Document of The World Bank FOR OFFICIAL USE ONLY Report No: ICR00005047 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-52350; IDA-H8390; TF-15135) ON A CREDIT IN THE AMOUNT OF SDR 5.9 MILLION (USD$9.07 MILLION EQUIVALENT) AND A GRANT IN THE AMOUNT OF SDR 4.9 MILLION (US$7.43 MILLION EQUIVALENT) TO THE KYRGYZ REPUBLIC FOR A SECOND HEALTH AND SOCIAL PROTECTION PROJECT August 31, 2020 Health, Nutrition & Population Global Practice Europe And Central Asia Region CURRENCY EQUIVALENTS (Exchange Rate Effective Dec 31, 2020) Currency Unit = Kyrgyzstan Som (KGS) KGS 69.85 = US$1 US$ 1.38 = SDR 1 FISCAL YEAR January 1 - December 31 Regional Vice President: Anna M. Bjerde Country Director: Lilia Burunciuc Regional Director: Fadia M. Saadah Practice Manager: Tania Dmytraczenko Agnes Couffinhal, Oleksiy A. Sluchynskyy, Ha Thi Hong Task Team Leader(s): Nguyen ICR Main Contributor: Sevil Salakhutdinova ABBREVIATIONS AND ACRONYMS ANC Antenatal care MMR Maternal Mortality Ratio ART Antiretroviral therapy MOF Ministry of Finance CEMD Confidential Inquiry into Maternal MOH Ministry of Health Deaths CISSA Corporate Information System of MOLSD Ministry of Labor and Social Social Assistance Development CVD Cardiovascular Disease MSB Monthly Social Benefit DP Development Partners MTCT Mother to child transmission DS Den Sooluk MTR Mid-term Review EmoNC Emergency obstetric and newborn ORS Oral rehydration salts care GDP Gross domestic product PAD Project Appraisal Document GIZ German Agency for International PDO Project Development Cooperation Objective GOK Government of the Kyrgyz Republic PHC Primary Health Care HIV/AIDS Human Immunodeficiency PMTCT Prevention of mother to Virus/Acquired Immune-Deficiency child transmission Syndrome IDA International Development RF Results Framework Association IFR Interim Financial Report SA Social Assistance IRI Intermediate Results Indicator SDC Swiss Agency for Development and Cooperation ISN Interim Strategy Note SGBP State Guaranteed Benefit Package JAR Joint Annual Review SP Social Protection JFs Joint Financiers SWAp Sector-wide approach KfW Kreditanstalt für Wiederaufbau SWAp1 First Health and Social Protection Project KGS Kyrgyzstan Som SWAp2 Second Health and Social Protection Project M&E Monitoring and evaluation TB Tuberculosis MBPF Monthly Benefits for Poor Families USAID United States Agency for with Children International Development MCH Maternal and Child Health VSLY Value of one statistical life year MDR Multi-drug Resistant WB World Bank MIS Management Information System WHO World Health Organization TABLE OF CONTENTS DATA SHEET .......................................................................................................................... 1 I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................... 6 A. CONTEXT AT APPRAISAL .........................................................................................................6 B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) ..................................... 12 II. OUTCOME .................................................................................................................... 17 A. RELEVANCE OF PDOs – High .................................................................................................. 18 B. ACHIEVEMENT OF PDOs (EFFICACY) ...................................................................................... 18 C. EFFICIENCY ........................................................................................................................... 24 D. JUSTIFICATION OF OVERALL OUTCOME RATING .................................................................... 25 E. OTHER OUTCOMES AND IMPACTS ......................................................................................... 25 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ................................ 26 A. KEY FACTORS DURING PREPARATION ................................................................................... 26 B. KEY FACTORS DURING IMPLEMENTATION ............................................................................. 27 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 30 A. QUALITY OF MONITORING AND EVALUATION (M&E) ............................................................ 30 B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ..................................................... 31 C. BANK PERFORMANCE ........................................................................................................... 32 D. RISK TO DEVELOPMENT OUTCOME ....................................................................................... 34 V. LESSONS AND RECOMMENDATIONS ............................................................................. 35 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................... 37 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ......................... 49 ANNEX 3. PROJECT COST BY COMPONENT ........................................................................... 51 ANNEX 4. EFFICIENCY ANALYSIS ........................................................................................... 52 ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ... 58 ANNEX 6. SUPPORTING DOCUMENTS .................................................................................. 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) DATA SHEET BASIC INFORMATION Product Information Project ID Project Name P126278 Kyrgyz Second Health and Social Protection Project Country Financing Instrument Kyrgyz Republic Investment Project Financing Original EA Category Revised EA Category Partial Assessment (B) Partial Assessment (B) Organizations Borrower Implementing Agency Ministry of Health, Ministry of Labor and Social Kyrgyz Republic Development Project Development Objective (PDO) Original PDO The proposed PDO is to: (i) improve health outcomes in four health priority areas in support of the “Den Sooluk” National Health Reform Program 2012-2016; and (ii) enable the Government's efforts to enhance effectiveness and targeting performance of social assistance and services Revised PDO The proposed new PDO is to contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program. Page 1 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) FINANCING Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing 9,070,000 9,068,331 8,241,500 IDA-52350 7,430,000 7,430,000 6,854,500 IDA-H8390 11,963,500 11,960,000 11,960,000 TF-15135 Total 28,463,500 28,458,331 27,056,000 Non-World Bank Financing 0 0 0 Borrower/Recipient 1,327,100,000 1,327,100,000 1,344,820,569 Bilateral Agencies 26,100,000 26,100,000 26,100,000 (unidentified) Total 1,353,200,000 1,353,200,000 1,370,920,569 Total Project Cost 1,381,663,500 1,381,658,331 1,397,976,569 KEY DATES FIN_TABLE_DAT Approval Effectiveness MTR Review Original Closing Actual Closing 03-May-2013 11-Jul-2014 15-Jun-2016 31-Dec-2018 31-Dec-2019 RESTRUCTURING AND/OR ADDITIONAL FINANCING Date(s) Amount Disbursed (US$M) Key Revisions 16-Nov-2015 4.99 Change in Loan Closing Date(s) 07-Mar-2017 13.65 Change in Project Development Objectives Change in Results Framework Change in Components and Cost Change in Legal Covenants 07-Apr-2017 14.65 Change in Loan Closing Date(s) 17-Sep-2018 25.68 Change in Loan Closing Date(s) Page 2 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) KEY RATINGS Outcome Bank Performance M&E Quality Satisfactory Moderately Satisfactory Modest RATINGS OF PROJECT PERFORMANCE IN ISRs Actual No. Date ISR Archived DO Rating IP Rating Disbursements (US$M) 01 27-Jul-2013 Satisfactory Satisfactory 0 Moderately 02 06-Mar-2014 Moderately Unsatisfactory 0 Unsatisfactory 03 18-Oct-2014 Moderately Satisfactory Moderately Satisfactory 0 04 23-Mar-2015 Moderately Satisfactory Moderately Satisfactory 0 05 26-Aug-2015 Moderately Satisfactory Moderately Satisfactory .19 Moderately 06 04-Jan-2016 Moderately Unsatisfactory 4.99 Unsatisfactory Moderately 07 19-Jun-2016 Moderately Unsatisfactory 9.49 Unsatisfactory Moderately 08 22-Nov-2016 Moderately Satisfactory 11.49 Unsatisfactory 09 16-May-2017 Moderately Satisfactory Moderately Satisfactory 15.28 10 08-Nov-2017 Moderately Satisfactory Moderately Satisfactory 19.28 11 19-Jan-2018 Moderately Satisfactory Moderately Satisfactory 21.18 12 26-Jun-2018 Satisfactory Moderately Satisfactory 25.68 13 13-Dec-2018 Satisfactory Moderately Satisfactory 26.63 14 13-Jun-2019 Satisfactory Moderately Satisfactory 26.63 15 30-Dec-2019 Satisfactory Moderately Satisfactory 27.06 Page 3 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) SECTORS AND THEMES Sectors Major Sector/Sector (%) Health 82 Public Administration - Health 41 Health 41 Social Protection 18 Social Protection 3 Public Administration - Social Protection 15 Themes Major Theme/ Theme (Level 2)/ Theme (Level 3) (%) Social Development and Protection 18 Social Protection 18 Social Insurance and Pensions 6 Social protection delivery systems 12 Human Development and Gender 82 Disease Control 54 HIV/AIDS 27 Tuberculosis 27 Health Systems and Policies 28 Health System Strengthening 28 ADM STAFF Role At Approval At ICR Regional Vice President: Philippe H. Le Houerou Anna M. Bjerde Country Director: Saroj Kumar Jha Lilia Burunciuc Director: Ana L. Revenga Fadia M. Saadah Page 4 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Practice Manager: Daniel Dulitzky Tania Dmytraczenko Agnes Couffinhal, Oleksiy A. Task Team Leader(s): Nedim Jaganjac Sluchynskyy, Ha Thi Hong Nguyen Sevil Kamalovna ICR Contributing Author: Salakhutdinova Page 5 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES A. CONTEXT AT APPRAISAL 1. Country-wide Context. Since independence in 1991, the country has made a strong advance towards the creation of a liberal market economy with the aim of promoting sustained economic growth and fighting poverty, and has sought international integration through trade and investment, and membership in the World Trade Organization. Economic reforms resulted in an average annual growth of 5.4 percent over the 5 years prior to 2009, a decline in poverty from 40 percent to 32 percent over 2006-2009, and a drop in extreme poverty from 9 percent to 3 percent over the same period. The 2010 political instability led to a 1.4 percent fall in gross domestic product (GDP) and a 2 percent increase in the poverty headcount. The incidence of poverty in rural areas (37 percent) was far higher than in urban areas (22 percent). With an estimated GDP per capita of US$1070 in 2011, the Kyrgyz Republic was one of the poorest economies in the Europe and Central Asia (ECA) region. The country was ranked 164 out of 178 on Transparency International's Corruption Perception Index, and Organization for Security and Co- operation in Europe missions characterized elections before 2009 as falling short of international good practice. In September 2012 a new Government was formed, and its agenda included a program of security, governance, anticorruption and, where feasible, ethnic reconciliation measures for securing political consolidation. 2. Health Sector Context. Since 1995, the Kyrgyz Republic has undertaken wide-ranging health financing and organizational reforms. The Manas (1996-2006) and the Manas Taalimi (2007-2011) health reforms programs launched comprehensive structural changes to health care delivery, financing and stewardship. Major outcomes of these programs included: significant improvements in financial protection of the population from catastrophic health related expenditures, improved equity in the utilization and access to health services, increased effectiveness of the delivery system with expanded coverage of primary health care (PHC) based on the family medicine model; and enhanced transparency and efficiency of public health expenditure. The Manas Taalimi program was supported by a sector-wide approach (SWAp) program, financed by pooled budget funding from Joint Financiers (JFs) including the World Bank (WB) under the First Health and Social Protection Project (SWAp1, IDA Grant No.H197-KG), and financing from other development partners (DPs). 3. These achievements notwithstanding, progress in key health outcomes remained limited. In 2010 the country had some of the highest maternal, infant and neonatal mortality rates among the former Soviet Union countries. With respect to infant mortality, the majority of deaths occurred within 24 hours of birth ( i.e., when a child is under the supervision of a health worker), suggesting a relative deficit in quality of care rather than in access. The Kyrgyz Republic ranked sixth among the countries of the Eurasian region for standardized mortality rate from coronary heart disease and ranked first in the mortality rate from cerebral stroke (The World Health Organization -WHO, 2009). Health system effectiveness to detect and manage cardiovascular diseases (CVD) was low. The country ranked 7th highest in the world for the proportion of the population with multi-drug resistant (MDR) tuberculosis (TB; WHO, 2011). The mandatory hospitalization in deteriorating facilities with inadequate infection control and the lack of second-line drugs to treat cases of drug-resistant TB contributed to this high rate. The country was also at a concentrated stage of the spread of human immunodeficiency virus (HIV) infection. HIV prevalence rate among injecting drug users was 13.6 percent in 2011. The number of women living with HIV and children born to HIV infected mothers increased. In addition to those challenges, the physical infrastructure had been decaying and there was a continued funding gap in the State Guaranteed Benefit Package (SGBP) leading to persistent high informal payments. Page 6 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 4. The Den Sooluk (DS, 2012-2016) which followed the Manas Taalimi program had as its main objective to establish conditions for the protection and improvement of the population's health as a whole, and for each individual, irrespective of social status and gender differences. The DS, approved by the Government in May 2012, was based on three interrelated pillars: (i) expected gains in health outcomes; (ii) core services needed to achieve expected health gains; and (iii) removal of health systems barriers that undermine delivery of core services and hence achievement of health gains. The DS program included four priority health improvement areas with expected gains in health outcomes and improvements in the delivery of core services : CVD, maternal and child health (MCH), TB, and HIV. Removal of health systems barriers to achieve improvements in outcomes across the four priority areas were grouped around the main functions of the healthcare system: service delivery (public health and individual services), financing, resource generation, and governance (see Figure 1). Embedded in the DS was the consensus between the Government of the Kyrgyz Republic (GOK) and donors to implement this program as a SWAp, continuing the approach used under the previous program. 5. Social Protection Context. After almost a decade of gains in living standards, the poverty rate began to increase since 2009 by 5 percentage points, reaching 36.8 percent in 2011. The unstable political and economic environment, food price pressures and slow growth in remittances contributed to the upward trend in poverty. An estimated 5 percent of the population lived in extreme poverty and was unable to meet its basic food needs. Inequality had risen in urban and rural areas as a result of internal and external shocks in 2010. A medium-term Social Protection Development Strategy for 2012-2014 was approved by the Government in 2011 aimed at reducing poverty and improving the well-being of vulnerable groups, including poor families and children, the disabled and the elderly. GOK had initiated several steps to improve efficiency and effectiveness of social assistance (SA): (a) a large number of categorical in-kind benefits and price subsidies were monetized and replaced with a monthly cash compensation program; (b) the number of categories of beneficiaries entitled to receive the monetized benefits was reduced; and (c) a means-tested program to support poor families with children was introduced and underwent a number of improvements. Nevertheless, remaining challenges in 2013 included: (a) two thirds of SA spending remained poorly targeted; (b) a large share of the poor did not have access to a social safety net; (c) lack of a coherent policy regarding people with special needs; (d) outdated procedures and process of disability certification; and (e) lack of social care services for vulnerable families and children, the disabled and the elderly. The WB supported the Ministry of Labor and Social Development (MOLSD) under the SWAp1, focusing on strengthening the capacity of the Ministry to administer SA through technical advice and limited procurement of equipment and services, and development of information management software for a SA beneficiary registry, as well as technical assistance to improve targeting Page 7 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) of benefits to reach the most vulnerable and poor. But there was still a lot to do to improve the effectiveness and targeting of SA and social services. Country partnership strategy and rationale for Bank involvement. 6. The Second Health and Social Protection Project (SWAp2) was aligned with the overarching areas of engagement of the Interim Strategy Note (ISN) for the Kyrgyz Republic (Report No. 62777-KG - June 16, 2011). The ISN, which succeeded the Country Assistance Strategy approved by the Board in May 2007, covered the period August 2011 to June 2013. The Project was consistent with two of the three ISN pillars, which, in turn, closely corresponded with the Government's main priorities: (a) improving governance, effective public administration, and reducing corruption; and (b) social stabilization, through social services, community infrastructure, and employment, with an emphasis on the South. The ISN noted that "the continuance of the multi-donor SWAp will be essential to maintain the State's credibility as provider of a critical public service." 7. There was a strong rationale at the time of project preparation for WB involvement to support the health sector and SA reform. The WB was well-positioned in the sector, having already steered key reforms (such as the creation of a single national health insurance fund, a unified benefits basket and new payment mechanisms) alongside other DPs through a SWAp; the WB was the lead donor in this group. Around the time of project identification, the country was also chosen as a pilot country on the MDG 5 Acceleration Framework 1 to improve maternal health. 8. The SWAp approach, as applied in the Kyrgyz Republic, meant supporting implementation of the Government national program through pooling donor funds with GoK budgetary funds in the Treasury and using these funds in accordance with the priorities of the Government program. The SWAp principle created the effect of a single national health sector program implemented under the leadership of the Ministry of Health (MOH), in close collaboration with DPs. In May 2012, GOK and 13 bilateral and multilateral DPs signed the Joint Statement for the Partnership between the Kyrgyz Government and Development Partners for the National Program on Health Care Reform in the Kyrgyz Republic 2012-2016: Den Sooluk. The Joint Statement committed signatories to a SWAp and to participate in its platform for dialogue on development coordination and management of DS, including the Joint Assessment Reviews (JARs) and the jointly negotiated annual Program of Work. For the DS the “JFs” which pooled their funds together were, in alphabetical order, Kreditanstalt für Wiederaufbau (KfW), Swiss Agency for International Development and Cooperation (SDC) and World Bank. Other agencies, which were members of the SWAp but did not pool their funds were considered as ‘parallel financers’. Theory of Change (Results Chain) 9. An explicit Theory of Change or Results Chain was not required in the Project Appraisal Document (PAD) at the time of the preparation. The Project followed the strategic approach applied in the DS reform strategy that was based on three principles related to each other: (a) expected improvement in health outcomes; (b) core services needed to achieve the expected improvement in health outcomes; and (c) identification and removal of barriers in the health care system that prevent coverage of core services, thus hindering the achievement of expected Development Goal 5 aimed to reduce maternal mortality and achieve universal access to reproductive health. The Acceleration 1 Millennium Framework sought to accelerate progress in countries seen as unlikely to be reach the goal by 2015. Page 8 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) improvement in health outcomes. A Theory of Change has been developed by the ICR Team and presented below in Table 1. Table 1: Theory of Change Activities/Inputs Outputs Expected Outcomes Long-term Outcomes Investments in equipment, Population interventions Improved delivery of core PDO 1: Improved health training of health workers. implemented; services in four priority outcomes in four health Coverage with evidence-based areas (CVD, MCH, TB, priority areas (CVD, individual medical services HIV). MCH, TB, HIV). increased; Institutional arrangements improved. Strengthening the capacity Hospital autonomy increased; Strengthened health care within Ministry of Health PHC strengthened by shifting core system. (MOH) to develop a detailed services from inpatient to implementation plan for outpatient PHC care; each key area of reform. Prescription practices and rational Financing training of health drug use improved; care managers and health Community-based mental health workers. improved; Providing equipment and Preventive services improved; supplies. Information systems in health sector implemented. Oversight and stewardship over fiduciary functions improved. Pooling of funds with donors Mechanisms for increasing Reduced financial gap in and the Government. financial options identified; the SGBP. Revision of the State Co-payment policy revised; Guaranteed Benefit Package Scope of benefits and services and co-payment policy. under State Guaranteed Benefit Package (SGBP) revised. Technical assistance and Fiduciary control and MOH Strengthened fiduciary training in key areas of capacity improved. capacity in health sector. fiduciary tasks. Financing advisory services Design and delivery of social safety PDO 2: Enhanced Reduced poverty and training in the areas of net programs to support the poor effectiveness and the social safety net and the vulnerable improved. targeting performance of programs design and Alternative targeting approaches social assistance and delivery. and different benefit structure services. Staff training for using the piloted and evaluated. registry of social assistance Functions and architecture of the beneficiaries. registry of social assistance Improving analytical capacity beneficiaries improved. of the MOLSD staff to use Registry of social assistance data from the registry, beneficiaries integrated with the supply of critical equipment, household social passport. automation of business Comprehensive information and processes. communication technology Page 9 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) strategy on improving benefit administration designed. Reviewing and developing National policy towards vulnerable proposal and a roadmap for groups, including people with the reform of the Disability special needs, strengthened. Certification Service. Roadmap for the reform of the Designing and testing an Disability Certification Service integrated approach to developed. provision of social assistance Integrated social service provision and social services. and day care centers for families in Developing standards and need designed and piloted at methodologies for core district level. social services. Project Development Objectives (PDOs) 10. The original PDO, as stated in the PAD and Financing Agreement, was to (i) improve health outcomes in four health priority areas in support of the DS National Health Reform Program 2012-2016; and (ii) enable the Government’s efforts to enhance effectiveness and targeting performance of social assistance and services. The wording of the PDO was consistent throughout the main text and Annexes of the PAD and in the Financing Agreement. Key Expected Outcomes and Outcome Indicators 11. Achievement of the PDO was to be measured through the following PDO level indicators: PDO 1: Improve health outcomes: (i) Percentage of Government consolidated health expenditures over total consolidated Government expenditures; (ii) Number of disease management Programs created and coverage of the population enrolled in disease management programs; (iii) Access of the patients to preventive care measured by percent of detected cases of hypertension (HT) at the primary health care level; (iv) Financial protection of population measured by level of out-of-pocket payments in the two poorest quintiles as a proportion of total household consumption. PDO 2: Enhance effectiveness and targeting of social assistance and services: (i) Share targeting of MBPF (Monthly Benefits for Poor Families with Children) transfers by reducing exclusion errors; (ii) Share of Social Assistance spending on poverty-targeted program(s). 12. The PAD also specified 15 intermediate results indicators (IRIs). Components 13. The original components of the Project are summarized in Table 2 below. These components reflected the Government’s reform priorities: Page 10 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Table 2: Project Components Component Sub- Description Estimated Actual component Cost Cost (US$ (US$ million) million) 1. Support for Improvement of the delivery of core services in four priority 13.5 12.1 implementation areas (CVD, MCH, TB, and HIV) through: (i) population (81.8% of Den Sooluk interventions; (ii) evidence-based individual medical services; total) program of and (iii) the appropriate institutional arrangements. reforms Improvement of deteriorating infrastructure. Strengthen the capacity of MOH for developing implementation plans for key areas of the reform, including: (i) hospitals’ autonomy; (ii) strengthening PHC by shifting core services from inpatient to outpatient PHC care (such as management of CVD, treatment of TB); (iii) prescription practices and rational drug use; (iv) community-based mental health; (v) preventive services; (vi) implementation of information systems of the health care sector. Improvement of information systems in three key areas: (i) improving the environment for eHealth development, setting up institutional arrangements for eHealth governance, regulation and implementation, improving capacities of institutions and facilities for eHealth utilization, (ii) improving technical infrastructure for implementation of clinical systems, and (iii) implementing fundamental clinical information systems. Support to finance the SGBP gap by: (i) identifying mechanisms for increasing financing options; (ii) conducting a comprehensive review of the co-payment policy, revising exempted categories, and copayment structures; and (iii) reviewing the scope of benefits and services under SGBP. Strengthen capacity of MOH to steward the reforms, including oversight and stewardship over fiduciary functions by providing technical assistance and training in key areas of fiduciary tasks. 2. Strengthening 2.1 Improving Technical assistance and capacity building to the MOLSD to: (i) 2 2 the policy and the strengthen the social safety net so that it can provide critical (12.1% administrative effectiveness support to the needy protecting against dire poverty and loss of total) capacity of the of the social human capital; and (ii) enhance the safety net's role in insuring MOLSD safety net against the impacts of different shocks. Advisory services and training in the areas of program design and delivery, including benefit targeting, outreach, enrollment, verification and control, payment, and other elements of benefit administration. Design and piloting of alternative targeting approaches and different benefit structure. Diagnostics and analytical work to introduce conditionalities for promoting investment into human capital accumulation by beneficiary households under the MBPF. Recommendations to reform the safety net and cash transfer programs under the Social Protection Public Expenditure Review. Further implementation and improving the registry of social assistance beneficiaries by: (i) staff training for system usage, improving analytical capacity of the MOLSD staff to use statistical data from the registry, technical enhancement, including supply of critical equipment, central database location, support to the MOLSD IT department in system maintenance; and (ii) functional and architectural improvements of the registry, including further Page 11 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) automation of business processes and generation of information for program planning, monitoring and evaluation. Integration of the registry with the household social passport and their gradual implementation at local level. 2.2 Support to Diagnostic review and proposals for the reform of the Disability 1 1 strengthening Certification Service with the objective of streamlining disability (6% total) the national certification in accordance with modern approaches focusing on policy towards abilities and opportunities for rehabilitation. Prepare a roadmap vulnerable for the development of individual rehabilitation plans and groups, building supportive infrastructure and services nation-wide. including Capacity building of the key players in the area of the modern people with disability certification models, their practical implementation special needs and lessons from international experience. Technical assistance to help the MOLSD design and test an integrated approach to provision of social assistance and social services that could (i) increase the impact of social assistance on the lives of the poor and the vulnerable; and (ii) improve the efficiency of the administration by streamlining duplicative efforts provided by social assistance and social services units. Design and pilot the introduction of integrated social service provision and day care centers for families in need using a one- stop-shop model at district level. Development of standards and methodologies for core social services. Development of sustainable mechanisms to involve non-Governmental agencies in the provision of social services for the vulnerable. 3. Contingency A rapid response to a request for urgent assistance in respect of No funds No funds emergency an event that has caused, or is likely to imminently cause, a allocated disbursed response major adverse economic and/or social impact in the health and social protection sectors associated with natural or man-made crises or disasters. Total 16.5 15.1 B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) Revised PDOs and Outcome Targets 14. In March 7, 2017, the Project underwent a major restructure, including a revision of the PDO, the Results Framework (RF), legal covenants, as well as components and costs. The simplified PDO became: “to contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program” and reflected the narrowing of the project scope and its simplified design to focus on improvements in the delivery of quality MCH services. 15. Revised PDO Indicators. The RF was revised to include new PDO level indicators (five were removed and four new ones introduced) and IRIs (nine new added) to reflect the significant change in the PDO, the implementation progress of the revised project components, and to improve the measurability of specific indicators, and the consistency of data sources (see Annex 1 for the revised RF). The additional PDO indicators included:  Proportion of normal deliveries in district (rayon) hospitals that received services following clinical protocols (Percentage)  Proportion of complicated deliveries in district (rayon) hospitals that received services following clinical protocols (Percentage) Page 12 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278)  Births attended by skilled health personnel (Number) (cumulative) (Corporate Results Indicator)  Diarrhea treatment with oral rehydration therapy among children under five (Percentage) 16. Also, the following IRIs were added:  Number of facilities adequately equipped to provide emergency obstetric and neonatal care (cumulative)  Number of pregnant women receiving any antenatal care (cumulative)  Number of providers trained in IUD insertion and removal (cumulative)  Number of children treated with ORS for diarrhea or with antibiotic for pneumonia (cumulative)  Proportion of HIV infected pregnant women that received antiretroviral drugs to reduce risk of mother-to- child transmission (percentage)  Number of family doctors, feldshers, TB doctors, and nurses trained on TB clinical protocols and guidelines (cumulative)  Number of family doctors, feldshers, and nurses trained on CVD (percentage)  Proportion of families with children receiving social assistance (MBPF) who are electronically registered (percentage)  Number of districts where the Social Registry Information System has been fully rolled out (cumulative). 