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1 Public Disclosure Authorized EUROPE AND CENTRAL ASIA Uzbekistan Health, Nutrition & Population Global Practice IBRD/IDA Specific Investment Loan FY 2011 Seq No: 8 ARCHIVED on 08-Jul-2015 ISR19550 Implementing Agencies: Public Disclosure Authorized Key Dates Key Project Dates Board Approval date:07-apr-2011 Planned Mid Term Review Date:16-Nov-2015 Original Closing Date:31-Dec-2016 Project Development Objectives Effectiveness Date:02-Nov-2011 Actual Mid-Term Review Date:-- Revised Closing Date:31-Dec-2018 Public Disclosure Authorized Project Development Objective (from Project Appraisal Document) The overall Project Development Objectives (PDOs) are to (1) improve access to quality health care at the primary level and atrayonmedical Unions (RMUs); and (2) strengthen the Government s public health response to the rise in non-communicable diseases(ncds). Has the Project Development Objective been changed since Board Approval of the Project Objective? Yes Board Approved Revised Project Development Objective (If project is formally restructured)phrpdodel The revised PDO is to (a) improve access to quality health care at the primary level and at Rayon Medical Unions; and selectedcitymedical Unions (CMUs); and (b) strengthen the Government's public health response to the rise in non-communicable diseases(ncds). Components Public Disclosure Authorized Name Improving Health Service Delivery:(Cost $ M) Strengthening Health Financing and Management Reforms:(Cost $5.95 M) Institutional Strengthening for NCD Prevention and Control:(Cost $3.38 M) Project Management:(Cost $5.55 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Unsatisfactory 7/8/2015 Page 1 of 11

2 Overall Risk Rating Moderate Substantial Implementation Status and Key Decisions The project continues to make moderate but uneven progress among project components. Component 1: The ten-month General Practitioner (GP) training continues to progress in a satisfactory manner. A total of 663 GP s are currently undergoing the training following the recently revised GP curriculum. This group is expected to complete training in June 2015, and a new group of 700 doctors is expected to join the program in September Eighteen new nursing guidelines (covering endocrinology, cardiology, neurology, nephrology, pulmonology and gastrointestinal diseases) were developed and have been approved by the MoH. Training of 24 nurse trainers from the oblast hospitals was conducted, who will later train the nurses in the rayon medical unions (RMUs). Continuing medical education courses have been provided to doctors in Tashkent city and Tashkent oblast. Twenty-two clinical protocols have been developed and are currently being translated into Uzbek language. Two training modules on gastroenterology and endocrinology have already been developed and approved by the Scientific Council, and two more are pending approval. A second round of training of the team of experts responsible for the clinical protocol development is planned for July Component 2: The implementation of Component 2 is still behind the schedule due to various reasons and factors, but there has been some progress because of the continued efforts of the implementation team in MoH. Component 3: The draft report of the STEPs survey is finalized. The final report is expected to be finalized and published shortly thereafter. A workshop was held on health promotion to discuss the activities planned under this sub-component in Kashkardarya and Fergana. The health promotion action plan has been approved by the Governor of Kashkardarya and approval is pending from Fergana region. Health promotion activities will also be conducted in schools in collaboration with the Ministry of Education. Training modules for primary health care workers in these two regions on preventive management of hypertension and diabetes based on the newly developed protocols are ready and training is expected to begin in June 2015 with technical support from WHO. Component 4. The implementation team in MoH has made great efforts to work with concerned government agencies to speed up the contract approval and registration process. A backlog of over ten contracts were approved and/or registered in the past few months. This progress has helped to improve the disbursement rate and the implementation of a few project activities which requires external technical assistance. 7/8/2015 Page 2 of 11

3 Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Substantial Substantial Macroeconomic -- Moderate Moderate Sector Strategies and Policies -- Moderate Moderate Technical Design of Project or Program -- Moderate Moderate Institutional Capacity for Implementation and Sustainability -- Moderate Moderate Fiduciary -- Moderate Substantial Environment and Social -- Moderate Substantial 7/8/2015 Page 3 of 11

4 Stakeholders -- Moderate Moderate Other -- Moderate Moderate Overall -- Moderate Substantial Results Project Development Objective Indicators PHINDPDOTBL Increased proportion of diabetic and hypertension patients referred from PHC facilities to RMUs, in accordance with treatment standards (Percentage, Custom) Value Date Jan Jun Dec-2018 It is planned to conduct a survey, which will define this indicator. On March 25, 2015 according to the Order of the MoH #126, a clinical protocol was approved on hypertension and type 2 diabetes management (based on PEN WHO protocol), in which criterion were defined for the referral of patients with hypertension and diabetes from PHC facilities to RMU. PHINDPDOTBL Improved perceived quality of PHC and secondary health care services in intervention areas (Percentage, Custom) Value Date 02-Oct Jan Jun Dec-2018 Survey is on-going, not yet finished. PHINDPDOTBL Increased proportion (number) of hospitals following NCD clinical guidelines developed under the project (at least 20 clinical guidelines) (Percentage, Custom) Value Date Jan Jun Dec /8/2015 Page 4 of 11

