Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized DATA SHEET TEMPLATE FOR PROJECT PAPER GEORGIA: PRIMARY HEALTH CARE DEVELOPMENT PROJECT (Credit No.3702) Borrower: Republic of Georgia Responsible agency: Ministry of Labor, Health and Social Affairs P Revised estimated disbursements (Bank FY/US$m) -based on current US/SDR exchange rate FY 1 2003 1 2004 1 2005 1 2006 1 2007 1 2008 I 2009/2010 Current closing date: 12/3 1/2009 Revised closing date: proposed to extend until 12/3 1/2010 Indicate if the restructuring is: Board approved -a RVP approved - Does the restructured project require any exceptions to Bank policies? Have these been approved by Bank management? Is approval for any policy exception sought from the Board? Revised project development objective/outcomes: (i) to improve coverage, utilization and quality of health care services, and; (ii) to strengthen Government stewardship functions in the health sector Does the restructured project trigger any new safeguard policies? NO Borrower IBRD/IDA Total 47816 - Yes WNo Yes -No Yes HNo Revised Financing Plan (US$m.) Source Local Foreign Total 4.46 0 4.46 14.40 9.1 23.5 18.86 9.1 27.96 2
PROJECT PAPER PROPOSAL TO RESTRUCTURE GEORGIA PRIMARY HEALTH CARE DEVELOPMENT PROJECT (Project ID P040555) A. Introductory Statement 1. This Project Paper seeks Board approval to introduce changes in the Georgia Primary Health Care Development Project (PHCD), Credit No.3702, Project ID PO40555 and the related amendments to the project s Development Credit Agreement. The proposed changes include: (i) changing the project development objectives and key performance indicators to better reflect priorities of Georgia s current health sector reform program; (ii) revision of project components, with added emphasis on sector stewardship activities; (iii) changing the project name to Health Sector Development Project to better reflect the nature of the proposed project restructuring; (iv) amending Schedule 1 of the Development Credit Agreement to allow the percentage of expenditures to be financed at 100 percent under a single new category combining works, goods, technical assistance, training, and incremental operating costs; (v) reallocation of Credit proceeds among the current expenditure categories to accommodate the proposed changes; (vi) changing the project procurement plan and prior review thresholds to reflect the October 2006 updated World Bank Procurement and Consultant Guidelines; and (vii) extending the project Closing Date by 12 months to December 31,2010. B. Background and Reasons for Restructuring 2. The SDR 16 million Credit (US$20.34) for this Project was approved on August 1, 2002 and became effective on May 6, 2003. The Project Development Objective, as stated in the Development Credit Agreement, is to improve coverage and utilization of quality primary health care (PHC), in the territory of the Borrower, based on a model of Family Medicine/General Practice. The Project includes three components: + Component I (US$16.2 million total costs): PHC Service Delivery: the overall objective of the component was to support development of PHC services in urban and rural areas of Georgia through rehabilitation of the facilities and provision of basic medical and office equipment. This component has three sub-components: (i) establishing PHC clinics and referral laboratories; (ii) PHC Referral Pilot at Kutaisi MCH Center; and (iii) Community-based Information, Education and Communication (IEC). + Component I1 (US$7.10 million total costs): Institutional Development: the objective of this component was to support institutional development and the capacity building in Family Medicine for the sustainable delivery of the PHC services through: (i) Capacity building for PHC Training; (ii) Capacity building in the management of PHC services; (iii) Strengthening Health Management Information Systems for PHC; and (iv) Support for PHC Financing Reforms. 3
+ Component I11 (USU.5 million total costs): Project Management Support. The objective of this component is to support project implementation by supporting the development and functioning of the Health and Social Implementation Center. 3. Progress to date: After initial delays, the implementation accelerated in 2006. Sixty one percent of IDA funds (SDR9.87 million or US$14.68 million) have been disbursed and an additional US$l.l million (4 percent) is committed. In terms of activities, the project has financed the rehabilitation of 103 primary health care centers, regional family medicine training centers, as well as the Kutaisi MCH Center under Component 1. Training of family medicine staff has also been supported. Under Component 2, an informatiodcommunication strategy has been developed and a Master plan for the PHC has been prepared. In addition, the capacity of the Health Policy Unit and the Center for Medical Statistics and Information has been strengthened. The project has made progress towards the achievement of its development objectives as measured by key performance indicators. About 71 percent of rural population have access to the PHC clinic within 15 minutes in project target areas (Imereti, Adjara, Shida Kartli regions) and national average utilization of PHC services increased from 1.4 to 1.85 (2006) visitskapita (3/capita target). A ten percent increase nationwide in the proportion of infants that receive timely immunization (DPT3) was observed amounting to an 86.8 percent coverage rate (2006). There has been a 7.5 percent increase (30 percent increase targeted) in the proportion of pregnant women to have had at least 4 perinatal visits compared to the baseline. 