17. Two IRIs were amended, including:  Change “Children immunized – under 5 years against Polio” to “Children immunized – under 12 months against Polio” to be in line with international practice and country’s HMIS  Change “Roadmap to reform disability certification service developed and endorsed by the Ministry” to “Roadmap to reform disability service developed.” 18. Nine IRIs were dropped, including:  Inter-sectoral determinants of health by conducting at least two comprehensive campaigns  Indicators in JAF have baseline and are up to date  Indicators in JAF are disaggregated by gender and location where applicable  Health personnel receiving training (number)  Share of social assistance (MBPF, Monthly Social Benefits (MSB) and Cash compensations) beneficiaries with records in the Social Assistance (SA) Beneficiary Registry  Turnaround time for processing MBPF applications  Number of beneficiaries of targeted social assistance programs  (Number of beneficiaries of the) Monthly Benefit for Poor Families with Children (MBPF)  (Number of beneficiaries of the) Monthly Social Benefits (MSB) Revised Components 19. The new design proposed two components. The first component focused on strengthening the delivery of quality MCH services, the second component was renamed to strengthening health system. While the first component contributed directly to the PDO, the second component seek to indirectly contribute to the PDO by strengthening health system, in particular PHC, improving financing of SGBP, and bringing SP and health together by focusing on SP activities that are linked more closely to health (such as improving the registration of the SGBP beneficiaries). Although it retained the HIV, TB, and CVD content, supported activities were geared toward strengthening PHC and improving Page 13 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) MCH. The dual component in the revised design allowed for a focus on the most important weakness (quality of MCH) while maintaining the SWAp principle. Table 2: Revised Project Components Component Sub-component Description Estimated Actual Cost Cost (US$ (US$ million) million) 1. Support to help the country maintain the high coverage of maternal 13.5 12.1 Strengthening health services, such as antenatal care, postnatal care, and (81.8% the delivery of institutional delivery; and to gain additional improvements in the total) quality MCH delivery of child health services. care services Support activities that strengthen the delivery of Emergency within the Den Obstetric and Neonatal Care (EmONC) services largely in the form of Sooluk National procurement of medical, laboratory, and infection control Health Reform equipment, drugs, and supplies including those required for EmNOC Program and child health services; developing clinical protocols and guidelines; and competency training of health workforce on EmNOC, primary health care according to protocols and guidelines including Integrated Management of Child Illnesses (IMCI) and maternal health care. Procurement of family planning methods especially intra-uterine devices (IUDs) and training providers in the use of IUDs. 2. Strengthening 2.1 Integration of Development of clinical protocols and guidelines and training of 3 3 health system TB, HIV, and CVDs health workers on CVDs and TB. Testing pregnant women for (18.2% within the Den services within HIV/AIDs, counseling and treating those infected as well as their total) Sooluk National the delivery of infected newborns, and securing the procurement of contraceptives Health Reform primary care to prevent further transmission of infection. Strengthen the delivery Program services of PHC services through the procurement of equipment for primary health care labs, development of lab certification standards and training of lab workers, TA to develop a PHC strategy on human resources for health, strengthening nursing functions including task sharing, and assessing the service delivery network to set the stage for future work on optimization. 2.2 Improvement Development of by-laws to be adopted for legislation on of the SGBP pharmaceuticals, a drug database for hospitals, TA for centralized delivery and other procurement of medicines, and stewardship function of the central health system MOH and oblast level management and coordination. strengthening activities 2.3 Improvement Strengthen mechanisms of data exchange between the MOLSD and of the registry of Mandatory Health Insurance Fund (MHIF) for effective provision of SGBP the SGBP. Enhancing enrollment and registration of beneficiaries of beneficiaries the main social assistance programs, Monthly Benefit for Poor Families with Children, and certification of the disabled population who benefit from copayment exemption under the SGBP. 3. Contingency A rapid response to a request for urgent assistance in respect of an No funds No emergency event that has caused, or is likely to imminently cause, a major allocated funds response adverse economic and/or social impact in the health and social disburs protection sectors associated with natural or man-made crises or ed disasters. Total 16.5 15.1 Page 14 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Other Changes 20. A legal covenant was changed to allow the Recipient adequate time (12 months instead of 6) to conduct the Procurement Post Review (covering the entire health sector and not just procurement funded from the JF’s funding) and issue its report given the lengthy process in procuring the services of an international consulting firm. 21. In addition to the March 2017 restructuring, as detailed above, the Closing Date of the Credit/Grant was changed in 2018, extending the Project by 1 year. The Closing Dates of SDC Grant were changed in 2015 and 2017, as the grant had to be extended every 2 years due to SDC’s cycle for releasing funding, as presented in Table below: Date Key Revisions Period of closing date extension November 16, 2015 Change in SDC Grant’s Closing Date From June 30, 2016 to June 30, 2017 (12 months) April 7, 2017 Change in SDC Grant’s Closing Date From June 30, 2017 to December 31, 2018 (18 months) September 17, 2018 Change in IDA credit and IDA Grant From December 31, 2018 to December 31, 2019 (12 Closing Date months) Rationale for Changes and Their Implication on the Original Theory of Change 22. There were several reasons for Level 1 restructuring of the Project. 23. By the time the Mid-Term Review (MTR) was conducted in June 2016 the limitations of the SWAp approach became obvious. While the SWAp effectively supported policy dialogue and donor coordination, it lacked precise outcomes that could be measured within the time frame of the Project. Also, there was no clear sense of precise activities to support reaching the outcomes which hindered Project implementation. The Project inherited the SWAp approach from the First Health and Social Protection Project (SWAp 1) but lessons learned from SWAp 1 (2005-2015) became available only at the time of MTR. These lessons suggested that it would be more appropriate to have a simpler project design, with a more realistic objective, and with relevant and measurable results that were more within the WB’s own ability to influence, control and contribute to the DS program outcomes. 24. In 2016, the situation with maternal health became critical, as reflected by the persistently high maternal mortality ratios; the highest among ECA countries. This occurred when maternal health service coverage indicators, such as Delivery Attended by Skilled Medical Personnel, Delivery in Health Facility, and Antenatal and Postnatal Care rates, were at their highest level reaching more than 90 percent. This indicated the need to shift from supporting increases in maternal health utilization rates to a focus on improving the delivery of quality of maternal health care services. The shift in focus to MCH as the key health system priority was a strong feature of the new project design that concentrated resources and activities on this aspect. 25. The original PDO was too ambitious compared to the funds allocated as well as client capacity. The project funding (including the pooled basket fund), only accounted for some 5 percent of the total spending from public and external sources, which comprised about 56 percent of total health expenditure. This modest funding to contribute to the achievement of the PDO, as stated (focused on long-term outcomes), as well as a thinly stretched project, would not have been able to achieve concrete results and intended long-term outcomes. The decision was taken to drop three health conditions from the PDO: HIV, TB and CVD. Page 15 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 26. While the decision was taken to focus the Project on MCH and drop three other health conditions, the commitment to the overall SWAp imposed obligations on the Bank to partners to continue with health system support. Given the inadequate attention to strengthening the key building blocks of the health system, a shift was required from supporting vertical programs to integrating their delivery into the health system, especially at PHC level. There was also a need to establish synergy between health and social protection components to achieve the PDO, especially those that would lead to improved access by the poor and the vulnerable to quality MCH services. Thus, the original Component 2 (which was devoted to social protection activities) was restructured to support functions of the healthcare system and social protection system to serve a common purpose related to the achievement of the proposed revised PDO aimed at improving delivery of quality MCH services. In addition, the initial RF included six PDO indicators with poor relevance to the original PDOs making it difficult to measure the progress towards their achievement. 27. A revised result chain established the clear pathway of effects from the PDO to intermediate outcomes and activities to focus on over the subsequent years. The RF was revised, with PDO indicators that focused on maintaining the high coverage level of institutional delivery, measuring management of cases according to clinical protocols for normal and complicated deliveries in all 63 district-level hospitals, adherence to evidence-based protocols at the PHC level for treatment of diarrhea, and maintaining the allocation of resources to the health sector. 28. The revised IRIs measuring progress made in activities chosen to support the achievement of the PDO focused on: maintaining high coverage of antenatal care, equipping hospitals with required basic equipment and supplies to provide emergency obstetric and neonatal care, prevention of mother-to-child transmission (MTCT) of HIV, coverage of key vaccines, treatment of childhood illnesses according to IMCI protocols, training of providers on family planning, CVD, TB and other key health conditions, health budget execution, and better targeting and coverage of the Social Registry Information System. Figure 2. Revised Theory of Change Activities Outputs PDOs/Outcomes Long-term Outcomes Equipping all major hospitals Maintaining high coverage of PDO: Improved delivery Improved maternal and (all oblast hospitals and antenatal care of quality maternal and child health outcomes three maternal/perinatal Management of cases according to child health care services. centers) with required basic clinical protocols in cases of equipment and supplies to normal and complicated deliveries provide emergency obstetric in all 63 district-level hospitals and neonatal care. This across the country included also major upgrade Adherence to evidence-based of lab capacity. protocols at the primary care level Training of providers on for treatment of diarrhea family planning, CVD, TB and Prevention of mother-to-child other key conditions transmission of HIV Coverage of key vaccines improved. Treatment of childhood illnesses according to IMCI protocols. Strengthening the capacity PHC strengthened. within MOH to develop a Prescription practices and rational detailed implementation drug use improved. plan for each key area of Community-based mental health reform. improved. Page 16 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Financing training of health Preventive services improved. care managers and health Information systems in health workers. sector implemented. Pooling of funds with donors Mechanisms for increasing and the Government. financial options identified. Revision of the State Scope of benefits and services Guaranteed Benefit Package under State Guaranteed Benefit and co-payment policy. Package (SGBP) revised. Technical assistance and Fiduciary control and MOH training in key areas of capacity improved. fiduciary tasks. Financing advisory services Better targeting and coverage and training in the areas of of the Social Registry Information the social safety net System. programs design and delivery. Staff training for using the registry of social assistance beneficiaries. Improving analytical capacity of the MOLSD staff to use data from the registry, supply of critical equipment, automation of business processes. Reviewing and developing National policy towards vulnerable proposal and a roadmap for groups, including people with the reform of the Disability special needs, strengthened. Certification Service. Roadmap for the reform of the Designing and testing an Disability Certification Service integrated approach to developed. provision of social assistance Integrated social service provision and social services. and day care centers for families in Developing standards and need designed and piloted at methodologies for core rayon level. services focused on social support and integration of social services. II. OUTCOME 29. The outcome rating for this project is assessed against the original (Phase 1 from project approval to Level 1 restructuring), and revised objective (Phase 2 from approval of restructuring to Project Closing December 30, 2019) using a split rating methodology, in line with ICR Guidelines, issued March 2, 2020. Page 17 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) A. RELEVANCE OF PDOs – High Assessment of Relevance of PDOs and Rating 30. The original PDO was directly aligned with the overarching areas of engagement of the Interim Strategy Note (ISN) for the Kyrgyz Republic (Report No. 62777-KG - June 16, 2011). Specifically, the project was consistent with two the ISN pillars: improving governance, effective public administration, and reducing corruption; and social stabilization. The ISN noted that "the continuance of the multi-donor SWAp will be essential to maintain the State's credibility as provider of a critical public service." The revised PDO was fully aligned with Country Partnership Strategy for the Kyrgyz Republic (Report No. 78500-KG – June 24, 2013). Specifically, the project supported Area of Engagement 1 on Public Administration and Public Service Delivery, Country Development Goal: Improving the efficiency and quality of essential public services. 31. The original and revised PDO are consistent with the Bank’s current Country Partnership Framework for the Kyrgyz Republic for the period (Report No. 130399-KG – October 10, 2018), especially around investments in human capital and improving public expenditure management, government efficiency, and accountability. 32. The relevance of the original and revised objectives remains High based on the past and current national priorities of the GOK. The original PDO aligned with the National Health Reform Program “Den Sooluk” for the period 2012- 2018 aimed at improving health outcomes and delivery of core services in four priority areas: CVD, MCH, TB and HIV. In the area of social protection, the Government had implemented in 2012-2014 a medium-term Social Protection Development Strategy aimed at reducing poverty and improving the well-being of vulnerable groups of population, as well as at improving the efficiency and effectiveness of cash benefits and social care services in combating poverty. Reforms in the area of social protection have been continued under the National Development Strategy for 2018- 2040 and the National Development Program “Unity, Confidence, Creation” for 2018-2022. 33. The revised PDO places a greater focus on improving the delivery of quality MCH services as one of the key priority areas of DS Program. This priority remains highly relevant under the current National Health Program “ Healthy People – Prosperous Country” for 2019 – 2030. B. ACHIEVEMENT OF PDOs (EFFICACY) Justification of Overall Efficacy Rating - Substantial (Phase 1) and High (Phase 2) Assessment of Achievement of Each Objective/Outcome 34. The assessment of Phase 1 of the project yields a Substantial rating for the PDO achievement. PDO 1: Improve health outcomes in four priority areas in support of the DS National Health Reform Program: Substantial 35. At the country level, several important achievements in terms of health outcomes and intermediate outcomes have occurred since the start of DS in 2012. Most indicators on MCH status show substantial improvement over the Page 18 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Project period. The main goals and objectives of the DS Program in the area of MCH were: (a) reduction of maternal mortality; (b) reduction of perinatal mortality of newborns; (c) reduction of child mortality from respiratory diseases in children under 5 years; and (e) reduction of child mortality from diarrhea among children under 5 years. 36. Kyrgyz Republic has demonstrated good progress in achieving outcome indicators with successful collaboration and coordination of DPs and MOH for accountability on MCH. The decline of maternal mortality per 100,000 live births went from 50.3 in 2012 to 27.8 in 2019. Kyrgyzstan is on track to reduce maternal mortality due to focused and consistent adherence to agreed approaches, and implementation of essential activities. The analysis of the leading cause of maternal mortality in the structure of causes shows that postpartum hemorrhage decreased from 30 percent in 2012 to 13 percent in 2018, which indicates improvement of management of the complications during delivery. 37. In 2015, the Kyrgyz Republic achieved the MDG4 goal of reducing child mortality rate by 2/3 compared with 1990. A steady decrease of perinatal and early neonatal mortality has been observed due to the targeted, effective measures at different levels and effective implementation of a plan of essential action on newborns and children. The MOH, with support of DPs, initiated an in-depth review into the situation of perinatal care. The results of this review will further inform strategic planning in this area. 38. There has been a steady decline in overall CVD and TB mortality since 2012. The CVD death rate decreased from 331.3 per 100,000 people in 2012 to 265.7 per 100,000 people in 2018. In 2018 the TB mortality rate was 4.6 deaths per 100,000 people, compared to 6.7 deaths per 100,000 people in 2014. The rate of successful treatment of newly diagnosed patients with bacteriologically proven pulmonary tuberculosis reached 81.7 percent (patients treated in 2017) and is approaching the target indicator recommended by WHO (85 percent). The high rate of MDRTB is a major problem for the country. By improving supplies of anti-TB drugs, the country expanded the access of patients with MDRTB to necessary medicines – from 78.9 percent in 2012-2017 to 91 percent in 2018. The rate of successful treatment of patients with MDRTB failed to reach the target indicator of the DS program (75 percent), however it demonstrated certain growth – from 42.4 percent to 53.3 percent (patients with MDRTB who were taken for treatment in 2016). 39. A number of health sector challenges remain. Some key health outcomes and outputs were lagging, such as TB, especially among patients with the drug-resistant form, and the percentage of treatment defaulters among them is high (21 percent). The mechanisms to ensure effective monitoring and control of TB treatment for patients on new treatment regimens on an outpatient basis are not in place. The resources and financial capacity of PHC do not provide a full package of services for such patients. The share of people living with HIV infection, who continue ART 12 months after the therapy began to drop as: (a) the key population group was unwilling to pursue ART; and (b) HIV-infected individuals were discovered at late stages of the disease, which led to their receiving ART with significant delays. Stigma and discrimination remain an important issue that TB and HIV patients face during treatment, affecting the patient’s attitude to the disease, to other TB and HIV patients, to the treatment regime, to the interaction with society and significantly complicates the organization of treatment, especially at the outpatient level. Low treatment adherence and drug resistance requires strategic actions throughout the country. 40. The role of PHC in detecting and managing non-communicable diseases had not been substantially improved. Family planning services were not receiving the priority they deserve, given the relatively high total fertility rate and the contribution family planning could make to reducing maternal and newborn mortality. Significant gaps remained in the competencies required for primary and secondary prevention among front line staff, and the quality of clinical care continued to need strengthening. Although significantly reduced during earlier periods, out-of-pocket Page 19 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) expenditures had gone up again and had disproportionately affected the poor. The project supported DS program, designed to improve health status in four priority areas through improving health system measures, had not been successful in adopting a whole system approach and had, over time, been managed as silo/vertical programs with little systematic investment in the key health system building blocks. 41. During this period, the GOK expenditure on health had been maintained at 13 percent of total government expenditure for 2014, 2015 and 2016; and the government maintained the integrity of MHIF as a single purchaser of health services. 42. In terms of achievement of the PDO indicators, one achieved its target, one surpassed its target, one was partially achieved, one was not on track, and three had either not been measured or had baselines which were incorrect. Two PDO indicators were achieved with one surpassing its end of project target as follows: (a) Percentage of Government consolidated health expenditures over total consolidated Government expenditures (13.1 percent actual compared to 13 percent end of project target); and (b) Number of disease management programs created (5 programs actual compared to 2 end of project target). One PDO indicator had been partially achieved: Share of Social Assistance spending on poverty-targeted program(s) (baseline 15.5 percent, actual 23.8 percent compared to 35 percent end of project target). The indicator that was not on track for achievement was the exclusion error of the Monthly Benefit for Poor Families with Children (MBPF) program (baseline 71 percent, latest value 79 percent, based on 2013 survey, and a target 60 percent). Furthermore, it was not measured for two years, and its choice was less than optimal to track achievement of the declared objective. The two indicators for which baseline values were questionable are: (a) Financial protection of population measured by level of out-of-pocket payments in the two poorest quintiles as a proportion of total household consumption (original baseline: 30 percent for poorest quintiles and 22 percent for 2nd poorest quintiles; yet the 2009 Kyrgyz Integrated Household Survey established a baseline value of 4.4 percent for poorest and 2.9 percent for 2nd poorest quintile); and (b) Access of the patients to preventive care measured by percent of detected cases of hypertension (HT) at the primary health care level (original baseline value 27 percent, target 50 percent; but later on the MOH reported that the baseline should be 4.1 percent). One sub-indicator remained unmeasured and with no baseline or end of project target: Coverage of the population enrolled in disease management programs. Overall, there was a challenge to assess project’s progress toward the PDO because some PDO indicators did not lend themselves to a valid measure of the PDO (for example, number of disease programs created did not directly influence health status). 43. In terms of IRIs, 2 out of 15 were achieved with mixed performance for the remaining 11. The following indicators were achieved: (a) Inter-sectoral determinants of health by conducting at least two comprehensive campaigns (8 campaigns were conducted compared to 2 end of project target); (b) Submission of Integrated Fiduciary Reports (IFRs) satisfactory to IDA within due dates according to Financing Agreement (all IFRs were submitted as expected by the end of the project target). A few of the IRIs were partially achieved, but many of the IRIs did not have end of project targets and others had no baseline. On balance achievement of this aspect is Substantial. PDO 2: Enable the Government’s efforts to enhance effectiveness and targeting performance of social assistance and services: Modest 44. By 2016, 1 PDO indicator was partially achieved: Share of Social Assistance spending on poverty-targeted program(s) (baseline 15.5 percent, 2016 value - 23.8 percent compared to 35 percent end of project target). Another PDO indicator was not on track for achievement: The exclusion error of the MBPF program (baseline 71 percent, latest Page 20 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) value based on 2013 survey 79 percent, target 60 percent). Furthermore, its measurement had not been taken in 2015 and 2016, and its choice was less than optimal to track achievement of the declared objective. 45. Analytical work on the targeting method being used and options to improve the targeting system was presented to the MOLSD with the conclusion that the targeting system was in need of substantial modernization. Progress with preparation of activities on this was slow due to the reluctance of the MOLSD to take decisive measures in this area, linked to concerns this might cause popular discontent in advance of the upcoming parliamentary elections in 2015. Work on the social protection (SP) Management Information System (MIS) was further developed and the Government resolution approved the corporate MIS as the primary tool and database for administration of the key SA programs starting from January 1, 2016. The target of 100 percent of all SA beneficiaries with records in the MIS was reached. Two contracts were signed by MOLSD to procure additional servers and computer equipment for the SP MIS. A diagnostic review of the disability certification and support services was carried out, which provided recommendations on development and strengthening the support services for the disabled. The project facilitated policy dialogue between MHIF and MOLSD on improving collaboration in data exchange between the two institutions to unify category definitions of beneficiaries. The project made considerable progress in establishing and rolling out an electronic social registry of beneficiaries. 46. In terms of IRIs two indicators were achieved: (a) Share of social assistance (MBPF, MSB and cash compensations) beneficiaries with records in the Social Assistance (SA) Beneficiary Registry (100 percent actual compared to 100 percent end of project target); and (b) Turnaround time for processing MBPF applications (3 days compared to 5 days end of project target, while baseline was 8 days). On balance this is rated Modest. 47. The assessment of Phase 2 yields a High rating for the PDO as all 5 of the PDO level indicators were met or surpassed their targets, 8 of the 14 IRIs surpassed their targets, and the rest were fully achieved. The Project has had a significant impact on the implementation of Government’s DS Health Care Reform Programs. Specifically, the restructured project implemented all aspects of its specific objectives in order to achieve the PDO “to contribute to improving delivery of quality maternal and child healthcare services within the “Den Sooluk” National Health Reform Program.” The discussion below summarizes achievements against this objective, as follows: PDO: Improving the delivery of quality MCH care services 48. The delivery of quality MCH service was improved. The project increased the coverage of pregnant women with quality health services. The project supported the development of clinical guidelines and training of health workers who attend deliveries in 63 rayon hospitals. A total of 36 clinical protocols, 7 standard operating procedures on obstetrics and gynecology, 6 clinical protocols on neonatology, and 14 standard operating procedures were developed. The capacity of healthcare providers on EmONC, neonatal resuscitation, management of common childhood illnesses, and breast-feeding was substantially improved. 49. The proportion of women who received services according to clinical protocols in the case of normal deliveries reached 84.1 percent, which surpassed the target by 1.6 times; in the case of complicated deliveries – it reached 42.9 percent in 2019, meeting the target. MCH service delivery has maintained its very high coverage of skilled attendance at delivery during life of the project with a gradual increase from 99 percent in 2013 to 99.5 percent in 2019. 50. The project addressed one of the most serious gaps in providing quality MCH care: the inadequate and improper EmONC provided at the tertiary level, which handles roughly 80 percent of complicated deliveries. The maternity units Page 21 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) of seven regional hospitals, two perinatal centers in Bishkek and Osh and the National Center of MCH were provided with a full set of basic equipment necessary for emergency obstetric care, including laboratories and eight mobile ICUs. Infrastructure of health organizations (heating, water and sewage systems) serving women and children have been improved. Computers for infant registration, managing inventories of insulin and contraceptives are available at the oblast and rayon levels. 51. The Project supported strengthening and reforming the laboratory services through the procurement of equipment for PHC laboratories, development of laboratory certification standards and training of laboratory workers. 52. The proportion of pregnant women that were registered before 12th week of pregnancy has increased by 6 percent from 76.7 percent in 2013 to 82.4 percent in 2019. The quality of contraception services was improved through training of 767 health workers in postnatal and post-abortion intrauterine device insertion and removal. The MOH joined the global initiative FP2020 and committed to increasing state funds for the purchase of contraceptives. 53. The MOH and partners actively implemented WHO recommended Beyond the Numbers approach with a focus on Confidential Enquiry into Maternal Deaths (CEMD) and Near-Miss Case Review. Two national reports on CEMD on investigation of cases of maternal deaths were analyzed, discussed and presented at various fora. The MOH and partners developed a national plan to implement CEMD recommendations; CEMD has been institutionalized by the MOH and the National MCH Center and a third round of CEMD is ongoing. 54. There have been a number of improvements with respect to child health. Prevention of MTCT of HIV was improved; the proportion of HIV positive pregnant women that received antiretroviral (ART) drugs to reduce the risk of MTCT exceeded the target (97.7 percent vs. a target of 95 percent). The delivery of quality child health care was improved, with the coordinated efforts of the MOH of the Kyrgyz Republic and partners within the framework of the HSS-2 Gavi Project high coverage of vaccination against the DTP3 and poliomyelitis (at least 95 percent) had been maintained. The quality of treatment of children with diarrhea and pneumonia was significantly improved as the number of children treated according to clinical protocols has increased from 53,000 to 193,649 children, and the proportion of children who received oral rehydration therapy increased from 77 percent in 2013 to 88.4 percent in 2019. The MOH, with support of international experts and partners, initiated the introduction of the perinatal audit. The results of the confidential review of the newborn death cases will help MOH identify and further address the barriers for families with newborns in the access and utilization of the quality services. 