The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) EUROPE AND CENTRAL ASIA | Kazakhstan | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2016 | Seq No: 11 | ARCHIVED on 29-Apr-2021 | ISR46071 | Implementing Agencies: Ministry of Health, Ministry of Health, Republic of Kazakhstan Key Dates Key Project Dates Bank Approval Date: 27-Apr-2016 Effectiveness Date: 27-Jun-2017 Planned Mid Term Review Date: 22-Jun-2020 Actual Mid-Term Review Date: 15-Jun-2020 Original Closing Date: 30-Jun-2021 Revised Closing Date: 30-Jun-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) The proposed Project Development Objective is to improve accessibility, quality, and efficiency of health service delivery, and reduce financial risks to the population that are caused by serious health problems. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Component 1. Supporting implementation of the national mandatory Social Health Insurance system:(Cost $16.63 M) Component 2. Strengthening of health service delivery to support implementation of the national mandatory Social Health Insurance system:(Cost $62.94 M) Component 3. Project management, monitoring and evaluation, and communications strategy:(Cost $10.43 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Overall Risk Rating Substantial Substantial Implementation Status and Key Decisions Health reform implementation. Since introduction of the mandatory social health insurance in January 2020, there has been a positive impact in terms of the volume of health care received by the population, including availability of expensive diagnostic services, planned/elective health services, and rehabilitation. Some quantitative indicators related to performance of the Social Health Insurance Fund in 2020 include: (i) 11 million of consultation and diagnostic services, 215 million of outpatient services, and 10,000 of expensive surgeries financed by the Social Health Insurance Fund; and (ii) 720,000 citizen inquiries have been processed and addressed by the Social Health Insurance Fund’s citizen engagement department. However, due to COVID-related quarantine measures and ensuing reductions in the provision of routine health services to the population during several months in 2020, the impact of the social health insurance implementation may have a delayed effect, including in terms of 4/29/2021 Page 1 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) measurable health outcome indicators. Since the start of collecting the contributions on July 1, 2017 and with expansion of contribution payer categories on January 1, 2020, the total amount of contributions pooled by the Social Health Insurance Fund reached KZT 550 billion and the health insurance coverage comprised 15.9 million (84.1%) of the total population as of January 2021. Project implementation status. Most project activities under all the three components have been completed, with a few ongoing activities to be completed by the current closing date of June 30, 2021. Under Component 1, activities supporting implementation of the Mandatory Social Health Insurance (MSHI) system have largely been finalized, including on strengthening the organizational and institutional structure of the MSHI system and enhancing purchasing and payment arrangements in the MSHI context. Under Component 2, most of the activities supporting the improvement of the health facility network, managing the quality of health care services, and strengthening human resources for health care are implemented satisfactorily overall, with support to Kazakhstan’s COVID-19 response effectively provided under the project through procurement of life-saving equipment. Under Component 3, continuous support has been provided to project management, monitoring and evaluation, communications, and citizen engagement activities. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate Moderate Moderate Macroeconomic Substantial Substantial Substantial Sector Strategies and Policies Substantial Moderate Moderate Technical Design of Project or Program Substantial Moderate Moderate Institutional Capacity for Implementation and Substantial Moderate Moderate Sustainability Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Substantial Substantial Substantial Other Substantial Substantial Substantial Overall Substantial Substantial Substantial Results PDO Indicators by Objectives / Outcomes Improve accessibility, quality, and effeciency of health service delivery and reduce financial risk IN00972884 ►Increase public expenditure share for PHC + consultation and diagnostic care + outpatient drugs (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 35.00 40.80 45.20 40.00 Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 4/29/2021 Page 2 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) End-target value for this indicator has been surpassed. The data reflected in PMU/MoH's annual progress report are based on annual National Health Accounts Comments: report for 2019. The data for 2020 will be available in Q4 of 2021. IN00972885 ►Percent of all surgeries included in the “outpatient elective surgeries” list performed as outpatient surgeries in project-supported hospitals and outpatient facilities (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 38.00 28.00 40.00 Date 18-Sep-2015 14-Aug-2020 12-Feb-2021 30-Jun-2021 This decrease (reversal) in the share of outpatient elective surgeries from 31.9% in 2019 to 28% in 2020 has been due to suspension of all routine health