Document of The World Bank FOR OFFICIAL USE ONLY Report No: 74098-UZ PROJECT PAPER ON A PROPOSED ADDITIONAL CREDIT IN THE AMOUNT OF SDR 60.6 MILLION (US$93 MILLION EQUIVALENT) TO THE REPUBLIC OF UZBEKISTAN FOR A HEALTH SYSTEM IMPROVEMENT PROJECT February 5, 2013 Human Development Sector Unit Europe and Central Asia Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ÿþCURRENCY EQUIVALENTS (Exchange Rate Effective: January 2013) Currency Unit = Uzbekistan Sum (UZS) 1 Sum = US$0.00050287 US$1 = 1988.56 Sum US$1.537 = SDR I FISCAL YEAR January I - December 31 ABBREVIATIONS AND ACRONYMS AF Additional Financing IMF International Monetary Fund CMU City Medical Union IP Implementation Progress CPIB Central Project Implementation Bureau IRR Internal Rate of Return CPS Country Partnership Strategy M&E Monitoring and evaluation CRH Central Rayon Hospital MFERIT Ministry for Foreign Economic Relations, Investment, and Trade CVD Cardiovascular Disease MOH Ministry of Health DALY Disability-Adjusted Life Year NCD Non-communicable Disease DCP Disease Control Priorities NHA National Health Accounts DO Development Objective NPV Net Present Value EC Expert Committee ORAF Operational Risk Assessment Framework EMF Environmental Management Framework PAD Project Appraisal Document EMP Environmental Management Plan PDO Project Development Objective FM Financial Management PHC Primary Health Care FY Fiscal Year RMU Rayon Medical Union GDP Gross Domestic Product SVP Primary Health Care Center (Russian) GP General Practitioner UNICEF United Nations Children's Fund HSIP Health System Improvement Project WHO World Health Organization ICB International Competitive Bidding IDA International Development Association IFR Interim Financial Report Vice President: Phillipe Le Houerou Country Director: Saroj Kumar Jha Country Manager Takuya Kamata Sector Director: Ana Revenga Sector Manager: Daniel Dulitzky Task Team Leader: Susanna Hayrapetyan ii UZBEKISTAN ADDITIONAL FINANCING FOR HEALTH SYSTEM IMPROVEMENT PROJECT CONTENTS Contents Project Paper Data Sheet................. . ....................... ....... iv I. Introduction ..........................................................1 II. Background and Rationale for Additional Financing in the amount of US$93 million.............. 1 III. Proposed Changes .................................................... 3 IV. Appraisal Summary of Proposed Additional Financing ...........5..........5 Annex 1: Results Framework and Monitoring .......................... ............ 11 Annex 2: Operational Risk Assessment Framework (ORAF) ................... ...... 18 MAP IBRD 33508 111 UZBEKISTAN ADDITIONAL FINANCING FOR HEALTH SYSTEM IMPROVEMENT PROJECT Project Paper Data Sheet Basic Information - Additional Financing (AF) Country Director: Saroj Kumar Jha Sectors: Health (98%) Compulsory health Sector Director: Ana Revenga finance (2%) Sector Manager: Daniel Dulitzky Themes: Health system performance (60%); Team Leader: Susanna Hayrapetyan Non-communicable diseases (30%); Child health Project ID: P133187 (10%) Expected Effectiveness Date: July, 2013 Environmental category: Partial Assessment Lending Instrument: SIL Expected Closing Date: December 31, 2018 Additional Financing Type: Basic Information - Original Project Project ID: P113349 Environmental category: Partial Assessment Project Name: Health System Expected Closing Date: December 31, 2016 Improvement Project Lending Instrument: SIL AF Project Financing Data ] Loan [x ] Credit [ ] Grant [ ] Guarantee [ ] Other: Proposed terms: AF Financing Plan (US$million) Source Total Amount (US $m) Total Project Cost: 125.5 Co-financing: Borrower: 32.5 Total Bank Financing: 93 IBRD IDA New 93 Recommitted Client Information Recipient: Republic Of Uzbekistan Responsible Agency: Ministry of Health Ministry of Health 12 Navoi Street Uzbekistan Tel: (998-71) 139-1954 office@jpib.uz Central Project Implementation Bureau (CPIB) Uzbekistan AF Estimated Disbursements (Bank FY/US$ million) FY 14 15 16 17 18 19 Annual 0.2 10 20.8 25 34 3 Cumulative 0.2 10.2 31 56 90 93 iv Project Development Objective and Description Original project development objective: The overall Project Development Objectives (PDOs) are to (1) improve access to quality health care at the primary level and at Rayon Medical Unions (RMUs); and (2) strengthen the Government's public health response to the rise in non-communicable diseases (NCDs). Revised project development objective: The Project Development Objectives (PDOs) are to (a) improve access to quality health care at the primary level, at Rayon Medical Unions (RMUs) and selected City Medical Unions (CMUs); and (b) strengthen the Government's public health response to the rise in non- communicable diseases (NCD). Project description: The proposed Additional Financing (AF) would finance the scale up of some of the activities that already constitute the original project as follows: Component 1: Improving Health Service Delivery Subcomponent 1.1: Hospital Service Improvement This sub component will improve hospital service delivery by: (a) refurbishing additional 57 RMUs and 15 selected CMUs with up-to-date equipment (including, inter alia, diagnostic and waste management equipment) and medical furniture; and (b) providing training to hospital managers and staff on, inter alia, hospital design, planning and management. Subcomponent 1.2: Primary Health Care Development This subcomponent will support primary health care development by expanding the following activities to additional urban and rural PHC facilities: (a) providing medical equipment; and (b) training of medical personnel in early diagnosis, screening, and treatment of priority NCDs. Subcomponent 1.3: Clinical Quality Enhancement This subcomponent aims at enhancing clinical quality by (a) providing on-site training of additional RMUs' and selected CMUs' pediatric and internal medicine doctors and nurses in new clinical treatment standards; (b) training of staff of the additional RMUs and selected CMUs in clinical case management and hospital administration; and (c) establishing quality improvement mechanisms to monitor implementation of the new clinical treatment standards. Component 2: Strengthening Health Financing and Management Reforms This component aims at supporting the development of a health information system for the hospital financing pilot in preparation for potential national level rollout, and expanding the training program for PHC facility managers in financial and health care management. Component 3: Institutional Strengthening on NCD Prevention and Control This component aims at strengthening the capacity in the control and prevention of NCDs by expanding surveillance and health promotion activities in selected regions in preparation for national level rollout. Component 4: Project Management Strengthen the capacity of the Ministry of Health (MOH), the Central Project Implementation Bureau (CPIB), and the Regional Project Implementation Bureaus for project management and implementation, monitoring and evaluation (M&E), environmental management pursuant to the Environmental Management Framework (EMF), and procurement and financial management (FM) through the provision of goods, consultants' services, training, and incremental operating costs for the additional 24 months of implementation. V Safeguard and Exception to Policies Safeguard policies triggered: Environmental Assessment (OP/BP 4.01) [ x ]Yes [ ]No Natural Habitats (OP/BP 4.04) [ ]Yes [ x ] No Forests (OP/BP 4.36) [ ]Yes [ x ] No Pest Management (OP 4.09) [ ]Yes [ x ] No Physical Cultural Resources (OP/BP 4.11) [ ]Yes [ x ] No Indigenous Peoples (OP/BP 4.10) [ ]Yes [ x ] No Involuntary Resettlement (OP/BP 4.12) [ ]Yes [ x ] No Safety of Dams (OP/BP 4.37) [ ]Yes [ x ] No Projects on International Waterways (OP/BP 7.50) [ ]Yes [ x ] No Projects in Disputed Areas (OP/BP 7.60) [ ]Yes [ x ] No Does the project require any waivers of Bank policies? [ ]Yes [ x ] No Have these been endorsed or approved by Bank management? [ ]Yes [ x ] No Conditions and Legal Covenants: Financing Agreement Reference Description of Date Due Condition/Covenant Schedule 2, Section 1, Part The Recipient shall, through Not later than February 28 of A.4 MOH, submit to the Association, each year starting from the the approved hospital investment investment and recurrent costs' plan for each year and the plans for 2013 and on annual respective recurrent costs' plan basis for the duration of the Proj ect. Schedule 2, Section 1, Part The Recipient shall, through Not later than February 28 of A. 5 MOH, submit to the Association, each year, starting from the the status of execution of the investment and recurrent costs' hospital investments and plans for 2013 and on an annual respective recurrent costs' plan basis for the duration of the for the preceding year Proj ect. Schedule 2, Section 1, Part The Recipient shall, through On a semi-annual basis for the A.6 MOH, submit to the Association, duration of the Project. reports from the HPOCs on implementation of the hospital improvement program Schedule 2, Section 2, Part The Recipient shall have its The audited Financial Statements B.3 Financial Statements audited in for each such period shall be accordance with the provisions furnished to the Association not of Section 4.09 (b) of the later than six months after the General Conditions. Each audit end of such period. of the Financial Statements shall cover the period of one fiscal year of the Recipient. vi I. Introduction 1. This Project Paper seeks the approval of the Executive Directors to provide an additional financing credit in the amount of SDR 60.6 million (US$93 million equivalent) to the Republic of Uzbekistan for the Health System Improvement Project (P133187). 2. The proposed Additional Financing (AF) would help finance the costs associated with the scaling-up of some of the activities initiated under the original credit to fully cover the country's remaining health facilities at the Rayon level, including selected City Medical Unions (CMUs), which could not be included in the original Project due to insufficient IDA allocation at the time the original Project was prepared (FY11). The cost of expanding the Project activities was estimated at US$93 million equivalent. The AF would ensure that all Rayon Medical Unions (RMUs) and selected CMUs in the country would be supported by the Project in line with the Government's Hospital Reform Program. In addition, we also seek approval for a restructuring of the Project to: (i) revise the Project Development Objective (PDO) by including selected CMUs; (ii) reword one Project Development Objective indicator; (iii) drop three intermediate indicators; and (iv) adjust the targets to account for this AF implementation period. Lastly, we request a 24-month extension of the original Project closing date, from December 31, 2016 to December 31, 2018. 3. The objectives of the Project are to: (a) improve access to quality health care at the primary level, at RMUs and selected CMUs; and (b) strengthen the Government's public health response to the rise in non-communicable diseases (NCDs). II. Background and Rationale for Additional Financing in the amount of US$93 million A. Background 4. The original credit for the Health System Improvement Project (HSIP) in the amount of SDR 59.6 million (US$93 million equivalent) was approved on April 7, 2011, and became effective on November 2, 2011, with an original closing date of December 31, 2016. 5. The HSIP consists of the following four components: (1) Improving Health Services Delivery; (2) Strengthening Health Financing and Management Reforms; (3) Institutional Strengthening for NCD Prevention and Control; and (4) Project Management. The project currently covers six out of thirteen regions of Uzbekistan as well as Tashkent City. The proposed AF would support the scaling up of activities initiated under the HSIP to fully cover the health facilities in the remaining seven regions of Uzbekistan(Tashkent oblast, Syrdarya oblast, Djizak oblast, Surkhandarya oblast, Navoiy oblast, Burkhara oblast, and Khorezm oblast) as well as selected CMUs. The AF would rely on the existing implementation arrangements and the capacity of the Ministry of Health (MOH), which would ensure timely implementation of Project activities and achievement of the PDOs. The Borrower is highly committed to scaling up project activities in order to improve RMUs' and CMUs' service delivery. The Government will through the state budget cover the cost of the hospital reconstruction and repair. In addition, the Government plans to invest approximately US$32.5 million of state funds to cover part of project related local costs, including taxes. 6. The proposed scaled-up activities are consistent with and respond to the fourth results area of the current FY12-15 Country Partnership Strategy (CPS)', namely "improving access to and outcomes of Uzbekistan FY12-15 CPS, Report #65028-UZ 1 social services", and in particular providing more accessible quality and sustainable health services, especially in the rural areas". B. Project Progress 7. The Project has been performing at a satisfactory level with respect to implementation progress and the PDOs. Legalcovenants have been substantially complied with to date. The Interim Financial Reports (IFRs) are satisfactory, and the Project's first audit for the Government's fiscal year (FY) 2012 is not due until June 30, 2013. Key activities planned for year one under each component have been initiated and/or are under implementation, including completion of training of 482general practitioners, delivery of critical technical assistance to support improvements in hospital planning, design, and clinical services quality, and fielding of the first national level NCD surveillance survey. The Government-supported civil works for RMUs is proceeding according to schedule, with approximately 38 RMUs ready to receive equipment and with staff being trained under the Project. Environmental issues related to the Government-financed civil works are being monitored per the Project's Environmental Management Framework (EMF). Renovation of all 100 RMUs is expected to be completed by 2014. However, the procurement of some sophisticated medical equipment through International Competitive Bidding (ICB) took slightly longer than anticipated because of the complexity of the packages. By mid-September 2012, three contracts totaling US$15.4 million were signed and 80 percent of first payments are expected to be made in December 2012. Two other contracts worth US$4.5 million are expected to be signed before the end of 2012. Although the current disbursement of US$751,370.00 is low compared to the disbursement projection, the commitment level shows that by June 2013, a total of US$17 million could be disbursed, which is in line with the disbursement projections for FY 2013. The total disbursements plus commitments represent approximately 16 percent of the original credit amount. 