4. Reasons for Restructuring: In the mid-l990s, Georgia embarked on a series of reforms in the healthcare sector. These sought to improve the mobilization, allocation, and management of public funds and to shift the healthcare delivery system away from the heavy emphasis on tertiary care to primary health care. Most recently, in 2006, the government launched a further major reform of the health sector, which composes four main areas: (i) increasing the private sector role in health financing and service provision by privatizing public health facilities; (ii) prioritizing public funds to finance health care for the poor and other vulnerable groups; (iii) channeling public health financing through private health insurance companies; and (iv) strengthening the regulatory role of the Ministry of Labor, Health and Social Affairs (MOLHSA). Given these policy changes, the Government requested that Bank support under the Primary Health Care Development Project be revised to reflect the new priorities. The government has decided not to continue to rehabilitate primary health care clinics, because these would be privatized, but rather to increase funds for additional training on family medicine, to revise family medicine guidelines, to strengthen the stewardship functions of the MOLHSA, and to develop a modernized public health information management system covering the entire health system rather than just PHC as was originally envisaged. To meet the new reform requirements in a dynamic policy environment in Georgia, the Bank agreed to restructure the project. It should be noted that this project was a core project under the 2003 Country Assistance Strategy and the key element under the Country Partnership Strategy Progress Report for FY2006-2009. This Project also complements the Poverty Reduction Support Operation (PRSO), which provided policy-based credits to the Government for a range of policy reforms including the reform in the health sector. In parallel to the PRSO, this Project finances a health management information system and provides technical assistance to the Government for better monitoring service provision by the private sector. The Project is conducting an impact evaluation of the Medical Assistance Program for the Poor, which is a key program under the 4
health sector reform. This kind of support is very critical to the success of the health reform in Georgia. C. Proposed Changes 5. During the restructuring mission in July 2008, the project was re-appraised and re-costed in order to reflect changes in Government priorities. As a result of the restructuring mission, it was proposed to revise the original project objectives, the project name, project components, and key indicators in the Results Framework. It should be noted that following the restructuring mission, the process was interrupted by the Russo-Georgia military conflict in August 2008. As a result, the project lost time for the implementation. In the letter to the Bank on October 20, 2008, the Government of Georgia requested formally project restructuring as well as the second extension of the project Closing Date from December 3 1,2009 to December 3 1, 201 0 in order to fully utilize the IDA credit and achieve the revised project development objectives. This letter reconfirms the proposed restructuring in order to meet the changing needs under the health sector reform program. The proposed changes are as follows: 6. Revised PDO, project name, and outcome indicators: The proposed revised PDO includes a new objective relating to the strengthening of the stewardship functions of the MOLHSA. The revised PDOs are to: (i) improve coverage, utilization and quality of health care services in the territory of the Recipient, and (ii) strengthen the Government s stewardship functions in the health sector. In order to better reflect the revised objectives, the project name would change to the Health Sector Development Project. In line with the proposed revisions in the PDO, the results framework is revised. During the course of the implementation, some indicators in the results framework became irrelevant and have been modified informally. A thorough assessment was made of all outcome and output indicators in the results framework during the restructuring mission and a set of new indicators have been proposed to ensure that the results framework more closely reflects the project activities. In total, 9 out of 17 indicators were modified, 7 were dropped and another 17 indicators were added. This restructuring allows indicators under the results framework to be formally changed (see Annex 1 for details on the original outcome and intermediate outcome indicators in the Project Appraisal Document and the proposed