Public Disclosure Authorized Public Disclosure Authorized The World Bank Implementation Status & Results Montenegro Healthcare System Improvement Project (Montenegro) (P082223) Operation Name: Healthcare System Improvement Project (Montenegro) Project Stage: Implementation Seq.No: 13 Status: ARCHIVED Last Modified : 25-Apr-2011 (P082223) Country: Montenegro Approval FY: 2004 Product Line: IBRD/IDA Region: EUROPE AND CENTRAL ASIA Lending Instrument: Specific Investment Loan Implementing Agency(ies): Ministry of Health Key s Board Approval 08-Jun-2004 Original Closing 28-Feb-2009 Planned Mid Term Review 12-Feb-2007 Last Archived ISR 21-Jun-2010 Effectiveness 01-Dec-2004 Revised Closing Actual Mid Term Review 12-Feb-2007 Project Development Objectives Project Development Objective (from Project Appraisal Document) The objective of the proposed Health System Improvement Project is to put in place the first phase of steps towards reform of the health system in the Republic of Montenegro, giving priority to increasing capacity for policy, planning and regulation; stabilizing health financing and improving primary health care service delivery. Has the Project Development Objective been changed since Board Approval of the Project? Yes No losure Authorized Public Disclosure Authorized Component(s) Component Name Component Cost 1. SUPPORT FOR HEALTH REFORM PROGRAM 5.13 2. PHASED IMPLEMENTATION OF PRIMARY HEALTH CARE DEVELOPMENT 14.18 3. PROJECT MANAGEMENT 1.26 Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Implementation Status Overview The Disbursement Rate has increased to 14.3%. Component 1 (Policy Support) has most of the technical assistance for policy support (i.e. on hospital financing reform, public private partnerships, quality assurance strategy) well in progress of being contracted. Further technical assistance will be advertised for technical support in defining benefits package Page 1 of 16
for secondary and tertiary care services. Tendering documents are also in progress for the development of information system components of the Drugs Agency, the Ministry of Health and the Institute of Public Health. Results Project Development Objective Indicators MoH stewardship of the health system improves as measured by increases of health related information and development of key health policies The Strategy for Health Care Development in Montenegro until 2020 (2003) approved; basic health system laws in draft; Montenegro inunion with Serbia and not yet with own country laws and regulations Information available: LSMS on health status and lifestyles available (2008); NHA for 2004-2006 developed (2008) and plan for institutionalization in effect, PHC Effic Study data available (2011), Health System Integrity Assessment Report developed. Policy Developments: Laws on Health Insurance, Health Care and Pharmaceuticals Approved; Strategic Health Insurance Development Plan to 2011 approved; PHC Reform Strategy approved; hospital network masterplan 2005-2010 approved; Secondary and Tertiary Reform Strategy under development; Masterplan 2010-2013 adopted. 11 new laws adopted or amended since 2008, Decision on Network of Health institutions adopted, developing legislative framework for PPP Target on track Secondary and Tertiary Care Reform Strategy developed and approved, including legislative framework for entering into public private partnerships in health; Further refine PHC policies; new masterplan adopted Page 2 of 16
HIF increases its capacity to perform its functions of pooling health resources; better allocating health resources; and contracting providers towards improved performance HIF in existence and developing improved control over pharmaceutical expenditures through pricing and information system with pharmacists All funds for health services pooled through the HIF; Comprehensive information system operational with pharmacists and PHC providers for monitoring and controlling performance; New model of contracting and financing of PHC operational based on capitation, fee for service and adjustments for geographical location and provision of services within a group practice; Contracts with private dentists signed. PHC IS fully operational nationwide, HIF has started electronic invoicing and development of information systems withgen hospitals nationwide. Target on track. HIF has developed the necessary groundwork for developing hospital budgets based on output (i.e. DRGs) rather than inputs includingdefining state-financed services, developing the information base, establishing a system of coding of diagnoses and grouping of diagnoses appropriate for Montenegro, and training of hospital staff. Additional contracts with private providers signed. Page 3 of 16