8. The AF is fully consistent with the World Bank Guidelines for Additional Financing (OP/BP 13.20) as it will finance the "implementation of additional or expanded activities that scale up a project's impact and development effectiveness". The AF meets the criteria and conditions of OP/BP 13.20 as follows: 9. The proposed additional investments are fully consistent with the original PDOs, which remain relevant after including the selected city medical unions (CMUs). The (revised) PDOs aim at: (i) improving access to quality health care at the primary level and at RMUs and selected CMUs; and (ii) strengthening the Government's public health response to the rise in NCDs. The proposed investments are also aligned with the current Country Partnership Strategy (CPS); 10. Implementation of the Project, including substantial compliance with legal covenants, is satisfactory. The Project's Implementation Progress (IP) and Development Objectives (DOs) have been rated Satisfactory. There are no outstanding or unresolved safeguard, environmental, social, or fiduciary issues in the Project. The AF would finance activities identical to the original Project and would not require any changes to the environmental category of the Project of B, nor would they trigger any new safeguard policies; C. Rationale for Additional Financing 11. The AF is technically justified. The Borrower is strongly committed to scaling-up the Project in order to expand coverage to the remaining seven regions of the country and to the selected CMUs nationwide to further improve access to quality health services. The institutional arrangements would remain unchanged, as they have been effective during the implementation of the current Project. The MOH will continue to be responsible for the implementation of all health activities. The implementing 2 agency has built a strong administrative capacity and technical expertise over the past several years and is therefore well positioned to utilize additional resources. 12. Overall, this AF, which has strong support of the Government of Uzbekistan, is a better mechanism to maximize development impact and results than a repeater project, a completely new operation, or non-lending instruments. This is mainly because the AF will use the well performing HSIP implementation and institutional arrangements as an instrument to maximize outcomes, while at the same time bringing additional funds, which would be particularly important in view of the implementation of the healthcare reforms. In addition, the activities financed under the AF will be implemented in parallel with the ongoing Project. A 24-month extension from December 31, 2016 to December 31, 2018, is deemed sufficient to complete both the original and AF activities. III. Proposed Changes Project Development Objectives (PDOs) 13. The original PDOs would be slightly revised to include selected City Medical Unions (CMUs) thatare located in small cities and are functionally and structurally similar to RMUs. There are no other hospitals in those cities, so some CMUs largely serve the rural population with free in-patient health care. The revised PDOs are to (1) improve access to quality health care at the primary level and at Rayon Medical Unions (RMUs) and selected City Medical Unions (CMUs); and (2) strengthen the Government's public health response to the rise in non-communicable diseases (NCD). The original and revised PDOs are presented in Table 1 below. Table 1. PDO Change Original PDO Revised PDO Improve access to quality health care at the primary Improve access to quality health care at the primary level and at Rayon Medical Unions (RMUs) level,at Rayon Medical Unions (RMUs) and selected City Medical Unions (CMUs); Strengthen the Government's public health response to No change the rise in non-communicable diseases (NCD) A. Results Framework 14. One of the four PDO indicators would be revised and the PDO and intermediate outcome indicator target values would be adjusted to reflect the scaled-up activities and the 24-month extension. PDO indicator number 3 would be slightly reworded to read as follows: "Increased proportion (number) of hospitals following NCD protocols developed under the project (at least 20 treatment standards)". The IDA Core Sector Indicators relevant for the project would be included in the results framework. The target values for the Key Performance Indicators would be adjusted to reflect the additional scope of activitiesand the proposed 24-month extension until December 31, 2018. No new PDO indicators would be added. The proposed changes are indicated in Table 2 below. 15. In addition, the results framework (Annex 1) is revised as follows: (a) three intermediate indicators are proposed to be dropped because during the first year of project implementation it was determined that they are not under the control of the project; (b) IDA core indicators for the health sector are added; and (c) target values are adjusted for the intermediate indicators. The proposed changes would enhance the impact of the Project, particularly for the rural population, who would be the main beneficiaries of the AF. 3 Table 2: PDO Indicator Changes Original PDO Indicator Revised PDO Indicator Original Target Revised Target Increased proportion of diabetic and No change No change hypertension patients referred from PHC facilities to RMUs, in accordance with treatment standards Improved perceived quality of PHC No change No change and secondary health care services in intervention areas Increased proportion of hospitals Increased proportion(number) of 100 percent (100 100 percent (172 following NCD treatment standards hospitals following NCD protocols hospitals) hospitals) (at least 20 treatment standards) developed under the project (at least 20 treatment standards) Issuance of a profile of NCD risk No change At least three reports Two reports factors and burden of disease published published B. Proposed Scaled-Up Activities 16. The design of the Project remains unchanged. The proposed AF would finance the scale up of some of the activities that already constitute the original project as follows: Component 1: Improving Health Service Delivery Subcomponent 1.]: Hospital Service Improvement 17. This subcomponent will improve hospital service delivery by: (a) refurbishing additional 57 RMUs and 15 selected CMUs with up-to-date equipment (including, inter alia, diagnostic and waste management equipment) and medical furniture; and (b) providing training to hospital managers and staff on, inter alia, hospital design, planning and management. Subcomponent 1.2: Primary Health Care Development 18. This subcomponent will support primary health care development by expanding the following activities to additional urban and rural PHC facilities: (a) providing medical equipment; and (b) training of medical personnel in early diagnosis, screening, and treatment of priority NCDs. Subcomponent 1.3: Clinical Quality Enhancement 19. This subcomponent aims at enhancing clinical quality by (a) providing on-site training of additional RMUs' and selected CMUs' pediatric and internal medicine doctors and nurses in new clinical treatment standards; (b) training of staff of the additional RMUs and selected CMUs in clinical case management and hospital administration; and (c) establishing quality improvement mechanisms to monitor implementation of the new clinical treatment standards. Component 2: Strengthening Health Financing and Management Reforms 20. This component aims at supporting the development of a health information system for the hospital financing pilot in preparation for potential national level rollout, and expanding the training program for PHC facility managers in financial and health care management. 4 Component 3: Institutional Strengthening on NCD Prevention and Control 21. This component aims at strengthening the capacity in the control and prevention of NCDs by expanding surveillance and health promotion activities in selected regions in preparation for national level rollout. Component 4: Project Management 22. Strengthen the capacity of MOH, the CPIB, and the Regional Project Implementation Bureaus for project management and implementation, monitoring and evaluation (M&E), environmental management pursuant to the EMF, and procurement and financial management through the provision of goods, consultants' services, training, and incremental operating costs for the additional 24-months of implementation. 