changes to the original indicators and the targets as well as the new indicators). Annex 2 provides the revised Results Framework with the baseline data and targets. The main outcome indicators to measure the success of the restructured project are as follows: Project Development Objective Improve Access Increase Utilization Enhance Quality Revised PDO Indicators % of population covered with re-trained family medicine providers Percentage of rural population with access to a PHC clinic within 30 minutes of transportation/ walking Increased immunization rate of (DPT3). Increased health care service utilization as measured by number of outpatient visits per capita (by poor and by general population) (threshold score for accessing MAP - 70,000) Increased satisfaction of population with PHC services in target areas, as measured by the utilization survey % of trained rural physicians who manage cases according to nationally approved treatment guidelines in project target areas Proportion of TB patients managed at the PHC level according to the 5
Project Development Objective I Revised PDO Indicators DOT stratew, Strengthen Stewardship Functions I % of health budget earmarked to program for poor I Key health laws revised & passed (health care, medical practice) I I Increased awareness of population on health care reforms I 7. Revised project components: The project design would be changed as follows: (i) the original sub-components 1.1 and 1.2 would be merged; (ii) sub-component 2.1 would be moved under Component 1, now renamed Strengthening the PHC System. This would consolidate all PHC related activities under Component 1, Additionally, Component 2 would be renamed Support for Health Sector Reform and the original sub-component 1.3 would be moved under this component. Also, the original sub-components 2.2 and 2.4 would be merged under a new sub-component 2.2. Component 3 on Project Management would remain unchanged. The table below shows comparisons of the original and revised project structure. Component 2: Institutional Development Sub-component 2.1: Capacity Building for PHC Training Sub-component 2.2: Capacity Building in the Management of PHC Services Sub-component 2.3: Strengthening Health Management Information Systems for PHC Sub-component 2.4: Support for PHC Health Care Financing Reforms I Component 3: Project Management I Component 2: Support for Health Sector Reform Sub-component 2.1: Information and Communication Campaign Sub-component 2.2: Capacity Building for MOLHSA in Policy, Regulation, Financing and M&E Sub-component 2.3: Strengthening Health Management Information Systems I Component 3: Project Management 8. The total estimated costs in US$ are based on the current SDWUS$ exchange rate of SDRl/US$1.48 (February 17, 2009). Hence the total Bank financing is estimated at US$23.5 million, The revised project description would be as follows: COMPONENT 1: Strengthening PHC System (US$17.8 million Bank financing) + Sub-component 1.1 : Upgrading Health Clinics: The objective of this sub-component is to increase access to critical primary health care services. This sub-component would finance the following activities: (i) rehabilitation of health clinics, including 1 reference laboratory; (ii) provision of equipment for clinics and family doctors; (iii) rehabilitation 6
and equipment of Kutaisi MCH Center; and (iv) equipment for Avian flu resuscitation units and anti-viral drugs for avian flu. + Sub-component 1.2: PHC Training: The objective of this sub-component is to strengthen capacity in PHC and improve the quality of care, through the: (i) rehabilitation and equipment of 5 regional Family Medicine Training Centers; (ii) establishment of Family Medicine Faculty; (iii) development of clinical guidelines and undergraduate nursing education curriculum; (iv) provision of training for PHC providers in family medicine, on clinical guidelines, and contract negotiatiodmanagement skills; and (v) provision of training on maternal and child care and health management to health practitioners and managers. COMPONENT 2: Support for Health Sector Reform (US$4.1 million Bank financing) + Sub-component 2.1 : Information and Communication (IC): The objective of this subcomponent is to increase awareness and understanding by the population of the Government s health reform program. Specifically, this includes information on programs for the poor, privatization of health facilities, contracting with private insurance, content of the benefit package, etc. The sub-component would finance the design and implementation of the IC campaign throughout Georgia. + Sub-component 2.2: Capacity Building in MOLHSA in Policy. Regulation, Financing and Monitoring and Evaluation. The objective is to support the development of capacity of the MOLHSA to analyze, monitor the sector as a basis for steering rather than rowing stewardship role. This sub-component would finance the following activities: (i) Strengthening the capacity of Health Policy Division in MOLHSA; (ii) institutionalization of M&E; (iii) support for development of regulatory capacity; (iv) the development and institutionalization of National Health Accounts; (v) carrying out