RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING APPROVED ON JANUARY 21, 2015 MINISTRY OF FINANCE AND PLANNING

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1 Public Disclosure Authorized The World Bank REPORT NO.: RES29190 RESTRUCTURING PAPER Public Disclosure Authorized ON A PROPOSED PROJECT RESTRUCTURING OF APPROVED ON JANUARY 21, 2015 TO MINISTRY OF FINANCE AND PLANNING Public Disclosure Authorized HEALTH, NUTRITION & POPULATION MIDDLE EAST AND NORTH AFRICA Public Disclosure Authorized Regional Vice President: Country Director: Senior Global Practice Director: Practice Manager/Manager: Task Team Leader: Hafez M. H. Ghanem Marina Wes Timothy Grant Evans Ernest E. Massiah Samira Ahmed Hillis, Christopher H. Herbst, Fernando Montenegro Torres

2 ABBREVIATIONS AND ACRONYMS MoH OMRs Ministry of Health Outside Medical Referrals

3 Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. BASIC DATA Product Information Project ID P Original EA Category Not Required (C) Approval Date 21-Jan-2015 Financing Instrument Investment Project Financing Current EA Category Not Required (C) Current Closing Date 30-Jun-2020 Organizations Borrower Ministry of Finance Responsible Agency Ministry of Health Project Development Objective (PDO) Original PDO The project PDO is to support the Palestinian Authority in securing continuity in healthcare service delivery and building its resilience to withstand future surge in demand for effective healthcare coverage. Summary Status of Financing Ln/Cr/Tf Approval Signing Effectiveness Closing Net Commitment Disbursed Undisbursed TF Feb Feb Feb Jun Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No

4 Note to Task Teams: End of system generated content, document is editable from here. I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING A mid-term review was conducted in July 2017 to assess the Project s performance. While the mission concluded that the project continues to advance well towards achieving the PDO, a few essential indicators revisions were seen as necessary, given the remaining period of the Project s life. Project disbursement is at 47% and fiduciary performance (both procurement and financial management) continues to be rated as satisfactory. The first component of the project Emergency and Rapid Response Window specifically allocated for Gaza hospitals - was successfully implemented and achieved with an excess disbursement of USD 73,939 over the original allocation of USD 2million. This contribution has secured the continuity of cleaning services provision in the MOH facilities in Gaza especially the surgical, intensive care and neonatal intensive care units. Prior to this intervention, cleaning services were only made available in the emergency units. Accordingly, there was substantial reduction in the accumulation of medical waste in critical units hence decreasing the probability of infection outbreak from 60% to 10% during the time of conflict in A satisfaction level of 85% was registered among MOH employees and patients versus 15% during the summer of The second component Rationalizing Outside Medical Referrals (OMR) is advancing well on many levels including key steps to regulate the referral management system such as: 1) the endorsement of the referral master plan; 2) the development of Memorandums of Understanding with service providers; 3) the development of referral guidelines; 4) the strengthening of the Service Purchasing Unit institutional capacity (SPU); and 5) the strategic purchasing of hospital level equipment. On the latter, the project has provided six operating rooms to Alia Hospital which are fully operational. The impact on hospital performance was very positive and included an increase in the number of surgeries, decrease in waiting time, a better working environment and increased staff morale. An Ultrasound Doppler for Beit Jala Hospital was also purchased and was used to conduct over 150 surgeries (saving over USD 150,000) thus reducing the need for costly outside medical referrals. Beit Jala Hospital is also in the process of receiving a much-needed sterilizer to replace a very worn out equipment (dating from 1999). The business analysis of the Integrated Government Health Insurance Management System (GHI MIS) was completed and acknowledged that a full-fledged system is far too ambitious to be finalized under the project given the current limitations of the systems in place. Accordingly, the MTR recommended to reduce the scope of this activity by supporting an agile, phased approach, rather than the adoption of a full complex system. Within the efforts of setting up a national pricing schedule for the top costliest conditions to eventually formulate comprehensive, competitive and transparent contracts with the service providers and based on the recommendations of the international consultant hired for this purpose, the Ministry decided to use an established international Diagnosis-Related Group (DRG) system as a base for the pricing of diagnosable conditions, while endorse the Procedure classification for non-diagnosable conditions. Technical discussions are currently underway to identify concrete next steps to move forward with the finalization of the pricing schedule. On component three Supporting Universal Health Coverage (UHC) to Strengthen Sector Resilience : this component has been challenging due to lack of a clear agreement on a long and comprehensive reform related to the pooling and separation of financing functions. Therefore, to attain some significant progress under this component, MoH will contract