23. Table 3 shows the project costs and financing plan and compares components under the original project at appraisal and the proposed AF. Table 3: Project Costs and Financing Plan by Component (in US$ millions) Component Original cost (IDA) AF (IDA) Revised cost (IDA) 1: Improving Health Service 82.17 88.95 171.12 Delivery 2: Strengthening Health 4.45 1.50 5.95 Financing and Management Reforms 3: Institutional Strengthening 2.98 0.40 3.38 on NCD Prevention and Control 4: Project Management 3.40 2.15 5.55 Total 93.00 93.00 186.00 24. Institutional and fiduciary arrangements for the project would remain unchanged under the proposed AF. Extension of the Closing Date 25. An extension by 24 months of the project closing date, from December 31, 2016 to December 31, 2018, is proposed in order to provide sufficient time to fully implement the scaled-up activities and achieve the PDOs. IV. Appraisal Summary of Proposed Additional Financing A. Technical 26. The technical design and the fiduciary arrangements would remain the same as under the original project. Experience has shown that the technical basis of the project is sound. The investment priorities would continue to focus on improving quality. 5 B. Economic and Financial Analysis C. Economic and Financial Analysis 27. Economic Analysis. The AF has the same economic rationale as the original Project. The estimated benefit of the Project is the economic value of the lives saved and serious disability averted by the investments made in the Project: (i) improved access to medical care; (ii) better quality of care; (iii) efficiencies in health delivery and from preventive care; and (iv) activities to fight NCDs. 28. Economic analysis of the Project required projecting the epidemiological scenario in Uzbekistan up to 2030 and then estimating how many disability-adjusted life years (DALYs) might be averted with the Project. Projections made by the World Health Organization (WHO)2 provided a useful counterfactual scenario of disease burden in Uzbekistan without the Project. 29. DALY reduction in each major disease category has been estimated for each intervention. Specifically, a 3 percent DALY reduction is linked with the project goals of expanding treatment guidelines for each specific disease, based on the presumed effectiveness from the Disease Control Priorities (DCP-2) project3 and the assumption that treatment guidelines will reach about 50 percent of the population who have physical access to health facilities. 30. Table 4 below summarizes the results of the economic analysis. Project costs were discounted at a basic rate of 11 percent to account for inflation in Uzbekistan4. Each DALY saved is valued at per capita income (using a starting value of about US$1,142 for 2011). The future stream of annual DALYs saved (that is, the benefits) is discounted at 3 percent following WHO and DCP-2 guidelines. The baseline scenario for the revised project that including the AF resulted in a net present value (NPV) of nearly US$236 million and a 29.1 percent internal rate of return (IRR), which is slightly lower than in the original project. Table 4: Results of the Economic Analysis Original project Revised project with AF Total Total costs bets Total costs Total benefits (000) (000) (000) constant, Net benefits constant, constant, 2012 Net benefits 2012 terms 2012terms 2012 terms terms 2012 terms Baseline scenario: deflator rate of 11% and DALY discount rate of 3% Values (in 000s) $372,948 $1,404,327 $1,031,379 $627,613 $1,858,214 $1,230,601 NPV (in 000s) $213,897 $236,018 IRR 30.9% 29.1% Alternative Scenario: deflator of 8% and DALY discount of 5% Values (in 000s) $434,878 $1,125,894 $ 691,015 $748,621 $1,489,790 $741,169 NPV (in 000s) $200,704 $185,956 IRR 23.4% 19.2% 31. The robustness of baseline scenario was tested altering the basic parameters of the economic analysis. Project costs were discounted at a lower rate of 8 percent to account for lower inflation in the 2 See http://www.who.int/healthinfo/global_burdendisease/estimates country/en/index.html. 3 See: http://www.dcp2.org/. 4 Based on International Monetary Fund (IMF) estimates (World Economic Outlook, April 2012) 6 country. Lower discount rates mean that the present value of project costs would be greater. Benefits were evaluated using a higher rate of 5 percent that reduces the present value of DALYs saved in the future. NPV and IRR analyses were quite sensitive to the value of a DALY (ranging from 1 to 3 times per capita gross domestic product (GDP), which raises the rate of return nearly threefold). With valuation of life near to what is used in U.S. studies, the project's IRR was unusually high. In contrast, the IRR was only somewhat sensitive to the discount rate for DALYs and not very sensitive to the deflator (inflation) rate or to the discount rate for DALYs averted. The alternative scenario (8 percent inflation and 5 percent discount for DALYs saved presented in Table 4) results in a NPV of about US$186 million and a 19.2 percent IRR. 32. However, because we used very modest effectiveness estimates, there is no major risk of overestimation of returns. For example, the overall reduction in DALYs from cardiovascular disease (CVD), the leading cause of death, is estimated at only about 5 percent over 20 years, whereas the U.S. interventions (prevention, specifically tobacco control), blood pressure management, and case management in hospitals have reduced CVD mortality by over 25 percent in the last two decades. 33. Financial Analysis. IDA will provide US$93million, of which about US$86.4million will be allocated for capital investment, in large part for the refurbishment and equipment of 57 additional RMUs and 15 CMUs, about US$1.2 million for technical assistance, US$3.9 million for training and the remaining US$1.5 million for additional operating costs. Recurrent costs are calculated at 10 percent of the investment costs, therefore totaling about US$8.6 million per year. Public health spending is estimated at around 2.5 percent of GDP, which represent about US$1 billion, so the recurrent costs generated by the Project represent a negligible share of public health spending. Additionally, public health spending is likely to increase relative to GDP over the next five years, and the Government will have a larger budget to sustain the recurrent costs, which are estimated generously for the Project. D. Institutional Arrangements 34. The institutional arrangements will remain the same as under the original project. Therefore, activities to be undertaken as a result of this AF will be executed under the direction of the MOH, in accordance with its assigned government function. The overall project oversight, including those activities enabled by this additional financing, will continue to be assumed by a structural unit chaired by the First Deputy Minister as stipulated by point 6 of the Decree of the Cabinet of Ministers of the Republic of Uzbekistan, No. 229 of August 12, 2009. Hospital Program Oversight Committees were established in April 2012 at the local government "Khokimiyat" level in all oblasts, including those not covered by the original Project. The Committees comprise representatives of the oblast health department, the oblast and rayon finance departments, and oblast administration. The main role of these committees is to oversee project implementation progress, ensure timely coordination with the State Hospital Investment and Recurrent Program, and decide on actions to address issues that may arise during implementation. To ensure that project objectives are reached, the Expert Committees (EC) established by the MOH under Health III (Order #35 dated February 2, 2012) will continue to function for specific project components. The WGs comprise appropriate leading specialists from the Ministry of Economy, Ministry of Finance (MOF), MOH, and other related organizations. Each WG is managed by an appointed WG leader. The activity of all WGs will continue to be coordinated by respective deputies to the Minister of Health. Decisions made by WGs will become effective after their approval by the MOH. The CPIB will coordinate the work of the WGs and provide them with necessary documents and other technical assistance. The oblast branches ofCPIB will provide close coordination of project activities and technical support in M&E and implementation. 