55. The project enhanced enrollment and registration of poor families with children in the main SA programs, including the MBPF program, and improved the registry of SGBP beneficiaries. The new modules of the Corporate Information System of Social Assistance (CISSA) were developed that considerably improved the operational efficiency of the SA and services, by enabling internal and external interoperability, and automatic data exchange with other Government agencies. The inter-agency data exchange has been rolled out; in April 2019, MOLSD issued a Directive to transition to CISSA in all districts of the country. The hardware base of the CISSA was strengthened once the new servers were delivered by the Project. Enhanced data exchange for the beneficiaries of SA categories between MOLSD and MHIF helped hospitals to determine the social exemption status of its patients on an almost real time basis. 56. The project facilitated the preparation of an integrated approach to the disability assessment system and the development of rehabilitation services. The MOLSD, in cooperation with the MOH and the Ministry of Education and Science, piloted certain elements of the International Classification of Functioning, Disability and Health, related to assessment of disability status and development of individual rehabilitation programs for individuals/children with Page 22 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) infantile cerebral paralysis, which covered 175 children. Based on the pilot outcomes, the Ministry defined a number of key steps with respect to the disability assessment system; it developed the “Roadmap for Optimization of the System of Assessment of Disability and Development of Rehabilitation Services for 2020-2023” (which became one of the instruments of the Kick-Off Plan for Implementation of the UN Convention on the Rights of Persons with Disabilities for 2020-2022). 57. Following the SWAp approach the Project provided support to strengthening healthcare system within the DS program. Support to integration of TB, HIV and CVD services in PHC resulted in training of 3,374 (vs. target 3,300); family doctors, feldshers TB doctors and nurses were trained on TB clinical protocol and guidelines with special focus on the identification and management of TB patients at the primary level. A total of 5,176 family doctors, feldshers and nurses were trained in CVD clinical protocols, including protocols on arterial hypertension, PEN-protocol, and acute cerebrovascular accident. A new approach to ensure a patient-centered model of TB care at the outpatient level, including elements of medical, social and psychological support, was developed and reflected in the roadmap to strengthen TB response, and has been launched as a pilot in Chui and Talas regions. In 2017, the proportion of TB patients treated completely on an outpatient basis was 26 percent on average nationally, while in the pilot districts of Chui region and Bishkek it was 34 percent and 37 percent, respectively. There was a reduction in the duration of their stay in hospitals by 40 percent. A new method of financing PHC to motivate health care workers for the successful completion of treatment of TB patients was developed and implemented, using saved financial resources after optimization of the TB hospital network; bonuses were paid to PHC doctors for 2,000 successfully treated cases at PHC level. The country had significant achievements in engaging PHC facilities into providing HIV prevention and treatment services, as well as care and support for HIV patients. People living with HIV infection can now receive services at PHC facilities, and 49 Family Medicine Centers now offer ART. The Kyrgyz State Medical Institute for Professional Development delivered the following training for 132 PHC doctors and 242 nurses: application of the updated clinical protocols; testing and counselling; laboratory diagnostics; medical monitoring; ART; palliative care; secondary infections; stigmatization and discrimination; prevention of HIV infection (including primary prevention treatment of medical personnel). 58. The Project supported the development of a PHC strategy on human resources emphasizing that strong comprehensive PHC remains an essential milestone for improving health outcomes in the Kyrgyz Republic. PHC faces multiple problems associated with work force management, including an aging workforce and limited entry of new candidates to PHC, low prestige and outward migration translating into severe staff shortages in PHC for both GPs and nurses. Staff motivation is low and there is a lack of good incentives to stimulate workforce development. In addition, the service delivery network was assessed and master plan for optimization of health service delivery was developed. 59. The Project supported ensuring sufficient and reliable financing for the health sector. The target set for government expenditure on health and for budget execution were fully met. Public spending on health as a percentage of total government spending was maintained at the target level of 13 percent during project implementation. The target of a less than 5 percent of negative deviations of the executed health budget from the initially approved annual budget for the health sector was fully achieved. In addition, IFRs satisfactory to IDA were submitted within due dates in accordance with the Financing Agreement. 60. The stewardship function of the central MOH and oblast level management and coordination was strengthened. A number of policy events was conducted with key GOK officials and policy makers to identify future strategic directions that could be supported by the WB and other partners to help improve efficiency, quality, and equity outcomes. The thematic sessions focused on four areas, including: (a) defining and revising the benefit package Page 23 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) to meet current and future needs; (b) organizing the service delivery system for the provision of integrated and patient-centered care; (c) strengthening strategic purchasing to improve quality and efficiency; and (d) improving governance and other system enablers for service delivery. Key recommendations included: (a) revising the SGBP to be explicit, transparent, adaptive to current and future health needs, and pro-poor targeted; (b) adopting measures to strengthen PHC workforce and accelerating the development of a Master Plan to optimize the service delivery network; (c) improving strategic purchasing for better quality and efficiency results, such as revising the provider payment to incorporate performance-based incentives and developing day hospitalization to save costs of inpatient care; and (d) developing a national body for quality management and strengthening managerial autonomy in health institutions. The DPs recognized that the efforts undertaken during the last couple of years in dialogue with the MOH and supporting the national health program created an enabling and supportive environment to push key reform measures and to unlock major potentials for improving efficiency, quality, and equity outcomes. C. EFFICIENCY Assessment of Efficiency and Rating - Substantial 61. A cost-benefit analysis was carried out during the preparation of this Report to calculate the benefits of the implemented restructured project (See Annex 4), including the benefits arising from the provision of antenatal care (ANC) services to pregnant women, the attendance of skilled health personnel during deliveries, children immunization (Polio3 and Penta3), treatment of children with ORS (oral rehydration salts) for diarrhea or antibiotic for pneumonia, provision of prevention of mother to child transmission (PMTCT) services to pregnant women living with HIV, and from increased productivity of health personnel due to training covered under the project in addition to the interventions to control TB and CVD. The project disbursed a total of US$27.06 million over 7 years. The analysis uses a 3 percent discount rate (consistent with similar contexts) to reflect the time preference and risk premium. The estimated benefits as a result of the project totals US$449.77 million. The overall Internal Rate of Return is calculated at 346 percent with a Net Present Value of US$337.93 million. This calculation is based on relatively conservative assumptions and yet the project benefits outweigh the costs with a benefit-cost ratio of 14.88, shedding light on the overall high value for money of the project interventions. Benefits / costs Present Value of Flows (US$) Benefits Accrued from Project Interventions (check the Cash flow: US$449.77 Million to 2023 write-up for details) The project disbursed a total of US$27.06 Million Costs: Investment cost plus recurrent costs over 7 years Net present Value 337.93 million Benefit-Cost Ratio 14.88 IRR (%) 346% 62. Implementation efficiency. Project start up suffered from delays. The Project became effective only on June 16, 2014, 13 months after its approval by the Board on May 3, 2013, due to considerable delays in Parliament’s ratification of the Financing Agreement that was a common problem with all projects in KR. After becoming effective, it took another 1.5 years to register a disbursement; delays were the result of the low capacity of MOH to implement reforms Page 24 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) as a result of high turn-over of staff, as well as the appointment of the new Minister of Health in November 2014. In December 2015, Implementation Progress was downgraded to Moderately Unsatisfactory, mostly because health part accounted for most of the Project funding and issues linked to lack of qualified human resources at the MOH. After the MTR in June 2016, significant progress was achieved in Project implementation and Implementation Progress was assessed as Moderately Satisfactory until the end of the Project. The Project closing date was extended by 12 months (to December 31, 2019) to accommodate for the delays and to enable completion of Project activities. Activities under the Project components were fully completed by the Closing Date. 63. On balance, despite delays at project start up, overall efficiency is rated as Substantial in view of considerable benefits accrued as a result of this project. D. JUSTIFICATION OF OVERALL OUTCOME RATING 64. The assessment of overall outcome uses the split evaluation methodology, per new Bank ICR guidelines issued on March 2, 2020, as follows: Phase 1 (2013-2016) Phase 2 (2017-2019) Relevance High Efficacy Substantial High Efficiency Substantial Outcome Rating Moderately Satisfactory Highly Satisfactory Original PDO 2013-2016 Revised PDO 2017-2019 Overall 1 Rating Moderately Satisfactory Highly Satisfactory 2 Rating value 4 6 Total disbursed 3 6.2 10.3 16.5 US$ million 4 Share of disbursement 50.5% 49.5% 100% 5 Weigh value (2 X 4) 2.02 2.97 4.99 Satisfactory 6 Final rating S (2.02+2.97=4.99 rounding to 5.0) E. OTHER OUTCOMES AND IMPACTS Gender 65. By addressing MCH, the project had a clear gender impact as discussed above. The project successfully supported key activities in pursuit of MDG 5 (including investment in maternal and newborn health and emphasizing maternal mortality as a human rights and equity issue), as well as Sustainable Development Goal 5: Gender equality (including providing women and girls with good quality health care). Page 25 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Institutional Strengthening 66. The project strengthened the governance and stewardship function, as well as institutional capacity, of the MOH, MOLSD and MHIF. The MOH assumed a leadership position in the formulation and implementation of health policy and in the coordination of other partners for its implementation. DS and a new national health program “Health Person – Prosperous Country” for 2019-2030 were developed and are being implemented under the leadership of the MOH. The strategic purchasing function of MHIF was improved through the development of regulation on harmonizing sources of funds for SGBP in accordance with the new budget code, as well as thrould supporting new provider payment modalities. The use of country capacity and systems for procurement, financial management and strategic management has supported a learning-by-doing approach and has strengthened capacity. Procurement and financial management were undertaken by MOH departments, which were supported by the Project. The Project implemented a country-wide roll out of 1C software in health facilities. Poverty Reduction and Shared Prosperity 67. The project contributed to poverty reduction in the Kyrgyz Republic by tackling a critical driver of maternal death. As explained in the Efficiency Analysis (see Annex 4), maternal death can have far-reaching and long-lasting societal impact. Difficultly for the remaining members of the household to manage, because mothers are typically the principal caregivers, and they often contribute financially to the household income as well. Children may be taken out of school, sent away to live with other families or, if girls, married early when the mother dies. Each of these steps can further entrench poverty and limit human capital development. III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME A. KEY FACTORS DURING PREPARATION Objective and design Original Project 68. As designed, the Project supported the Government’s national health sector program DS (2012–2018); all components constituted integral parts of the DS and benefitted from significant client ownership because the Project derived from the Government’s reform program and sectoral goals. The DS’s design and the continued availability of financial and technical support for its implementation under SWAp2 ensured good continuity of support for health reform provided under SWAp1. Likewise, the Project also included continued support to MOLSD to ensure the full operationalization of the social protection administrative system improvements relating to the accuracy and efficiency of targeting. 69. The design of the Project was rather complex and ambitious compared to the funds allocated for project implementation and existing client capacity. The initial PDO was ambitious, complex, and broad. The health sector related part of the PDO was formulated on the level of long-term outcomes (that is improving health status of population). More specifically, these goals tied the WB to “improve health outcomes in four health priority areas in support of the Den Sooluk’’. At the same time some health outcomes, such as reducing maternal mortality, are high level Page 26 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) impact indicators beyond the control of the health sector itself. The financial support under the project was a relatively small part of overall expenditure: the total SWAp funding (not just the WB project) represented 2.3 percent of total health expenditure and 0.1 percent of GDP in 2014. The capacity of the MOH was limited: relatively low numbers of staff for the task, and weak links to the oblast /rayon levels to ensure implementation on the ground. The project results matrix included seven PDO indicators with poor relevance to the stated objectives making it difficult to measure the progress towards achievement of the PDO. 70. The Project comprised two major components spanning two different sectors, health and SP. Both components were overly ambitious operating in a high risk institutional and political environment. The decision to attach a social protection component to the health SWAp was based on the following reasons. Including an SP component was highly relevant to the political context at time of the Project design through providing targeted SA to decrease poverty of vulnerable population. It was also important to continue policy dialogue initiated under the SWAp 1 on increasing targeting and effectiveness of SA and services and to avoid the administrative time and costs of preparing a standalone project with quite a limited amount of available funds (US$3 million). The original intention was to link the two sectors to create synergy, but it was not effectively supported through implementation arrangements that envisaged separate management of each aspect. Restructured project 71. The June 2016 MTR concluded that there was a need to have a simpler project design, with a more realistic objective, and with relevant and measurable results that were more within the WB’s own ability to influence, control and contribute to the DS program outcomes. The shift in focus to MCH as the key health system priority was a strong feature of the new project design that concentrated resources and activities on this aspect and which achieved good results. 72. Following the SWAp principle of the Project, the new design kept the activities supporting overall health system strengthening and SP activities aimed at fostering synergy between health and social protection components to serve a common purpose that related to the achievement of the proposed revised PDO, especially those that would lead to improved access of the poor and the vulnerable to quality MCH services. B. KEY FACTORS DURING IMPLEMENTATION 73. As indicated above, there were serious delays in Project start-up. While the Project was approved by the Board on May 3, 2013, followed by signing of the Agreement on December 16, 2013, there were considerable delays in Parliament’s ratification of the Financing Agreement, and the Project became effective on June 16, 2014. The PDO/Implementation Progress was downgraded to Moderately Unsatisfactory given the fact that the Project had not yet been declared effective more than nine months after the Board approval. 74. There were substantial delays in the Project implementation during Phase 1 that were the result of the compromised capacity of MOH to implement reforms due to high turn-over of staff and low salaries and inability of the sector to retain qualified staff. The Project implementation arrangements for the health component didn’t include a separate Project Implementation Unit, rather relying on existing MOH staff. The new Minister of Health (appointed in November 2014) was not fully cognizant of SWAp principles and how it contributed to the DS. After his appointment, several key mid-level MOH managers who had gained significant capacity were dismissed, creating an atmosphere of uncertainty within the MOH. Additionally, the multiple (almost uninterrupted) parallel inspections by various bodies, Page 27 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) such as Prosecutors, Accounting Chamber, or Anticorruption Agency, interfered with normal functioning of the MOH and generated anxiety among MOH staff. 75. The lack of qualified human resources had a direct impact on the project implementation progress. While in October 2014 the PDO and the Implementation Progress were upgraded to Moderately Satisfactory, in December 2015, these were downgraded to Moderately Unsatisfactory, mostly attributable to the health sector part of the project and issues linked to lack of qualified human resources at the MOH. As of November 2015, four legal covenants related to procurement and financial management (including the development of a multi-year strategy for procurement system and of a fiduciary capacity building plan) were overdue. These two were affected by the delays in awarding of contracts to successful bidders in the tender for consulting services for procurement and financial management support to MOH and analytical studies as a basis for reforms and progress. 76. MOH was not able to fully discharge its leadership role and responsibility. An independent review of DS and SWAP2 prepared in support of the MTR pointed out that “MoH now tends to be reactive organisation, with little opportunity for policy development, policy dialogue with DPs, or strategic problem solving and implementation.” Continued weak links to the oblast level and lack of local autonomy for decision making meant that most problems that could have been solved at the local level gravitated to MOH in Bishkek. 77. During implementation of Phase 1 of the Project, the capacity of the procurement unit was insufficient, as only two procurement specialists were available, including one newly hired specialist without acceptable experience in procurement. In 2016 it was recommended that MOH seek the necessary budget for intensive procurement training of these specialists (as well as MOH coordinators of the Project and other staff involved in the evaluation process). In 2015 the chief accountant of the MOH resigned with significant turnover in the members of this fiduciary team. The rating for Procurement in December 2015 was downgraded to Moderately Unsatisfactory due to significant delays in procurement processes. 78. On the SP front, the pace of the reform supported by the project was slow and non-linear due to political factors and weak capacity of MOLSD. The Government faced multiple pressures to reverse its policy of targeting more resources to the poor. The MOLSD’s agenda was also threatened by lack of appropriate funding provision from the Republican Budget. 79. All of these reasons contributed to the significant delays in Project implementation during Phase 1. The progress toward PDO and the overall implementation progress was rated as Moderately Unsatisfactory. The main issues were: (a) limited implementation capacity of the MOH given the lack of a dedicated implementing unit; (b) overly ambitious PDOs and the challenges to see results given the SWAp input-heavy funding mode and the indicators that did not strictly link to the PDOs; and (c) a delay in fulfilling dated legal covenants. 80. In 2015 the Government decided to extend the DS program by 2 years, from the end of CY2016 until the end of CY2018, given the significant delay in its start. 81. The MTR took place in June 2016 and reviewed progress in implementation of both the DS and the WB project, with a view to introduce the needed adjustments to solve bottlenecks in Project implementation and revise the Result Framework. MOH and MOLSD actively participated in the MTR and provided necessary inputs. An MTR Committee chaired by the Minister of Health was formed to lead the MTR preparation process for DS and SWAp2; the Committee coordinated the different Working Groups and prepared a review report of DS and SWAp-2 ahead of the MTR. The report Page 28 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) reviewed implementation progress and updated the list of DS’s indicators and targets, looking at focus/refocus of priorities for the DS extension period as well as updating the work plan up to the end of 2018. An independent review team was contracted to provide an independent assessment of DS and SWAp project. 82. The MTR led to a Level 1 restructuring of the Project, including, but not limited to: (a) scaling down the PDO for the Health and SP components; (b) revision of the RF; and (c) revision of legal covenants as necessary. As requested by the WB management and agreed with the Government, the task team significantly revised key performance indicators in the Project RF to provide more relevant indicators for monitoring of progress towards PDO attainment. On the SP side, it was proposed to focus the component on (a) further development of the SP MIS; and (b) disability reform. 83. After the MTR and project restructuring, significant progress was achieved in Project implementation. The Project components made substantial progress and rating of the PDO was upgraded to Moderately Satisfactory based on improvements in the RF. All ratings related to implementation were upgraded to Satisfactory or Moderately Satisfactory. Progress in implementation was mainly due to a growing ownership by the GOK and the project team’s proactive implementation support to the borrower. Different technical working groups met on at least a quarterly basis to discuss and review the work program. All dated legal covenants were complied with. A Multi-Year Procurement Strategy for the health sector was prepared and discussed with the WB. 84. At the same time continued turnover in and understaffing of the procurement unit of the MOH led to delays in implementing several key goods and services contracts, including procurement packages, as well as the development of a master plan for optimization of health facilities network, e-Health and medical equipment procurement packages, EmONC medical equipment for 10 major hospitals and equipment for Emergency Units for the KfW supported hospitals. That led to the need for an extension of the project Closing Date to December 31, 2019. Major positive aspects in project implementation 85. Major positive aspects in project implementation include: (a) alignment of donor funding around national programs which helps improve efficiency and focus on the country’s own priorities; (b) ability to maintain regular policy dialogue on important issues regarding UHC, health system operation, and health insurance policies; (c) strong, coherent, and highly visible group of JFs, which has enabled significant influence on policy developments in the health sector; and (d) efforts to strengthen country systems, not only in health, but also in fiduciary capacity of the health sector. 86. JARs were conducted with participation from teams of the MOH and MHIF staff, with partner representatives of the German Agency for International Cooperation (GIZ), KfW, SDC, UNFPA, UNAIDS, UNICEF, the United States Agency for International Development (USAID), WHO, and the WB. The JARs reviewed the programs of the DS supported by this SWAp, implementation and benchmarks of disbursement against pool funding of DS; progress by each priority area (CVD, MCH, TB, HIV/AIDS) and component (public health, individual services, financing, human resources, pharmaceuticals, strategic planning and Health Information System). The WB and Government flexibility in addressing implementation issues was critical; both the MOH and the WB team demonstrated flexibility at various stages of implementation that allowed for adjustments to better reflect evolving needs and more closely aligning the WB support with the overall reform agenda. Page 29 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Factors subject to WBG control 87. The WB undertook appropriate supervision and monitoring during project implementation. These elements are described in more detail in Section IV.C “Quality of Supervision”. Factors outside the control of government, implementing agencies and WB 88. The macroeconomic and political context for the project was initially challenging. A transitional government was in place following the 2010 revolution, which meant that ambitious reform of state level institutions was unlikely. The outcomes were also achieved despite significant economic and financial volatility in the Kyrgyz Republic, and for the most part while it was a low income country. The importance of this should not be under-estimated: economic growth had been volatile; the real growth in GDP ranged from -0.1 percent at the start of DS in 2012, rose to 10.9 percent in 2013, and fell back again to 3.6 percent in 2014. Such volatility makes long-term planning very difficult, including estimating the fiscal space for health, defined simply as the ability to generate additional budgetary resources for health without prejudice to a country's financial sustainability. 89. The budget sequestration caused delays with implementation of project activities. For example, training of health professionals was delayed in the last months of 2017 due to the budget sequestration. IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME A. QUALITY OF MONITORING AND EVALUATION (M&E) M&E Design 90. The original RF could have done a better job in explaining the results chain, and in distinguishing between higher level impacts beyond the direct control of the health sector and those outputs and outcomes within MOH and Project control. The indicators for tracking progress lacked an explicit Theory of Change to explain how inputs and activities are meant to generate outputs and outcomes. The PDO level indicators were not linked to the PDO. 91. The IRIs included in the RF applied for the DS indicators. This package of indicators included higher level impacts such as the maternal mortality ratio, under five mortality and infant mortality. These are, of course, essential trends to track and assess, and therefore have an important place in the DS indicators. But they are each subject to numerous confounding influences outside the health sector. Tracking progress on the maternal mortality ratio and attributing causality is notoriously difficult, especially in relatively small populations and over short periods of time. The DS package of indicators should therefore have retained those higher level impact indicators because they are important; however, those higher level impacts should have been placed in a special category ‘’above the line” of what MOH could directly affect and be accountable for. The DS package of indicators should then have presented and tracked “below the line” those interventions that drive health outcomes and performance that MOH can control and are accountable for. 92. At the time of the MTR, the team started work to intensively revise the RF, to ensure a more effective monitoring of progress towards the attainment of PDO; outcome and output indicators were refined. The design of the RF was substantially changed during the restructuring, and the unmeasurable and irrelevant indicators were removed. As a Page 30 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) result, five PDO indicators and nine IRIs were dropped and two IRIs were amended. Nine IRIs were added ensuring better targeting and better measurability of the progress toward the objectives. These indicators reflect a set of improved results, given the focused scope of the project and its simplified design, that allowed capturing the project achievements. Several IRIs were added to the Result Framework for tracking IDA18 results. The selected Corporate Results Indicators include the number of people receiving essential health, nutrition and population services, which data is the sum of the number of children (under 5) immunized and the number of deliveries attended by a skilled health personnel. 93. Overall, the RF was deemed adequate for the remaining Project implementation period. M&E Implementation 94. During the first phase of the Project there were a number of issues with the measurement of some of the PDO indicators. Three out of five PDO indicators were stale due to issues with measurement, lack of baseline or inadequate baseline. For instance, there was an issue with the indicator “access of patients to preventive care measured by % of detected cases of hypertension (HT) at the primary health care level”. From the PAD, the baseline is 27 percent (2012) with an end target of 50 percent; official data from MOH indicated that the value of the baseline should be 4.1 (2012) with an actual value as of November 2014 of 6.1. Similarly, there was no baseline or target for the PDO indicator “Coverage of the population enrolled in disease management programs”. 95. The MOH regularly collected data to track progress towards achieving the PDO indicators and IRIs. The Republican Medical Information Center collected, vetted and distilled health and statistical data reported by health facilities. The JARs were undertaken throughout the life of the project. A mid-term review and end-of-Program review of DS, conducted in 2016 and 2018, respectively, were both rigorous and candid and informed strategy and implementation. M&E Utilization 96. M&E was used under the Project not only as a management tool to evaluate the status of the implementation of activities, but also to stimulate and inform policy dialogue, to help prioritize activities to support the reform agenda, monitor the impact of policy reform on health sector performance, and inform the design of GOK’s new health sector program. Justification of Overall Rating of Quality of M&E 97. Overall Rating of Quality of M&E: Modest based on the following. The RF enabled the measurement of PDO achievements after the Project restructuring. At the same time the original RF had deficiencies which made monitoring of the progress towards achievement of the PDOs challenging. The original PDOs were too high level, and too ambitious. All six PDO indicators did not strictly link to PDOs making it difficult to measure the progress towards achievement of the PDO. As a result, the RF was substantially revised at the MTR, resulting in four new PDO indicators and 14 intermediate results indicators, which were diligently and timely measured and reported on subsequently. B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE 98. Environmental and social. The Project was assessed as a Category B, as only moderate negative environmental impact was anticipated. An Environmental Management Plan (EMP) was developed and refined in consultation with a broad range of local stakeholders and publicly disclosed. Stakeholder meetings confirmed the existence of an Page 31 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) adequate legal and regulatory framework for activities envisaged in the EMP. Provisions for environmental screening were included in the Project Operations Manuel. The EMP included provisions to mitigate potential adverse environmental impacts resulting from the whole Program, and not just those financed under SWAp2. The Overall Safeguards Rating was Satisfactory during project implementation. 