The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Health Systems Improvement Project (P171150) EUROPE AND CENTRAL ASIA | Bosnia and Herzegovina | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2022 | Seq No: 1 | ARCHIVED on 22-Jun-2022 | ISR51854 | Implementing Agencies: Bosnia and Herzegovina, Federal Ministry of Finance, Federation of Bosnia and Herzegovina, Federal Ministry of Health, Federation of Bosnia and Herzegovina, Ministry of Finance, Republika Srpska, Ministry of Health and Social Welfare, Republika Srpska Key Dates Key Project Dates Bank Approval Date: 07-Apr-2022 Effectiveness Date: -- Planned Mid Term Review Date: -- Actual Mid-Term Review Date: Original Closing Date: 31-Dec-2027 Revised Closing Date: 31-Dec-2027 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The Project Development Objective is to contribute to improvement in the quality of care and in the financial sustainability of the health care systems in Republika Srpska and the Federation of Bosnia and Herzegovina. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Increasing health system performance in Republika Srpska:(Cost $53.42 M) Increasing health systems performance in the Federation of Bosnia and Herzegovina:(Cost $21.40 M) Front-End Fee (financed from loan):(Cost $0.18 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO -- Satisfactory Overall Implementation Progress (IP) -- Satisfactory Overall Risk Rating -- Substantial Implementation Status and Key Decisions The project was approved by the World Bank Board on April 7, 2022. As subsequent steps towards approval for Loan Agreement signing and effectiveness are ongoing, the Project Implementing Unit within the Federal Ministry of Health of the Federation of Bosnia and Herzegovina (FBiH), and the Planning, Analysis, Financing and Project Implementation Department within the Ministry of Health and Social Welfare in the Republika Srpska (RS) will undertake the development of a Project Operations Manual and its submission for the Bank’s review. The needs for technical consultancies to support the reforms under the project will be identified in discussion with the Bank team and included under the Multi-Donor Trust Fund-financed activities. Since the project is yet to become effective, 0 percent of the total International Bank for Reconstruction and Development loan (No. 93510-BA) of USD 75 million has been disbursed. Progress towards approval: Both FBiH and RS counterparts demonstrated their strong and continued commitment to implementing the health sector reforms with the Bank’s support, including through undertaking important steps towards establishing the legislative framework to support the 6/22/2022 Page 1 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) implementation of activities under the project. Following approval of the loan by the World Bank, the Bosnia and Herzegovina governments have initiated their internal approval procedures. On May 26, 2022, the Bosnia and Herzegovina Council of Ministers endorsed the negotiated Loan Agreement for the project. Once the Loan Agreement has been cleared by the state-level Presidency and the Parliamentary Assembly, the approval procedures will be initiated with entity-level governments and parliaments. The RS Government has initiated the preparation of the Decision on the Acceptance of the Loan, to be adopted by the Government and the National Assembly. However, the forthcoming general elections scheduled for October 2022 may pose risks to timely signing and effectiveness of the Loan Agreement. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Substantial -- Substantial Macroeconomic Substantial -- Substantial Sector Strategies and Policies Substantial -- Substantial Technical Design of Project or Program Substantial -- Substantial Institutional Capacity for Implementation and Substantial -- Substantial Sustainability Fiduciary Substantial -- Substantial Environment and Social Low -- Low Stakeholders Moderate -- Moderate Other Moderate -- Moderate Overall Substantial -- Substantial Results PDO Indicators by Objectives / Outcomes Contribute to improvement in the quality of care in BiH's health care systems IN01153592 ►The percentage of health care providers demonstrating quality gains through a defined set of indicators that are publicly disclosed (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures increases in the quality of health care services in both Republika Srpska and Comments: Federation of BiH. Health care quality indicators that are already defined and measured by ASKVA and AKAZ will be used, i.e. a parallel system will not be created. Baseline is set as zero since the indicator measures improvements in health care quality. 6/22/2022 Page 2 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) IN01153595 ... in Republika Srpska (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 IN01153597 ... in Federation of Bosnia and Herzegovina (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Contribute to improvement in quality of care and financial sustainability in BiH's health systems IN01153590 ►The percentage reduction in the rate of hospital admissions where the only recorded diagnosis is arterial hypertension, or where the principal diagnosis is uncomplicated arterial hypertension (Text, Custom, PBC) Baseline Actual (Previous) Actual (Current) End Target To be defined within the No Actual (Current) 20% reduction from Value -- first year of the project value yet baseline Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. Uncomplicated arterial hypertension is chosen because it is, in a high-performing health system, almost always treatable in primary care and almost never a valid reason for hospital admission. This indicator therefore measures quality and efficiency of the health care network, ensuring more management by Comments: primary care and avoiding unnecessary hospitalization, in both Republika Srpska and Federation of BiH. Attention to this indicator should also improve the accuracy of clinical coding upon a patient's admission or discharge (and thereby improve understanding of hospital activity and ensure correct reimbursement). The value is the number of admissions per 100 000 population. IN01153596 ... in Republika Srpska (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target To be defined within the No Actual (Current) 20% reduction from Value -- first year of the project value yet baseline Date 01-Jun-2021 -- 10-Jun-2022 31-Dec-2026 IN01153598 ... in Federation of Bosnia and Herzegovina (Text, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target To be defined within the No Actual (Current) 20% reduction from Value -- first year of the project value yet baseline Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 6/22/2022 Page 3 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Contribute to improvement in the financial sustainability of BiH's health care systems IN01153591 ►The percentage of health care providers achieving a debt ratio of 0.5 or less at the end of the financial year (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 -- 20.00 75.