7 35. As with the original project, for Component 2 of the AF, the Inter-Ministerial Methodological Commission on Health Financing will coordinate health financing and management reforms issues and make recommendations for important policy decisions in that regard. E. Environmental and Social Safeguards 36. The AF triggers OP 4.01 since the Credit will support improvements in hospital waste management.The rehabilitation of health facilities will be financed exclusively by the Government budget. 37. Project activities related to installation and operation of waste management equipment and rehabilitation of existing health care facilities are expected to have localized environmental impacts. However effective mitigation measures will reduce the risks related to these environmental impacts and associated longer-term public health impacts. The Environmental Management Framework (EMF) prepared for the original Project provides environmental management guidelines, including those for health care waste management. Based on the EMF, a site-specific Environmental Management Plan (EMP) is to be prepared prior to beginning construction by the government at each site. The same procedures would be adopted for sites to be rehabilitated by the government during the period of the AF. The EMF prepared under the original Project detailed the monitoring methodology and the respective agencies responsible for monitoring. This format will also be utilized for the proposed scaled-up activities. The EMF was also updated to include mitigation measures related to procurement and installation of medical waste equipment, steps to be taken for improved occupational safety practices and a detailed monitoring plan. The revised EMF was disclosed in-country on the MOH's website on November 15, 2012 and in the Bank's Infoshop on December 3, 2012. 38. The AF does not finance any construction of facilities. All refurbishment and improvement will be financed exclusively by government budget and take place in existing facilities.There will be noland acquisition, relocation, or any impacts on access to resources or services. Correspondingly, OP 4.12 on Involuntary Resettlement will not be triggered for the AF. 39. Key social issues arising from the project context and its development objectives identified during the original Project remain relevant for the AF. The last Living Standards Assessment (May 2003) confirmed that Uzbekistan showed a marked difference in urban and rural social development indicators, and the poor in rural areas as a target vulnerable group withthe worst access to health care. There have been improvements and changes since 2003, yet the poor in rural areas remain to be a target vulnerable group. The proposed scaled-up activities will contribute to overcoming this gap by improving access to health care for the general population, and in particular for vulnerable social groups and in marginalized geographic areas. Lower-income groups tend to use lower-level facilities, such as outpatient facilities and rayon hospitals, more often than higher-income groups and, hence, would benefit to a greater extent from upgrading the RMUs. Increased transparency in the system would contribute to minimizing the effect of networks and social connections, which still seem to play an important role in accessing treatment. Increased transparency is also expected to have a positive impact on informal payments, especially in the referral network. In addition, the current fund allocation system favors richer and more urbanized regions. Thus, the introduction of a more balanced resource allocation system would also help to bridge geographic differences in the distribution of funds, which tend to disproportionately impact the poorer regions of the country and, in turn, the poorer strata of the population in these regions. Although the project will improve access to quality health services for entire rural population in Uzbekistan, the elderly and women will benefit the most as the Project will help to improve access to quality health services close to their residence, and hence save time and resources. 8 F. Fiduciary * Procurement 40. The arrangement for procurement management under the original Project will remain unchanged. The CPIB will be responsible for procurement under the AF. The procurement capacity assessment carried out for the original Project concluded that the CPIB has adequate staffing and experience to carry out procurement activities under the project, and this assessment remains unchanged for the AF project. The CPIB has acquired practical experience with the Bank's procurement procedures through implementation of projects financed by the Bank. The on-going projectprocurement rating is considered Moderately Satisfactory. The main procurement risks in the health sector include: (i) the protracted contract and medical equipment registration requirements in the country, which may cause procurement delays; and (ii) the low level of competition due to the high cost of doing business in the country and the low level of development of the local manufacturing industry. To mitigate these risks, the CPIB will continue to coordinate and follow up with the registration authorities to simplify the procedure for suppliers. The Bank will closely monitor this aspect of the contracts implementation and propose remedial actions if contracts are overly delayed. MOH and the CPIB have agreed to pay special attention to procurement packaging arrangements and further strengthen theircapacity to monitor the quality of equipment delivered under the project. The procurement packaging arrangements will be made with a view to attract wider international participation in the bidding process, and the CPIB will advertise procurement accordingly. The Project Implementation Bureau in each region will work with the CPIB to monitor the quality of deliverables. To supplement the procurement plan for the original Project, an 18- month procurement plan for the AF project was prepared and agreed with the Bank. The Bank's Guidelines on Procurement of Goods, Works, and Non-Consulting Services (January 2011) and Guidelines on Selection and Employment of Consultants (January 2011) will apply for the on-going HSIP as well as the AF project. * Financial Management 41. The financial management arrangements of the original Project will remain unchanged for the AF. The CPIB will continue to be responsible for the financial management (FM) arrangements including the flow of funds, staffing, accounting, reporting, auditing, and verifying all payment-supporting documents before processing the payments from the Bank and government sources. The FM arrangements for HSIP have been reviewed as part of Project supervision and have been found moderately satisfactory.Meanwhile, the planning and budgeting capacity is to be enhanced. In particular, the project budget should be prepared in the format acceptable to the Bank and to be broken down by quarter. 