HIF controls the increasing cost of nationally financed pharmaceuticals and medical materials Share of HIF expenditures spent on drugs: 19.2% Share of HIF expenditures spent on drugs and medical materials: 28.4% HIF not yet analyzing pharmaceutical expenditures Share of HIF expenditures spent on drugs: 16.3% Share of HIF expenditures spent on drugs and medical materials: 24.0% HIF Annual Report on Pharmaceutical Expenditure 31-Dec-2008 2009 Figure to become available when HIF Financial Report for 2010 is released Over time, the HIF has expanded the list of drugs so overall costs may rise even with reductions in drug prices. Due to the economic crisis and changes in excha nge rates for imported drugs, reasonable 2012 targets are: Share of HIF expenditures spent on drugs ator below 18.0% Share of HIF expenditures spent on drugs and medical materials at or below 27.5% HIF annual deficit reduced 0.8 million Euros surplus Zero deficit 31-Dec-2010 HIF became Treasury budgetary unit in 2010 so has zero deficit. Zero deficit (assuming possible small deficits in 2009-2010 and economic recovery 2011-2012). Page 4 of 16
Reduced waiting time (from arrival to consultation) in primary care Podgorica patients reporting 21 minutes or more: 57% To prevent confusion with baseline dates, additional indicators from HIF admin time for wait time reported in "current". Podgorica patients reporting 21 minutes or more: 46% (2008) Patients outside of Podgorica reporting 21 minutes or more - 68% (2008) Average waiting time for patients in Podgorica: 8 min, 41 sec; Average waiting time for patients outside of Podgorica: 38 min. 59 sec 2008 AF Baseline figures slightly revised bc original numbers were preliminary. Revised numbers from 2008 Public opinion survey. New POS to be fielded in 2011 for categorical indicator. Podgorica patients reporting 21 minutes or more: 30% Patients outside of Podgorica reporting 21 minutes or more: (2009 Baseline - 15 %) improvement Page 5 of 16
Increased duration of PHC Consultation Podgorica patients reporting 21 minutes or more: 34% To prevent confusion with baseline dates, additional indicators from HIF admin time for wait time reported in "current". Podgorica patients reporting 11 minutes or more: 42% (2008) Patients outside of Podgorica reporting 11 minutes or more # 16% (2008) Average consultation time for patients outside of Podgorica with prior appointment: 6 min. 59 sec. Average consultation time for patients in Podgorica with prior appointment: 7 min. 6 sec Average consultation time for patients outside of Podgorica with prior appointment: 7 min. 49 sec, without prior appointment: 6 min. 15 sec. Average consultation time for patients in Podgorica with prior appointment: 8 min. 12 sec, without prior appointment: 6 min. 26 sec. Average waiting time for patients in Podgorica:23 min, 21sec. Average waiting time for patients outdie of Podgorica:48 min. 4 sec. 2008 AF Baseline figures slightly revised bc original numbers were preliminary. Revised numbers from 2008 Public opinion survey. New POS to be fielded in 2011 for categorical indicator. Podgorica patients reporting 11 minutes or more: 70% Patients outside of Podgorica reporting 11 minutes or more: (2009 Baseline + 25 %) improvement Page 6 of 16