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. Debt ratio = total debt / total assets. This indicator measures the effectiveness of financial management within health care facilities in both Republika Srpska and Federation of BiH. It captures longer term Comments: financial stability (by including assets) and can also reflect progress in reducing arrears (a subset of liabilities). It is well-established internationally as a measure of financial health. Baseline value will be confirmed during the first months of project implementation. IN01153593 ... in Republika Srpska (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 -- 20.00 75.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 IN01153594 ... in Federation of Bosnia and Herzegovina (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 -- 20.00 75.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Intermediate Results Indicators by Components Increasing health system performance in Republika Srpska IN01153599 ►Percentage of health care providers that have established and disclosed an annual, representative patient satisfaction survey consistent with international benchmarks (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks stronger health systems governance, through ensuring measurement by health care Comments: providers of satisfaction among service users. IN01153601 ►Percentage of health care service users engaged in providing facility-level feedback on performance who report that their engagement was effective in planning and delivering service improvements (Percentage, Custom) 6/22/2022 Page 4 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 70.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks stronger health systems governance, through measuring citizen engagement in Comments: monitoring service performance, as well as in planning improvements in local health care services. IN01153603 ►Number of clinicians and health care managers trained in health care quality monitoring and improvement techniques (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 250.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks strengthened health systems governance, through enhanced clinical and managerial Comments: capacity to monitor and improve the quality and outcomes of care. IN01153605 ►Number of studies conducted to allow concentration of specialist health care into fewer providers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 6.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures progress in identifying specific services or patient pathways where quality and Comments: efficiency could be improved if they were provided by fewer, specialist providers. IN01153607 ►Percentage of hospitals publishing waiting times for selected secondary health care services (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 95.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks accessibility of health care services, to help ensure that efforts to control health Comments: systems spending do not compromise access to care. The indicator also promotes transparency in health systems governance. IN01153609 ►The gap between the percentage of hypertensive men and the percentage of hypertensive women whose hypertension is adequately controlled, as defined by current clinical guidelines (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 13.00 -- 13.00 5.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 6/22/2022 Page 5 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Project not yet effective. This indicator reflects the effectiveness of the detection and treatment of hypertension in primary care, and directly supports achievement of PDO Indicator 2. It also tracks an important gender gap: hypertensive men are less aware, less treated, and less controlled than hypertensive women. Adverse health risks that lead to elevated blood pressure, such as smoking, unhealthy diet and excessive alcohol Comments: consumption are related to social norms (and not biological differences), and are, therefore, gender issues. The baseline value, 13%, is the difference between 22.2% of hypertensive women who have safe blood pressure, and 9% of men of hypertensive men who have safe blood pressure. Self-evidently, a decrease in the rate of control of hypertension in women to meet that of men will not count as success for this indicator. Rather, a levelling-up in the rate of control across both genders is expected. IN01153611 ►Number of health care providers or health insurance funds submitting financial reports, including overdue unpaid liabilities, to the appropriate authorities on time (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 95.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator monitors the capacity to provide sufficiently detailed financial reports, including data on Comments: overdue unpaid liabilities (arrears) that is currently not collected. IN01153613 ►Number of studies of patient pathways conducted to determine true cost and adjust reimbursement tariff (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 4.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures progress in assessing the true cost of care and ensuring that health care Comments: providers are appropriately reimbursed for providing these services. IN01153615 ►Transfers from the general government budget to the health insurance fund for the purposes of paying health care insurance for special categories of the population, '000 000 BAM (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 106.50 -- 106.50 106.50 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures transfers made from the government regular budget to the health insurance fund, and from the health insurance fund and to health care providers, to maintain health insurance, and coverage of the health care needs, of: war veterans, refugees, the unemployed, social welfare recipients Comments: and other categories, as defined in Article 10(a) of the Law on Health Insurance published in Official Gazette No. 18/99. It is a means to monitor continuity and equity of access to the health care systems as efficiency reforms are undertaken. Baseline value is maintained as the target value throughout the project cycle, and actual (current) values are annually recurring/measured values, and not cumulative. Increasing health systems performance in the Federation of Bosnia and Herzegovina IN01153600 6/22/2022 Page 6 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) ►Percentage of health care providers that have established and disclosed an annual, representative patient satisfaction survey consistent with international benchmarks (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks stronger health systems governance, through ensuring measurement by health care Comments: providers of satisfaction among service users. IN01153602 ►Percentage of health care service users engaged in providing facility-level feedback on performance who report that their engagement was effective in planning and delivering service improvements (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 70.