42. The 1 C accounting software utilized by the CPIB for accounting and reporting purposes allows the automatic generation of IFRs and SOEs.Further actions will be requiredfrom the CPIB to ensure protection from unauthorized access and modification of financial data. 43. Internal Control arrangements at the CPIB should be enhanced. In particular, the CPIB needs to introduce monthly formal reconciliation of the WB disbursement data with project's accounting records and XDR/USD reconciliation via Client Connection. The backup of accounting data is to be performed on the monthly basis. * Disbursement 44. The AF will disburse as the original Credit. It will disburse through transaction based disbursement methods that include: reimbursements with full documentation, reimbursements on basis of 9 Statements of Expenditures for small expenditures with defined thresholds, payments against Special Commitments, direct payments to third parties, and payments through the Designated Account. To facilitate project implementation, a separate Designated Account will be opened at the same financial institution as the original Credit. The Designated Account, which will be managed by the CPIB, will be replenished on a quarterly basis, as needed. The total ceiling will be limited to US dollar xx million. The Designated Account will be audited annually in conjunction with the audit of the project financial statements. Disbursements will be made on the basis of full documentation for (i) contracts for goods costing more than the equivalent of US$500,000 each; (ii) services under contracts of more than the equivalent of US$100,000 each for consulting firms and more than the equivalent of US$50,000 each for individual consultants; and (iii) all incremental operating cost. Disbursements below these thresholds and for expenditures against incremental operating costs and training would be made according to certified Statement of Expenditure (SOEs). 45. For all expenditures financed under Statement of Expenditures, full documentation in support of the SOEs will be retained in the CPIB for at least two years after the project closing date. This information will be available for review by Bank missions during project supervision and by the project's auditors. SOEs will be audited in conjunction with the annual audit of the project. Further instructions on the size of the minimum application and how funds will be withdrawn from this Credit will be provided in the Disbursement Letter. V. Operational Risk Assessment Framework 46. The ORAF (Annex 2) assesses the overall rating of the HSIP and AF as Moderate, given the Government's strong commitment to the health sector reform agenda supported by the Project, and the satisfactoryproject implementation status of the ongoing HSIP. Implementation risk for the AF could be substantial as previously uncovered oblastsmay need time to get familiar with the Project and project management. The fraud and corruption risk rating for the AF project is high, in view of the risks related to procurement of medical equipment that have been identified globally, particularly in preparation of bids, collusion in bidding, and capacity of post installation service. Such risks may be significantly heightened where local competition among experienced bidders is weak and where capacity to monitor quality of deliverables is lacking.The CPIB is advised to apply heightened diligence to the procurement of medical equipment under the AF. The functional unit established at the MOH, headed by the First Deputy Minister and responsible for project monitoring and oversight, and regional representatives in the oblasts have helped to carry out Project activities without substantial difficulties in the first year of the HSIP and are expected to play an equally important role throughout the project implementation period, including the extended period under the AF. 10 Annex 1: Results Framework and Monitoring UZBEKISTAN ADDITIONAL FINANCING AND RESTRUCTURING OF THE HEALTH SYSTEM IMPROVEMENT PROJECT Results Framework Revisions to the Results Framework Comments/ Rationale for Change PDO The overall Project PDO 1 Revised The first original PDO has been Development Objectives slightly revised to reflect the (PDOs) are to:- (1) improve The overall Project Development Objectives project's coverage of not only access to quality health care at (PDOs) are to (1) improve access to quality RMUs but also "selected City the primary level and at RMUs, health care at the primary level, at Rayon Medical Unions (CMUs)". These and (2) strengthen the Medical Unions (RMUs) and selected City CMUs are located in small cities, Government's public health Medical Unions (CMUs). and are functionally and structurally response to the rise in NCDs. similar to RMUs. PDO indicators Current (PAD) F -Proposed change* 1. Increased proportion of Continued diabetic and hypertension patients referred from PHC facilities to RMUs, in accordance with treatment standards. 2. Improved perceived quality Continued of PHC and secondary health care services in intervention areas. 3. Increased proportion of Revised Clarified that use of only those hospitals following NCD clinical guidelines developed under treatment standards (at least 20 3. Increased proportion (number) of the Project will be monitored. Also treatment standards). hospitals following NCD clinical guidelines added 'number' of hospitals as well developed under the project (at least 20 as proportion as stating data in clinical guidelines), absolute count of hospitals will be more demonstrative in showing the Target value: Revised from 100 to 172 quantity of hospitals using clinical RMUs and CMUs. guidelines. Target now includes additional 57 RMUs and 15 CMUs under the AF. 4. Issuance of a profile of NCD Continued NCD surveillance though national risk factors and burden of survey is recommended to happen disease. Target value: Revised from publication of once every five years; therefore only three reports to two. two reports are possible during the lifetime of the Project. clinial gidelnes) Intermediate Results indicators Current (PAD) Proposed change* 1.1 Hospitals equipped with Continued Wording revised to match that of the medical and waste management Core Sector Indicator and target now equipment Health facilities constructed, renovated and includes additional 57 RMU and 15 or equipped (Health facilities equipped) CMU hospitals and 344 clinics to be Target value: Revised from 100 to 516. equipped under the AF. 1.2 New treatment standards Revised Indicator slightly revised to reflect developed and adopted by the correct terminology of clinical MOH (CVD, diabetes, etc.) 1.2 New clinical guidelines developed under guidelines. Number of guidelines to the Project and adopted by the MOH (CVD, be developed under project diabetes, etc.). decreased to twenty, as UNICEF is already assisting the MOH in Target value: Revised from 25 to 20 developing the other five. 1.3 Urban polyclinics' doctors Revised Indicator reworded to reflect that receiving training under the 10- doctors in both urban and rural PHC month training GP program 1.3 Number of doctors of urban and rural facilities will be trained under the PHC facilities receiving training under the project. 10-month training GP program. 1.4 Health personnel at PHCs Continued Target now reflects additional scope (doctors and nurses) receiving of the AF. training under continuous Target value: Increased the number of professional education doctors and nurses to be trained to include CMU personnel. 1.5 Hospital management staff Continued Increase in managers trained is due receiving training on hospital to the inclusion of CMUs. management Target value: Increased from 477 to 516 1.6 Hospital core staff receiving Continued Target now reflects additional scope training on waste management of the AF. Target value: Increased to include extra personnel from additional RMUs and CMUs 1.7 Health personnel receiving Continued Target now reflects additional scope training on clinical case of the AF. management (NCDs and Target value: Number of doctors and nurses pediatrics) increased to reflect additional RMUs and CMUs 1.8 People with access to a basic Dropped The definition of this indicator was package of health unclear and not possible to track within current context of Uzbekistan health services and this Project in particular. 