99. Procurement. At the beginning of the Project the delays in procurement were related to the low number of staff handling procurement in the MOH and the departure of the Head of Procurement Unit of the MOH. Additionally, the anxiety generated by the on-going multiple checks discouraged staff from taking actions and responsibility for procurement. Another reason for the slow progress was the low quality of the documents submitted to the WB for review and no objection, which required multiple exchanges between the WB and the MOH. 100. After the MTR the procurement management improved substantially. A Multi-Year Procurement Strategy for the Health Sector was prepared and discussed with the WB that also aimed at capacity building. An Order of the Ministry of Finance (MOF) related to the approval of the Harmonized Procurement Operational Manual for Health Sector goods was signed on 16 August, 2016, which allowed the harmonized bidding document to be uploaded into the MOF e-procurement website and allowed hospitals to use this document in the procurement of health sector goods via the e-procurement system. 101.The WB’s procurement guidelines were followed. Capacity was slowly built through a learning-by-doing process with the close and constant support of the WB’s procurement team. The WB and other partners provided needed technical expertise to ensure proper technical specifications in bidding documents. The tendering process was largely good. Annual independent procurement audits were envisaged to carry out post reviews. 101. At the same time continued turnover and understaffing of the MOH’s procurement unit led to delays in implementing several key goods and services, including the development of a master plan for optimization of health facilities network, e-Health and medical equipment procurement packages, EmONC medical equipment for 10 major hospitals and equipment for emergency units for KfW supported hospitals. 102. Financial Management: The MOH and MOLSD carried out the financial management responsibilities in a satisfactory way, with no issues identified. Quarterly financial reports were prepared and submitted in a timely manner, providing reliable financial information, and the Audit Reports had unqualified opinions. The MOH and MOLSD had appropriate skills and ability to manage the Project financial management and disbursement issues. The Project supported automation of accounting and reporting systems at the central level of the MOH, MHIF, and the MOLSD with 1C software properly incorporating the new chart of accounts and payroll module; the software was subsequently rolled out to all health facilities. The WB supported the development and implementation of a comprehensive fiduciary capacity building plan for the health sector, and strengthened the internal audit function within MOH and MHIF, including automation of the audit workflow. C. BANK PERFORMANCE Quality at Entry 103. The Bank’s performance at entry was Moderately Satisfactory. Page 32 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 104. The Project’s PDOs were fully aligned with and complemented the development priorities of the DS Program, and the design reflected lessons learned from past projects. As under SWAp 1, the Project was designed to be flexible in order to adapt to evolving sector needs. In addition, both during the preparation and first year of implementation, technical assistance was provided to refine the five-year Program of Work and prepare detailed implementation plans for DS priority areas. Implementation arrangements for the components were clearly described in the PAD. 105. The team understood the risks and carefully described them and emphasized the importance of flexibility in implementation, including the possibility of needing mid-course corrections. First, each component left scope for in- process adjustments; this flexibility is a feature of WB-financed projects that makes them especially useful for supporting complex reforms. Second, the Project supported a broad range of reforms but recognized that some may proceed more smoothly or successfully than others, due to the inherent unpredictability of complex change and the inability to predict reform trajectories with complete accuracy. The Project therefore spread ‘reform risk’ across multiple fronts and allowed for strength in one direction to compensate for weakness in another. 106. At the same time the project design was rather complex and ambitious given the funds allocated for project implementation and limited client capacity. The Project followed design of SWAp1 that established the foundation for health sector reforms with the objective to deeper these reforms and continue supporting sector-wide policy dialogue and donor coordination. At the time of Project preparation, the lessons from SWAp1 were not available as the ICR for that project was completed only in December 2015. Quality of Supervision 107. The Bank's performance during Project implementation was Satisfactory. 108. Sufficient budget and staff resources were allocated, and the Project was adequately supervised and monitored. WB supervision took place on a regular basis and provided appropriate and well-targeted advice and observations. The aide memoires provided evidence of regular supervision and professional advice given by the WB’s experts throughout the Project life. The Implementation Status Reports realistically rated the performance of the Project both in terms of achievement of PDOs and implementation. In addition, the feedback received by the ICR mission during the interviews with stakeholders, clearly showed the GOK’s appreciation of the technical skills and advice provided by the WB, not just on the Project but also on health sector related issues. 109. Immediately after the project was downgraded to MU in January 2016 team started internal discussions to diagnose root causes and potential solutions and dialogue with JFs and counterparts for possible restructuring. There was a pre-MTR mission in April 2016 and MTR in June 2016. 110. The 2016 MTR included Round Tables and workshops with stakeholders that highlighted key issues to ensure the sustainability of the work started and helped to identify measures to overcome delays in Project implementation. This resulted in the Project being restructured to revise the PDO and the RF to better monitor the progress towards achievement of the PDO. Subsequently significant progress was achieved in Project implementation; the Project demonstrated notable achievements in the implementation of health sector reforms under most of its components. In August 2018 the WB extended the project Closing Date in order to complete project activities. 111. The WB effectively assumed the role of lead coordinating partner, facilitating and coordinating the collaboration among the JFs (the WB, KfW, and SDC), and across DPs more broadly. The WB reviewed and approved the annual Page 33 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) procurement plan, provided prior review and no objection not only on the JFs’ funding, but also government funding. The WB took lead responsibility for supervising fiduciary aspects on behalf of the JFs, engaging with the MOF and tracking its obligations on the allocation of public funds for health and on the full use of these funds. WHO maintained its leading support to building and using M&E capacity; the SDC oversaw adherence to waste management safeguards, medical education, autonomy of health providers and support to village health committees; KfW supported fiduciary capacity building and technical assistance; TB and HIV programs were supervised by the Global Fund, USAID and KfW; and the MCH program was supervised by UNICEF with participation of WHO, UNFPA, GIZ, USAID. 112. Aide-memoires and Summary Notes from JARs were systematic in their focus on development impact. They were overtly linked to points of consensus reached at these meetings, grounded in progress reports and reviews of implementation of work plans; they included JF’s observations on issues constraining successful program implementation and the reform agenda, as well as their clear guidance and recommendations on how to resolve them. Moreover, increasingly over time, the Aide-memoires/Summary Notes and follow-up discussions ensured that there was a strong coherence between the annual Program of Work and the sector-wide procurement plan. DPs assessed the quality and scope of annual Program of Work and approved them during JARs. Thematic Meetings and JARs were evidence-based: in their preparation, in their conduct, and in the follow-up; they focused, appropriately, on the achievement of the broader Program objectives. A broad range of informants consistently reported on the quality and intensity of the supervision of fiduciary aspects, which were highly supportive and pedagogical in nature and contributed to the strengthening of MOH capacity. The WB and JFs supported an in-depth evaluation of DS and the development of a new national health strategy, based on the evidence and lessons generated by the evaluation. 113. The World Bank used its convening power and comparative advantage under the Project for policy dialogue, including negotiations to ensure GOK expenditure on health was maintained at 13 percent of total government expenditure. Also, in cooperation with other DPs, the GOK agreed to keep the separation between the MOH and the MHIF. 114. The WB and Government flexibility in addressing implementation issues was critical. Both the MOH and the WB team demonstrated flexibility at various stages of implementation that allowed for adjustments to better reflect evolving needs and more closely align with the overall reform agenda. Justification of Overall Rating of Bank Performance 115. Based on the foregoing, the overall rating of Bank performance is Moderately Satisfactory. D. RISK TO DEVELOPMENT OUTCOME 116. Risk to development outcome is substantial. 117. The risk to health sector development outcomes is Substantial. Although Kyrgyz Republic continues to make progress towards health development goals, challenges still remain, and these should be addressed in order to safeguard achievements made, and accelerate the rate of progress. These challenges include: socioeconomic and geographic inequality, poor quality of health services, lack of emphasis on practical skills in the curricula for training of healthcare providers, weak integration of antenatal, postnatal and family planning health care services at the PHC level, weak multi-sectoral approach to tackling MCH problems, turnover and lack of medical specialists in remote rural areas, and low commitment of local governments in addressing the health issues. Poor quality of pre-conception and Page 34 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) antenatal care which result in failure to detect and manage high risk pregnancies and obstetric complications contribute to high maternal mortality, and early neonatal deaths, including stillbirths. Persisting high prevalence of anemia continues to increase the risks of perinatal, maternal, and child mortality, as well as impaired cognitive functioning in children. Lack of continuity of care requires improvement of clinical pathways and system of referrals and counter-referrals between levels of care. Current infrastructure of MCH facilities needs further refurbishment. 118. The new Health Strategy is now under implementation, its technical content grounded in an in-depth evaluation of DS 2012-2018 and a preparation process that provided for the input and vetting by a range of actors and stakeholders, both national and international. Partners recognized that the efforts undertaken during the last couple of years in dialogue with the MOH and supporting the national health program created an enabling and supportive environment to push key reform measures and to unlock major potentials for improving efficiency, quality, and equity outcomes. Partners’ support in the next phase of the health sector development is pivotal and catalytic. It can leverage additional parallel financiers, non-traditional donors, and the private sector to support the national health program to be outlined in the upcoming Health Sector Strategy. Enhanced support will be crucial in bringing together various donor-funded pilots and institutionalizing the promising ones, including the WB’s Result-Based Financing pilots and the Swiss-supported facility autonomy project. 119. The project and its restructuring has prepared the Government and DPs for the subsequent WB PfR operation: Primary Health Care Quality Improvement Program (P167598), which directly took into account lessons of the SWAp implementation and moved away from the general sector-wide support of the Government to the operation that is fully focused on tangible results. 120. Government ownership and commitment to health reform and policies are critical to sustaining – and further consolidation of – health outcomes and impacts. While MOF and MOH have improved overall sector governance under the SWAp2, there remain several factors of concern. First, very low civil service salaries have undermined MOH’s ability to attract and retain high quality staff both to undertake strategic management (evidence-based policy analysis, planning, programming, budgeting, M&E) and fiduciary management (financial management, audit and procurement functions). Throughout the project life and up to now, MOH invests heavily in recruitment and on-the-job training of staff, only to lose them to more competitive markets once they become fully proficient. Second, the oblast level of MOH is undersized and understaffed, rendering it incapable of strategic management and oversight of implementation of the national health program on-the-ground at the regional level. 121. The financial sustainability of any successor health reform program will be a major challenge. This is particularly so given the high total fertility rate, increasing burden of long-term and expensive non-communicable diseases, the high level of exemptions from co-payments and the prospects of some DPs scaling down their support over time now that the Kyrgyz Republic has graduated from low income country status. V. LESSONS AND RECOMMENDATIONS 122. The SWAp mechanism to implementing the project demonstrated positive outcomes but also revealed shortcomings. Major positive aspects include: (a) alignment of donors funding around a national program which helps improve efficiency and focus on a country’s own priorities; (b) the ability to maintain regular policy dialogue on important health reform issues; (c) a strong and highly visible group of JFs which enabled significant influence on policy developments in the health sector; and (d) use of country systems and capacity, especially for procurement, financial management and strategic management that helped to increase country commitment and strengthen the Ministry’s Page 35 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) institutional development and capacity. On the other hand, some critical issues are: (a) with the ambitious goal to support the broad national program the high level policy dialogue is sometimes not followed by concrete actions; (b) lack of a sense of results, especially those that can be measured within the time frame of the project; (c) challenge in striking a balance between donor involvement and government ownership; and (d) a SWAp imposes high costs on the WB team due to heavy involvement in transactions and inputs. 123. Government commitment is critical for the successful implementation and WB projects must be fully consistent with Government reform plans. This is especially true of reforms that are technically and politically complex. The Project supported implementation of the DS Health Reform Program for the years 2014-2018, and all Project components were an integral part of this Program. 124. MOH stewardship and leadership is key. In a situation of high staff turnover in the Ministry the major challenge is to ensure sustainable capacity building. The high turnover of Ministers, and the lack of a strong governing board in MHIF, added to the importance of MOH and MHIF having stable, capable, stewardship and leadership functions in order to implement Government policy. The connection with regional level and stewardship function of MOH in assessing and disseminating of regional pilots should be strengthened. 125. Explicit Theory of Change with connections between activities and measurable outcomes is critical to successful implementation of a project. The clear sense of results is needed, especially those that can be achieved and measured within the time frame of the Project. The RF should not include indicators which don’t have baseline. 126. To strengthen collaboration across health and social protection in implementing a joint project , it is recommended to clearly identify the synergies between the proposed social protection and health agenda at the design stage as well as ensure consistency of implementation arrangements, establishment of joint steering committees, and joint monitoring of project implementation. . Page 36 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS A. RESULTS INDICATORS A.1 PDO Indicators Objective/Outcome: To contribute to improving delivery of quality maternal and child health care services. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Proportion of normal Percentage 5.70 58.00 84.10 deliveries in district (rayon) hospitals that received 01-Jul-2014 31-Dec-2018 30-Jun-2019 services following clinical protocols Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Proportion of complicated Percentage 2.50 43.00 43.00 deliveries in district (rayon) hospitals that received 01-Jul-2014 31-Dec-2018 30-Jun-2019 Page 37 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) services following clinical protocols Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Births (deliveries) attended Number 150000.00 916000.00 1091765.00 by skilled health personnel (number) 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Diarrhea treatment with oral Percentage 77.00 80.00 88.50 rehydration therapy 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Page 38 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Government health Percentage 13.70 13.10 13.10 expenditure as % of total government expenditure 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target achieved. A.2 Intermediate Results Indicators Component: Component 1. Strengthening the delivery of quality MCH care services within "Den Sooluk" National Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of facilities Text 0 10.00 10 adequately equipped to provide emergency obstetric 31-Dec-2013 31-Dec-2018 31-Dec-2019 and neonatal care (cumulative) Comments (achievements against targets): Target achieved. Page 39 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of pregnant women Number 148000.00 909000.00 1050516.00 receiving any antenatal care 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of providers trained Number 0.00 200.00 691.00 in postnatal and postabortal IUD insertion and removal 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Children immunized Number 135000.00 850940.00 987476.00 Page 40 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) (number) 31-Dec-2013 31-Dec-2018 31-Dec-2019 Children immunized - under Number 135000.00 838848.00 987476.00 12 months against DTP3 (number) 31-Dec-2012 31-Dec-2018 31-Dec-2019 Children immunized - under Number 135000.00 837000.00 982793.00 12 months against Polio (number) 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of children treated Number 53000.00 177000.00 193649.00 with ORS for diarrhea or with antibiotic for pneumonia 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Component: Component 2. Strenghtening Health System within the "Den Sooluk" National Health Reform Program Page 41 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Proportion of HIV infected Percentage 96.10 95.00 97.70 pregnant women that received antiretroviral drugs 31-Dec-2013 31-Dec-2018 31-Dec-2019 to reduce risk of mother-to- child transmission Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of family doctors, Number 0.00 3300.00 3374.00 feldshers, TB doctors and nurses trained on TB clinical 31-Dec-2013 31-Dec-2018 31-Dec-2019 protocols and guidelines Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Page 42 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Number of family doctors, Number 0.00 4500.00 5176.00 feldshers and nurses trained on CVD 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Percentage of negative Percentage 5.00 4.40 2.00 deviations of the executed health budget from the 31-Dec-2012 31-Dec-2018 31-Dec-2019 initially approved budget and quarterly allocations and execution of the health budget Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Submission of IFRs Yes/No N Y Y Page 43 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) satisfactory to IDA within due 31-Dec-2012 31-Dec-2018 31-Dec-2019 dates according to Financing Agreement Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Proportion of electronically Percentage 0.00 100.00 100.00 registered families with children receiving social 31-Dec-2013 31-Dec-2018 31-Dec-2019 assistance (MBPF) who are electronically registered Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Number of districts where Number 20.00 57.00 57.00 the Social Registry Information System has been 31-Dec-2013 31-Dec-2018 31-Dec-2019 fully rolled out Page 44 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Roadmap to reform disability Yes/No N Y Y service developed 31-Dec-2012 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target achieved. Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion People who have received Number 0.00 1816000.00 2079629.00 essential health, nutrition, and population (HNP) 31-Dec-2013 31-Dec-2019 31-Dec-2019 services Number of children Number 0.00 837000.00 987864.00 immunized 31-Dec-2013 31-Dec-2018 31-Dec-2019 Page 45 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Number of deliveries Number 0.00 916000.00 1091765.00 attended by skilled health personnel 31-Dec-2013 31-Dec-2018 31-Dec-2019 Comments (achievements against targets): Target surpassed. Page 46 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) B. KEY OUTPUTS BY COMPONENT Objective/Outcome 1 To contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program 1. Proportion of normal deliveries in district (rayon) hospitals that received services following clinical protocols 2. Proportion of complicated deliveries in district (rayon) hospitals that received services following Outcome Indicators clinical protocols 3. Births (deliveries) attended by skilled health personnel (number) 4. Diarrhea treatment with oral rehydration therapy 5. Government health expenditure as % of total government expenditure 1. Number of facilities adequately equipped to provide emergency obstetric and neonatal care (cumulative) 2. Number of pregnant women receiving any antenatal care 3. Number of providers trained in postnatal and postabortal IUD insertion and removal 4. Children immunized (number) 5. Children immunized - under 12 months against DTP3 (number) 6. Children immunized - under 12 months against Polio (number) 7. Number of children treated with ORS for diarrhea or with antibiotic for pneumonia 8. Proportion of HIV infected pregnant women that received antiretroviral drugs to reduce risk of Intermediate Results Indicators mother-to-child transmission 9. Number of family doctors, feldshers, TB doctors and nurses trained on TB clinical protocols and guidelines 10. Number of family doctors, feldshers and nurses trained on CVD 11. Percentage of negative deviations of the executed health budget from the initially approved budget and quarterly allocations and execution of the health budget 12. Submission of IFRs satisfactory to IDA within due dates according to Financing Agreement 13. Proportion of electronically registered families with children receiving social assistance (MBPF) who are electronically registered 14. Number of districts where the Social Registry Information System has been fully rolled out Page 47 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 15. Roadmap to reform disability service developed 16. People who have received essential health, nutrition, and population (HNP) services Component 1. Strengthening the delivery of quality MCH care services within "Den Sooluk" National Health Reform Program 1. Clinical protocols for normal and complicated deliveries in district (rayon) hospitals implemented 2. Oral rehydration therapy for diarrhea treatment provided to 88% of children under 5. 3. Maternity units of 10 regional hospitals and city perinatal centers equipped with a full set of basic Key Outputs by Component equipment necessary for emergency obstetric care (linked to the achievement of the 4. Improved registration of women for antenatal care Objective/Outcome 1) 5. 691 providers trained in postnatal and postabortal insertion and removal of IDU 6. 96% of children under 12 months immunized against DPT3 7. 95% of children under 12 months immunized against Polio 8. 90% of children under 5 with diarrhea received oral rehydration therapy 9. 97.7% of HIV positive pregnant women received antiretroviral drugs to reduce risk of mother-to-child transmission Component 2. Strenghtening Health System within the "Den Sooluk" National Health Reform Program 1. Government health expenditures maintained at the level of 13% of total government expenditures 3. 3374 family doctors, paramedics, TB specialists and nurses trained on TB clinical protocols and guidelines 4. 5176 family doctors, paramedics and nurses trained in cardiovascular clinical protocols 5. IFRs satisfactory submitted to IDA within 75 days upon the end of reporting period 6. 100% of families with children certified to receive social assistance and electronically registered with the Social Registry Information System. 7. The Social Registry Information System rolled out in 57 districts 8. Roadmap to reform disability service developed. Page 48 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION A. TASK TEAM MEMBERS Name Role Preparation Nedim Jaganjac Task Team Leader(s) Alexander Balakov Procurement Specialist(s) Arman Vatyan Financial Management Specialist Amy Evans Social Specialist Aly Zulficar Rahim Social Specialist Supervision/ICR Agnes Couffinhal, Oleksiy A. Sluchynskyy, Ha Thi Hong Task Team Leader(s) Nguyen, Susanna Hayrapetyan Irina Goncharova Procurement Specialist(s) Arman Vatyan Financial Management Specialist Johanne Angers Team Member Mohammad Ilyas Butt Procurement Team Kristine Schwebach Social Specialist Alaa Mahmoud Hamed Abdel-Hamid Team Member Asel Sargaldakova Team Member Maya Razat Team Member Rustam Arstanov Environmental Specialist Meerim Sagynbaeva Team Member Nodar Mosashvili Team Member Farangis Dakhte Procurement Team Kunduz Ermekbaeva Procurement Team Page 49 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) B. STAFF TIME AND COST Staff Time and Cost Stage of Project Cycle No. of staff weeks US$ (including travel and consultant costs) Preparation FY11 .400 2,106.36 FY12 2.200 46,548.81 FY13 39.761 168,654.11 Total 42.36 217,309.28 Supervision/ICR FY14 41.640 95,878.36 FY15 51.625 102,856.91 FY16 66.937 86,062.48 FY17 52.102 147,634.79 FY18 31.824 133,536.49 FY19 44.144 131,719.24 FY20 22.392 118,763.64 Total 310.66 816,451.91 Page 50 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 3. PROJECT COST BY COMPONENT Amount at Approval Actual at Project Percentage of Approval Components (US$M) Closing (US$M) (US$M) Component 1 – Strengthening the delivery of quality MCH care services 13.50 12.10 90 within the "Den Sooluk" National Health Reform Program Component 2 – Strenghtening Health System within the "Den Sooluk" 3.00 3.00 100 National Health Reform Program Component 3: Contingent Emergency Response (no 0 0 0 funds allocated) Total 16.50 15.10 91 Page 51 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 4. EFFICIENCY ANALYSIS Scope of the analysis 1. This cost-benefit analysis proceeds from an intervention logic that the delivery of MCH services would improve access to maternal, neonatal and child health, and consequently will decrease the maternal mortality and stillbirth rate, in addition to MTCT of HIV; this is in addition to interventions to control TB and CVD. The project duration was 7 years (2014-2020), and since the 1 st disbursement was in year 2 of the project and ended in year 7, we consider that the costing of the economic analysis starts in 2015 and ends in 2019, while the benefits flows start in approximately 2016. 2. In the analysis, a social prospective is employed and there are two main factors affecting the results which are (a) a timeframe based on a time horizon of 10 years; and (b) the discount rate used in this economic analysis aims to reflect the preference of the project beneficiaries and Government to receive the benefits of the reduced morbidity earlier than later (time preference) and to explain the increased ambiguity about receiving predicted benefits further into the future (risk premium). To ensure uniformity and comparability with other economic evaluations for similar interventions, the discount rate was set at 3%. 3. Benefits and costs are expressed in US$ monetary terms in the analysis, and are adjusted for the time value of money, so that all flows of benefits and flows of project costs over time (which tend to occur at different points in time) are expressed on a common basis in terms of their net present value. For the purposes of consistency, the costs included in the analysis are extracted from the World Bank’s Projects Portal. Benefits Accrued from Birth Deliveries Attended by Skilled Health Personnel 4. Recent evidence in low and middle-Income countries showed that giving birth with the support of skilled health personnel is linked with a reduced probability of both of maternal mortality and stillbirths. This is because of the increased chances to spot and manage potential maternal and child complications during delivery. The project financially supported pregnant women to give birth with the support of skilled health personnel. - Reduced Maternal Deaths 5. According to Graham et. al, 24.5% (16-33) of all maternal deaths may be avoided through the primary or secondary prevention of four main complications (obstructed labor, eclampsia, puerperal sepsis and obstetric hemorrhage) by skilled attendance at delivery. The model highlights the importance of considering the potential of skilled attendance to impact not only on maternal mortality but also morbidity and emphasizes their primary prevention role through effective and appropriate management of normal labor and delivery. Therefore, the attendance of deliveries by skilled health personnel under the project is expected to reduce the maternal deaths by 24.5%. 6. Based on maternal mortality ratio numbers published by UNICEF, the MMR estimate in Kyrgyzstan during the lifetime of the project is 764. Therefore, the project is thought to have saved around 187 mothers. This calculation is explained by 764 MMR estimates in Kyrgyzstan * 24.5% reducing MMR = 187. 7. Following Stenberg et al (2016) in a conservative approach we assumed that the value of one statistical life-year (VSLY) equals 1.5 times the per capita gross domestic product (GDP) to monetize the benefits accrued from the intervention, each VSLY equals US$ 1,923.66 (1.5* US$1,282.44 GDP per capita of year 2013). In Page 52 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Kyrgyzstan the median age of women at giving birth to their first baby is 22 years 2, and the life expectancy is 71.4. Saving 187 mothers’ lives will yield a total economic benefit of US$4,448,244. This calculation is explained by: (187 lives saved * 49.4 life-years saved per person* 1,923.66 VSLY* 25% Effectiveness Rate). - Reduced Stillbirths 8. According to Yakoob et. al, skilled birth attendance showed a 23% significant reduction in stillbirths, where the Delphi process supported the estimated reduction in stillbirths by skilled attendance and experts further suggested that the provision of Basic EOC had the potential to avert intrapartum stillbirths by 45% and with provision of Comprehensive EOC this could be reduced by 75%. These estimates are conservative, consistent with historical trends in maternal and perinatal mortality from both developed and developing countries and are recommended for inclusion in the Lives Saved Tool model. Therefore, the attendance of deliveries by skilled health personnel under the project is expected to reduce the stillbirths by 23%. 