a Health Sector Performance Assessment; (vi) technical assistance on health financing reforms; and (vii) conducting the Impact Evaluation of the Medical Assistance Program for the Poor. + Sub-component 2.3: Strengthening of Health Management Information System (HMIS): The objective is support the development of the HMIS. Specifically, this includes (i) the rehabilitation and equipping of the Center for Medical Statistics, which has been merged with the National Center for Disease Control; (ii) technical assistance to analyze the existing flows of health related information and to develop a conceptual framework, conduct a bankable feasibility study including an implementation plan for a future system of health information management at a national level; and (iii) the design of the HMIS. COMPONENT 3: Project Management (US$1.60 million Bank financing) + This component would continue to support effective administration and coordination of the project. This includes managing the resources.of the project, procuring goods and services under the project, operating the financial management system, and ensuring timely and appropriate reporting. 7
Other related proposed changes: 9. In order to reflect changes made in the project, as outlined above, the following additional changes are proposed: a new single expenditure category entitled, Provision of Civil works, Goods, Consultant Services and Training, and Incremental Operating Costs, with an allocation of SDR 6.6 million added to the Allocation of Credit Proceeds in Schedule 1. This category would be financed at 100 percent in line with the 2005 Country Financing Parameters, which allow for such financing. reallocations between expenditure categories to accommodate the proposed changes. The reallocations proposed are as follows: Allocation of Credit Proceeds (SDR) D. Analysis The project Closing Date would be extended by12 months to December 31, 2010 because the implementation of the new activities under the restructured project requires a longer project time period. The procurement thresholds under the restructured project would be based on the updated Procurement and Consultant Guidelines (2004) as revised in October 2006. The procurement plan will specify those contracts which are subject to the Bank s prior review. IO. The government of Georgia has taken a radical approach to change both the financing and provision of health care services in Georgia. This approach has the potential to increase financing to the health sector through private investment and to improve management of health 8
service provision. However, the approach also bears substantial risks. One of the major risks is whether the government would have the capacity to regulate and monitor the provision of health service by the private sector as well as the purchasing function performed by private insurance companies. This risk is addressed by the proposed changes under the project by increasing support to capacity building for the Ministry of Health to enhance its stewardship functions. 1 1. Another risk is that a large proportion of population who are poor are not eligible for the government s Medical Assistance Program for the Poor, which covers the extremely poor, and who will have difficulties to access health care after the privatization of the health facilities. The project supports an evaluation to assess the impact of the government s reform programs on the access to and utilization of health services and will provide hard evidence to policy makers on the feasibility of the approach being taken. 12. The proposed changes, however, do not have a major effect on the original economic, technical, institutional, environmental, and social aspects of the project. In terms of project implementation and financial arrangements, these would continue to be used under the restructured project. Also, the existing procurement procedures would apply for all project activities. A revised procurement plan for the restructured project has been prepared and reviewed by the Bank team. Lastly, the proposed changes to the project do not affect the environmental category of the project or trigger new safeguard policies. The restructuring does not involve any exceptions to Bank policies. E. Expected Outcomes 13. The proposed changes in the project s development objectives and its design are reflected in a revised set of outcome and intermediate outcome indicators of the project that are attached to this Project Paper (see Annex 1 and Annex 2). The revised results framework, which includes ten outcome indicators as well as a set of component-related indicators, has been discussed and agreed on with all relevant project agencies. F. Benefits and Risks 14. The project is expected to yield benefits in support of Georgia s health sector reform to improve the health status of its population. As a result of the project: (i) relevant health facilities would be rehabilitated and equipment provided; (ii) health staff would be trained and certified to provide family medicine on the basis of new family medicine guidelines; (iii) the capacity of the MOLHSA and related agencies would be strengthened in policy analysis, monitoring and evaluation, and in regulation. Importantly, it is expected that the main benefit of the restructured project would be that it provides the support to the government at this critical time to be able to monitor and evaluate its health reform program and to ensure that the most vulnerable groups of the population have access to good quality healthcare services. 15. The main risk of the project not being able to achieve its development objective is the unstable political environment and the frequent change of policy makers and policy decisions. The relatively low capacity of the implementing agency to carry out the project activities in a very dynamic and a complex political environment is another risk. The latter risk is of particular 9