services for a few months during the lockdown periods Comments: (38% indicated as actual previous value was for Q2 of 2020). IN00972886 ►Percent of all contracted inpatient services subject to technical audit (annually) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 14.00 26.00 30.00 Date 18-Sep-2015 14-Aug-2020 12-Feb-2021 30-Jun-2021 This decrease (slight reversal) in the share of all contracted inpatient services subject to technical audit has decreased from 26.6% (2019) to 26% (2020) due to limited scope of technical audits during the Comments: pandemic (14% indicated as actual previous value was for Q2 of 2020). IN00972887 ►SHIF is fully functional based on predefined criteria (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 18-Sep-2015 14-Aug-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved. Full functionality of the SHIF is reflected in all the six criteria having been satisfied as part of its functioning as the purchaser of health services under the SGBP and MSHI: (i) the law on MSHI was adopted and relevant by-laws were updated; (ii) SHIF signed contracts with providers for a specific sets of services; (iii) the insurance package has been approved (Government Decree No.421 dated June 20, 2019) and is under implementation; (iv) SHIF completed annual external financial audits for previous years; and (v) Comments: SHIF has positive balance between revenues and expenses; (iv) while utilization of, and payments for, regular health services were adversely affected by the COVID-related restrictions in Quarters 1 and 2 of 2020, the adjustments to payment terms and schedules subsequently implemented by the SHIF have introduced flexibility that allowed the achievement of the last criterion (health facilities received payments for services contracted by SHIF, in accordance with payment schedules specified in their contracts). IN00972888 ►Proportion of the bottom 40% of households spending 10% and more on health services and non-food goods in the health sector out of total expenditure on paid services and non-food goods (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.50 10.70 10.70 12.80 Date 30-Jun-2016 14-Aug-2020 12-Feb-2021 30-Jun-2021 4/29/2021 Page 3 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) The revised end-target value for this indicator has been achieved. Based on data for 2019 from the Statistics Committee, the value of this indicator has decreased to 10.7%. Comments: The 2020 value for this indicator will be available in Quarter 3 of the calendar year 2021. Overall Comments PDO Satisfactory progress of health sector reforms and, respectively, towards achievement of the PDO is reflected in some of the PDO-level indicators while some reversal is observed in others given the impact of COVID-19 restrictions. Specifically, three out of five indicators (PDO 1, 4, and 5) have already achieved their end-targets while two indicators (PDO 2 and 3) recorded reversals. Intermediate Results Indicators by Components Component 1. Supporting implementation of the National Mandatory Social Health Insurance System IN00972889 ►Percent of population for whom SHIF received SHI contributions/subsidies (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 83.90 84.10 83.00 Date 18-Sep-2015 17-Jun-2020 31-Mar-2021 30-Jun-2021 This indicator has achieved its end-target value. MSHI coverage (SHI contributions/subsidies received) comprised 15.9 million (84.1%) of the total Comments: population as of January 2021 (data for this indicator was updated following the mission). IN00972892 ►Achievement of key benchmarks for functioning social health insurance system (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Partial Yes Yes Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved. The Road Map for MSHI implementation was approved through MoH Order No.764 dated October 16, Comments: 2017 and key benchmarks for a functioning social health insurance system have been achieved. IN00972893 ►Key adjustments in the contracting methods are adopted to include incentives for providers to improve quality (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No Yes Yes Yes Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 This indicator is achieved. Contracts with key adjustments to improve quality are already being implemented as part of the second- Comments: phase of the MSHI reform as of January 2020 (based on MoH Order dated March 16, 2020). 4/29/2021 Page 4 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Component 2. Strengthening of health service delivery to support implementation of the national mand IN00972890 ►Number of fully functional regional PHC excellence centers (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 17.00 17.00 16.00 Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved. 16 regional PHC excellence centers have been identified through the MoH Order No.239 dated May 5, Comments: 2018. Following the establishment of the new Turkestan oblast on June 19, 2018, this number has increased to 17 and all of them have achieved the criteria of their full functionality. IN00972891 ►Number of regions implementing disease management programs with evidence-based effectiveness, including incentives for health providers and patients (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 2.00 17.00 17.00 16.00 Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved. Following the establishment of the new Turkestan oblast on June 19, 2018, this number has increased to Comments: 17 and all of them are implementing disease management programs for the three conditions (arterial hypertension, diabetes, and chronic heart failure) based on the MoH Order No.348 dated June 11, 2018. IN00972894 ►Number of educational programs developed and implemented in medical education institutions based on competence-based approach and professional standards through strategic partnerships (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 16.00 18.00 5.00 Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 End-target value for this indicator has been surpassed. Activities measured by this indicator have been implemented ahead of schedule and on a much larger scale. 