALTH SYSTEM MODERNIZATION PROJECT (APL II) IN SUPPORT OF THE SECOND PHASE OF THE HEALTH SECTOR REFORM PROGRAM IDA CREDIT NO 42670 ADDITIONAL FINANCING FOR THE HEALTH SYSTEM MODERNIZATION PROJECT (APL II) IBRD LOAN NO.79870 March 20, 2019 Human Development and Economic Management Independent Evaluation Group Currency Equivalents (annual averages) Currency Unit = Armenian dram (dram) 2004 $1.00 dram 533.43 2011 $1.00 dram 372.50 2005 $1.00 dram 457.70 2012 $1.00 dram 401.76 2006 $1.00 dram 416.04 2013 $1.00 dram 409.62 2007 $1.00 dram 342.08 2014 $1.00 dram 415.91 2008 $1.00 dram 305.96 2015 $1.00 dram 477.91 2009 $1.00 dram 363.28 2016 $1.00 dram 480.48 2010 $1.00 dram 373.66 Abbreviations ALOS average length of stay IEG Independent Evaluation Group APL adaptable program loan IT Information technology BBP basic benefit package NHA National Health Account CBA cost-benefit analysis PHC primary health care EMP Environmental Management Plan PHRD Policy and Human Resources GDP Gross domestic product Development HPIU Health Project Implementing Unit PPAR Project Performance Assessment HSPA Health Sector Performance Report Assessments SHA State Health Agency HWM health waste management USAID United States Agency for ICR Implementation Completion and International Development Results Report WHO World Health Organization IDA International Development Association All dollar amounts are U.S. dollars unless otherwise indicated. Fiscal Year Government: January 1–December 31 Director-General, Independent Evaluation Ms. Alison Evans Director, Human Development and Economic Management Mr. Auguste T. Kouame Manager, Corporate and Human Development Ms. Emanuela Di Gropello Task Manager Ms. Mercedes Vellez ii Contents Preface ................................................................................................................................................................ vii Summary ............................................................................................................................................................. ix 1. Background and Context .......................................................................................................................... 1 2. Health System Modernization Project (APL I) ................................................................................... 3 Relevance of the Objectives and Design .............................................................................................. 3 Objectives ..................................................................................................................................................................... 3 Relevance of the Objectives ................................................................................................................................... 4 Design ............................................................................................................................................................................ 4 Relevance of Design .................................................................................................................................................. 6 Implementation ........................................................................................................................................... 11 Key Dates ..................................................................................................................................................................... 11 Planned versus Actual Expenditure by Component...................................................................................... 11 Implementation Experience ................................................................................................................................... 11 Achievement of the Objectives ............................................................................................................. 13 Objective 1: Expanding Access to Quality Primary Health Care ............................................................... 13 Objective 2: Improving Quality and Efficiency of Selected Hospital Networks .................................. 15 Objective 3: Laying Groundwork for Effective Health Sector Policy Making and Monitoring (Governance) ............................................................................................................................................................. 17 Efficiency ....................................................................................................................................................... 19 Outcome ..................................................................................................................................................................... 21 Risk to Development Outcome ........................................................................................................................... 21 Bank Performance .................................................................................................................................................... 21 Borrower Performance .......................................................................................................................................... 22 Monitoring and Evaluation .................................................................................................................................. 23 3. Health System Modernization Project (APL II) ............................................................................... 24 Relevance of the Objectives and Design ........................................................................................... 24 Objectives .................................................................................................................................................................. 24 Relevance of the Objectives ................................................................................................................................ 24 Design ......................................................................................................................................................................... 25 Relevance of Design ............................................................................................................................................... 26 Implementation ......................................................................................................................................... 28 Key Dates ................................................................................................................................................................... 28 iii Planned versus Actual Expenditure by Component.................................................................................... 28 Implementation Experience ................................................................................................................................. 29 Achievement of the Objectives ............................................................................................................ 29 Objective 1: Provide More Accessible Health Care Services to the Population ................................. 29 Objective 2: Provide More Quality Health Care Services to the Population ....................................... 31 Objective 3: Provide More Sustainable Health Care Services to the Population .............................. 33 Objective 4: Strengthen Ministry of Health Capacity for More Effective