9. The total still birth estimates in Kyrgyzstan during the lifetime of the project is 11,136. This intervention is thought to decrease the stillbirth by 23 % and save 2,561 lives, and this will yield a total economic benefit of US$87.95 million. Its concluded through: (11,136 stillbirths * 23% effectiveness on babies * 71.4 life-years saved per person* $1,923.66 VSLY* 25% effectiveness rate) Benefits Accrued from Providing Antenatal Care Services to Pregnant Women 10. Recent evidence in low and middle-income countries specified that a higher frequency of antenatal contacts by women with health providers is linked with a reduced probability of both of maternal mortality and stillbirths. This is because of the increased chances to spot and manage potential maternal complications. The project financially supported pregnant women during pregnancy to be able to attend ANC visits. - Reduced Maternal Deaths 11. According to Lincetto et al3, one third of maternal deaths (33%) are owing to causes such as hypertension (pre-eclampsia and eclampsia) and antepartum hemorrhage, which are directly related to inadequate care during pregnancy. Therefore, the ANC provided to pregnant women under the project is expected to reduce the maternal deaths that occur during pregnancy by 33%. 12. Based on maternal mortality ratio numbers published by UNICEF, the MMR estimate in Kyrgyzstan during the lifetime of the project is 764. Therefore, the project is thought to save around 252 mothers. This calculation is explained by 764 MMR estimates in Kyrgyzstan * 33% ANC reducing MMR = 252. 13. Following Stenberg et al (2016) in a conservative approach, we assumed that the value of 1 statistical life- year (VSLY) equals 1.5 times the per capita GDP to monetize the benefits accrued from the intervention, each VSLY equals 1,923.66 (1.5* $1,282.44 GDP per capita of year 2013). In Kyrgyzstan the median age of women at giving birth to their first baby is 22 years4, and the life expectancy is 71.4. Saving 252 mothers’ lives will yield a 2 National Statistical Committee (Kyrgyz Republic), and ICF International, 2013. 2012 Kyrgyz Demographic and Health Survey: Key Findings. Bishkek, Kyrgyz Republic, and Calverton, Maryland, USA: National Statistical Committee (Kyrgyz Republic), and ICF International. 3 Antenatal Care (Ornella Lincetto, Seipati Mothebesoane-Anoh, Patricia Gomez, StephenMunjanja): Reviewing Ethiopia's Health System Development (a similar GDP/capita and belonging to the African region). 4National Statistical Committee (Kyrgyz Republic), and ICF International, 2013. 2012 Kyrgyz Demographic and Health Survey: Key Findings. Bishkek, Kyrgyz Republic, and Calverton, Maryland, USA: National Statistical Committee (Kyrgyz Republic), and ICF International. Page 53 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) total economic benefit of US$5,991,512. This calculation is explained by: (252 lives saved * 49.4 life-years saved per person* 1,923.66 VSLY* 25% Effectiveness Rate). - Reduced Stillbirth Rate 14. According to Afulani (2016), the stillbirth rate is higher among the women who did not receive any ANC; 5.6 % compared to 1.5 % among women who received some ANC. Hence, the impact of providing ANC to women on stillbirth rate is assumed to be decreased by 4.1%. The total stillbirth estimates in Kyrgyzstan during the lifetime of the project is 11,136. The project is thought to decrease the stillbirth by 4.1 % and saved 457 lives, and this will yield a total economic benefit of US$15.7 million. It is concluded through: (11,136 stillbirths * 4.1% ANC effectiveness on babies * 71.4 lives saved per person* $1,923.66 VSLY* 25% effectiveness rate) Benefits Accrued from Immunization Services for Children (Polio3 and Penta3) 15. Based on study by Sachiko Ozawa et al5, economic analysis was done considering the broader economic impact of illness, net returns on investment in vaccination in low and middle-income countries amounted to 44 times the cost with an uncertainty range of (27–67). Given that the total cost of vaccination intervention under the project is US$5,307,287, the investment in immunization yielded US$233.5 million; (US$5,307,287* 44). Benefits Accrued from Treatment of Children with ORS for Diarrhea or with Antibiotics for Pneumonia - Reduced Cost and Burden of Diarrheal Diseases 16. According to Ranju Baral et. al, the average cost of illness with diarrheal diseases is US$36.56 per outpatient episode and US$159.90 per inpatient episode, where direct medical costs accounted for 79% (83% for inpatient and 74% for outpatient) of the total direct costs. 17. Based on the assumption that half the children covered under this intervention received ORS treatment for diarrheal diseases (96,825 children), where without the ORS treatment 50% of will need outpatient care with the cost of US$3,539,904 (96,825 children * 50% who will need outpatient care * US$36.56 cost of outpatient care) and 10% will need inpatient care with the cost of US$3,096,448 (96,825 children * 10% who will need inpatient care * US$159.9 cost of inpatient care). 18. Given that the effectiveness of the ORS as a treatment for dehydration is 90%, the project’s investment in ORS treatment yielded US$5,972,716 ((US$3,539,904 + 3,096,448) *90% effectiveness of ORS treatment). - Reduced Cost and Burden of Pneumonia 19. According to Shanshan Zhang et. al: the total cost (per episode) for management of severe pneumonia ranges between US$242.7–559.4 with an average of US$401. Based on the assumption that half the children covered under this intervention received antibiotic treatment for pneumonia (96,825 children), and given that the effectiveness of the antibiotics in prevention of complications of pneumonia and preventing it to be severe pneumonia is 50% the project’s investment under this intervention yielded US$4,853,328 (US$401 * 96,825 children * 50% prevented severe pneumonia cases * effectiveness rate of 25%). 5Return on Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011-20. Sachiko Ozawa et al. Page 54 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Benefits Accrued from Providing PMTCT Services to Pregnant Women Living with HIV 20. Literature6 suggests that the risk of the MTCT of HIV — without PMTCT services, including antiretroviral preventive interventions, the risk of perinatal HIV transmission has varied between 15-45% with an average of 30%, depending on maternal risk factors and whether breastfeeding is practiced or not, while the risk of MTCT is reduced to less than 1% with PMTCT services and ART. The project provided PMTCT services to 881 pregnant women living with HIV, yielding US$3,305448. This is arrived to through (881 cases * (30% risk without PMTCT - 1% risk with PMTCT) * US$30.20 economic burden of HIV per month7 * 12 months * 71.4 years of life * effectiveness rate of 50%). Benefits Accrued from Training of Health Personnel (Increased Productivity) 21. Based on the assumption that the project intervention in training health personnel will increase their productivity by 10%, 23,353 health personnel (who are assumed to be 30 years old when they received the training) were trained under the project, yielding US$37.86 million as increase in health personnel productivity. This is arrived to by using their monthly average salary equivalent to US$450.4 (21,9000 KGS according to WHO) as a proxy measure for productivity; (23,353 workers * US$450.4* 10%* 12 months* 10% effectiveness*30 working years till retirement8). Benefits Accrued from Reduced Mortality from TB 22. Based on the assumption that the project intervention to control of TB resulted in the change (decrease by 2.1) in the rates of mortality between the years of 2011 (baseline) and 2017 from 8.7 to an average of 6.6 per 100,000 population over the years of the project, yielding US$13.35 million. Where the average number of lives saved during the project is 763 (2.1 change in mortality * 5,959,000 population)/100,000 population) * 6 years. Following the conservative approach of Stenberg et al (2016) we assumed that the value of one statistical life-year VSLY equals 1,923.66. In Kyrgyzstan the median age of infection by TB is assumed to be 35 years old, and the life expectancy is 71.4. Saving 763 lives will yield a total economic benefit of US$13,352,207. This calculation is explained by: (763 lives saved * 36.4 life-years saved per person * 1,923.66 VSLY * 25% Effectiveness Rate). Benefits Accrued from Reduced Mortality from CVD - Reduced Mortality from CVD in Population Age Group 30-39 23. Based on the assumption that the project intervention to control of the CVD among the population group (30-39 years) resulted in the change (decrease by 12.4) in the rates of mortality between the years of 2011 (baseline) and 2017 from 51.2 to an average of 38.8 per 100,000 population aged 30-39 years over the years of the project, yielding US$10.67 million. Where the average number of lives saved during the project is 609 (12.4 change in mortality * 817,000 population in the age group)/100,000 population * 6 years. Following the conservative approach of Stenberg et al. (2016), we assumed that the value of one statistical life-year VSLY 6 Patricia M Flynn et. al: Prevention of mother-to-child HIV transmission in resource-limited settings. 7 Ak Nayaryan Poudel et. al: The economic burden of HIV/AIDS on individuals and households in Nepal: a quantitative study. 8 Given that the average age of retirement of both men and women in Kyrgyzstan is 60 years. Page 55 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) equals 1,923.66. Assuming the median age of death within the age group is 35 years old, and the life expectancy is 71.4. Saving 609 lives will yield a total economic benefit of US$10,669,168. This calculation is explained by: (609 lives saved * 36.4 life-years saved per person * 1,923.66 VSLY * 25% Effectiveness Rate). - Reduced Mortality from CVD in Population Age Group 40-59 24. Based on the assumption that the project intervention to control CVD among the population group (40- 59 years) resulted in a change (decrease by 36.1) in the rates of mortality between the years of 2011 (baseline) and 2017 from 51.2 to an average of 273.5 per 100,000 population aged 40-59 years over the years of the project, yielding US$26.17 million. Where the average number of lives saved during the project is 2,543 (36.1 change in mortality * 1,174,000 population in the age group)/100,000 population) * 6 years. Following the conservative approach of Stenberg et al (2016) we assumed that the value of one statistical life-year VSLY equals 1,923.66. Assuming the median age of death within the age group is 50 years old, and the life expectancy is 71.4. Saving 2,543 lives will yield a total economic benefit of US$26,170,296. This calculation is explained by: (2,543 lives saved * 21.4 life-years saved per person * 1,923.66 VSLY * 25% Effectiveness Rate). Summary: 1. Combining all the above benefits, the project is thought to have benefits that far exceed the costs as described in the below tables. Table 4.1 Summary of the Benefits Accrued by the Project Interventions Benefits In US$ Millions Benefits accrued from Birth Deliveries Attended by Skilled Health Personnel 92.40 Benefits accrued from Providing ANC to Pregnant Women 21.67 Benefits accrued from Immunization of Children (Polio3 and Penta3) 233.52 Benefits accrued from Treatment children with ORS for Diarrhea or Antibiotics 10.83 for Pneumonia Benefits accrued from Providing PMTCT Services to Pregnant Women Living with 3.31 HIV Benefits accrued from Training Health Personnel 37.86 Benefits accrued from Reduced Mortality from TB 13.35 Benefits accrued from Reduced Mortality from CVD 36.84 Total 449.77 2. Based on the set of assumptions outlined above and on bringing in the financial costs of the project investments, the returns to the project are summarized below: Page 56 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Table 4.2 Project Returns (at 3% discount rate) Benefits / costs Present Value of Flows (US$) Benefits Accrued from Project Interventions (see Cash flow: US$ 449.77 Million to 2023 above for details) Costs: Investment cost plus recurrent costs. The project disbursed a total of US$27.06 Million over 7 years. Net present Value 337.93 million Benefit-Cost Ratio 14.88 IRR (%) 346% 3. Making assumptions on the benefits and associated returns of project, the project broke even during the its life in 2014 with zero disbursement. Again, the project broke even towards the second half of 2015; this was due to the pace and trend of disbursement and implementation of activities. The figure below shows the two Break-even point for the project. Figure 4.1 Project Costs and Benefits Discounted Cash Flow under the Project 70 60 50 40 MILLIONS, USD 30 20 10 - 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Costs Benefits Page 57 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS Letterhead of the Ministry of Labor and Social Development of the Kyrgyz Republic Date: 08/25/2020 Ref. No. 17-9/5744 Attn. of: Mr. Naveed Hassan Naqvi World Bank Country Manager for the Kyrgyz Republic Dear Mr. Naveed Hassan Naqvi, On behalf of the Ministry of Labor and Social Development, let me congratulate You on the start of your work in our country and wish You great success. The Ministry of Labor and Social Development of the Kyrgyz Republic has a good experience of cooperation with the World Bank for many years. The completion of the World Bank SWAp-2 Project is an example of this cooperation. The effective implementation of this project allowed us to obtain high economic benefits from investment, which led to the further development of the entire social protection system, as well as the development of information systems and technologies. On the proposed document, the Implementation Completion and Results Report (Report) of the Second Health and Social Protection Project (Project), financed by IDA Credit 52350, IDA Grant H8390 and Trust Fund TF-15135, which completed on December 31 st, 2019, the Ministry offers a number of comments: - on pages 21 and 22 in Figures 1 and 2 in sentences: Centers for the provision of comprehensive (integrated) social services have been developed and tested (on a pilot basis) We suggest removing the words “at the community level”, the Ministry worked to integrate the range of social services at the district level, not at the community level. - on page 27, paragraph 48, it is necessary to change in the Russian version the abbreviated name of the state benefit in the text from “ЕЕПМСГ” to “ЕПМС” (which stands for “ежемесячное пособие малообеспеченным семьям, имеющим детей” or “monthly allowance for low-income families with children”). Best regards and looking forward to long-term cooperation. State Secretary /signature/ K. Adiev Executor: Ch. Mambetaipova, Tel.: 66-10-18 Page 58 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) BORROWER’S CONTRIBUTION TO ICR Report of the Ministry of Health of the Kyrgyz Republic on the results of the health sector reforms under SWAp2 for the ICR “Den Sooluk” Program was approved by the Resolution of the Government of the KR (GoKR) #309, issued on 24 April 2012, and was later extended till 2018 by the Resolution of the GoKR #267, issued on 11 May 2017. “Den Sooluk” Program focused on achieving specific health indicators (MDG 4, 5 and 6) by expanding the access of the population to key services, improving the quality of medical care, and eliminating the barriers in healthcare system that were not addressed under two previous programs. “Den Sooluk” Program had been implemented through the Sector Wide Approach (SWAp) by the Ministry of Health of the KR (hereinafter referred to as the “MoH KR) and its partners. The development partners supported the Program by allocating funds to state budget or by providing parallel financing. “Den Sooluk” Program had a well-established mechanism to maintain implementation-related dialog. Program’s implementation status was regularly assessed through joint annual reviews (JAR), healthcare summits, technical meetings and internal quarterly reviews. The MoH KR hired technical coordinators (TC) to monitor “Den Sooluk” Program’s implementation in priority areas and components, and in PHC facilities. One of the functions of the TC was to improve the dialog between all levels of the healthcare sector (central level, tertiary healthcare organizations, oblast level). It took more time than it was originally expected to have the Memorandum of Understanding agreed and signed by the GoKR and the Joint Financing Participants (WB, Kreditanstalt fuer Wiederaufbau (KFW), Swiss Embassy in the KR), and then to have “Den Sooluk” Program and respective financial agreements (that were signed by the GoKR and JFP) approved by the Parliament (Jogorku Kenesh). In this connection SWAp funding began as late as in 2014. “Den Sooluk” Program activities had several funding sources: the national budget, WB’s Second Additional Financing and parallel financing. Protection of maternal and child health Maternal and newborn health Rate of neonatal mortality per 1,000 livebirths: Decrease in the rate of neonatal mortality by 2018: target indicator – 10.7 deaths per 1,000 newborns, actual indicator – 10.9 deaths per 1,000 newborns (in 2016 – 13.4 deaths; in 2017 – 12.5 deaths). In 2019 the indicator was 10.6 deaths per 1,000 newborns. Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target 11.0 10.7 Actual 14.0 13.5 14.7 12.8 11.3 10.3 10.9 10.6 Neonatal mortality rate slightly fluctuated, and in 2019 it dropped to 10.6 deaths. The main causes of neonatal mortality were perinatal factors: premature delivery and congenital malformation. Rate of mortality rate due to asphyxia decreased. Page 59 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Maternal mortality rate (per 100,000 livebirths) Decrease in the maternal mortality rate (baseline rate in 2011 – 47.5 deaths per 100,000 newborns; target rate – no more than 30.3 deaths). Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target 47.4 47.2 47 46.8 46.6 30.3 30.3 30.3 Actual 50.3 39.2 50.7 38.5 30.3 31.2 30.4 27.8 In 2019, the maternal mortality rate was 27.8 deaths per 100,000 livebirths (updated data). It should be noted that the validity of statistical data is improving – the gap between the official statistics and the findings of assessment studies is decreasing. According to the updated data, the main causes of maternal mortality include extragenital diseases – 31.8%; (in 2016 – 33.3%; in 2017 – 39.6; 2018 – 28.8%), hemorrhage – 22.7% (in 2016 – 18.8; in 2017 – 14.6; in 2018 – 13.5%), septic complications – 18.2% (in 016 – 22.9; in 2017 – 10.4; in 2018 – 19.2%), hypertensive illness – 15.9% (in 2016 – 22.9; in 2017 – 10.4; in 2018 – 18.2). Maternal mortality occurs in tertiary in-patient facilities (99.6 cases), secondary healthcare facilities (29.1 cases), and primary care facilities (9.9 cases) of national, oblast and municipal level. This is explained by the fact that expectant/new mothers from risk group are concentrated in secondary and tertiary facilities. In 2010, the country introduced a new national-level mechanism – Confidential Reviews of Maternal Mortality Cases (CRMMC). In 2014, the first CRMMC Report for 2011-2012 was presented, followed by the second CRMMC Report for 2014-2015. The reports provided key recommendations to decrease maternal mortality rate. The Additional Program of the Mandatory Health Insurance (part of the Subsidized Medicines Package provided under the State-Guaranteed Benefit Package that is implemented by the Mandatory Health Insurance Fund) grants women, who have medical insurance, access to several types of contraceptives. Despite the above, women are poorly aware about the Additional Program. Seeking to address the needs of 50% of women that face high medical and social risks associated with maternal mortality, in 2018 the country developed a 5-year plan (covering the period until 2023) for incremental increase in the government funding. In pursuance of its obligations under the “ Family Planning 2020” Global Partnership and in accordance with the 5-year plan, in 2018 the country began to procure combined oral contraceptives for those women, using government funding. Page 60 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) In order to address the needs for intrauterine devices (IUD), SWAp2 provided funding to procure 220,000 IUD. MHIF, MoH KR and the Parliament (Jogorku Kenesh) of the KR annually monitor and evaluate implementation of subsidized prescriptions for contraceptives that get reimbursed under the Additional Program of Mandatory Health Insurance at the primary care level, as well as assess the level of awareness of reproductive-age women about their eligibility for subsidized contraceptives. Infant mortality rate (per 1,000 live-births) Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target 20.5 19.9 19.3 19.2 19.0 18.0 17.9 Actual 20.0 19.9 20.2 18.0 16.6 15.6 14.8 15.1 In 2019, the country had 173,484 live-births that is 1.3% higher than in 2018 (171,149 livebirths). Therefore, the country reached the target indicator. The actual indicator in 2016 was 16.6 deaths per 1000 newborns; in 2017 – 15.6 deaths; in 2018– 14.8 deaths; in 2019 – 15.1 deaths. Despite the consistent downturn trend, the indicator remains high. 2,621 infants under 1 year of age died in 2019, which means that the infant mortality rate was 15.1 deaths per 1,000 livebirths (in 2016 – 16.6 deaths; decrease by 9.1%). Infant mortality analysis revealed that most deaths occur within first 24 hours after birth, when newborns are still under the care of medical specialists. It is alarming that the mortality rate of children under 2 years of age at home or within first 24 hours after hospitalization also remains high. According to the National Statistics Committee, the main causes of infant mortality include perinatal causes (68.9%), congenital abnormalities (15.6%) and respiratory diseases (8.5%). Child mortality rate (under 5 years of age) (per 1,000 live-births) by 2019 (target indicator – no more than 19.8 deaths per 1,000 live-births). The target indicator was achieved. The actual indicators were as follows: in 2016 – 19.8 deaths per 1,000 live-births; in 2017 – 18.6 deaths per 1,000 live-births; in 2019 – 17.4 deaths per 1,000 live-births. Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target 24.5 21.9 21.1 20.3 19.5 No No No more more more than than than 19.8 19.8 19.8 Actual 23.4 23.2 23.0 21.5 19.8 18.6 17.3 17.4 Share of children under 2 years of age who have access to integrated vaccine complex Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target >96% >96% >96% >96% >96% >96% >96% >96% Actual 96.5% 96.8% 95.8% 96.9% 96.9% 94.5% 94.4% 94.2% Page 61 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) In 2018, the target indicator was not achieved. According to updated reports, in 2019 the actual indicator was 94.2%. In 2018, the target indicator (at least 96%) was not achieved due to several causes: mothers refused to vaccinate their children; migration; interrupted supply of polio vaccine from the UNICEF, caused by changes in the state procurements procedures (the vaccine was supplied with 2-month delay). In 2018, seeking to expand preventive vaccination program, the government allocated KGS 100.1 million, which included the 25% reserve stock of vaccines and disposable materials that is maintained to fight potential deterioration of the epidemiological situation related to infections that can be controlled with vaccines. The government procured vaccines and disposable materials to the amount of KGS 46,972,004.59. The Global Alliance for Vaccination and Immunization allocated KGS 84,124,364.08. Within the first 8 months of 2018, the vaccination program covered 72.1% of children under 2 years of age. Seeking to address public distrust to immunization, the government developed the “Planned Immunization Communication Strategy for 2018-2020”. The Strategy aimed to improve public awareness, increase public trust to immunization, ensure broad public cooperation and interdepartmental coordination. % of children under the age of 6 months with exclusive breastfeeding (EB) Indicator 2012 2013 2014 2015 2016 2017 2018 2019 Target 63 64 65 66 67 75 75 75 Actual 66.2 71.9 75 74.2 72.2 75.9 77.6 The target indicator was achieved (in 2018 – at least 75%). The actual indicators were as follows: in 2016 – 72,2%; in 2017 – 75.9%; in 2018 – 77.6%. From 2012 to 2018 the percentage of children under the age of 6 months with exclusive breastfeeding grew from 66.2% to 77.6%. The growth in this indicator can be attributed to the activities, implemented under the “Baby Friendly Hospital Initiative” (BFHI). The BFHI is implemented by the MoH KR and builds on the legal framework that is aligned with the “Global Strategy for Infant and Young Child Feeding”, the “International Code of Marketing of Breast- milk Substitutes”, and respective resolutions of the World Health Assembly. Seeking to expand the BFHI, the government included respective activities to “ Den Sooluk National Strategy for Healthcare Reforms for 2012-2018” and the “National Program for Food Security and Nutrition for 2015-2017”. Implemented activities: Improvement of the legal framework: ─ The Law of the KR “On the Reproductive Rights of Citizens, and the Guarantees for Enforcement Thereof” was adopted (Law #148, adopted on 4 July 2015); ─ “Package of Services Related to Perinatal Care” was approved (MoH KR’s Order #647, issued on 28 November 2012); ─ Women who did not have medical insurance received free-of-charge insurance certificates to get access to the programs offered under mandatory health insurance (MHI); Page 62 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ─ The Resolution “On the Day-Case Children’s Ward in In-Patient Facilities” was approved (joint order by the MoH (Order #11, issued on 15 February 2016) and the Mandatory Health Insurance Fund (Order #42, issued on 15 February 2016)); ─ “Safe Motherhood Communication Strategy” under the “Community Action for Health” Program was approved; ─ 36 clinical protocols and 7 standard operating procedures for obstetrics and gynecology, 16 clinical protocols and 14 standard operating procedures for neonatology, 25 clinical protocols for pediatrics were approved; ─ Action plan and guidelines for feeding children in emergency situations were approved; ─ Standard operating procedures for infection control in surgical facilities were approved; ─ “National Program for Food Security and Nutrition for 2015-2017 ” was approved (GoKR’s Resolution #618, issued on 4 September 2015); ─ The order “On Monitoring of Healthy Children by Primary Care Facilities” was approved (Order #585, issued on 9 October 2015); ─ Regulation “On the Committee for Medical Services Quality in Healthcare Facilities ” was approved (Order #454, issued on 4 August 2015); ─ Standards for Accreditation of Obstetric Organizations in the KR were approved; ─ Mechanism for procurement of contraceptives with government funds was developed (to address the needs of reproductive-age women, who are at medical and social risks, associated with maternal mortality); ─ Standard operating procedures for effective vaccine management were approved; ─ “Tool for Monitoring of Young Children Development”, “Guidelines for Young Children Development” and “Journal to Track Development of Children from the Moment of Birth and Up Until 7 years of Age” were approved. Improvement of supplies and facilities: ─ Equipment for provision of first obstetrical and neonatal care for obstetrical facilities was procured; ─ Laboratory equipment for maternity wards of oblast-level combined hospitals was procured; ─ 8 mobile intensive care units for maternity wards of 7 oblast-level combined hospitals and the National Mother and Child Protection Center were procured; ─ Perinatal Center is being built in Bishkek as a part of the “Motherhood and Childhood Protection Project; Phase 4 and 5” (the construction works are to be completed in 2019); ─ Newborn simulators to support on-the-job training of medical staff in primary resuscitation of newborns were procured; ─ Resource Center at Issyk-Kul Oblast Combined Hospital was created to ensure continuous development of specialists (the Center has access to necessary information technologies); ─ Computer equipment for Family Medicine Centers, territorial and oblast-level hospitals (2 oblasts) was procured to support electronic registry of newborns; ─ Computers to manage stocks of insulin and contraceptives were procured; ─ Vehicle for emergency transportation of pregnant women, expectant/new mothers and children was procured for “Tayan” Family Medicine Center (from a remote area in Batken Oblast); ─ Intrauterine devices (ID) for vulnerable women were procured; ─ More than 50 schools for pregnant women were established; ─ In 2018, procurements of contraceptives for reproductive-age women, who face medical and social risks, were centralized; ─ There is ongoing work (under the “Motherhood and Childhood Protection Project”) on developing sketch plan and detailed design for construction of perinatal centers in Osh and Talas; Page 63 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ─ Basic equipment suits to support emergency pre-hospital care of children were procured for Family Medicine Centers. Cardiovascular diseases (CVD) I. Progress in achieving the expected outcomes 1. Since 2012 the total rate of mortality due to CVD has been steadily decreasing – from 331.3 deaths per 100,000 people in 2010 down to 265.7 deaths in 2018. 2. The total rate of mortality due to CDV among working-age people has been decreasing: (i) people who are 30-39 years of age – from 45.5 deaths per 100,000 people in 2012 down to 38.5 deaths in 2014 and down to 28.8 deaths in 2017; (ii) 40-59 years of age – from 308.9 deaths per 100,000 people in 2012 down to 284.5 deaths in 2014 and down to 247.1 deaths in 2017. The rate of mortality among male population decreased as follows: (i) 30-39 years of age – from 70.0 deaths in 2012 down to 56.5 deaths in 2014 and down to 42.1 deaths in 2017; (ii) 40-59 years of age – from с 443.4 deaths in 2012 down to 427.8 deaths in 2014 and down to 414.9 in 2017. The rate of mortality among female population decreased as follows: (i) 30-39 years of age – from 21.1 deaths in 2012 down to 20.5 deaths in 2014 and down to 15.4 deaths in 2017; (ii) 40-59 years of age – from с 185.8 deaths in 2012 down to 153.2 deaths in 2014 and down to 135.7 deaths in 2017. 3. The rate of mortality due to brain hemorrhage among people younger than 65 years of age decreased from 31.7 deaths per 100,000 people in 2012 down to 30.0 deaths in 2014 and down to 26.3 deaths in 2017 (decrease in the mortality rate is observed among both groups – male and female population). 4. The rate of mortality due to myocardial infraction among people younger than 65 years of age decreased from 13,6 deaths per 100,000 people in 2011 down to 12.3 deaths in 2014 and down to 10.4 in deaths in 2017 (decrease in the mortality rate is better among female population than male). Therefore, the CVD-related activities had significant progress in achieving the established indicators (many indicators, that were established as targets for 2018, were achieved as early as in 2014-2016). It confirms that the Program employs proper strategy, which includes facilitating the outreach and awareness-raising work (efforts to control risk factors), strengthening the primary care and introducing clinical protocols for evidence-based healthcare. II. Key activities – promoting healthy lifestyle and controlling risk factors. Seeking to develop an efficient policy that could help promote healthy lifestyle, create favorable environment for preservation and promotion of health, and facilitate partnership and cooperation with all sectors of civil society, the country implements the “Program for Preventing and Controlling Noncommunicable Diseases (NCD) in the KR in 2012-2020” that was approved by the GoKR’s Resolution #597, issued on 11 November 2013. In 2013, “ Den Sooluk” Program conducted “STEPS” research to assess the epidemiological control of NCD-related risk factors in the Kyrgyz Republic. The research was based on the WHO’s tool. Every year the country implements large-scale outreach work to mitigate risk factors. As a part of the World Heart Day the country has annual nation-wide campaigns “Find Out Your Blood Pressure!” and “Week of Hypertension” to raise awareness about CVD prevention measures and identify people with high arterial blood pressure. Arterial Blood Pressure Check Points were organized in “Kyrgyz Telecom” offices, rayon government offices, large malls, family medicine centers and other localities. The campaigns were organized with the active participation of the Republican Health Promotion Center and the National Center Page 64 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) for Cardiology and Therapy. To support the “Find Out Your Blood Pressure!” campaign respective video was produced. The video was broadcasted by the Public Television and Radio Broadcasting Corporation and oblast-level TV channels. In order to raise public awareness, various leaflets were published in large numbers: “ Healthy Lifestyle” (CVD prevention measures), “Major CVD Risk Factors: What You Need to Know and Be Able to Do to Protect Yourself”, “Hypertensive Disease”. Since 2015 the country has been implementing “ABP Control at the Workplace” initiative to raise awareness of different organizations about CVD-related risk factors and prevention measures. Members of public health committees conducted respective outreach campaigns with staff in 51 cities and rayon capitals. Cross-sectoral tobacco consumption control  According to the Law of the KR “On Introduction of Amendments to Certain Legislative Acts of the Kyrgyz Republic” (Law #52, issued on 10 March 2015) the Tax Code of the Kyrgyz Republic was so amended, as to raise the excise tax by the factor of two or more.  