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks stronger health systems governance, through measuring citizen engagement in Comments: monitoring service performance, as well as in planning the design and delivery of local health care services. IN01153604 ►Number of clinicians and health care managers trained in health care quality monitoring and improvement techniques (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 500.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks strengthened health systems governance, through enhanced clinical and managerial Comments: capacity to monitor and improve the quality and outcomes of care. IN01153606 ►Number of studies conducted to allow concentration of specialist health care into fewer providers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 6.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures progress in identifying specific services or patient pathways where quality and Comments: efficiency could be improved if they were provided by fewer, specialist providers. IN01153608 ►Percentage of hospitals publishing waiting times for selected secondary health care services (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 95.00 6/22/2022 Page 7 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator tracks accessibility of health care services, to help ensure that efforts to control health Comments: systems spending do not compromise access to care. The indicator also promotes transparency in health systems governance. IN01153610 ►The gap between the percentage of hypertensive men and the percentage of hypertensive women whose hypertension is adequately controlled, as defined by current clinical guidelines (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 13.00 -- 13.00 5.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator reflects the effectiveness of the detection and treatment of hypertension in primary care, and directly supports achievement of PDO Indicator 2. It also tracks an important gender gap: hypertensive men are less aware, less treated, and less controlled than hypertensive women. Adverse health risks that lead to elevated blood pressure, such as smoking, unhealthy diet and excessive alcohol Comments: consumption are related to social norms (and not biological differences), and are, therefore, gender issues. The baseline value, 13%, is the difference between 22.2% of hypertensive women who have safe blood pressure, and 9% of men of hypertensive men who have safe blood pressure. Self-evidently, a decrease in the rate of control of hypertension in women to meet that of men will not count as success for this indicator. Rather, a levelling-up in the rate of control across both genders is expected. IN01153612 ►Number of health care providers or health insurance funds submitting financial reports, including overdue unpaid liabilities, to the appropriate authorities on time (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 95.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator monitors the capacity to provide sufficiently detailed financial reports, including data on Comments: overdue unpaid liabilities (arrears) that is currently not collected. IN01153614 ►Number of studies of patient pathways conducted to determine true cost and adjust reimbursement tariff (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 4.00 Date 01-Jul-2021 -- 10-Jun-2022 31-Dec-2026 Project not yet effective. This indicator measures progress in assessing the true cost of care and ensuring that health care Comments: providers are appropriately reimbursed for providing these services. Performance-Based Conditions 6/22/2022 Page 8 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) IN01153616 ►PBC 1 The percentage reduction in the rate of hospital admissions where the only recorded diagnosis is arterial hypertension, or where the principal diagnosis is uncomplicated arterial hypertension (Text, Outcome, 10,000,000.00, 0.00%) Baseline Actual (Previous) Actual (Current) Year 5 To be defined within the No Actual (Current) value Value -- -- first year of the project yet. Date -- -- 10-Jun-2022 -- Comments: Project not yet effective. IN01153617 ►PBC 2 Introduction of updated hospital reimbursement methods for four patient groups, based on evidence-based care pathways (Text, Output, 8,000,000.00, 0.00%) Baseline Actual (Previous) Actual (Current) Year 5 Identify appropriate pathways of care for the No Actual (Current) value (no condition set for Value four patient groups, as set -- yet. this year) forth in the Project Operational Manual. Date -- -- 10-Jun-2022 -- Comments: Project not yet effective. IN01153618 ►PBC 3 Completion of all technical and policy pre-requisites for transfer of primary health care providers to the treasury system, with actual transfer of 5 primary care centers achieved (Text, Intermediate Outcome, 11,000,000.00, 0.00%) Baseline Actual (Previous) Actual (Current) Year 5 Budget codes created for No actual (current) value (no condition set for Value -- all primary care centers yet. this year) Date -- -- 10-Jun-2022 -- The Bank team received informal correspondence from the RS MoHSW and Ministry of Finance that all 15 primary care centers have been transferred to the treasury system. Following verification by an independent Comments: verification agency, the actual (current) value of this indicator will be updated. The project will disburse against the achievement of this PBC once it is effective. IN01153619 ►PBC 4 Increase in the percentage of health care providers using patient satisfaction measures and service-user engagement in business planning, including publicly disclosed patient satisfaction rates. (Text, Outcome, 8,000,000.00, 0.00%) Baseline Actual (Previous) Actual (Current) Year 5 Value Citizen Feedback -- No Actual (Current) value (no condition set for Mechanisms (CFM) yet. this year) 6/22/2022 Page 9 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) methodology and digital platform developed Date -- -- 10-Jun-2022 -- Comments: Project not yet effective. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed Not P171150 IBRD-93510 USD 75.00 75.00 0.00 0.00 75.00 0% Effective Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date Not P171150 IBRD-93510 07-Apr-2022 -- -- 31-Dec-2027 31-Dec-2027 Effective Cumulative Disbursements 6/22/2022 Page 10 of 11 The World Bank Implementation Status & Results Report Health Systems Improvement Project (P171150) Restructuring History There has been no restructuring to date. Related Project(s) There are no related projects. 6/22/2022 Page 11 of 11