18 competence-based educational programs were developed and have been implemented since 2018: one in General Practice (Bachelor), one in Pediatrics (Residency), three in Public Health (Bachelor, Master, doctorate), one in Traumatology and Orthopedics (Residency), one in Nuclear Medicine Comments: (Residency), one in Emergency Care (Residency), one in Anesthesia and Rehabilitation (Residency), one in Neurology (Residency), three in Nursing Care (vocational, Master, doctorate), one in Healthcare Management (Master), one in Bioengineering (Master), one in Medical Laboratory Technician specialty (Master), one in Paramedical specialty, and one in Medical Physics specialty. Three more programs are under development and planned to be implemented in 2021. IN00972895 ►Unified register of human resources for health implemented (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 4/29/2021 Page 5 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) Methodology and module for planning and forecasting human resources for health have been developed. However, completion of the unified register of human resources for health is challenging due to several factors. Comments: This indicator is planned to be revised as part of the project restructuring, with the rationale for the revision to be reflected in the Restructuring Paper. IN00972896 ►Health personnel receiving training (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 8,527.00 9,511.00 3,400.00 Date 18-Sep-2015 17-Jun-2020 10-Feb-2021 30-Jun-2021 End-target value for this indicator has been surpassed. As of February 10, 2021, a total of 9,511 health sector workers have been trained under all Project Comments: components, including 1,489 health sector workers trained in 2020. IN00972897 ►Health facilities constructed, renovated, and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 56.00 56.00 50.00 Date 18-Sep-2015 17-Jun-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved due to an increased number of health facilities equipped with COVID-19 Comments: related equipment. IN00972898 ►Percentage of patients reporting improved health services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value n/a 36.8% 40.4% +10% over baseline Date 18-Sep-2015 15-Apr-2020 12-Feb-2021 30-Jun-2021 This indicator has been achieved. Baseline: The December 2018 (baseline) survey found that, on average, 22.5% of patients across all the regions have reported improvements in health services provision. 2020: In a follow-up survey conducted in Q3 of 2020, in response to the question "How would you assess Comments: changes in health services provision in public health facilities over the last 6 months?", 40.4% of respondents reported improvements in health services provision, 29.6% reported no changes, 5.1% reported worsening, and 25% had difficulty answering this question. IN00972899 ►Increase in transparency, credibility, and effectiveness of the complaints handling system (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 54.80 71.00 60.00 Date 18-Sep-2015 15-Apr-2020 12-Feb-2021 30-Jun-2021 Comments: This indicator has been achieved. 4/29/2021 Page 6 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) 2018: Based on findings from December 2018, on average, 57% of the population across all the regions rated the transparency, credibility, and effectiveness of the existing complaints handling system as High. 2019: In follow-up survey conducted in August 2019, 54.8% of those who used the existing complaints handling system rated its transparency, credibility, and effectiveness as High, and 45.2% rated it as Low. 2020: In a follow-up survey conducted in Q3 of 2020, in response to the question "How would you assess transparency, credibility, and effectiveness of the existing complaints handling system in health facilities?", assessment of 71.0% of respondents who used the complaints handling system in health facilities was "High" and that of 29.0% was "Low". Overall Comments IR All but one intermediate results (IR) indicators have been achieved. Performance-Based Conditions Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P152625 IBRD-86170 Effective USD 80.00 80.00 0.00 31.96 48.04 40% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P152625 IBRD-86170 Effective 27-Apr-2016 01-Nov-2016 27-Jun-2017 30-Jun-2021 30-Jun-2021 Cumulative Disbursements 4/29/2021 Page 7 of 8 The World Bank Implementation Status & Results Report Social Health Insurance Project: Improving Access, Quality, Efficiency and Financial Protection (P152625) PBC Disbursement Achievement Disbursed amount in Disbursement % PBC ID PBC Type Description Coc PBC Amount Status Coc for PBC Restructuring History Level Approved on 11-Dec-2018 ,Level 2 Approved on 24-Dec-2018 Related Project(s) There are no related projects. 4/29/2021 Page 8 of 8