Increase utilization rates for primary health care for the general population (in Podgorica and outside Podgorica) and the Roma 11.4% of population in Podgorica report use of PHC; 21% of Roma in Podgorica report use of PHC 39.1% of population in Podgorica report use of PHC (LSMS); 36.9% of general population (including Podgorica) report visiting their GP (LSMS); 30.9% of Roma in Podgorica report visiting their GP (LSMS) 31-Dec-2008 2008 AF baseline figures slightly revised bc original numbers were preliminary. Revised figures all based on LSMS. New HH survey tobe fielded in 2011 Target groups (population in Podgorica, outside of Podgorica and Roma) report visiting their Chosen Doctor at or close to 40% Increase satisfaction for primary health care of the general population (in Podgorica and outside of Podgorica) and specifically for the Roma In Podgorica, 62% of the population totally satisfied and 20% partially satisfied In Podgorica, 42% of the population totally satisfied and 44% partially satisfied (POS); for the gen population (including Podgorica), 71% of the population satisfied (LSMS survey); and for the Roma, 87.7% satisfied (LSMS survey) 31-Dec-2008 2008 AF baseline figures slightly revised bc original numbers were preliminary. Revised figures from POS and LSMS. New POS and HH survey to be fielded in 2011 In Podgorica, 70% of the population totally satisfied and 27% partially satisfied; for the population outside of Podgorica, 66% of the population totally satisfied and 31% partially satisfied; and satisfaction of the Roma population remains high (i.e. 87.7% or higher) The general population target should be slightly changed since based on HH survey, not public opinion survey. Will be discussed during mission in May. Page 7 of 16
Referral rates from PHC to hospitals controlled Proportion of patients referred to specialists = 24.43% Proportion of patients referred to hospitals = 1.73% 31-Dec-2009 2009 data. Proportion of patients referred to specialists = 26.30% Proportion of patients referred to hospitals = 1.91% 31-Dec-2010 2009 baseline - 10% increase Maintain or improve immunization rates (%) for DPT and measles (already high) following reform DPT (initial and follow-up): 86% MMR (initial and follow-up): 82% DPT (initial and follow-up): 94% MMR (initial and follow-up): 92% 31-Dec-2008 DPT (initial and follow-up): 94% MMR (initial and follow-up): 92% Baseline immunization rates are for Podgorica only. Team is working with IPH to see whether these figures can be obtained or whether they should be replaced with national immunization figures. Will update in May mission. Intermediate Results Indicators Adoption of bylaws and administrative documents covering health insurance, health care and pharmaceuticals Laws on Health Insurance, Health Care and Pharmaceuticals in Draft Laws on Health Insurance, Health Care and Pharmaceuticals Approved and largely operational. 434 Pharmaceutical drugs approved with 8 subregulations, 11 new laws and 4 new bylaws adopted since 2008 Laws maintained, including additional sub-regulations for pharmaceuticals Page 8 of 16
Revision of policy, benefits, and standards for primary care Montenegro system of PHC inherited from former Yugoslavia PHC Strategy defined and adopted; basic benefit package defined and adopted; normative standards defined and adopted; payment mechanism defined and fully operational nationally. PHC Policies (particularly the payment mechanism and care protocols) refined based on implementation Development of the reform for revision of policy, benefits and standards for secondary and tertiary care None Master Plan 2010-2013 adopted. Decision on Network of Health institutions adopted; Secondary and Tertiary HC Strategy under development Masterplan developed and adopted; benefit package of HIFfinanced secondary and tertiary care services defined; and the informationbase for developing an output (i.e. DRG) based financing model established Page 9 of 16
Drugs Agency developed to better perform its functions of regulating and ensuring the quality of drugs in Montenegro None Drugs Agency Established Drugs Agency has registered 18.9% of total drugs available on the market in Montenegro 31-Dec-2010 Significant progress has been made. 2008 AF baseline revised to 1.9% based on drugs agency definition of registered as "formally complete" phase. PHC Patients are aware of and supportive of health reform 54% (in Podgorica) Drugs Agency functional as a regulatory agency Drugs Agency has registered 10-15% of total drugs available on the market 74% (in Podgorica) 70% or higher (nationally) 70% (nationally) 31-Dec-2008 2008 AF baseline slightly revised bc original numbers were preliminary. New POS to be fielded in 2011 Page 10 of 16