concern given the project s ambitious nature, a relatively short remaining implementation period, and a set of activities which tend to be highly labor intensive, such as the provision of training to a large number of medical staff. On the positive side, the project implementation unit is highly competent with excellent staff and management, which benefits from continued support from high Government levels. Also, to further mitigate this risk, technical assistance will be provided to MOLHSA and other government agencies to assist policy makers in overseeing the reform progress. 16. Policy environment in Georgia, especially in the health sector is very dynamic. It imposes high risk for this operation. However, it also provides opportunities for high gain because it allows the Bank to stay engaged in the health sector to influence important policy development in Georgia. 10
Annex 1. Proposed Changes in the Results Framework Indicators Original Indicators (from PAD) Revised or Indicators (in Project Paper) Proposed Changes Original (from PAD) Revised or Approximately 50% of the population with access to a PHC clinic within 30 mins of wal kinglother transportation Population with access to PHC services completing at least three visits per capita per year 20% increase in the proportion of infants in the population that receive immunization (DPT3) on time At least 50% of population enrolled with certified family medicine practitioners by 2008 90% of providers trained in family medicine actually practicing family medicine 90% of rehabilitated facilities have trained family medicine doctors, nurses and basic equipment Regional Family Medicine Training Centers operational YO of rural population with access to PHC clinic within 30 mins of transportatiodwalking Increased healthcare service utilization as measured by number of out-patient visits per capita (by poor and by general population) (threshold score for accessing the MAP - 70,000) Increased immunization rate of (DPT3) YO population covered with retrained family medicine providers YO of PHC providers trained in family medicine (countrywide) Regional Family Medicine Training Centers rehabilitated and equipped (operational) This indicator is revised to add rural, because the project finances only rural clinics. Revised to better define the indicator. Revised to better define the indicator. Revised to better define the indicator. Revised to make this indicator measurable. Kept as original. Revised to better define the indicator. 20% increase from 78% in 2004 90% 90% 5 2.6fpclyr for poor; 2.3lpclyr for gen. population 90% of DPT3 coverage 50% 50% 90% 5 PHC norms and standards and master plan translated and implemented as laws Basic health information systems for PHC developed and implemented Key health norms revised and passed (healthcare, medical practice) IC campaign designed and implemented Revised to better define the indicator. Revised to include expanded scope of the campaign. Laws passed IC campaign carried out 11
Analytical studies and Analytical studies and I Revised to better evaluations needed for developing healthcare financing reforms for PHC completed and used to revisehedefine implementable strategies for healthcare financing evaluations needed for developing healthcare financing reforms complete and used to reviselredefine strategies define the indicator. Health sector performance evaluation completed HMIS system developed I Studies and analysis carried out HSPE report produced System designed and implemented for PHC 30 40 % of trained rural physicians who manage cases according to nationally approved treatment guidelines in project target areas Increased awareness of population on healthcare 70 30 Number of new, rehabilitated and equipped health clinics Number of rural practices equipped I 98 Increased satisfaction of population with PHC services in target areas, as measured by the utilization survey Number of physicians trained in new clinical guidelines Increased satisfaction (70%) 550 Kutaisi center rehabilitated, equipped and staff trained Center rehabilitated, equipped and staff trained 12