In pursuance of the of the GoKR’s Resolution “On Approving the List of Illustrative Warnings about the Ill Effects of Tobacco for Human Health to Be Placed on Packs and Packages of Tobacco Products ” (Resolution #719, issued on 22 Decembers 2014), in July 2015 first warnings began to appear on cigarette packs (6 months before the target date).  Patient charts were so amended, as to include a section that describes tobacco consumption as a risk factor (MoH KR’s Order #447, issued on 7 August 2014, “On Approving Normative Documents at the Primary Care Level”). Key personalized services – measures to improve the quality of services in healthcare organizations  Seeking to improve the quality of services that are provided to patients with CVD, the Program developed and implemented special trainings programs to support pre-service education and further professional development of doctors and nurses. The trainings were dedicated to CVD-related primary and secondary prevention measures, methods of early detection of CVD, and strategies for preventive and therapeutic interventions that use evidence-based medicine.  The Program introduced evidence-based medicine into health service practices; reviewed and updated clinical protocols for hypertensive disease, stable angina and acute myocardial infarction; developed clinical manual for continuous arrhythmia and got them approved by the Expert Board (in 2015); developed clinical manual and clinical protocols for diabetes and submitted them to the Expert Board for approval.  Cardiological offices were established in all oblast-level Family Medicine Centers; in order to ensure appropriate staffing, the National Center for Cardiology and Therapy (NCCT) trained specialists in functional and ultrasonic diagnostics;  Angiographic machines were procured for the NCCT, Research Institute for Cardiac Surgery and Organ Transplantation, South Region Research Center for Cardiovascular Surgery (city of Jalal-Abad), and Osh Inter-Oblast Hospital.  Cardiological equipment for oblast-level, municipal and territorial hospitals and oblast-level Family Medicine Centers was procured and installed. Tuberculosis I. Progress in achieving the expected results Page 65 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 1. The statistics for 2018 indicates that the tuberculosis infection rate in the Kyrgyz Republic remains stable, and even demonstrates certain downward trends. In 2018, the country had 5,249 newly diagnosed cases of tuberculosis (82.9 thousand cases per 100,000 people). In 2017, these numbers were 5,616 and 90.6 respectively (including patients that serve time in facilities of the State Service for Execution of Punishment). 2. Respective data indicates that in 2018 the nation-wide tuberculosis mortality rate was 4.6 deaths per 100,000 people, compared to 5.2 deaths per 100,000 people in 2017 (including deaths among patients that served time in facilities of the State Service for Execution of Punishment). In the civilian sector the tuberculosis mortality rate was 4.6 deaths per 100,000 people (in 2017 this number was 5.1 deaths per 100,000 people). 3. By improving supplies of anti-tuberculosis drugs, the country expanded the access of patients with multi-drug resistant tuberculosis to necessary medicines – from 78.9% in 2012-2017 to 91% in 2018. 4. The rate of successful treatment of newly diagnosed patients with bacteriologically proven pulmonary tuberculosis reached 81.7% (patients, treated in 2017) and is approaching the target indicator recommended by WHO (85%). 5. The access to culture-based testing for drug sensitivity grew from 26.0% (in 2016) to 52% (in 2018). 6. While the rate of successful treatment (the total number of patients who underwent treatment) of patients with multi-drug resistant tuberculosis failed to reach the target indicator (75%), it demonstrated certain growth – from 42.4% to 53.3% (patients with multi-drug resistant tuberculosis who were taken for treatment in 2016). 7. In 2018 the rate of access to first-choice and second-choice anti-tuberculosis drugs was 100% (the target indicator was achieved). The country ordered drugs that were enough to support 50 courses of treatment for children with multi-drug resistant tuberculosis. The delivery is expected in 2019. II. Key activities The overwhelming majority of the planned activities was completed successfully due to well-coordinated work of the National Anti-Tuberculosis Program (NATP), MHIF and the development partners that invested into “Den Sooluk” Program (by allocating funds to its budget or providing parallel financing). In 2012-2018 the country had several important achievements: 1. Key services for the population 1. Under the “Tuberculosis-4 National Program for 2013-2014” the country approved the “Advocacy, Communication and Social Mobilization Strategy” (ACSMS) to engage civil society, media and other organizations that could help identify patients with tuberculosis, improve treatment, prevent stigmatization and discrimination of patients. This activity was continued by the “Win TB” and the “TB Challenge” projects and the Republican Center for Health Promotion, which successfully implemented it in the regions of the country. 2. Every year the country has ACSMS-related activities, month-long campaigns dedicated to the World Tuberculosis Day, as well as broad information campaigns. 3. In 2012, in cooperation with the USAID’s “Quality Healthcare Project” and SDC’s “Community Action for Health” (CAH) project the country developed the “Strategy for Engaging Population in Tuberculosis Control Activities under CAH Program”. 4. The country developed a manual for Family Medicine Centers’ Health Promotion Units (HPU FMC) and guidelines for Rural Health Committees (RHC) to guide their work with communities, and prepared handout materials that could help identify patients with tuberculosis, improve treatment, prevent stigmatization and discrimination of patients. Page 66 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 5. Seeking to raise public awareness about tuberculosis, the country with active support from the development partners held annual information campaigns, organized TV shows and press-conferences, disseminated materials through TV-channels, radio stations, printed media and Internet resources. 2. Key personalized services – measures to improve the quality of services in healthcare organizations 1. The MoH KR by its respective order approved 8 clinical practice guidelines and a compilation of protocols that were prepared in accordance with international standards for: tuberculosis and HIV infection (TB/HIV), palliative care to patients with tuberculosis, TB-related infection control, TB disease in children (updated in 2018), primary care (PC), drug resistant tuberculosis, multidrug resistance tuberculosis. It also approved the National Guidelines for Monitoring and Evaluation of Anti- Tuberculosis Service of the KR. The compilation of protocols was printed in large quantities. 2. Tuberculosis-related accounting and reporting forms were updated and approved (in pursuance of the MoH KR’s Order #417, issued on 2 July 2018, “On Improving Tuberculosis-Related Accounting and Reporting”). 3. The MoH KR developed and approved the order “On Approving the Plan for Introduction of New Anti- Tuberculosis Drugs and Shortened Treatment Patterns” (Order #284, issued on 26 April 2016). In 2017, the shortened treatment patterns and the new anti-tuberculosis drugs to treat drug resistant tuberculosis were put into medical practice. In 2017, 131 patients were selected nation-wide for “shortened pattern” treatment; in 2018 – 201 patients. In 2017, 150 patients were selected for personalized treatment with bedaquiline/delamanid; in 2018 – 399 patients. 4. In 2013, the country launched new National Reference Laboratory (NRL). In 2010, the country began to introduce rapid methods of testing for TB and DR TB, based on molecular genetic examination (GenoTypeMTBDR+, MGIT and Xpert MTB/RIF). Today the republic has 24 Xpert MTB/RIF platforms. In 2017, the country introduced a new diagnostics method – GenoType MTBDRsl (Hain-test for detect resistance to second-choice anti-tuberculosis drugs). 5. Model to transport sputum and drugs for patients with TB (with government delivery service) was developed to ensure nation-wide access of patients to medical examinations and treatment. 6. The GoKR by Resolution #448-б, issued on 3 October 2017, approved the “ Tuberculosis-5 National Program for 2017-2021” (strategic document that determines the key priority areas, as related to tuberculosis control in the Kyrgyz Republic). HIV infection I. Progress in achieving the expected results 1. Indicator “The share of people who undertook tests for HIV infection and know their results” – 60% by 2018. In accordance with the updated indicators matrix of “Den Sooluk” Program, the indicator that reflects the share of population who undertook tests for HIV infection and received the test's result, should be 60% by 2018. This indicator is calculated building on the results of the sentinel HIV surveillance that is organized every 2-3 years. The latest surveillance was held in 2016. The next round is expected in 2019, and its results will be ready only by 2020. In 2016 the rate of participation in the sentinel HIV surveillance among different groups was as follows: IDU – 43.7%; MSM – 20.2%; patience with RSV – 49.1%. Therefore, the target indicator (60% for each group) was not achieved. These data were obtained with RDS (respondent driven sample) method, which covered volunteer respondents, who were not covered by any HIV-prevention programs. 2. Indicator “Decrease in the mother-to-child HIV transmission rate” – 3% of new-births by 2018. In 2015 the mother-to-child HIV transmission rate was 2.4%; in 2017 – 1.7%; in 2018 – 3%. (in 2012 – 5.3%; target indicator – 3%). While the actual indicator was 3%, the number of women with HIV and Page 67 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) of children, who were born from HIV-infected mother, grew. Thus, in 2017 there were 14 cases of mother-to-child transmissions of HIV (in total, 796 patients with HIV were identified). It indicates that this infection is penetrating from the community of injection drug users to general population. 3. Indicator “Increase in the share of people living with HIV infection (PLHIV), who continue antiretroviral therapy (ART) 12 months after the therapy began”. The target indicator, as established for PLHIV who continue to receive ART twelve months after the therapy began, is 95%. In 2015, the actual indicator was 75.8%, while the baseline number was 88,2%. In 2017, the actual indicator grew to 84%, in 2018 it dropped to 77%. It should be noted that the target indicator for 2017-2018 was amended (≥85%). The decision to decrease the target was based on the following factors: (i) the key population group was unwilling to pursue ART, (ii) HIV-infected individuals was discovered at late stages of the disease, and as a result they began to receive ART with significant delays, (iii) the target indicator, as established under “Den Sooluk” Program, was not aligned with the indicator, as established under the “National Program for Stabilization of HIV Epidemic in the Kyrgyz Republic for 2012-2016”, which had a more realistic target for individuals who pursue ART for more than 12 months (85%). Notwithstanding the above, the decreased target indicator also was not achieved (because PLHIV were unwilling to pursue ART). In this connection the country established a working group to develop suggestions and recommendations that could help improve the willingness to pursue ART. During the 7 years of “Den Sooluk” Program implementation (2012-2018), most Program’s activities were funded through parallel financing (funds from GFATM), which raises concerns about sustainability of the activities. Seeking to address this concern, the Government developed and approved the “ National Program for Coping with HIV Infection” and respective Implementation Road Map that addresses all problems (Resolution #852, issued on 30 December 2017). Key personalized services – measures to improve the quality of services in healthcare organizations Key services in primary healthcare facilities The country had significant achievements in integrating different healthcare authorities and levels and engaging primary healthcare facilities into providing HIV prevention and treatment services, as well as care and support for HIV patients. Due to the Program, PLHIV can now receive services at primary healthcare facilities, and 49 FCM now offer ART. In pursuance of the updated WHO’s recommendations, and in accordance with the “Test and Treat” strategy (that prescribes ART to all people living with HIV, irrespective of the amount of CD4 lymphocyte) the MoH KR updated its “Clinical Protocols for HIV-Infection” (Order #903, issued on 10 October 2017). As a part of “Den Sooluk” Program, the Kyrgyz State Medical Institute for Professional Development (KSMIPD) delivered the following trainings for PHC doctors (132 participants) and nurses (242 participants): application of the updated clinical protocols; testing and counselling; laboratory diagnostics; medical monitoring; ART; palliative care; secondary infections; stigmatization and discrimination; prevention of HIV infection (including primary prevention treatment of medical personnel). Key services in in-patient facilities Obstetrical facilities offer pregnant women (who did not undergo HIV test before) rapid HIV tests and HIV preventive treatment (antiretroviral drugs). Obstetrical facilities take capillary blood for their rapid tests, and pregnant women, who come to maternity wards without prenatal records or results of HIV tests, are checked by maternity wards with such rapid test method. Page 68 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Public healthcare I. Progress in achieving the expected results 1. Indicator “Number of secondary schools that have implemented the Health Promotion Program ”. 2. Indicator “Number of vocational schools that have implemented Healthy Vocational School Program ”. MoH KR in cooperation with the Ministry of Education and Science of the KR and the Kyrgyz Education Academy developed and introduced a nation-wide extracurricular program to promote healthy lifestyle among 1-11 grade students of 2,222 schools. Seeking to promote healthy lifestyle in the educational system, the MoH KR developed 12 methodological recommendations and guidelines for teachers, as well as 2 guidelines for parents. In order to support implementation of these guidelines, the MoH KR as a part “Den Sooluk” Program organized training workshop for school deputy principals and teachers (the trainings covered 95% of schools). Further success of disease prevention programs is subject to strengthening the educational sector. In 2013, the Initial Professional Education Agency (IPEA) approved the “ Strategy for Implementation and Development of the Healthy Lifestyle Program in VET”. This program ended in 2018, and in this connection the IPEA and the MoH KR developed a follow-up strategy, titled “Management of Healthy Lifestyle Program in Initial Professional Education Facilities for 2019-2021”. The new strategy focused on ensuring equal conditions for strengthening health and forming healthy lifestyle by facilitating cross-sector cooperation between IPEA and other stakeholders. 3. Indicator “Number of functioning Rural Health Committees (RHC) ”. The country has a volunteer network, comprising 1,670 Rural Heath Committees (target number – 1,670) that work in 1,480 villages (target number – 1,480), as well as Public Health Committees that work in 51 cities and rayon capitals (target number – 10). The committees in close cooperation with primary healthcare facilities and various projects provide health promotion services. Every year the Public Healthcare Committees in cooperation with media organize at least 4 awareness raising campaigns that reach out to 3,500,000 people and cover the following topics: identification of individuals with hypertension, prevention of tuberculosis and echinococcosis, etc. 4. Indicators “Number of villages that participate in the Community Action for Health Program (CAHP) ” and “Number of cities that participate in Healthy Cities Program”. By early 2018, about 85% of the villages in the country participated in health-promotion programs, and the number of rural health committees (RHC) reached 1,670. Every year the country had at least 4 nation-wide campaigns that were organized through the volunteer network (rural health committees) to promote health. In 2018, 102 public healthcare committees were established in 51 cities and rayon capitals as a part of the strategy for engaging with urban population. The committees work through a network of 1,980 public activists. Cooperation with municipal authorities, rayon governments, local self-governments and local communities is improving. The country had 7 round tables to discuss improvement of outreach work with local communities through heads of neighborhood committees, public activists and nongovernment organizations. Every year rayon capitals and cities organize special events to commemorate WHO’s annual days, engaging various partners and covering wider population. 5. Indicator “Number of accredited laboratories that have necessary equipment to perform the approved types of laboratory investigations”. By modernizing laboratory facilities according to the contemporary requirements, the country can introduce new services that respond to the needs of its population and businesses, as well as align the facilities with international standards. Laboratories of 15 public healthcare facilities were accredited in accordance with international standards (ISO/IEC 17025, ISO 17043 and ISO 15189). 2 more laboratories submitted respective application documents to the Kyrgyz Accreditation Center. 6 test laboratories (Departments for Disease Prevention and State Sanitary and Epidemiological Surveillance, and Centers for Disease Prevention and State Sanitary and Epidemiological Surveillance of the cities Page 69 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) of Osh, Bishkek and Karakol, as well as Kadamjai Rayon and Jaiyl Rayon) were added to the Unified Register of Certification Bodies and Test Laboratories of the EEU. 6. Indicator “Number of newly implemented methods of laboratory investigations”. In order to expand the types of laboratory investigations, public healthcare organizations introduced more than 60 modern research methods, which include 17 methods of sanitary-biological investigations, and 20 methods of diagnostic of infectious and parasitic diseases (including enzyme- linked immunosorbent assay (ELISA) for ascaris infection, lambliasis, toxocariasis, echinococcosis, as well as molecular genetic (PCR) investigation for ascaris infection, highly infectious diseases, bacterial and serosal meningitis). In addition, the country introduces new investigation methods that meet the technical requirements of the EEU. Thus, the country introduced new methods of sanitary and hygienic investigations that use modern high-accuracy equipment (atomic absorption spectrometer, mass-spectrometer, etc.) that help determine about 20 types of volatile, halogen-containing, nonorganic, organic potentially hazardous chemical substances in household chemistry, toys, furniture products, clothing and textiles, consumer goods, individual protection gears, packaging materials, etc. 7. Indicator “Improving the quality of laboratory investigations, including diagnostic of infectious and parasitic diseases”. Seeking to improve the quality of investigations performed by laboratories of public healthcare facilities, every year the country organizes random interlaboratory comparisons. Also, since 2012 the accredited laboratories annually participate in professional efficiency tests and comparisons (in Russia, UK, Denmark, Australia, Kazakhstan, Finnish Environment Institute (SYKE), etc.). In 2016, the country introduced the European Standards for Antibiotic Susceptibility Testing (EUCAST, Version 5, 2015). In the current year the country introduced updated EUCAST (2018) and now organizes trainings on amended standards for laboratory specialists (with the support from WHO). In 2017-2018, the project on coping with drug resistance in Central Asia provided the country with 300 sets for molecular detection of resistance. In 2018, in accordance with respective memorandum with the Russian Federation on introduction of International Health Regulations the country received culture media for laboratories (including laboratories for highly infectious diseases). The project on medical wastes, implemented with the support from Swiss Government, organized workshops for bacteriologist on methods of conducting antimicrobial agent sensitivity tests and interpreting their results. In 2017- 2018, 12 laboratories procured consumables for microbiological investigations of patients from high- risk wards. In 2016-2017, 44 laboratory specialists from the Disease Prevention and State Sanitary and Epidemiological Surveillance, Osh Center for Disease Prevention, Bishkek Center for Disease Prevention and the State Sanitary and Epidemiological Surveillance completed trainings on new methods of laboratory investigations and quality management systems that were delivered by the Federal Center for Hygiene and Epidemiology of the Federal Service for Oversight of Consumer Protection and Welfare of the Russian Federation. Investments into human resources The healthcare sector reform includes reforms of medical education. Seeking to improve the quality of post- graduate education, the country revised its “Regulation on Post-Graduate Medical Education in the KR”. The revised Regulation strengthens practical training of post-graduate students, allows use of regional clinical facilities to promote decentralized post-graduate education, calls for development of new requirements for preparation of highly specialized doctors and extends training periods. MoH KR created Working Groups to revise the legal framework that regulate nursing care and curriculums of medical colleges (Order of the MoH KR #575, issued on 6 May 2019), and approved the “ Program for Page 70 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Development of Nursing Care and Education”. On 1 September 2019, medical colleges introduced new curriculums aligned with the State Education Standards, that had been approved by the Ministry of Education and Science of the KR (for all medical professions). The new standardized curriculums and syllabi are applicable to all medical colleges of all types of incorporation and departmental affiliation that provide secondary medical and pharmaceutical education; the new curriculums/syllabi are based on credit- hours. Over the course of the reporting period the country organized round tables on “ Review of Secondary Medical Education in the KR, Barriers and Needs for Improving Nursing Training” and discussions of further steps to reform secondary and high nursing education. The country had two round tables for medical colleges (i) “Program for Development of Nursing Care in the Kyrgyz Republic” that discussed draft “Catalogue of Competencies for Nurses”, and draft educational standards for all medical professions, (ii) “Medical Education in the KR: Problems and Solutions ” that discussed interdepartmental and cross-sectoral cooperation to regulate medical education in the KR and accreditation of medical universities. The MoH KR developed and approved the following documents for Family Medicine/General Practitioner specialty (post-graduate level): catalogue of competencies; curriculum for decentralized post-graduate medical education; assessment tools (standardized assessment forms); standard operating procedures (SOP) for family doctors/general practitioners; list of healthcare facilities where post-graduate students can undertake clinical practice (Order #631, issued on 4 September 2018); minimal standards and assessment indicators for such clinical facilities; categories of in-patient and out-patient clinical facilities; as well as categories of PHC facilities to train post-graduate students who pursue “General Practitioner” specialty (Order #408, issued on 31 May 2018). The MoH KR also approved guidelines for managers of healthcare facilities that clinical practice for post-graduate students (Order #138, issued on 15 March 2019, “ On Approving Guidelines for Managers of Healthcare Facilities that Serve as Clinical Training Facilities for Post-Graduate Students”). Requirements for GP/family doctor postgraduate training were developed and approved by respective order of the MoH KR (Order #224, issued on 30 March 2018). Kyrgyz State Medical Institute for Professional Development (KSMIPD) already prepared and approved 80 professional development programs for healthcare workers. These programs build on evidence-based medicine and respond to the needs of practical healthcare. KSMIPD established a sustainable system of distance learning (DL) for family doctors. KSMIPD uses several formats of DL and keeps expanding the list of courses. Today, the KSMIPD is introducing a year-long continuous education system, which includes short-cycle courses, interactive workshops, off-site/on-site trainings, peer discussion groups, credit-based learning. KSMIPD decentralizes continuous education (by facilitating the role of professional associations and research centers) and promotes distance learning and tele-health. Seeking to improve the workforce policy, the country has developed the “ National Healthcare Development Program until 2030”, which comprises the “Program for Development of Healthcare Workforce”. Pharmaceutical policy In 2014, the GoKR adopted the “Program for Development of Medicines Circulation for 2014-2020” (hereinafter referred to as the “National Program”) (Resolution #376). The National Program outlined the strategic areas of the government medicine policy, as related to the different challenges of the healthcare system: improvement of the legal framework, establishment of a complex policy to decrease costs of medicines and medical devices (M/MD) (including regulation of prices, optimization of the state procurement system, rational use of medicines, development of M/MD-related information systems, prevention of unethical marketing of M/MD), institutional development of the national regulator, etc. Seeking to ensure cost-effective access to safe, efficient and high-quality M/MD, the National Program Page 71 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) provides a complex of measures that are currently at various stages of implementation. The main strategic task (as determined by “Den Sooluk” Program and the National Program) was to initiate work on developing an efficient legal framework to create a foundation to address other tasks. Thus, seeking to address corruption-related risks, the country organized corruption-related assessment of its legal framework that regulates circulation of medicines. The MoH KR used the findings of this assessment to prepare Anti-Corruption Action Plan and inform the work of the Interdepartmental Expert Working Group that was established to review the legislation that regulates circulation of medicines and to impellent the National Program (MoH KR’s Order #603, issued on 4 April 2014). On 2 August 2017 the President of the Kyrgyz Republic signed and the Parliament (Jogorku Kenesh) approved the Law “ On Circulation of Medicines” (Law #165), the Law “On Circulation of Medical Devices” (Law #166), and the Law “On Amending Certain Legislative Acts that Regulate Circulation of Medicines and Medical Devices ” (Law #167). It should be noted that the new Law “On Medical Devices” is one of the first of its kind in post-Soviet countries, addressing the complex nature of the market of medical devices and equipment. The draft Law “On Medical Devices” meets the EEU requirements, as established for regulation of circulation of medical devices. For the purpose of implementing the above-mentioned laws, the Office of the GoKR approved 15 by-laws. National List of Vital Medicines and Medical Devices (NLVMMD) On 6 June 2018, the GoKR approved the “National List of Vital Medicines and Medical Devices” (Resolution #274). In pursuance of this Resolution, on 24 September 2018, the MoH KR issued Order #532 “On Revising Hospitals’ and Additional Lists of Medicines and Medical Devices that are Used by Healthcare Organizations of the Kyrgyz Republic”. Share of unregistered M/MD that have been added to the NLVMMD. NLVMMD is the core element of the system of monitoring the availability of vital medicines and serves a tool to promote access of the population of Kyrgyz Republic to clinically efficient, cost-effective and safe medicines. When country has as few unregistered medicines in its NLVMMD as possible, it proves affordability and availability of medicines in this country. In pursuance of the abovementioned Resolution, the MoH KR issued Order “ On Revising Hospitals’ and Additional Lists of Medicines and Medical Devices that are Used by Healthcare Organizations of the Kyrgyz Republic” (Order #532, issued on 24 July 2018), and sent respective circular letter to all healthcare organizations. Regulation of medicines prices in the Kyrgyz Republic Seeking to decrease medicines prices, the GoKR issued the Resolution “ On Approving the Temporary Rules for Regulating Medicines Prices in the Kyrgyz Republic” (Resolution #579, issued on 29 October 2019). At the first stage the government will regulate prices for 54 international generic names of medicines (300 trade names) that are listed in the NLVMMD and are reimbursed to out-patients under the Additional Program of Mandatory Health Insurance and the State-Guaranteed Benefit Package. In accordance with the approved price regulation mechanism, the government compares manufacturer’s prices with prices for similar medicines in other countries. National Database of Medicines and Medical Devices of the Kyrgyz Republic In pursuance of the Resolution of the GoKR “On Approving the Concept for Creation of an Electronic Database of Medicines and Medical Devices in the Kyrgyz Republic” (Resolution #743, issued on 27 October 2015), the Resolution of the GoKR #40-р, issued on 2 February 2016, and the Resolution of the Page 72 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) GoKR #243-р, issued on 3 June 2016, the MoH KR is working to create the Electronic Database of Medicines and Medical Devices of the Kyrgyz Republic (hereinafter referred to as the “NDBMMD KR”). The NDBMMD KR will enable electronic tracking of movement of medicines and medical devices from importers and local manufacturers to consumers. The NDBMMD KR will become a part of the Unified Healthcare Information System of the Kyrgyz Republic. NDBMMD’s Stage 1 (“Establishment of a Unified Regulatory Information Service, and Its Implementation into the System of State Procurements of M/MD”) was completed; the Information Service was integrated with the State Procurement Portal; currently the Information System is being tested and prepared for pilot implementation. MoH KR developed an adapter and all necessary web-services and published them in “TUNDUK” system of interdepartmental electronic coordination to be integrated with the State Procurement Portal. All integration-related technical works were completed. MoH KR intends to test run the Information System to check the exchange of information between the NDBMMD and the State Procurement Portal (with participation of healthcare organizations and suppliers of M/MD). Centralized procurements Seeking to decrease prices and transportation costs, ensure uniform prices and determine proper procurement volumes, the MoH KR resolved to introduce centralized procurements of medicines and medical devices for healthcare organizations. Centralized procurement procedure is established by Paragraph 8 of Article 10 of the Law of the Kyrgyz Republic “On State Procurements”. In order to centralize tenders, the MoH issued respective order, developed and approved the Centralized Tender Procedure and the Centralized Tender Format. On 2 May 2019, the MoH KR announced centralized tender for 75 lots, covering the procurement needs of 111 healthcare organizations. The total cost of the lots was KGS 201.3 million. On 23 May 2019, the State Procurement Portal opened the submitted tender applications. The tender attracted 19 applicants (18 local and 1 from Russia). The MoH KR analyzed and compared the applications and selected 13 winners for 53 lots. The main benefit of centralized tenders is the ability to procure items for lower prices. 