5 WHO which has been playing a leading role in the UHC agenda and possesses the required technical capacity. The required UHC expertise coupled with top technical experts on board in addition to the Palestinian National Institute for Public Health (PNIPH - a scientific institute overseen by WHO) renders WHO a suitable entity for the implementation of this component. It will help achieve a number of UHC related activities focusing on strengthening the evidence based data of MoH in the areas of Health Financing and Human Resources for Health (HRH) for UHC. Discussions are underway with the WHO to finalize the contractual arrangements by February With regard to component four Project Management and Capacity Building : Progress under this component is going well. The PMU is functioning effectively with two core and dedicated team members on board (Procurement and Financial Specialists) supported and overseen by MoH senior and technical officials. Ongoing efforts are made to hire a local health specialist to provide technical support to the PMU. This should be finalized in February A Communication Strategy for two years has been initiated aiming at further educating citizens about their health rights and also supporting the ongoing reforms in the public health system, with focus on the new referral system. Training events for medical doctors are being organized in the top condition areas including: 1) anesthesiology Intensive Care Unit; 2) ECHO Pediatric Diagnostics; 3) Pediatric Nephrology; 4) Pediatric Pulmonology; 5) CT angiogram and Cardiac CT Angiogram services and 6) Urology and Kidney Endoscopy. Note: Formatting instructions for this document. A. Header 1. [All sub-sections must have a continuous paragraph numbering for the entire main text or for each annex per institutional standard.] (a) This is the sub-para numbering for this level. This is the sub-para numbering for this level. This is the sub-para numbering for this level. (i) (ii) This is the sub-para numbering for this level. This is the sub-para numbering for this level. This is the sub-para numbering for this level. This is the sub-para numbering for this level. (iii) This is the sub-para numbering for this level. This is the sub-para numbering for this level. II. DESCRIPTION OF PROPOSED CHANGES Based on the Mid Term Review conducted in July 2017 and on the consultations with the Ministry of Health, it was concluded that a few result indicators would need to be revised for the project to: a) meet its development objective; b) adjust the scope of some of the activities and c) enhance the project s performance. Accordingly, the following changes are being proposed: 1) Revising the PDO indicator utilization rates in the hospitals of Shifa and Rafedia do not deteriorate or improve up to 10% compared to a baseline end September 2014 to include Alia Hospital. Since the Project has provided

6 substantial assistance to Alia Hospital through the strategic purchasing of necessary equipment (amounting to USD 850,000), it is important that the Project captures the impact of this contribution on the utilization rates. 2) Revising the PDO indicator the total cost of referrals reduced by 15% by end of the project to read instead as follows average annual growth of total expenditure in OMRs of a four-year period lower than the proposed baseline which is the period (<13.19%). Due to factors beyond MOH s control (population growth; the volatile emergency situations; complex and costly services etc.), and despite the substantial progress in revamping the referral management system, the cost of referrals remains very difficult to be contained, at least for the remaining period of the Project. Accordingly, the indicator has been revised to reflect the average annual growth of total expenditure which should be more attainable. 3) Revising the end target of the intermediate indicator health facilities constructed, renovated and/or equipped from 5 to 2. The reduction in the end target is being proposed to capture the substantial support extended to Alia Hospital. Six operating rooms were fully equipped an intervention that contributed to an increase in the number of conducted surgeries; decrease in the waiting period for surgical operations; increase in public satisfaction as well as medical staff morale. In addition to Alia, the project supported Beit Jala hospital through the provision of much needed equipment: a) ultrasound Doppler and b) Sterilizer. It is worth noting that both Alia and Beit Jala Hospitals serve the Southern governorates population and based on the MoH s request, enhancing the quality of services provided by these two hospitals is highly needed otherwise stretching aid to 5 facilities would reduce the impact of the contributions. 4) Amending the intermediate result indicator a consolidated health information system (HIS) for referrals, billing and health insurance in both the West Bank and Gaza is fully operational to read instead as a consolidated health information system for referrals and health insurance operational. Based on the Government Health Insurance (GHI MIS) business analysis completed in September 2017 which clearly highlights MoH s processes weaknesses, the need to reduce the scope of the GHI MIS activity was highlighted. The Project should focus on achievable activities during the life of the project to improve the health insurance system by introducing some key features such as: a) electronic services; b) a set of benefit packages with detailed and separate provisions; c) electronic interoperationality between the HIS and other MOH IT systems and so forth. 5) Revising the end target of the intermediate result indicator new referral contracts/mous negotiated with all outside providers from 40 to 30. One of MoH s adopted strategies to enhance the referral management system including cost and quality control is to reduce the number of contracted service providers. Hence the end target of this indicator is being revised to capture this strategy. Note to Task Teams: The following sections are system generated and can only be edited online in the Portal. III. SUMMARY OF CHANGES Changed Change in Results Framework Not Changed Change in Implementing Agency Change in DDO Status Change in Project's Development Objectives Change in Components and Cost