1.9 Training New Core Sector Indicator included. Will represent total cumulative health Health personnel receiving training personnel trained annually under the project. 2.1 Staff of reformed PHC and Continued Target now reflects additional scope hospitals receiving training in of the AF. financial management Target revised to reflect increased number of personnel to be trained under AF 12 Intermediate Results indicators Current (PAD) Proposed change* 2.2 Percent of recurrent Dropped Annual health sector expenditures expenditures not related to for the different types of facilities is salary relative to actual determined by the overall budget expenses of: allocated to the sector. As such the a) PHCs project is not able to influence this b) Rayon hospitals allocation therefore the indicator c) Urban polyclinics was dropped. 2.3 National Health Accounts Continued developed and published 2.4 Public Expenditure Review Continued developed .2.5 Volume and Cost contract Continued introduced in 3 hospitals in Fergana oblast 2.6 New The indicator reflects advances in the implementation of the provider Number of urban PHC facilities (urban payment reforms in outpatient family policlinics) converted to per capita facilities that are supported by the financing system project. 3.1 Number of video clips on Continued health education on cardiovascular risk factors 3.2 Number of people screened Dropped There is no special registration of for (a) hypertension, and (b) people who underwent screening for diabetes through community- hypertension and diabetes, so based screening programs in obtained information may be targeted areas unreliable. 3.3 Percent of population in Continued targeted oblasts knowing cardiovascular risk factors 3.4 Public Health specialists Revised Indicator revised to reflect that both (surveillance staff) trained in surveillance and health promotion data collection and analysis, 3.4 (a) Public Health specialists public health specialists will be including trainers, in all oblasts (surveillance staff) and (b) health promotion trained. specialists trained * Indicate if the indicator is Dropped, Continued, New, Revised, or if there is a change in the end of project target value 13 REVISED PROJECT RESULTS FRAMEWORK UZBEKISTAN: HEALTH SYSTEM IMPROVEMENT PROJECT The overall Project Development Objectives (PDOs) are to (1) improve access to quality health care at the primary level, at Rayon Medical Unions (RMUs) and selected City Medical Unions (CMUs); and (2) strengthen the Government's public health response to the rise in non-communicable diseases (NCDs). Baseline Cumulative Target Valuesh Description (indicate E Unit of Original Data Source/ Responsibili definition, etc.) Indicators a Project Frequency ty for Data Measure Start 2012 2013 2014 2015 2016 2017 2018 Methodology Collection (2011) PDO Level Results Indicators 1 Increased proportion of % 0 5 10 2 surveys, Beneficiary Independent A) Number of diabetic and hypertension Population/facil firm hired by diabetic patients patients referred from PHC ity survey, CPIB referred from facilities to RMUs, in accordance review of PHC facilities to with treatment standards. records in RMUs according medical to the treatment facilities standards\ Number of diabetic patients referred from PHC facilities to RMUs B) Number of hypertensive patients referred from PHC facilities to RMUs according to treatment standards\ Number of hypertensive patients referred from PHC facilities to RMUs 2.Improved perceived quality of % PHC: 85.5 87 90 3 surveys, of Beneficiary Independent Beneficiary rating PHC and secondary health care which the Population firm hired by of medical services in intervention areas Secondary first survey survey CPIB services health: (baseline) (infrastructure, 69.5 75 85 was financed doctor's under Health consultation time II of waiting) in PHC facilities (urban family 14 Baseline Cumulative Target Valuesh Description (indicate E Unit of Original Data Source/ Responsibili definition, etc.) Indicators a Project Frequency ty for Data C Measure Start 2012 2013 2014 2015 2016 2017 2018 Methodology Collection (2011) policlinics and ambulatory network of CRMP) and secondary health care (RMU and CMU). 3.Increased proportion (number) % 10 30 55 77 172 Special Monitoring of Independent In 157 RMUs and of hospitals following NCD (Numb studies to be medical records group of 15 CMUs clinical guidelines developed er) conducted experts under the project (at least 20 each year involved in clinical guidelines) [REVISED] starting from the 3rd year of development implementat of NCD ion treatment standards hired by CPIB 4.Issuance of a profile of NCD No. of 0 Monitor- Base-line Final At least 2 2 reports Risk factors CPIB local risk factors and burden of disease reports ing indi- survey, surve reports surveillance consultants cators Report y, 2nd published data determined and local defined published report in the course of sociological pub- STEPS survey firm lished INTERMEDIATE RESULTS Intermediate Results (Component 1): ImprovingHealth Service Delivery 1.Health facilities constructed, No. 0 0 516 Annual Progress Report CPJB (including 157 renovated and or equipped RMUs, urban (Health facilities equipped) family policlinics, [REVISED] X central city multi- profile policlinics, City Medical Unions and SVPs) 1.2 New clinical guidelines No. 0 0 8 6 6 0 20 Annual Progress CPIB developed under the project and Reports adopted by the MOH (CVD, diabetes and etc.) 1.3 Doctors of urban and rural No. 4,482 482 518 500 500 500 500 3,000 Annual Progress Report CPJB PHC facilities receiving the X trained training under the 10-month training GP program 15 Baseline Cumulative Target Valuesh Description (indicate E Unit of Original Data Source/ Responsibili definition, etc.) Indicators a Project Frequency ty for Data C Measure Start 2012 2013 2014 2015 2016 2017 2018 Methodology Collection (2011) 1.4 Health ersonnel at PHCs No. 0 doctors 1,300; 1,500; 1,500; 1,700; 1,700; 1,700; 9,400; Annual Progress reports CPJB 1.4ctr Hah prsnel) aPcs X 0 nurses 14,250 14,250 14,250 14,250 14,250 14,25 85,500 (doctors and nurses) receiving 37,945 0 training under continuous professional education nurses trained No. 0 0 175 125 111 105 516 Annual Progress reports CPJB 3 staff employees 1.5 Hospital management staff X x 172 hospitals receiving training on hospital (excluding financial management management) No. 0 0 80 90 100 120 126 516 Annual Progress reports CPJB (3 staff X employees x 172 hospitals) To be 1.6 Hospital core staff receiving trained per training on waste management hospital: Director; Head Administrator; Chief Nurse X No. 0 100 190 200 202 310do therapists Annual Progress CPJB a) 1002 doctors doctors doctors doctors doctors ctors and reports (therapists and 284 350 nurses 400 400 630nu pediatrici pediatricians): 6 1.7 Health personnel receiving nurses nurses nurses rses ans - staff employees x training on clinical case 1002, 157 RMUs =942 nurses - and 60 from management (NCDs and 2064 CMUs pediatrics) b) 2064 nurses: 12 staff employees x 157 RMUs= 1,884 and 180 from CMUs X No. 0 Total number of 1.8 Health personnel receiving 16182 17375 17435 17711 17707 18008 104418 health personnel training [NEW] trained annually under the project People with access to a basic package of health [DROPPED] Intermediate Results (Component 2): Strengthening Health Financing and Management Reforms 2.1 Staff of reformed PHC and No. 0 100 418 