established, equipped, curriculum developed Family Medical Facility developed 40 20150 I Master plan developed and used Master plan developed Laws revised (healthcare, medical practice) Laws revised 30% increase in the number of ARI/DD cases managed at the PHC level 30% increase in the proportion of pregnant women who have had at least 4 prenatal visits 50% increase in the proportion of adult patients seen in refurbished PHC clinics for whom blood pressure is recorded in patients medical records Improved knowledge and practice of practices related to healthy lifestyles (smoking, diet, wellbeing check-ups) I Policy and decision-making capacity strengthened as measured by number of health policy staff trained, improved policy analysis, regular reports on health reform implementation and institutionalized M&E This indicator is dropped because no disaggregated data reported for this indicator. Dropped. The project has no direct inference on this indicator. It is not appropriate indicator to monitor project performance. Dropped due to lack of data. Dropped due to the project activities have been changed and does not directly affect lifestyle changes. Capacity strengthened 13
20% increase in the number of cases managed according to internationally and nationally approved treatment guidelines 40% increase in the number of appropriate referrals (appropriately defined according to the I Dropped. More appropriate indicators have been introduced in this area. Dropped. More appropriate indicators have been introduced. I number of ARI/DD cases managed at the PHC level indicator appeared twice in the PAD. 14
Annex 2: Proposed Project Results Framework Project Development Objective (PDO) Access L'tilization Quality PDO Indicators?LO of population covered with retrained family medicine providers Percentage of rural population with access to a PHC clinic within 30 minutes of transportation' walking Increased immunization rate of (DPT3). Increased health care service utilization as measured by number of out-patient visits per capita (by poor and by general population) (threshold Baseline (original and new indicators)/ 0.6 (2004) 20% (2008)' 78% (2004) 2lpcly for poor 2lpcly for G. Pop (2006) 66% (2006) 0% (2008) Proposed Targets 50% Data sourceskomments MOLHSA Reports 50% To be measured by household survey (total rehab facilities of 800 rural) 90% I NCDCPublic Health for poor 2.3lpclyear for G. DOD Increased satisfaction (70%) 30% household utilization survey As measured by household utilization survey As measured by Facility Survey Stew a rd s h i p functions Sub-component 1.1: Upgrading health clinics Sub-component 1.2: PHC Capacity Strengthening project target areas Proportion of TB patients managed at the PHC level according to the DOT strategy. YO of public health expenditure earmarked to program for poor Key health laws revised and passed (health care, medical practice) Increased awareness of population on health care reforms Number of new, rehabilitated and equipped health clinics Number of rural practices equipped Kutaisi center rehabilitated, equipped and staff trained Regional Family Medicine Training Centers rehabilitated and equipped (operational) Family Medical Faculty established, equipped, curriculum developed 3% (2004) 3.6% (2006) 0 (2008) 46% (2006) 0 0 (2007) 0 No family medicine faculty 40% 30% Laws passed 70% 120 98 Center rehabilitated equipped and trained staff 5 Family Medical Facility established National TB Center MOLHSANHA Data As measured by number of laws revised and passed As measured by public opinion survey Actual 103 done 98 done MCC training to be provided in 50 districts to 120 doctors and will include Kutaisi Rehabilitated and equipped 3 centers; I training in 4 Family Medical Facility established I The 20% is for the total population and the data for the rural population is been collected. 15
% of PHC providers trained in family medicine (country-wide) 5 yo 50% At the beginning of the project 105 doctors were trained by DFID. (the total doctors need for training in country is 2,200 and 1,205 to be trained by project) Sub-component 2.1: Information and Communication Sub-component 2.2: Capacity Building for MOLHSA in Policy, Regulation, Financing and M&E 90% of rehabilitated facilities have trained family medicine doctors, nurses and basic equipment % of PHC staff trained in contracting/ management 20 family medicine guidelines developed and adopted, and 50 guidelines distributed Number of physicians trained in new clinical guidelines IC campaign designed and implemented Master Plan developed and used 0 (2008) 0 0 No IC campaign No MP 90% 40% 20150 550 IC campaign carried out Master plan developed HSPIC 404 doctors to be trained out of 1,042 rural doctors Printing and distribution will be done for all guidelines Of the 2,200 in country Master plan developed Laws revised (health care, medical practice) Policy and decision-making capacity strengthened Analytical studies and evaluations needed for developing health care financing reforms completed and used to revise/redefme strategies. Health sector performance evaluation (HSPE) completed Laws revised Capacity strengthened Studies and analysis carried out HSPE report produced As measured by number of health policy staff trained, improved policy analysis, regular reports on health reform implementation, and institutionalized M&E. Sub-component 2.3: Strengthening Health Management Inform a tio n Systems HMIS system developed HIMS system designed Consultant assessed the current systems 16