Operational health information systems in HIF, primary health care providers, pharmaceutical supply chain, to provide timely, accurate data on key elements of performance (expenditure, service utiliza HIF Pharma and Insuree Register System Operational Information System between HIF, primary health care providers and pharmaceutical supply chain, encompassing the required elements of performance fully operational. HIF has started electronic invoicing and development of business information systems with general hospitals nationwide Target on track Information system between HIF, primary health care providers and pharmaceutical supply chain continue to be operational. IT systemfor drugs includes both public and private provider prescribed drugs. The information system connecting the HIF and hospitals, providing among other things information on the coding and costs related necessary to develop out-put based financed ie (DRGs), is launched. Increase percentage of patients (adults and children) in Podgorica with a Chosen primary care doctor (out of total insurees) 0% 87.26% 31-Dec-2010 ACHIEVED 85% Number of facilities renovated/constructed in Podgorica 0 of 10 7 of 10 30-Jun-2010 ACHIEVED 7 of 10 (including 2 which are being financed by the state budget) Page 11 of 16
Number of facilities equipped with computer and medical equipment in Podgorica 0 10 of 10 have medical equipment 10 of 10 have computer equipment 30-Jun-2010 ACHIEVED 10 of 10 have medical equipment 10 of 10 have computer equipment Decreasing in the percentage of referrals made for an injectable drug (ampoule treatment) 32124 referrals for such treatments 29287 referrals for such treatments 12% decrease in Podgorica (2006) in Podgorica or 7% decrease 31-Dec-2008 Update for 2009 to be provided in next report. Adoption of PHC Guidelines 0 No quality Guidelines adopted 10 PHC Guidelines Adopted Page 12 of 16
Proposal developed for the appropriate quality assurance system in Montenegro No proposal No proposal Proposal well developed, including lessons learned from the region and addresses the legal, institutional, financial and technical aspects of a quality assurance system Number of PHC Teams (1 Chosen Doctor + 1 Nurse) provided retraining in family Medicine Nationally Preparing Retraining Program 222 teams and additional 25 Nurses/techs. Target on track Retraining Program Completed with a total of 255 teams (1 Doctor + 1 Nurse) retrained. Family Medicine specialization established and operational at Medical Faculty Not established Family Medicine included in curriculum of undergraduate medical education. Family Medicine Specialization Program Implementation Model developed. Target on track Family Medicine Specialization to be established and initial cohort of students to be enrolled Page 13 of 16
Increase percentage of patients (adults and children) outside of Podgorica with a Chosen primary care doctor (out of total insurees) 0 85.24% 31-Dec-2010 Target achieved 85% Number of facilities renovated/constructed outside of Podgorica 0 0 Reconstruction in progress. 1 (Bijelo Polje) Number of PHC facilities equipped with computer and medical equipment outside of Podgorica 0 31-Dec-2008 20 of 20 equipped with computer equipment 0 of 20 equipped with medical equipment. 20 of 20 equipped with computer equipment 20 of 20 equipped with medical equipment Health personnel receiving training Core Indicator Number 0.00 469.00 Target on track 510.00 255 Teams (1 Doctor + 1 Nurse) Page 14 of 16
Health facilities constructed, renovated, and/or equipped Core Indicator Number Data on Financial Performance (as of 24-Feb-2011) Financial Agreement(s) Key s 0.00 7.00 Target on track 8.00 Project Loan No. Status Approval Signing Effectiveness Closing P082223 IBRD-78190 Effective 03-Nov-2009 19-Nov-2009 10-Dec-2009 P082223 IDA-39180 Closed 08-Jun-2004 11-Jun-2004 01-Dec-2004 31-Dec-2009 P082223 TF-55474 Closed 25-May-2006 25-May-2006 28-Jun-2007 30-Nov-2008 Disbursements (in Millions) Project Loan No. Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P082223 IBRD-78190 Effective USD 7.20 7.20 0.00 1.02 6.13 14.00 P082223 IDA-39180 Closed USD 7.00 6.85 0.15 7.41 0.00 108.00 P082223 TF-55474 Closed USD 0.31 0.31 0.00 0.83 0.00 265.00 Disbursement Graph Page 15 of 16
Key Decisions Regarding Implementation An implementation support trip is planned for mid-may 2011. Restructuring History There has been no restructuring to date. Related Projects P114275-Health System Improvement Additional Financing Page 16 of 16