418 418 418 418 2190 (to coincide Progress report CPIB hospitals receiving training in X with training financial management cycle) 16 Baseline Cumulative Target Valuesh Description (indicate E Unit of Original Data Source/ Responsibili definition, etc.) Indicators a Project Frequency ty for Data C Measure Start 2012 2013 2014 2015 2016 2017 2018 Methodology Collection (2011) 2.2 Percent of recurrent % 6.1% At least Annual MOF/MOH CPIB expenditures not related to salary 20% records relative to actual expenses of: a) SVPs b) Central Rayon hospitals (CRHs) c) Urban family polyclinics [DROPPED] 2.3 National Health Accounts No. 0 1st report 2nd report 2 reports 2 reports NHA reports MOH/Statisti developed and published cal Committee 2.4 Public Expenditure Review No. 0 1st report 2nd report 2 reports 2 reports PER reports CPIB developed No 0 ToR Developm Payment Results Con- All 3 Obl. Finance 2.5 Volume and Cost contract developed ent and started analyzed tract hospitals Departments/ introduced in 3 hospitals in signing of renew- are paid Obl. Health Fergana oblast contracts ed accord- Departments by hos- ing to / MOH pitals contract 2.6 Number of urban PHC No. 0 76 36 43 155 Progress Reports CPIB facilities (urban family policlinics) converted to per capita financing system [NEW] L Intermediate Results (Component 3): Institutional Strengthening for NCD Prevention and Control 3.1 Number of video clips on No. 0 3 3 6 Progress report Institute of health education on Health/CPIB cardiovascular risk factors 3.2 Number of people screened for (a) hypertension, and (b) diabetes through community- based screening programs in targeted areas [DROPPED] 0 Baseline 5% 10% General Independent Number of pilot increas increase Population firm hired by oblast respondents 3.3 Percent of population in e Survey CPIB familiar with risk targeted oblasts knowing factors of cardiovascular risk factors cardiovascular diseases/total number of respondents 3.4 (a) Public Health specialists X No. 0 50 50 0 20 0 20 140 Annual Progress report Institute of (surveillance staff) and (b) health Health/CPIB promotion specialists trained 0 0 12 12 12 54 90 17 Annex 2: Operational Risk Assessment Framework (ORAF) Uzbekistan:Additional Financing to Health System Improvement Project (P133187) Stakeholder Risk Rating Moderate Description: Risk Management: Continued advocacy by the Bank for the reform agenda with intensive consultations with Govemment and donor's Rik thath soem t' engagemnt i community; communication strategy implemented to inform stakeholders on reform agenda; tote hathn scref e n Beneficiary surveys to be carried out over the project period to monitor, among other things, patients' satisfaction with not maintained since thesevcdliry development of the CPS 12-15; Govemment unwillingness to share MOH/CPIB Preparation Recurrent: Due Frequency in information on health statistics and Date: July2013 Three: progress clearly communicate the reform agenda; end beneficiaries have limited voice in influencing quality of health services Capacity Rating Moderate Description: Risk Management: There is a risk of insufficient coordination of project activities Regional representatives of CPIB are posted in each Health Department for coordination of activities and technical across various agencies and levels support and serve as the Hospital Program Committees. (central, oblast levels); T r D D implementation delays may occur Resp: Bank Stage: Implementation Recurrent: Due Date: Frequency Status: In due to weak management capacity at x 0 June, 2013 Once: progress the oblast level; major impediment Risk Management: to project implementation would be the government requirement for Project Operations Manual will be updated to reflect the additional financing activities contracts registration and price Resp: Client Stage: Implementation Recurrent: Due 30 June, Frequency Status: Not yet verification by the MOH and the 0 Date: 2013 Once due Ministry for Foreign Economic 18 Relations, Investment, and Trade (MFERIT). Risk Management: The country office has been working with the government to reduce the time for contract registration Resp: Bank Stage: Implementation Recurrent: Due Frequency: Status: In XQ Date: progress Capacity: govemment intemal Risk Management: review and approval procedures Project Operational Manual to clearly define processes and roles and responsibilities on technical and fiduciary areas. could cause delays for project colde elays fResp: Client Stage: Implementation Recurrent: Due 30 June, Frequency: Status: completed implementation 0 Date: 2012 Once Risk Management: Regional representatives of CPIB posted in each Oblast Health Dept. help to improve coordination of activities and technical support in M&E. Resp: Client Stage: Implementation Recurrent: Due Frequency: Status: In x 0 Date: progress Governance Rating High Description: Risk Management: There is a strong executive system 1. Country office has been working with the government to improve governance through ongoing dialogue. with few checks and balances; Resp: Client Stage: Implementation Recurrent: Due Frequency: Status: In Transparency International and x Date: progress indicators for the country are among Bank the lowest in the world; Low transparency and external 0 accountability and limited voice and participation of citizens. Design Rating Low Description: Risk Management: Minimal risk as this is a scale up of an on- going project with Resp: Stage: Recurrent: Due Frequency: Status: satisfactory implementation rating. 0 Date: 19 Social and Environmental Rating Low Description: Risk Management: The EMF was disclosed before appraisal of Health 3 project. The updated EMF for the AF project was disclosed in country The project triggers Environmental and in the Bank's Infoshop in December 3, 2012. Compliance of civil works to the revised construction and environmental Safegruardiolicy OPd 4.1bectaun o norms and standards is monitored by the CPIB. The Bank implementation support missions will review the progress during construction and rehabilitation prjc. mlmntto eid work tobe fnaned uingproject implementation period. works to be financed using Govemment's funds (Bank funds Resp: Bank Stage: Implementation Recurrent: Due Frequency: Status: in will finance equipment, not & Date: progress constructions). OP 4.12 is not Client triggered because there will be no xO resettlement or land acquisition. The risk lies in whether the implementation of safeguards will be smooth. Program and Donor Rating Low Description: Risk Management: The risk in this area is minimal because the project supports the Govemment's health reform agenda. DueF Govemment is financing all civil works (est. at US$300 million 0 equivalent) and is not dependent on other donors' contribution. Delivery Monitoring and Rating Moderate Sustainability Description: Risk Management: Risk is limited given the CPIB is Annual Hospital Investment and Recurrent Plans, including plans execution, will be subject to Bank review (Legal Covenant). staffed with consultants who have Bank to continue advising on application of good contract management practices. experience in managing Bank Resp: Client Stage: Implementation Recurrent: Due Frequency: Status: i financed projects; weak contracts R Due Fe ncSau I management may lead to poor x quality of goods and services. 20 55°E 60°E 65°E 70°E KAZAKHSTAN To Atreau .- Arl 45N 45°N -. Sea 20>01 leve/ of Aral Sea -990 leve/ of Aral Sea ZBEKISTAN \ 1960 leve/ of Aral Sea Ust-y u r t P alte a uKAZA KH STAN P / a1t e a u Myo.. ........·- AZ HST \ KARA ALPAKSTAN K z TNkus KYRGYZ TQNvylord ( kdelyÃ¥aTgh; REPUBLIC Vchkuduk T (4301m aoro NAMANGAN'srhhkek ° . ....-Urgench yo \ ) ANDIZH AN KHOREZMu SYRDARYA TASHKENT cl H ---'' SKENT 'n iz. 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