ICRR 11332 Report Number : ICRR11332 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 08/22/2002 PROJ ID : P008318 Appraisal Actual Project Name : Health Sect Restruct Project Costs 47.1 39.8 US$M ) (US$M) Country : Bulgaria Loan /Credit (US$M) Loan/ US$M ) 26 21.2 Sector (s): Board: HE - Health (90%), Cofinancing Central government US$M ) (US$M) administration (10%) L/C Number : L4000 Board Approval 96 FY ) (FY) Partners involved : Council of Europe Fund; Closing Date 12/31/2001 12/31/2001 Government of Bulgaria; EU-PHARE Prepared by : Reviewed by : Group Manager : Group : Roy Jacobstein Timothy A. Johnston Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives The objectives of the Project were 1) to improve the Bulgarian health care system’s efficiency and facilitate health sector restructuring, and 2) to ensure continuing provision of essential health services during transition and beyond and thereby protect and/or improve the health of the Bulgarian populace. b. Components The project had four components: Policy Analysis and Management ($2.8M at appraisal; $2.58M, or 6%, of actual project costs); Primary Health Care ($14.6M at appraisal; $9.4M, or 24% of actual costs); Emergency Medical Services ($13.4M at appraisal; $15.22M, or 38% of actual costs); and Blood Transfusion ($10.7M at appraisal; $12.73M, or %32% of actual costs). c. Comments on Project Cost, Financing and Dates Two Amendments, in 2000 and 2001, were made to the project, adjusting somewhat allocations among component, but without changing project objectives. In 1998 the Government asked that half of the loan be converted into Deustsche Marks; due to this conversion, $3.33M, or 13% of the original loan amount, was lost due to exchange rate losses. Unused funds from the loan totaled $1.55M. 3. Achievement of Relevant Objectives: The project achieved its relevant objectives, both overall and within each component, and exceeded output targets in some components. Despite initial delays, the project benefited from strong support from government and other stakeholders. The project appears to have significantly aided the transition/health sector reform process in Bulgaria. It was implemented concurrently with the passage (in 2000) of major health sector reform legislation, including the introduction of national health insurance, changes in the provider payment system, and strengthening of family medicine. The project helped establish a Health Policy and Economic Analysis Unit in the MOH, which has informed the reform process with useful studies and assistance, e.g., a recently completed hospital rationalization strategy, and coordination of implementation of a long-term National Health Strategy and Action Plan. The project supported the expansion of the primary health care network into rural areas. All 1800 General Practitioner (GP) practices were provided with basic equipment, repair works completed on 380 primary health care practices, and 1070 GPs were trained. The project also streamlined and upgraded the emergency medical services system, and restructured and upgraded the national blood transfusion system, which now meets European standards for safety and quality. Evidence is inadequate, however, to assess the extent to which the project contributed to improved health outcomes. Improved emergency services may have reduced mortality from heart attacks etc., but some other key outcome indicators (e.g., child vaccination) declined slightly during the project period. 4. Significant Outcomes/Impacts: By the end of the project, one-fourth of all Bulgarian physicians had become family doctors; of this cohort, 55% formerly worked outside of rural health services. The ICR estimates that the project led to increased PHC service access for almost 1&1/2 million Bulgarian citizens. A number of studies documented increased patient satisfaction with this greater access to services. The emergency medical system was improved, with substantial training delivered and a Global Positioning System installed; dispatch and arrival times were reduced and the number of deaths in the emergency setting were reduced from 4.6 to 2.7/1000. A centralized blood transfusion network was established, with 5 regional Blood Transfusion Centers and 1 National Center now functioning to state-of-the-art standards. 5. Significant Shortcomings (including non-compliance with safeguard policies): Initial implementation over the first 1-2 years of the project was slow and weak, although subsequent performance improved significantly. Although equipment and construction was initially to have been targeted at poor areas, this equity criteria was subsequently dropped. It is not clear whether all the equipment distributed is being adequately utilized or maintained. Whether or not the increase in insurance payments to primary health care providers has resulted in decreased informal payments was not documented (and it may be too early in transition to do so). There is some indication in the ICR Annexes that, with the introduction of national health insurance, coverage for the uninsured and ethnic minorities (Roma) remain unresolved issues. 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Highly Satisfactory Highly Satisfactory Institutional Dev .: High High Sustainability : Likely Likely Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: The outcome of this project confirms the importance of good management at the PMU level, adequate Bank resources throughout the design and implementation period, and strong and sustained Government commitment. If the Bank Project can be one of the structural vehicles for the reform process, as was apparently the case in Bulgaria, that is also valuable in fostering ownership and promoting better outcomes. A strongly-supported policy and analysis unit can make a useful contribution to the reform process. Investment in job-specific training geared to individual performance improvement and organizational capacity development can make a substantial difference in project outcome. Finally, as the Cofinancier (the Council of Europe Development Bank) notes, regular and open communication among lenders, borrowers, and implementing unit personnel, as well as between lenders themselves is valuable to enhance project performance and ownership. 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: The ICR provides a good overview of the project, and includes some useful annexes summarizing national health indicators and surveys of public attitudes toward primary and emergency health services. Several of the assertions of project impact were not backed up by adequate evidence, however. Moreover, the ICR text places too much emphasis on highlighting project achievements, at the loss of a more disinterested analysis of the strengths and weaknesses of the project and reforms (e.g., coverage of the uninsured and Roma, financial sustainability of compulsory national health insurance, under-the-table payments, etc.) and of the relation between the project and the reforms (e.g., the relative role of project-financed equipment vs. changes in provider payment incentives in encouraging relocations to rural practices).