7 PDO_IND_TABLE The World Bank Change in Loan Closing Date(s) Cancellations Proposed Reallocation between Disbursement Categories Change in Disbursements Arrangements Change in Disbursement Estimates Change in Systematic Operations Risk-Rating Tool (SORT) Change in Safeguard Policies Triggered Change of EA category Change in Legal Covenants Change in Institutional Arrangements Change in Financial Management Change in Procurement Change in Implementation Schedule Other Change(s) Change in Economic and Financial Analysis Change in Technical Analysis Change in Social Analysis Change in Environmental Analysis IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_RESULTS_TABLE RESULTS FRAMEWORK Project Development Objective Indicators Utilization rates (out-patient, emergency and obstetrics) in the hospitals of Shifa, Rafedia and Alia Hospital do not deteriorate or improve up to 10% compared to a baseline end-september, 2014 Value Shifa occupancy: 89%, Shifa occupancy: 92%, Shifa occupancy: 89%, Rafedia occupancy: 85% Rafedia occupancy: Rafedia occupancy: Obstetrics Shifa: 76% 87.6%; Alia occupancy: 85%, Alia occupancy: Revised Obsetrics Rafedia: 94% 136% 136%

8 Outpatient Shifa: 578,646 Outpatient Rafedia: 163,262 Obstetrics Shifa:96% Obstetrics Rafedia: 81.5% Obstetrics Alia: 105% Outpatient Shifa: OC= , ER= Oupatient Rafedia: Outpatient Alia: OC=102046, ER= Obstetrics Shifa: 76% - Obstetrics Rafedia: 94% - Obstetrics Alia: 105% Outpatient Shifa: 578,646 - Outpatient Rafedia: 163,262 - Outpatient Alia: Date 25-Jan Dec Dec-2019 Average annual growth of total expenditure in OMRs of a four-year period lower than the proposed baseline which is the period (<13.19%) Value 13.19% 13.19% <13.19% Revised Date 25-Jan Dec Dec-2019 Gap in geographic equity for referral cost (between the West Bank and Gaza) reduced by 80 percent relative to baseline Value 1.7:1 1:7:1 1:15:1 No Change Intermediate Indicators IO_IND_TABLE Utilization rates (outpatient, emergency, and obstetrics) in the hospitals of Shifa, Rafedia and Alia do not deteriorate or improve by up to 10% compared to a baseline end September 2014 Value Shifa occupancy:89% - Nasser occupancy: 74% European Gaza Hospital: 79% Shifa occupancy: 92% Rafedia occupancy: 87.6% Obstetrics Shifa: 96% Same ratio as baseline Revised or improve up to 10%

9 Obstetrics Rafedia: 81.5% outpatient Shifa: OC= , ER= Outpatient Rafedia: Date 25-Jan Dec Dec-2019 Referral protocols and procedures for the ten costliest conditions defined and rendered operational Unit of Measure: Number Value No Change A consolidated Government Health Information System (HIS) for referrals and health insurance is operational Value 0 not operational A web-based system operational in all hospitals taking referrals Revised Date 25-Jan Dec Dec-2019 HIS operational in selected hospitals Unit of Measure: Number Value No Change Health facilities constructed, renovated, and/or equipped (number) Unit of Measure: Number Value Revised Date 25-Jan Dec Dec-2019

10 Direct project beneficiaries (no), of which female (%) Unit of Measure: Percentage Supplement Value No Change New referral contracts/ MOUs negotiated with all outside providers Value Revised Date 25-Jan Dec Dec-2019 Purchasing agency (either independent or part of the MOH) created, staffed and made operational Value 0 Functional Functional No Change People with access to a basic package of health, nutrition or reproductive health services Unit of Measure: Percentage Value No Change Direct project beneficiaries (no), of which female (%) Unit of Measure: Percentage Breakdown Value No Change External audit (medical and financial)

11 Value Not available Functional Functional No Change Health personnel receiving training (number) Unit of Measure: Number Value No Change Grievance and Redress Mechanism (GRM) for OMRs and access to Health Care designed and fully operational by end of the project Value Complaints manual and posters have been finalized and Not available disseminated. Four Fully functional No Change workshops conducted at regional level - two remain to be delivered Communciation strategy on UHC developed and consultation workshops conducted to promote the concept of citizens' engagement One consultation One consultation Value 0 workshops were No Change workshop conducted conducted

12 Note to Task Teams: End of system generated content, document is editable from here.