53 lots (out of 75) to the total value of KGS 142.4 million were successful. As compared to the tender value, the centralized procedure helped to save KGS 29.0 million under the successful lots. As compared to the tender prices that were used in 2018, the government saved KGS 55 million. Under the re-tendered 27 lots (to the total value of KGS 37.6 million), 18 lots were successful (to the total value of KGS 29.6 million). As compared to the tender value, the centralized procedure helped to save KGS 6.4 million. As compared to the total tender value, the total savings under the centralized tender procedure were KGS 35.4 million. Information systems Currently, the healthcare system has more than 10 information systems; the level of computer literacy of healthcare workers has significantly improved; almost all healthcare organizations are equipped with computers. Seeking to digitize the healthcare, the GoKR approved the “Digital Health Program of the Kyrgyz Republic” and respective “Implementation Plan for 2016-2020” (GoKR’s Resolution #134, issued on 18 March 2018). Also, with the support from the international consultant, who was provided by the World Bank (Evaldas Dobravolskas), the “Architecture for the National Digital Health System of the Kyrgyz Republic” was Page 73 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) developed and approved by the MoH KR’s Order #190, issued on 15 March 2018. Digital health will cover primary and emergency care, preventive treatment, inpatient treatment, and provision of drugs. It will also help raise public awareness, improve quality of doctors and improve sector management. Establishment of common information environment will require availability at healthcare organizations of network and computer equipment and medical information systems to process digital medical records, enabling healthcare organizations to create a unified Health Passport, while integration of data from different information systems (through “Tunduk” enterprise service bus) will ensure continuity of treatment and provision of necessary healthcare services during patient’s lifetime. As of today, more than 30 healthcare organizations introduced digital medical records that cover major business-processes (admission, hospitalization, diagnostic, treatment, administration of drugs, laboratory services). The MoH facilitates interdepartmental cooperation and electronic exchange of documents to promote digital services and improve transparency. The MoH KR together with the State Registration Service are improving the Medical Certificate digital solution that is now available online to all healthcare organizations. Medical Certificate helps to obtain information by dates of birth or dates death and to ensure timely registration with the Registry of Births, Marriages and Deaths. As a result of implementation of the Medical Certificate, women can receive birth certificates for their children, as soon as they are discharged from maternity ward (in Bishkek and Osh). The MoH KR was provided with a server in order to connect it and its structural subdivisions to “Tunduk” Interdepartmental Electronic Exchange System. Currently the MoH KR is linking its information systems with “Tunduk” to integrate them with information systems of other state agencies and provide state services. The central core of digital healthcare is the Unified System of Data Repositories and Services of Digital Healthcare. The System will provide transparent, secure, reliable and continuous storage of integrated digital health records of all patients, ensure exchange of medical data, as well as will help support operative monitoring and efficient management of healthcare resources and provision of quality healthcare services. Healthcare financing I. Progress in achieving the expected results Rule 1. Government healthcare expenditures should make up at least 13.0% of all government expenditures. In 2018, the government healthcare expenditures amounted to 13.1% of the total expenditures. In 2019, the government healthcare expenditures were 13.0%. It should be noted that the KR achieved these results in a step-by-step manner – for example, in the 2005 these expenditures made up 10.3% of the national budget, and only by 2010 the country was able to raise it to 13%. This has been maintained it at this level ever since. Rule 2. Variance from the approved budget should not exceed 5%. As indicated in Table 1, the country met the target indicators for the last three years. According to the National Treasury’s procedures, budget implementation is assessed by comparing it with the initial budget and later with the revised budget. Page 74 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Table 1: Healthcare budget implementation (mil. KGS) Indicator 2014 2015 2016 2017 2018 Revised budget 16185 13 238.5 12 090.5 12 647.3 13 715.1 Cash execution of the 15508 12 727.8 11 660.4 12 058.8 13 108.3 budget Budget variance -4.2% -3.9% -3.6% -4.7% -4.4% Source: MoH KR Financial Statement for 2014-2018 Data for 2019 are “live data”, and as such can be different in the Annual Report. Rule 3. Non-salary expenditures in the healthcare sector, as budgeted in the approved national budget, should make up 35% of the total government expenditures. Table 2: Current non-salary expenditures in the healthcare sector (mil. KGS) 2014 2015 2016 2017 2018 (target 2019 indicator) Government expenditure on healthcare 14 346.6 14 649.5 14 921.6 15 795.0 16 362.2 18343.4 Salaries + dedications to the Social Fund 8 849.1 9 051.1 9 361.4 9 745.8 9 565.4 9397.3 Non-salary expanses 5 497.5 5 598.4 5 560.2 6 049.2 6 796.8 8946.1 Share of non-salary expanses in the total 48.7 38.3 38.2 37.3 38.3 41.5 healthcare expenditure, % Source: MoH KR Financial Statement for 2014-2019 In order to support the healthcare financing system, the country: ─ Met the healthcare budget formation and implementation rules (rules 1 and 2); ─ Maintained the solidarity principles in healthcare funding by strengthening the existing mechanisms for accumulating healthcare funds and improving the procedure for procurement of healthcare services that the Mandatory Healthcare Insurance Fund procures under the State- Guaranteed Benefit Package (Single-Payer System); ─ Optimized the mechanisms for procurement of healthcare services under the Single-Payer System. Since 1 January 2018, all funding sources of healthcare organizations (national budget, MHI, fee- based services and co-funding by patients) are consolidated under the Single-Payer System. Consequently, the country dismissed all regulations that governed the use of funds received from MHI and patients (co-funding). Currently the country is working to improve the healthcare budget formation process and is introducing medium-term budget framework that uses the funding system that is not based on specific budget items; ─ Completed (in 2015) introduction of equal funding standards (for healthcare organizations from Bishkek); ─ Developed mechanisms to finance short-term stay of children in in-patient facilities; Page 75 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ─ Implemented result-oriented funding principles in all in-patient facilities and primary care facilities; ─ Made sure pregnant women have free-of-charge access to Mandatory Health Insurance Certificates that provide access to drugs under the Additional Program of Mandatory Health Insurance; ─ Introduced (as a part of the efforts on improving the public healthcare funding system) new indicators to measure the quantitative characteristics of services: sanitary control, epidemiological control and laboratory investigations; ─ Amended the funding mechanism for pre-graduate medical education – placed it under the Integrated Spending Line that is funded from government education grants; ─ Implemented specific activities to improve procurement of healthcare services, so as to improve their quality and decrease financial burden on the population; ─ Further optimized the funding system by integrating the vertical programs into the general system of healthcare services. Thus, in order to improve sustainability of government funding, on 1 July 2015 the healthcare-related budget of Bishkek Municipality was transferred to the national level. With that, the obligations with respect to funding healthcare organizations were divided between MoH KR and MHIF. In 2016, specialized healthcare services (oncology, hematology, cardio surgery, and psychiatry) also introduced the Single-Payer System. Therefore, MoH KR now funds 127 healthcare organization, MHIF – 264 organizations (in total the country has 391 healthcare facilities). By introducing medium-term budget framework, the country can prioritize healthcare programs, as well as improve planning, budgeting and paying procedures (can pay service providers for specific results). Procurements, administrated by the MoH KR Implementation of the Procurement Plan of “Den Sooluk” Program under SWAP-2 Project in 2015-2019 Goods: In 2015-2019, the MoH KR procured the following medical equipment as a part of “ Den Sooluk” Program:  Medical equipment for the National Center of Cardiology and Therapy, the Research Institute for Cardiac Surgery and Organ Transplantation, and Osh Oblast Combined Hospital (angiographic machines – 5 units; ultrasonography machines; electrocardiography machine – 1 unit; inspirometer – 1 unit; blood gas analyzer – 1 unit, etc.); contract value – USD 4,144,000, including USD 1,044,670 that were covered by SWAP-2 Project;  Mobile intensive care units for maternity units of Batken Oblast Hospital, Jalal-Abad Oblast Hospital, Issyk-Kul Oblast Hospital, Talas Oblast Hospital, Naryn Oblast Hospital, Chui Oblast Hospital, and the National Mother and Child Protection Center (8 units); contract value – USD 1,100,000;  X-ray equipment for territorial hospitals; contract value – USD 2,172,000;  Medical equipment for oblast-level cardiological departments of Issyk-Kul Oblast FMC, Talas Oblast FMC and Chui Oblast FMC; contract value – USD 68,660 thousand;  Vaccine refrigerating equipment for vaccination departments (216 pc.); contract value – USD 178,150;  Computer and office equipment for pilot projects (under “Mental Health” component); contract value – USD 106,350; Page 76 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278)  Computer equipment and “1C” accounting software to support masterclasses in the regions (MHIF); contract value – USD 52,590;  Server, network and communication equipment, including 2 servers for the situation room, critical information infrastructure of the corporate healthcare network, and information system that supports government efforts in narcotics sphere; contract value – USD 95,310;  Intensive care equipment for 7 oblast hospitals, children hospitals and territorial hospitals (artificial lung ventilation units for newborns and children, oxygen concentrators, gas analyzers); contract value – USD 429,730;  Vitamin-mineral premix for 6-24 months old children; procured through UNICEF; contract value – USD 278,023;  Server, network and communication equipment for the MoH KR, MHIF, the Republican Healthcare Information Center, the Department for Provision of Drugs and Medical Equipment, the Republican Center for Health Promotion, as well as for classrooms that are used to support trainings for doctors and nurses from primary care facilities; contract value – USD 93,330;  Diagnostic equipment for FMCs from Chui Oblast and Bishkek (8 X-ray machines and 10 electrocardiography machines); contract value – USD 1,605,550;  Medical equipment for territorial combined hospitals (Chui, Talas and Issyk-Kul), FMCs from Bishkek (4 districts) and Batken, Bishkek Municipal Clinical Hospital #1 and Bishkek Municipal Clinical Hospital #6; contract value – USD 547,350;  Artificial lung ventilation machines (for neonatal and adult patients) for maternity units of oblast hospitals, perinatal centers in Bishkek and Osh, Bishkek Maternity Clinic #1 and Bishkek Maternity Clinic #2; contract value – USD 1 154,120;  Equipment for intensive care units of oblast hospitals, territorial hospitals for children and adult patients (artificial lung ventilation machine for newborns and adults, bedside monitor, defibrillator); contract value – USD 608,000;  Computer and office equipment for healthcare organizations and the MoH KR to work on the new healthcare development strategy; contract value – USD 255,450;  Commissioning of the Phase 1 of the Data Center (additional equipment for the existing server rooms of the MoH and MHIF); contract value – USD 76,430;  Computer, network and communication equipment for pilot implementation and testing of the base version of “Electronic Health Record” software in healthcare organizations; contract value – USD 55,680;  Computer equipment and equipment for simultaneous interpretation for the Republican Scientific Medical Library; contract value – USD 124,150;  Non-clinical equipment (newborn simulators) to practice clinical skills (Kyrgyz State Medical Institute for Professional Development, medical colleges in Bishkek, Naryn and Talas); contract value – USD 151,640;  Basic set of equipment for emergency pre-hospital care for children for 7 oblast-level FMCs and FMCs from remote areas; contract value – USD 248,580;  Laboratory equipment for 10 healthcare organizations (7 oblast-level combined hospitals, National Mother and Child Protection Center, perinatal centers in Bishkek and Osh); contract value – USD 852,382;  Laboratory equipment for 10 healthcare organizations (7 oblast-level combined hospitals, National Mother and Child Protection Center, perinatal centers in Bishkek and Osh) that provide emergency obstetrical and neonatal care; contract value – USD 936,660, as well as USD 54,000 (under failed lot in 2019);  Medical equipment for the Accident and Emergency Department under the “ Improvement of the Emergency Care in the KR” project (KfW); contract value – USD 682,500; Page 77 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278)  Server and network equipment for the Electronic Healthcare Center; contract value – USD 93,000;  Equipment for different departments of the Electronic Healthcare Center; contract value – USD 93,000;  Medical equipment for the Accident and Emergency Department under the “ Improvement of the Emergency Care in the KR” project (KfW); contract value – USD 233,700;  Hematology and biochemical analyzers for oblast-level FMCs, the Endocrinology Center under the MoH KR, and the Republican Diagnostics Center under the MoH KR; contract value – USD 490,510. Technical Maintenance Fund (TMF) The Procurement Plan included USD 400,000 for medical equipment repairs (Technical Maintenance Fund). This money was disbursed only in 2019 (from 2017 to 2019 it was carried over from year to year) after the Board for Technical Maintenance Fund of the MoH KR gave the approval to use KGS 20,774,962 (USD 297,635.55). MoH KR announced 8 tenders. 6 tenders were successful and resulted in agreements for repair of the following equipment: 1. “PHILLIPS OPTIMUS” X-ray machine; contractor – “MEDCO INTERNATIONAL” LLC; contract value – KGS 1,996,000; works were completed, and payment was made; 2. Atomic absorption spectrophotometer; contractor – “Strelets” LLC; contract value – KGS 2,185,500; works are in progress; 3. X-ray machine with graphical viewer; contractor – “Medco International” LLC; contract value – KGS 3,106,700; works are in progress; 4. PLS-112 X-ray machine; contractor – “Leader Medical” LLC; contract value – KGS 975,000; works are in progress; 5. Laboratory equipment; contractor – “Farma Garant” LLC; contract value – KGS 4,002,300; works were completed, and payment was partially made; 6. Angiographic machine; contractor – “Unihelp” LLC; contract value – KGS 4,100,000; works were completed, and payment was made. Consulting services Using funds of SWAp-2 project, “Den Sooluk” Program implemented two large projects:  Master Plan;  National Database. Master Plan Contract value – USD 1,237,400 The GoKR began to develop a general strategic plan for socio-economic development of the country till 2040. Being an important aspect of the population’s wellbeing, healthcare is an essential element of this plan. Seeking to assess the condition of the healthcare infrastructure, to review norms and standards, and to determine if the healthcare model can adequately respond to the current needs, the MoH KR initiated procurement of consulting services to support development of the Master Plan. The goal of the Master Plan is to create such healthcare model that can provide all population of the Kyrgyz Republic with access to high-quality and cost-effective medical services. The Master Plan will focus on streamlining the secondary and tertiary medical care and improving respective infrastructure. The Master Plan should establish fundamental principles that could be used as a basis for other national-level plans for development of Page 78 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) specific areas of healthcare management. The Master Plan will inform the GoKR’s efforts, as it pertains to the development of the general strategic plan for socio-economic development of the country till 2040. National Database of Medicines and Medical Devices Contract value – USD 368,500 On 27 October 2015, the GoKR adopted the Resolution #743 " On Approval of the Concept for Creation of an Electronic Database of Medicines and Medical Devices in the Kyrgyz Republic " to create respective national database. Within the framework of the project, the MoH KR initiated development of the National Database of Medicines and Medical Devices (hereinafter referred to as the “NDB”). The NBD was created to increase transparency and optimize circulation of medicines on the territory of the Kyrgyz Republic, to improve control over the budget of healthcare organizations, to streamline the distribution of medicines in the retail network, as well as to detect sales of illegally imported or counterfeit medicines/devices. In December 2019, the Ministry’s Department for Provision of Drugs accepted the NDB (by signing respective acceptance certificate). The software for the NDB was supplied with a one-year warranty. The supplier will also provide technical support within the warranty period. Financial and operational audit Contract value (2015-2019) – USD 1,060,100 In 2015-2019, the MoH KR attracted professional auditors to perform Annual Financial and Operational Audits to assess financial statements of “Den-Sooluk” Program (under SWAp-2 project). The auditors checked accounting records (that serve as source of data for consolidated financial statements) of the Ministry of Finance/Treasury; MoH KR; MoH KR’s subordinate organizations that receive funding directly from MoH KR; MHIF and its territorial departments. The MoH KR used the auditors’ descriptions of the situation and recommendations for improving financial reporting to streamline the day-to-day operations of its financial specialists and accountants. Annual follow-up reviews of procurements Contract value (2015-2019) – USD 247,000 In order to make sure that healthcare facilities followed the Grant Agreement and the Operation Manual with respect to organizing procurements, finding service providers and implementing contracts under SWAp Project, the MoH KR organized annual follow-up reviews of procurements. The auditors carefully reviewed procurements of goods, works, services (including consulting services), as well as implementation of respective contracts. The auditors studied documentation and records of procurement departments and made site visits to inspect the quality and quantity of supplied goods, works and services. As needed, they compared prices, specified in contracts, with prices under similar contracts or with international market prices. Resultant audit reports included description of detected shortcomings and risks related to procurement processes, as well as auditors’ comments and recommendations. Audit findings helped procurement specialists enhance their capacity, so as to improve future procurements of goods, works and services (including consulting services) and administration of contracts. Page 79 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Individual consultants Seeking to enhance the institutional capacity of its departments, the MoH KR procured services of international and local technical consultants, who provided the MoH KR with most valuable assistance, as related to medical treatment policy; finance, payment and procurement procedures; Kyrgyz and English translations. “Mental Health” Component In accordance with of the SWAp-2’s Procurement Plan for 2015-2019 the MoH KR implemented the following activities under “Mental Health” Component to the total amount of USD 750,000: ─ Procured computer and office equipment and furniture for pilot projects – USD 104,600; ─ Developed the “National Program for Protection of Mental Health of the Population of the KR” and respective Action Plan – USD 71,350; ─ Supported the pilot project on establishment of community-based services for mental health protection – USD 89,750; ─ Implemented remote advisory services on mental health, which connected the Republican Center for Mental Health with pilot projects in Osh Oblast, Jalal-Abad Oblast, Batken Oblast, city of Osh and Osh State University – USD 29,990; ─ Developed and implemented clinical protocols and standards – USD 74,560; ─ Developed and implemented pre-graduate and post-graduate training modules for nurses on mental disorders– USD 30,000; ─ Developed new methods to fund community-based and other types of mental health services that could substitute institutional care – USD 49,300; ─ Conducted a training at the end of the project – USD 59,970; ─ Organized trainings on methods of preventing and detecting mental disorders for rural healthcare committees, rural health posts and nongovernment organizations from the south of Kyrgyzstan – USD 44,290; ─ Organized trainings on new methods of mental care services for specialists from the pilot community centers – USD 89,910; ─ Operating costs – USD 70,400. Page 80 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) “On the letterhead of the Ministry of Labor and Social Development of the Kyrgyz Republic” 13 January 2020 Ref. #61/163 To: World Bank Country Office in the Kyrgyz Republic The Ministry of Labor and Social Development of the Kyrgyz Republic presents its Implementation Completion and Results Report on the World Bank’s “ Second Health and Social Protection Project”. The Report is based on the recommendations provided in the Aide-Memoire prepared by the World Bank’s Mission that worked with the Ministry on 5-6 December 2019. The Report uses the World Bank’s format and features the following areas: 1) assessment of the intervention’s objectives, structure and implementation process, as well as lessons learned during the intervention; 2) assessment of the Project’s outcomes against the agreed upon Development Goals of the Project; 3) assessment of the Borrower’s performance with respect to preparation and implementation of the intervention, emphasizing the lessons learned (especially those lessons that can be potentially instrumental in the future); 4) assessment of the performance of the Bank, other financial institutions and partners. This letter has 11-page annex. K. Adiev, Official Secretary /signed/ Page 81 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Annex 1 Ministry of Labor and Social Development Implementation Completion and Results Report of the World Bank’s “ Second Health and Social Protection Project” (SWAp-2) The Report contains the following areas: 1) Assessment of the intervention’s objectives, structure and implementation process, as well as lessons learned during the intervention. The “Second Health and Social Protection Project” was implemented by the Ministry of Labor and Social Development. The Project was funded through the conventional investment mechanism, which the World Bank uses for its Social Protection Component. The Ministry of Labor and Social Development received technical assistance to strengthen the social safety net, so as to make sure the system is capable of providing needy citizens with necessary support to ensure protection and increase investments into the social capital. The main objective of the technical assistance was to enable the Ministry to improve efficiency and targeting of social protection and services. The key target groups comprised poor and vulnerable population, including individuals with disabilities and low-income families with children. The Ministry continued comprehensive reformation of the social safety net. The reforms included development of new types of monetary benefits and social payments, and integration of various information management systems. These efforts were made in response to the fact that the country lacks sufficient mechanism to engage needy and low-income families in active employment promotion measures. Thus, below the poverty line live more males (26.3%) than females (25%). The level of employment of the population aged 15 years and older is higher among males than females (71.1% and 41.9%, respectively). In order to address these issues the Project designed, piloted and then assessed specific measures, which included encouraging low-income families to improve their standards of living; engaging available labor potential and deploying material assets of low-income families; improving social responsibility of low- income families; and reversing welfare mentality. The project piloted a new mechanism of providing monthly monetary benefits to low-income families with children (hereinafter referred to as the “MMBLIF”) under “Social Contracts” tool. This pilot intervention was based on the following legal framework – Resolution of the GoKR “On Pilot Project for Provision of Monthly Benefit Payments to Families with Children through Social Contracts” (resolution #486, issued on 6 September 2016). Despite all those reform efforts, the amount of monetary benefit to low-income families remains low (KGS 810 per child), making up as little as 20% of the minimum subsistence level. Notwithstanding the above, this monetary benefit is not the only type of social support to low-income families. Families with “low- income” status receive subsidized services from other state agencies (medical services, educational services, etc.). Therefore, state assistance to low-income families is much wider, and is not limited to monetary benefits. With that in mind, the Ministry with the technical assistance, which was provided under the World Bank’s “Second Health and Social Protection Project” (hereinafter referred to as the “Project”), analyzed the Page 82 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) current practices with respect to its targeting approach (including the recently adopted Law of the Kyrgyz Republic “On State Benefits in the Kyrgyz Republic”), as well as practices of other KR’s agencies that also feature certain elements of targeting. Drawing on the Electronic Social Assistance Register, which was created under the previous project (SWAp-1), the Ministry continued to develop the Corporate Integrated System of Social Assistance. Particularly, it implemented new functional and architectural solutions that help to maximize technical capabilities of this Register (including automatization of additional business processes and ensuring easy access to information, as might be needed for planning, monitoring and assessing purposes). The key objective of that work was to implement and then ensure efficient application of the Corporate Integrated System of Social Assistance (CISSA) that manages separate registers of social benefits, payments and services of different structural divisions of the Ministry, and covers all social risks. The Project’s objectives for its later stages included introduction of completely paperless document flow (through the mentioned corporate system) and establishment of long-range tasks, concerning harmonizing and coordinating information management systems of the Ministry and ensuring their sustainability. The system features centralized management of all processes, provides “one-stop-shop” access to information that might be needed to assess any social risk, and helps improve targeting of state benefits, social payments and services. In order to enhance Ministry’s technical capacity, the Ministry was provided with necessary server and computer equipment (for its central and regional offices). In addition, the Ministry’s IT Department received other types of support: (i) existing computers in regional offices underwent technical maintenance, (ii) risks of unavailability of access to the electronic registry as a result of blackouts were mitigated, (iii) the server room was so upgraded, as to meet international standards. With the assistance from the World Bank the Ministry conducted diagnostic review of its disability assessment procedure (Disability Assessment Board). The objective of that exercise was to optimize the process of assessing disability degree by introducing modern approaches that focus on individual’s actual physical capabilities and potential for rehabilitation. Medical criteria for disability assessment were reviewed, and a new method of disability assessment (which relies on the International Classification of Functioning, Disability and Health) was proposed. New approaches to reforming the system of certifying and supporting clients (individuals with disabilities) were developed and piloted. All activities under this intervention were focused on introducing systemic approach: (i) the material and technical resources of the disability assessment system were significantly improved (office equipment and medical equipment provided); (ii) regional capacity-building trainings on international standards (International Classification of Functioning, Disability and Health) that covered the entire chain of interaction with concerned agencies (Ministry of Education and Science, Ministry of Health, rayon departments of social development) were conducted; (iii) special-purpose vehicles to transport individuals with disabilities and conduct disability assessment were supplied, so as to implement the principle, stating that social services should be brought directly to recipients,; (iv) new improved module for CISSA on “Disability Assessment Board” was created (available in online and offline mode). 2) Assessment of the Project’s outcomes against the agreed upon Development Goals of the Project. The main objectives of the Project were to encourage low-income families to improve their standards of living; engage available labor potential and deploy material assets of low-income families; improve social Page 83 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) responsibility of low-income families; and reverse their welfare mentality. As a part the Project the Ministry piloted an initiative on providing monthly monetary benefits to low-income families with children (MMBLIF) through “Social Contracts” tool. “Social Contracts” tool was piloted from 1 September 2016 through 1 September 2019 in Alamedin, Ak-Tala and Nooken rayons, as well as in the city of Uzgen. 176 low-income families signed social contacts. Targeted social assistances (in the form of onetime payments) totaled KGS 5,450.3 mil. Respective funding was provided through one and two tranches from the Republican budget. Participants of the pilot initiative received respective trainings from the Ministry and learned how to disseminate information and handouts. Necessary rules and regulations were drafted and adopted to provide the pilot initiative with legal framework. The pilot had successful outcomes, helping the Ministry achieve one of the key objectives of its Social Adaptation Program. Thus, social contracts were successfully implemented by 143 families engaged in livestock breeding (81.25% of total number of families); 22 families engaged in plant farming (12.5%); and 11 families, engaged in entrepreneurial activities (6.25%). The efficiency monitoring findings demonstrate that positive development trends were observed in 73% of the families. 