5 Currently, translation of the developed 22 clinical protocols into Uzbek is being finalized and the draft training programs on their introduction has been developed. PHINDPDOTBL Issuance of a profile of NCD risk factors and burden of disease (Text, Custom) Value 0 First report will be ready by the end of March 2015 First report will be ready by July 2015 At least 3 reports published The Bank team would like to commend the MoH and the CPIB on finalizing the draft report of the STEPs survey. A round table discussion on the key findings of the report is planned with key stakeholders including the MoH, the MoF, and the Ministry of Economy (MoE) May The final report is expected to be finalized and published shortly thereafter in August Overall Intermediate Results Indicators Hospitals equipped with medical and waste management equipment (Number, Custom) Value Thus, digitizers to 109 facilities, refrigerators to 188 were delivered and 110 facilities received ultrasound machines, 105 facilities autoclaves, 186 facilities cool boxes for vaccines, 105 facilities syringe pumps 63 facilities (including 53 CRH, 58 CRMP, 5 training centers) received X-Ray equipment, which was installed in 5 facilities, digitizers were delivered to 6 facilities, 96 facilities received autoclaves, 115 facilities received syringe pumps, 201- laboratory centrifuges, 115- hematocrit centrifuges, 201- portable ECG, 115- patient monitor, 115- pulseoxymetry device, 115-set of fibrogastroscopes, 115 facilities received ultrasound machines, 200-dry-air sterilizer, 16 - cool boxes for vaccines, 16 - refrigerators for blood storage, 120 facilities received autorefractors. 87 facilities received ophthalmoscope/otoscopes, 106 scales for adults and children, 104 height meter with chair, 75 Autorefractometers, 75 Automated chart panel, 43 Slit lamp and others. 7/8/2015 Page 5 of 11

6 New clinical guidelines developed and adopted by the MOH (CVD, diabetes, etc.) (Number, Custom) Value The 5-th protocol on lung/pulmonary diseases was developed within the framework of cooperation with WHO, TIPME and Republican Specialized Scientific and Practical Medical Center for Phthisiology and Pulmonology Four (4) Clinical protocols, developed with the participation of specialists from the leading medical centers based on the adaptation of WHO clinical guidelines on basic NCDs -PEN (CVD, diabetes, asthma and chronic obstructive pulmonary disease (COPD)) for PHC facilities were developed and approved by Ministry of Health. Total of 22 protocols are under translation into local language. Doctors of urban and rural PHC facilities receiving the training under the 10-month GP training program (Number, Custom) Value Training of 640 physicians accepted for academic year is underway. (original plan was 500) Health personnel at PHCs (doctors and nurses) receiving training under continuous professional education (Text, Custom) Value 0 doctors, 0 nurses 6770 doctors, 20,396 nurses 7026 doctors, 20,908 nurses 9400 doctors, nurses Date 10-Mar Jan Jun Aug /8/2015 Page 6 of 11

7 Hospital management staff receiving training on hospital management (Number, Custom) Value The training is conducted out of the Government funds Hospital core staff receiving training on waste management (Number, Custom) Value Health personnel receiving training on clinical case management (NCDs and pediatrics) (Text, Custom) Value -- 5 doctors 5 doctors 1002 doctors and 2064 nurses Preparation for the training of physicians and nurses of RMU is in process. 26 nurses of OCMMC were trained as trainers by the program IMCI and 24 nurses of OMMC were trained as trainers on clinical protocols 7/8/2015 Page 7 of 11

8 Health personnel receiving training (Number, Custom) Value Date 01-Mar Jan Jun Dec-2018 Staff of reformed PHC and hospitals receiving training in financial management (Number, Custom) Value Trainings will be conducted after the hiring of the company on training logistics. The training module has been prepared National Health Accounts developed and published (Text, Custom) Value reports The government decided to use SHA instead of NHA and the Bank team agreed. Introduction of SHA is underway. Public Expenditure Review developed (Text, Custom) Value reports According to the Ministry of Health Order #497 dd. April 8, 2013 on the analysis of state expenditures for public health, collected information is being consolidated and analyzed. On November 1, 2013, the meeting was held in the Ministry of Finance on the issues of arranging 7/8/2015 Page 8 of 11

9 information exchange between the Ministry of Finance and the Ministry of Health within the frame of establishing the information systems on strengthening health financing and management reforms. Volume and Cost contract introduced in 3 hospitals in Fergana oblast (Text, Custom) Value All 3 hospitals paid according to contract The COM Resolution #37 dd. February 13, 2013 on piloting the hospitals financing was issued. The Temporary regulations on the order of financing of Fergana oblast central rayon hospitals was developed and submitted to the Ministry of Finance for endorsement, as well as the contract forms, including mutual obligations and responsibilities of the parties for each model. The process of contracting the international firm to assist in the development of financing mechanism is nearing completion. Following the recommendations of the MoF, Tentative Regulation on the arrangements of Central Rayon Hospitals financing in Fergana oblast was revised taking into account the introduction of basic standard costs per one treated case. The new draft Tentative regulation was submitted to the Ministry of Finance for agreement on December 26. Agreement of provisions for contracts with the Ministry of Finance is reached. Number of urban PHC facilities (urban family policlinics) converted to per capita financing system (Number, Custom) Value Date 05-Feb Jan Jun Dec /8/2015 Page 9 of 11

10 Number of video clips on health education on cardiovascular risk factors (Number, Custom) Value The development of video clips is connected with the activity of international company. The hiring of the international company was initiated Percent of population in targeted Oblasts knowing cardiovascular risk factors (Percentage, Custom) Value Date 07-Apr Jan Jun Dec-2018 Public Health specialists (surveillance staff) and (b) health promotion specialists trained (Number, Custom) Value Date 10-Mar Oct Oct Dec-2018 With the participation of the International experts, the workshop was conducted on health promotion in Kashkadarya oblast on December 9-10, where 16 specialists were trained on healthy lifestyle and on the development of Activity Plan in the field of health promotion. Overall Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed 7/8/2015 Page 10 of 11

11 P IDA Effective XDR % P IDA Effective XDR % Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P IDA Effective 07-Apr Sep Nov Dec Dec-2016 P IDA Effective 07-Mar Jul Sep Dec Dec-2018 Cumulative Disbursements Restructuring History There has been no restructuring to date. Related Project(s) P Additional Financing to Health System Improvement Project 7/8/2015 Page 11 of 11