RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING NORTH EAST AND RED RIVER DELTA REGIONS HEALTH SYSTEM SUPPORT PROJECT APPROVED ON MAY 31, 2013

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1 Public Disclosure Authorized RESTRUCTURING PAPER REPORT NO.: RES30220 Public Disclosure Authorized ON A PROPOSED PROJECT RESTRUCTURING OF NORTH EAST AND RED RIVER DELTA REGIONS HEALTH SYSTEM SUPPORT PROJECT APPROVED ON MAY 31, 2013 TO SOCIALIST REPUBLIC OF VIETNAM Public Disclosure Authorized HEALTH, NUTRITION & POPULATION EAST ASIA AND PACIFIC Public Disclosure Authorized Regional Vice President: Country Director: Senior Global Practice Director: Practice Manager/Manager: Task Team Leader: Victoria Kwakwa Ousmane Dione Timothy Grant Evans Toomas Palu Huong Lan Dao

2 ABBREVIATIONS AND ACRONYMS

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 Partial Assessment (B) Approval Date 31-May-2013 Financing Instrument Investment Project Financing Current EA Category Partial Assessment (B) Current Closing Date 31-Dec-2019 Organizations Borrower Socialist Republic of Vietnam Responsible Agency Ministry of Health Project Development Objective (PDO) Original PDO The Project Development Objective is to increase the efficiency and equity in the use of hospital services in selected provinces ofthe North East and Red River Delta Regions. Summary Status of Financing Ln/Cr/Tf Approval Signing Effectiveness Closing Net Commitment Disbursed Undisbursed IDA May Aug Oct Dec 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.

5 I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING 1. Project status (a) By the time of project restructuring, the Progress towards achievement of Project Development Objective (PDO) was rated Moderately Satisfactory; the justification for this rating is the fair progress toward achieving PDO indicators. The achievement of the target for utilization rate of district hospitals by the poor and near poor has slightly increased. With the Project support for training and equipment, the provincial and district hospitals can perform new services that previously could only be provided at the higher level. So far, there have been 1,477 new techniques (704 at provincial level, and 773 at district level) transferred, and more than 620,000 patients have received new techniques at the local hospitals. (b) The Implementation Progress of the Project is rated as Moderately Satisfactory. At the time of the restructuring, the Project has disbursed almost 50% of the Credit, slightly behind the originally planned disbursement schedule. The main areas of progress are: (i) the beneficiary hospitals report a significant increase in new clinical techniques, previously only available at higher level hospitals, that they can perform; (ii) with support from the Project and contributions from Project provinces, 100% of the near-poor have health insurance cards, which is over the end-project target of 70%; (iii) the Project has surpassed the intended results in the number of Project hospitals implementing the Continuous Quality Improvement program (100% of the Project hospitals are implementing the program compared to 75% target); and (iv) the number of health personnel receiving training is 4,748, compared to the target of 4, Rationale for restructuring: Revision of the Project Indicators. Following the Mid-Term Review, it was agreed that certain changes to the Results Framework needed to be introduced in order to ensure that the indicators directly correspond with the Project activities and expected Project outcomes and to ensure the measurability of each indicator. Of the four PDO indicators, three relating to referrals, as currently formulated, do not capture the progress made by the Project. This is because of issues related data availability, data quality, and attribution. Consequently, while the Project is making progress towards achievement of the PDO, some of the current indicators do not reflect that. The logic behind the indicators is that with the Project support on training and equipment to lower level hospitals, capacity of the hospitals is improved so that they can perform more clinical techniques and don t have to refer patients to the higher-level hospitals. Since the referrals cannot be properly measured, the Project will measure the number of patients treated with new medical technologies, with an assumption that if this number increases, it would actually mean a similar decrease for similar services provided inappropriately at higher levels. Following are the main concerns relating to the quality of the results framework indicators that need to be revised.

6 Attribution: This is the main concern. Clearly, improvement of the service delivery capacities at lower level hospitals is not exclusive in terms of leading to the reduction of the referrals to upper level hospitals. There are other factors coming into play, in addition to the comprehensive package of Project interventions, with the aim of improving the service delivery capacity at lower levels. There have been changes, which were not anticipated at Project design stage, but have resulted in the increase of referrals across the board. The most important change identified is the hospital payment policy through health insurance. In 2016, health insurance has introduced a ceiling on global payments to hospitals, in addition to fee-for-service. As a result, hospitals have increased the referral of patients to upper level hospitals to avoid exceeding the payment ceiling, especially when the end of the year is approaching. The Vietnam Social Security (VSS) also provided the national referral rate, which was increased to an even higher rate than that expected for the Project provinces. Data availability: The Project has contracted the Health Insurance Research Institute to provide referral data for three of the four PDO indicators on the assumption that the health insurance claim data would be the most reliable and accurate in comparison to health facility self-reporting data on referral and expenses. However, the institute has faced significant challenges in gathering the requested data due to the unavailability of data, and the delay by beneficiary hospitals in submitting data. Data quality: There is a concern about the accuracy of the hospitals disease coding practice. In principle, all hospitals are required to apply the ICD 10 to code diagnoses, however, the accuracy of the coding process is questionable since no clear instructions or guidelines are available, and there is insufficient effort for validating information in place. The VSS and the Ministry of Health have been informed and the issue discussed, but no specific intervention has been implemented to improve the overall coding quality. This issue will seriously affect the PDO indicators if the Project monitoring can only capture certain ICD codes.