51% of the families increased their incomes, and incomes of 23% of the families exceeded the guaranteed minimum income (GMI). It should be taken into account that more than 1/4 of the population lives below the poverty line. That fact makes it impossible to implement the Program, because the Ministry lacks sufficient resources to cover everyone. As resources are limited, it is important to determine priorities for social protection. Monetary- based social support is not the only tool that utilizes targeting approach. Certain elements of targeting are also implemented in other important social services provided by the state: social protection, medical care, energy costs reimbursements, benefits to elderly citizens, various kinds of subsidies, etc. All these programs rely on certain elements of targeting, either directly or indirectly. In other words, families with “low-income” status in addition to monetary benefits have access to subsidized services that are provided by other state agencies (medical services, educational services, etc.): 1. Ministry of Health of the KR – Program of State Guarantees for Provision of Citizens with Medical and Social Assistance; 2. Ministry of Education and Science of the KR – Scholarships to Orphans and Nutrition Standards in Social Institutions; 3. Social Fund of the KR – Subsidized Pension Support and Compensation Payments in Response to Increased Tariffs for Electricity; 4. Bishkek City Government – Resolution of Bishkek City Council #316, of 12.06.2012 “On Social Support to Low-Income Residents of Bishkek and to Residents of Bishkek who are Eligible for Benefits”; 5. Ministry of Labor and Social Protection of the KR – 11 types of monetary benefits. Calculation of aggregated assistance that is provided under these programs at the local level yielded the following numbers: (i) family that consists of 3 individuals with disabilities and 1 pensioner receives KGS 31,000 per months, (ii) disabled pensioner with three kinds from Bishkek receives KGS 7,500 per month, is exempted from payments to the school fund, have access to free medical care and drugs, and receives housing allowances (that cover 50% of all costs, associated with housing and utilities), (iii) single mother from Naryn who has a child with disabilities receives KGS 10.9 thousand per month, and is eligible to buy drugs with 90% discount. Therefore, the state provides low-income families with wider support that goes beyond monetary benefits. According to the 2018 Multiple Indicators Cluster Survey (MICS), various types of social payments or monetary benefits are provided to 58% of all households. Page 84 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) Seeking to improve the targeting mechanism, the Ministry organized focus groups with beneficiaries of state social benefits programs, staff of local social development services, local self-governments and local kenesh members in 14 cities and rayons throughout the republic. The objective of the exercise was to assess quality, accessibility and affordability of state social programs. The focus groups had 510 participants (originally 350 participants were expected). Local self-governments and local council members took very active part in the discussions. Almost 90% of the participants noted that state support should be targeted. 417 of the participants (82%) were women, 93 participants – men (18%). 90% of the participants were older than 40 years of age. 68% of the participants stated the following factors as the main drivers of poverty: (a) family has low income; (b) family has many children; (c) family has member/members with disabilities. When discussing costs related to applying for state monetary benefit, 85% of the respondents noted high transportation costs (applicant has to visit various state agencies, some of them multiple times). Few participants also mentioned fees for certain verification certificates (verification certificates from state service or municipal territorial administrations). Application process is time consuming, and applicants have to travel long distance to submit application. These factors discourage many families from applying for social services. The focus-groups revealed that about 2% of the surveyed families did not submit applications because the process was time-consuming (even though those families believed they were eligible for social support). Applicants have to spend from 3 to 12 days to complete application process, and have to make up to 4 trips to application offices. 10% of the respondents who did not submit applications among other impeding factors also noted the need to travel excessively long distances. 30% of the participants of the focus-groups said that their applications for state monetary benefits got denied at a certain stage. 95% of the denials were made on the grounds that the applicant’s income exceeded the social assistance eligibility threshold. While those unsuccessful applicants were appraised as having sufficient level of income, they feel vulnerable and live in difficult conditions (among other things they cannot even afford food in sufficient quantities, as not to starve), and require certain targeted assistance. Potential applicants lack awareness about the social assistance eligibility criteria – they have no clue that they are ineligible, until their applicants are officially denied on the grounds of income level. 100% of the participants shared the opinion that the amount of monetary benefits was low, but stated that without the benefit their lives would be even harder. They also believed that the eligibility threshold for targeted poverty-relieve benefits was too low. Nevertheless, 90% of the participants noted that state support should be targeted – wealthy families do not need support, and proper administration of benefits can help increase the amount of benefit. All participants of the focus-group expressed the opinion that such functions as identification of needy families and collection of applications and verification documentation should be returned to Aiyl Okmotu. At that level they personally know all families (know their quality of life) and can “cut off” wealthy families from state benefit programs at early stage. The recipients of benefits believe that Aiyl Okmotu can provide assistance and support more efficiently, as Page 85 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) compared to rayon/municipal administration. It comes from the fact that Aiyl Okmotu serves smaller population and that Aiyl Okmotu’s staff is the same local community, and as such is more responsive. Moreover, there are specific examples, when Aiyl Okmotu found unorthodox solutions to decrease poverty in rural area (for example, rent out land to poor families on preferential terms for up to 5 years). The targeted social assistance, as defined in the legislation, is often understood as eligibility for assistance on the grounds of belonging to target population group, and not on the grounds of real needs. As a result, the very principle of targeting on the grounds of real need is lost in the body of laws that are designed to ensure social protection of specific population groups (military personnel that participated to armed conflicts, blood donors, Chernobyl cleanup workers, individual who live in high-altitude areas and equated localities, purged individuals, etc.). Such principle of targeting monetary benefits can promote welfare mentality. When targeted assistance is provided exclusively because the applicant’s income is below the minimum subsistence level, it entails the situation when assistance is provided not only to unemployable disabled citizens, but also to able-bodied employable individuals, which creates “poverty trap” (decreases motivation to increase income). Therefore, assistance should be provided only to those individuals, who really cannot overcome hardships without assistance from the outside. One of the main achievements of the Ministry and the Project is the complete implementation of the corporate system of data management in the social register, as well as significant decrease in paper-based document flow. CISSA supports all transactions that constitute “full operation day”, enabling electronic data management, as related to state monetary benefits and payments to children and families in hardships; medical disability assessments and individual rehabilitation programs; as well as many other social services, including provision of wheelchairs and vouchers for health resort treatment. The Ministry introduced protected interagency data exchange system, which provides access to required personal data of individuals who apply for state benefits, social payments and services. This system will promote transparency of data, improve the quality of services and enhance the targeting of benefits and payments. Implementation of new architectural modules helped to achieve the following objectives: (i) organize centralized database of social assistance, and make it accessible for all structural divisions of the Ministry; (ii) ensure access to external databases to enhance targeting; (iii) introduce “one-stop-shop” application mechanism (Electronic Application Form); (iv) ensure compatibility of CISSA’s data with municipal level payment systems, and enable exchange of information in the form of “Social Certificate” that provides verified information that can be used by other agencies, including Aiyl Okmotu; (v) introduce modern system of electronic processing of reporting forms at all levels of the Ministry, so as to prepare complete, reliable and transparent data that can inform administrative decisions; (vi) provide access to comprehensive electronic information to inform strategic decisions and medium-term and long-term measures of social protection; (vii) integrate CISSA’s operational database with other financial data and registries of the Ministry; (viii) improve the system of payments and the system of delivery of state benefits, payments and social services. In the meantime, the Ministry in cooperation with the Project conducted a two-stage audit of CISSA. The first stage (system audit) checked the degree and quality of CISSA’s implementation, and produced a set Page 86 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) of recommendations that would help address a number of problems with CISSA’s implementation and maximize its technical capabilities. The revealed problems were successfully resolved, which improved cooperation and coordination between, and better defined responsibilities of, the Ministry’s divisions that use CISSA and the CISSA’s developers. When the first stage of the Project was completed, all efforts related to finalization and improvement of the system virtually ceased. Despite the shortcomings identified by the audit, users at the rayon level noted that working with the system was more convenient and ensured higher reliability, as compared to working with paper documents. Meanwhile, despite the GoKR’ resolution that enforced implementation of social payments and services through CISSA, all other laws and regulations recognized only paper-based document flow, so regulatory bodies checked only paper documents. As a result, in 2018 there were significant discrepancies between data provided by CISSA and data contained in paper-based reports. The system audit identified practical steps that should be taken to ensure efficient implementation and application of CISSA. Thus, the audit provided practical recommendations for prompt resolution of issues, related to implementation of CISSA; recommendations for creation of training systems to teach users how to work with CISSA; recommendations for introduction of Electronic Application Form that would integrate all modules under one system of in-house and interagency data exchange; recommendations for monitoring of implementation of CISSA; suggestions for monitoring of provision of social assistance and services, including suggestions for optimization of reporting. Following up on the recommendations of the CISSA system audit, the Ministry implemented the following steps: (i) established CISSA Implementation Commission, comprising representatives of all divisions of the Ministry; (ii) improved the system of technical support and the system of teaching the users how to work with CISSA; (iii) determined personal responsibilities of the heads of specific structural divisions and subordinate organizations; (iv) implemented Electronic Application Form (EAF) as primary registration of individuals who apply for any type of social assistance and services. (EAF registers all applicants in the system, regardless of what type of assistance or service they originally apply for. When such registered citizens apply to other structural divisions and organizations that also utilize CISSA, specialists from those organizations simply enter respective PIN-code to find the applicant and update his or her data with respect to specific assistance or service.) The Ministry and the Project also conducted final audit. This audit covered CISSA’s business process and investigated how CISSA was improved through implementation of the recommendations of the system audit and introduction of new modules of social assistance and services. At the time of the audit, CISSA had efficient business processes, as it pertained to designation and provision of social assistance and services. It was a fully functional system that could efficiently perform most of the tasks that were formulated in the specifications when the system was introduced and further improved. The audit determined that in order to ensure efficient implementation of CISSA and maximize its technical capabilities, the Ministry first of all should follow all ongoing improvements to their logical end. Recommendations of the CISSA’s business processes audit were focused on the following: (i) address “weaknesses” (decrease risks related to human factor); (ii) increase personal responsibility of parties under interagency agreements (responsibility for performance quality and for risk mitigation); (iii) introduce high- quality and constructive control (internal and external) over designation and provision of benefits and services (i.e. audits and inspections, leveraging CISSA’s capabilities); (iv) prepare high-quality manuals and implement training opportunities for CISSA’s users, so as to ensure required level of users’ competency. Page 87 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) In addition, the audit of the business processes determined that the laws and regulations that govern the processes of designation and provision of social assistance and services should be amended to recognize CISSA’s functions. The audit suggested adopting framework regulations and completing them with methodology guidelines that would provide detailed description of the processes. Following up on the results of the second audit, the following documents were developed: (i) model interagency agreements on exchange of data between information systems of different agencies; (ii) standard manuals for CISSA users; (iii) training programs that can be used by heads of specific divisions to teach their staff how to work with CISSA. With respect to optimization of the disability assessment system, the WB’s Project and respective stakeholders (Ministry of Health, Ministry of Education and Science, and the Republican Center for Medical and Social Assessment) implemented a number of activities to improve performance in provision of social services: (i) streamlined the disability assessment process by introducing international standards (International Classification of Functioning, Disability and Health), (ii) introduced individual rehabilitation plans, (iii) developed a new format of providing rehabilitation services. From 1 June 2017 through 1 July 2018 the Ministry (in cooperation with the Ministry of Health and the Ministry of Education and Science) piloted certain elements of the International Classification of Functioning, Disability and Health (ICFDH), related to assessment of disability status and development of individual rehabilitation programs (IRP) for individuals/children with infantile cerebral paralysis (hereinafter referred to as the “Pilot”). The Pilot covered 197 adults and children with infantile cerebral paralysis (22 adults). The Ministry set out the following objectives for that Pilot: (i) demonstrate how the modern international standards of disability assessment and rehabilitation of individuals with disabilities (ICFDH) can be leveraged to improve the current interagency coordination and ensure a unified approach to rehabilitation; (ii) demonstrate how ICFDH helps establish a systemic approach to disability assessment and rehabilitation of IRP, and combine these two processes into a single process; (iii) identify barriers and risks for implementation of IRP by managing real cases of individuals/children with infantile cerebral paralysis,. The Pilot had a monitoring and evaluation system that helped to track the interim results and the final outcomes of disability assessment and rehabilitation of individuals/children with infantile cerebral paralysis under the staged rehabilitation process that involves several agencies. The Pilot demonstrated positive dynamics of the key indicators (qualitative and quantitative). By the end of the Pilot the rate of achievement of the indicators reached 97% (for example, the indicator that catches the “Share of Properly Filled-Out IRP” grew from 66% in the 3rd quarter of 2017 to 94% in the 1st quarter of 2018). It shows that specialists from the three areas (social protection, healthcare and education) are improving their understanding of ICFDH’s elements and can operationalize the tools of the Pilot. While the Pilot’s duration was only 1 year, the Pilot fulfilled its key objective – it demonstrated that modern approaches to disability assessment and rehabilitation are implementable in Kyrgyzstan. Pilot’s outcomes were disaggregated into two groups: (i) benefits for individuals with disabilities (they significantly improved their social integration, while their families gained better understanding of the importance of continuous rehabilitation), and (ii) benefits for state agencies (they learned about modern approaches to disability assessment and rehabilitation of individuals with disabilities). The Pilot also developed methodological materials and guidelines, and proposed amendments to existing laws and regulation that govern issues related to individuals with disabilities (implementation of these amendments is the key precondition for Page 88 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) achievement of the abovementioned long-term objectives). All proposed changes were reflected in the key document that establishes the medical and social assessment procedure (Resolution of the Government of the Kyrgyz Republic “On Medical and Social Assessment in the Kyrgyz Republic” (resolution #68, issued on 31 January 2012), as amended by the Resolution of the Government of the Kyrgyz Republic “On Amendment of Certain Resolutions of the Government of Kyrgyz Republic” (resolution #675, issued on 14 December 2016)). Necessary amendments were also prepared for the key regulatory document that governs operations of the Disability Assessment Board and its relations with the healthcare system. The suggested optimization of the medical and social assessment provides for “bio-psycho-social” model of disability assessment. Currently the country uses “medical” model of assessment that does not meet the modern requirements with respect to promotion of the disabled individuals’ rights for socialization and integration into society. Meanwhile, the ICFDH is applicable to any sphere that provides services to people: healthcare, social protection, education, employment, transportation, construction, social insurance, etc. ICFDH can help improve those spheres focusing on “universal design”, which ensures equal rights and opportunities for individuals with any type of disabilities. Suggestions were made to change the criteria for determining degrees of functional impairment of children and adults with disabilities, as well as categories of disabilities, using ICFDH elements. Mechanisms were suggested to simplify the procedure of disability assessment (and preparation for such assessment) in health organizations. Introduction of ICFDH to the system of medical and social assessment will help stimulate active measures of social protection, giving further impetus to the development of the system of rehabilitation services (especially at the local level). In accordance with the objectives and outcomes of the Pilot the Ministry defined a number of key steps with respect to the disability assessment system. Thus, it developed the “Roadmap for Optimization of the System of Assessment of Disability and Development of Rehabilitation Services for 2020-2023” (which became one of the instruments of the Kick-Off Plan for Implementation of the UN Convention on the Rights of Persons with Disabilities for 2020-2022). 3) Assessment of the Borrower’s performance with respect to preparation and implementation of the intervention, emphasizing the lessons learned (especially those lessons that can be potentially instrumental in the future). The pilot intervention on providing monthly monetary benefits to low-income families with children (MMBLIF) through “Social Contracts” tool had several positive lessons and outcomes. Thus, the intervention determined a mechanism to provide the most vulnerable families with follow-up support (after completion of the initiative). The mechanism will help sustain the results, achieved by the intervention- covered families. The best practices in this area indicate that in the future such work should be institutionalized, so as to make sure the families remain on the path of positive development and do not degrade to their original state. At that, it is very important for the Ministry to properly track the follow-up support, and determine if it brings the desired outcomes. The lessons of the intervention were analyzed, and respective recommendations were developed: (i) follow up on the positive outcomes of the “Social Contract” tool, and align the tool with the recently adopted Law “On State Monetary Benefits in the KR” (2018); (ii) staff of local of social development departments should prepare lists of families that receive monetary benefits, and share such lists with local self-governments; (iii) apply the “Social Contract” tool on declarative principle to work with families that are eligible for monetary benefits for third and every subsequent child in accordance with the new law; (iv) continue to support, consult and control intervention- covered families for another year of two (it will help families to become more responsible, stay focused on achieving life goals, and reverse welfare mentality); iv) continue to support the “Social Contract” tool for another 1 or 2 years in the same regions that were covered by the pilot intervention; (vi) replicate the “Social Contract” tool in other regions of the republic. Page 89 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) The Ministry and its development partners adopted a joint resolution, where they discussed ways to improve the targeting mechanism for state benefit programs and strengthen the target approach to provision of social assistance. The resolution prioritizes the following: (i) improve social protection and facilitate investments into social capital; (ii) implement state programs in accordance with targeted approach; (ii) actively use interagency information exchange mechanisms. In this resolution the parties documented the key lessons and results of their cooperation, and declared that they support the policies and visions, as stated in the “National Strategy for Development of the Kyrgyz Republic for 2018-2040” (“NDS”) and manifested through accession to the “2030 Global Agenda for Sustainable Development”, which prioritizes development of human capital as the key driver of social and economic development of the country (so as to make sure no one is left behind). The national social safety net with evidence-based and efficient programs is one of the mechanisms to achieve these priorities. The earlier reforms in the sphere of social protection are continued under the “UNITY, CONFIDENCE, CREATION Development Strategy of the Kyrgyz Republic for 2018-2022”, “Kick-Off Plan for Implementation of NDS’s Medium-Term Objectives”, “DIGITAL KYRGYZSTAN Digital Transformation Concept”, etc. The lessons learned during these efforts helped determine next steps: (i) finalize the sectoral “Program for Development of Social Safety Net, Labor and Employment” (among other things using the results of the round table, organized to explore findings of studies and analysis); objectives of the Program should be aligned with the NDS KR; (ii) drawing on the sectoral program and the National Social Policy Priorities (that are defined in the NDS KR and the SDG 1.3.) develop an action plan, specifying short-term and medium-term measures to improve the coverage of those who need social support (including monetary benefits to low-income families); the action plans should include measures to test the approaches that help improve the mechanism of identifying such families and safeguarding their access to guaranteed social assistance; (iii) make sure the programs that are not aimed at poor and vulnerable citizens are not expanded any further (including the programs that replace subsidized services with monetary compensations). Significant efforts were made to institutionalize CISSA. The Ministry was actively involved into discussions of problems and challenges, related to management of information systems, and the Project organized well-coordinated work in this regard at the level of the Ministry’s local offices and its national- level administration. The Project determined and recommended specific tasks for the Ministry’s offices and departments, implementation of which will help ensure long-term sustainability the earlier achieved objectives. “Concept of Development of Information Systems Management” and respective Implementation Plan for this program document were prepared and recommended to the Ministry. In contrast to how this type of work was organized in previous years, now all stages of CISSA’s finalization are regulated by administrative decisions in the form of executive orders, instructions and resolutions. Implementation of such administrative decisions is supervised by Implementation Commission, Official Secretary, and Deputy Minister who is responsible for CISSA. Cooperation agreements on electronic exchange of information under “TUNDUK” Interagency Cooperation System were signed with the following ministries and agencies: State Registration Service; “Kyrgyz Pochtasy” State-Owned Enterprise; Mandatory Health Insurance Fund; State Tax Service; Social Fund; State Inspectorate for Veterinary and Phytosanitary Safety; recently established agency that regulates databases of movable and immovable property of citizens. These agreements enable the Ministry to obtain necessary data on individuals who apply for social Page 90 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) assistance and services from information systems of other agencies, which decreases paper-based document flow. The Ministry achieved certain success under its efforts on optimization of the system of disability assessment and rehabilitation of individuals with disabilities. Meanwhile, in the light of the recently ratified Convention on Rights of Persons with Disabilities these efforts should be continued through implementation of proposed recommendations. Thus, the Roadmap details further improvements that are required for the legislative framework that governs medical and social assessment and rehabilitation of individuals with disabilities. Drawing on the Pilot’s lessons, monitoring findings and success stories, the Ministry will harmonize changes to other legal documents in the sphere of inclusive education, healthcare, provision of rehabilitation equipment, participation of NGOs in rehabilitation process, etc. Amendments are also required for the resolution of the GoKR, which establishes functions and responsibilities of the Disability Assessment Board (such amendments should expand cross-agency tasks of the Board and introduce CISSA). 4) Assessment of the performance of the Bank, other financial institutions and partners during preparation and implementation of the intervention, including assessment of the relations with all these organizations, focusing on determining the degree of efficiency of the outcomes. All in all, the program was implemented successfully. We would like to emphasize the efficient cooperation of the Ministry with the World Bank and other co-funding agencies and organizations, in terms of ensuring continuity and sustainability of the best practices in social protection. During the reporting period the Ministry closely coordinated with development partners: UNICEF, World Food Program of the UN, International Labor Organization. Under the Project the Ministry efficiently collaborated with these organizations to improve social protection measures, which included increasing access of vulnerable families to social support and expanding the range of social services; providing adequate social support to children from poor families; providing socially venerable population groups with easy access to the guaranteed social support and rehabilitation services; strengthening the Corporate Integrated System of Social Assistance and facilitating information exchange between different agencies, which improves administrative performance and decreases barriers and costs for eligible recipients and the social safety net. Successful implementation and integration of different information systems of social support was made possible due to the Ministry’s close cooperation with multiple partners implementing different initiatives that covered various aspects of the social assistance reform: (i) EU’s “Sectoral Reform of Social Protection” project – implementation and institutionalization of database of children who live in specialized institutions; functional analysis and reorganization of business processes of local offices of social development; introduction of social services; (ii) UNICEF – development of a database of children and families in hardships, as well as integration of the database with CISSA; (iii) World Food Program of the UN – development of a module for social assistance, as well as integration of the module with CISSA; (iv) Bishkek City Government and district-level administrations – information exchange; improvement of the CISSA’s transparency; making sure CISSA is compatible with the system that administers benefits and other payments from the local budget; MHIF – access to the data of recipients of various benefits and social payments; provision of trainings on XML programming to the MHIF’s IT staff in order to organize exchange of information with external healthcare databases. Considering the broad spectrum of cooperation with different ministries and agencies, the Ministry is of the Page 91 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) opinion that the development partners (WB and the Ministry) maintained efficient and successful relations at all stages of the Project. Project Implementation Unit and staff of the Ministry and its structural divisions and subordinate organizations closely coordinated to deliver good outcomes. 5) Suggested follow up measures The Project prepared and agreed with the Ministry the following follow up measures: (i) outsource further works on CISSA to complete the “one-stop-shop” initiative, (ii) create legal framework that would legitimize exchange of information with external registers, decrease the amount of paper-based verification documents, ensure protection of personal data, and support further reforms with respect to monetary benefits. Strategic objective should be to improve the efficiency in application of electronic information, so as to support social protection processes and streamline decision-making in the Ministry. Electronic Application Form lays the foundation for establishment of physical (in addition to the virtual) “one-stop-shop” system. Under such mechanism once citizen is registered in the system he/she obtains access to all types of social assistance and services that he/she is eligible for (it means that after registration citizen can apply for any assistance or service in any location in Kyrgyzstan through any front-office specialist, who will check his/her data in CISSA and designate monetary benefit or service). In this connection, it might be useful to start working on a strategy to transit to a system, where registered citizens can be served in any local office of the Ministry of Labor and Social Development (this refers to services that are not connected to purpose-specific budget of specific program). Another potential sphere of application for CISSA is creation of an integrated model for social protection. “Family Social Certificate” tool has already paved the way for such model. The Ministry already can provide individuals with disabilities not only with monetary allowances, but with wheelchairs and rehabilitation services. Once educational, health, sports and cultural institutions are connected to such integrated information exchange system, the Ministry will be able to work on really inclusive programs for children with disabilities. Eventually, all agencies that are involved in social protection will be able to align their work pertaining to social protection of citizens. Social Certificate will provide information on the entire spectrum of social assistance and services provided by the government to the given family. It will enable the government to analyze resources that have been made available to needy families, and improve budgeting and targeting of social protection. Page 92 of 93 The World Bank Kyrgyz Second Health and Social Protection Project (P126278) ANNEX 6. SUPPORTING DOCUMENTS 1. Project Appraisal Document 2. Financing Agreement 3. Interim Strategy Note (ISN) for the Kyrgyz Republic (Report No. 62777-KG - June 16, 2011) 4. Country Partnership Strategy for the Kyrgyz Republic (Report No. 78500-KG – June 24, 2013) 5. Country Partnership Framework for the Kyrgyz Republic for the period (Report No. 130399-KG – October 10, 2018) 6. Restructuring Papers 7. Aide Memoires and Back-to-Office Reports 8. Management and other important letters and memoranda 9. Implementation Status and Results Reports (ISRs) 10. Borrowers Contribution to ICR Page 93 of 93