7 II. DESCRIPTION OF PROPOSED CHANGES (a) Revise Indicator 1: Reduction in the percent of patient referred from provincial to central level hospitals in five intervention areas to Number of patients treated using new techniques/procedures at provincial level hospitals in five intervention areas (b) Revise Indicator 2: Reduction of patient referred from district hospitals to provincial hospitals for deliveries, Child pneumonia and appendicitis that have had techniques transferred to Number of patients treated using new techniques/procedures at district level hospitals in three intervention areas. (c) Drop indicator 3: Reduction in the self-referral rate by patients from 13 participating project provinces to 9 central hospitals in the five intervention areas: because the self-referral rate as information collected by VSS can only capture portion of the self-referrals. Indicators 1 and 2 will be collected directly from beneficiary hospitals, using their current information and reporting system. The proposed indicators will be able to directly reflect the Project activities and outcomes. In parallel, the World Bank task team has advised the government to commit to a deeper and comprehensive analysis on what has possibly contributed to the increase of referrals, on which a proposed change of plan could be prepared, if needed. The Central Project Management Unit will revise the Project Operational Manual to update the changes to the Results Framework, and get it approved by the Ministry of Health. Note: The five project intervention areas at the provincial level are: (i) cardiology (internal medicine); (ii) obstetrics/gynecology; (iii) pediatric; (iv) oncology; and (v) trauma (surgical); and the three project intervention areas at the district level are: (i) obstetrics/gynecology; (ii) pediatric; and (iii) injury (surgical). 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

8 PDO_IND_TABLE Change in DDO Status Change in Project's Development Objectives Change in Components and Cost Change in Loan Closing Date(s) Cancellations Proposed Reallocation between Disbursement Categories Change in Disbursements Arrangements Change in Disbursement Estimates Change in Overall Risk Rating 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 Twenty percent reduction in the percent of patients referred from provincial to central level hospitals in five intervention areas.

9 Value Marked for Deletion Date 22-Feb Mar Sep-2019 Ten percent reduction in the percent of patients referred for deliveries, child pneumonia and appendicitis from district hospitals to provincial hospitals Value Marked for Deletion Date 18-Apr Mar Sep-2019 Ten percent reduction in the self-referral rate by insured patients from the participating project provinces to Central Hospitals in five intervention areas Value Marked for Deletion Date 22-Feb Mar Sep-2019 At least fifteen percent increase in the use of inpatient and outpatient health services by the poor and insured near poor in the local hospitals. Value No Change Date 22-Feb Mar Sep-2019 Use of Inpatient services by the insured poor and near poor in the local hospitals Breakdown Value No Change Use of Outpatient services by the insured poor and near poor in the local hospitals

10 Breakdown Value No Change Number of patients benefiting new clinical techniques in five intervention areas (cardiology (internal medicine); obstetrics/gynecology; pediatric; oncology; and trauma (surgical)) tranferred by the p (Thousand) Value New Date 31-May Nov Dec-2019 Number of patients benefiting new clinical techniques in three intervention areas (obstetrics/gynecology; pediatric; and injury (surgical) transferred by the Project at district hospitals Value New Date 31-May Nov Dec-2019 Intermediate Indicators IO_IND_TABLE Number of new technical services is transferred from central to provincial hospitals and district hospitals Value No Change Date 22-Feb Mar Sep-2019 Increase in the percent of project hospitals implementing Continuous Quality Improvement (CQI) or equivalent quality improvement process

11 Value No Change Date 22-Feb Mar Sep-2019 Health facilities constructed, renovated, and/or equipped (number) Value No Change Date 01-Nov Mar Jun-2019 Health personnel receiving training (number) Value No Change Date 22-Feb Mar Sep-2019 At least seventy percent of near poor have health insurance Value No Change Date 22-Feb Mar Sep-2019 Increase of patient satisfied with (a) the overall quality of care, (b) reduction of waiting time, and (c) availability of services and (d) diagnostic facilities at provincial and district hospita Value No Change Date 30-Jun Mar Sep-2019 Provincial Level: Overall Quality Breakdown

12 Value No Change District Level: Overall Quality Breakdown Value No Change Provincial Level: Waiting Time Breakdown Value No Change District Level: Waiting Time Breakdown Value No Change Provincial Level: Availability of services Breakdown Value No Change District Level: Availability of services

13 Breakdown Value No Change Provincial level: Availability of diagnostic facilities Breakdown Value No Change District level: Avalability of diagnostic facilities Breakdown Value No Change People with access to a basic package of health, nutrition, or reproductive health services (number) Value No Change Date 30-Jun Mar Jun-2019 Increase in the knowledge on health insurance (a) benefit package; (b) rights, (c) responsibility; and (d) operation mechanism among near poor people Value No Change Date 18-Apr Mar Sep-2019

14 Knows at least 3 benefits Breakdown Value No Change Knows at least 3 responsibilities Breakdown Value No Change Knows operation mechanism among near poor people Breakdown Value No Change Knows rights Breakdown Value No Change Complete and Timely Project reporting, including Progress Reports, Monitoring and Evaluation Updates, Year 1, Midterm and End of Project surveys, Annual Plans Unit of Measure: Text

15 Value Not applicable Satisfactory Satifactory assessment Date 18-Apr Mar Dec-2019 No Change Note to Task Teams: End of system generated content, document is editable from here.