Document of The World Bank FOR OFFICIAL USE ONLY Report No : RES17320 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF DISEASE PREVENTION AND CONTROL PROJECT CREDIT APPROVED ON MARCH 27, 2013 TO THE REPUBLIC OF ARMENIA February 27, 2015 Health, Nutrition and Population Global Practice 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. ABBREVIATIONS AND ACRONYMS DA Designated Account FM Financial Management HPIU Health Project Implementation Unit IDA International Development Association IP Implementation Progress MCH Maternal Child Health MC Medical Center MOH Ministry of Health NCD Non-Communicable Disease OBGYN Obstetrics and Gynecology PBF Performance Based Financing PDO Project Development Objectives PHC Primary Health Care POM Project Operational Manual SC Steering Committee SHA State Health Agency USD United States Dollar Regional Vice President: Laura Tuck Country Director: Henry G. Kerali Practice Manager/Manager: Daniel Dulitzky Task Team Leader: Wezi Msisha Page 2 of 21 REPUBLIC OF ARMENIA Disease Prevention and Control Project CONTENTS Page No. A. SUMMARY 2 B. PROJECT STATUS 3 C. PROPOSED CHANGES 3 ANNEX 1: RESULTS FRAMEWORK AND MONITORING 10 Page 3 of 21 DATA SHEET Armenia Disease Prevention and Control Project (P128442) EUROPE AND CENTRAL ASIA 0000009074 Report RES17320 No: Basic Information Specific Investment Project ID: P128442 Lending Instrument: Loan Partial Assessment Regional Vice President: Laura Tuck Original EA Category: (B) Partial Assessment Country Director: Henry G. R. Kerali Current EA Category: (B) Senior Global Practice Timothy Grant Evans Original Approval Date: 27-Mar-2013 Director: Practice Daniel Dulitzky Current Closing Date: 15-Dec-2019 Manager/Manager: Team Leader: Wezi Marianne Msisha Borrower: Ministry of Finance & Economy Responsible Ministry of Health, HSMP-PIU Agency: Restructuring Type Form Type: Full Restructuring Paper Decision Authority: Country Director Approval Restructuring Level 2 Level: Financing ( as of 09-Dec-2014 ) Key Dates Approval Effectiveness Original Revised Project Ln/Cr/TF Status Signing Date Date Date Closing Date Closing Date P128442 IDA-52220 Effective 27-Mar-2013 17-May-2013 22-Jul-2013 15-Dec-2019 15-Dec-2019 P128442 TF-14138 Effective 11-Jul-2013 27-Sep-2013 27-Sep-2013 31-Dec-2018 31-Dec-2018 Disbursements (in Millions) Cancelle Disburs Undisburs % Project Ln/Cr/TF Status Currency Original Revised d ed ed Disburse Page 4 of 21 d P128442 IDA-52220 Effective USD 35.00 35.00 0.00 5.57 27.85 16 P128442 TF-14138 Effective USD 1.80 1.80 0.00 0.00 1.80 Policy Waivers Does the project depart from the CAS in content or in other significant Yes [ ] No [ X ] respects? Does the project require any policy waiver(s)? Yes [ ] No [ X ] A. Summary of Proposed Changes This proposed Level II restructuring responds to the request of the Government of Armenia (the Borrower) of November 26, 2014, and seeks the approval of the Country Director to make changes to the Disease Prevention and Control Project (the Project) ( P128442; Credit No. 5222-AM). The proposed changes aim at reallocating an amount of US$8.1 million that became available as a consequence of the mis-procurement without cancellation declared in September, 2014, and related to the Vanadzor Medical Center (MC) civil works. The restructuring includes: (a) modifications of the Project results framework consisting of revision of some Project Development Objective (PDO) indicators and intermediate results indicators, including baseline and target values; (b) revision of activities in component 1 “Performance-Based Financing (PBF)” and sub-component 2.1 of component 2 “Improving Efficiency and Quality of Selected Hospitals”, respectively; and (c) revision of certain legal covenants related to the PBF component. Change in Implementing Agency Yes [ ] No [ X ] Change in Project's Development Objectives Yes [ ] No [ X ] Change in Results Framework Yes [ X ] No [ ] Change in Safeguard Policies Triggered Yes [ ] No [ X ] Change of EA category Yes [ ] No [ X ] Other Changes to Safeguards Yes [ ] No [ X ] Change in Legal Covenants Yes [ X ] No [ ] Change in Loan Closing Date(s) Yes [ ] No [ X ] Cancellations Proposed Yes [ ] No [ X ] Change to Financing Plan Yes [ ] No [ X ] Change in Disbursement Arrangements Yes [ ] No [ X ] Reallocation between Disbursement Categories Yes [ X ] No [ ] Change in Disbursement Estimates Yes [ X ] No [ ] Change to Components and Cost Yes [ X ] No [ ] Change in Institutional Arrangements Yes [ ] No [ X ] Change in Financial Management Yes [ ] No [ X ] Change in Procurement Yes [ ] No [ X ] Change in Implementation Schedule Yes [ ] No [ X ] Page 5 of 21 Other Change(s) Yes [ ] No [ X ] Appraisal Summary Change in Economic and Financial Analysis Yes [ ] No [ X ] Appraisal Summary Change in Technical Analysis Yes [ ] No [ X ] Appraisal Summary Change in Social Analysis Yes [ ] No [ X ] Appraisal Summary Change in Environmental Analysis Yes [ ] No [ X ] Appraisal Summary Change in Risk Assessment Yes [ ] No [ X ] B. Project Status The Credit was approved on March 27, 2013, in the amount of SDR 22,800,000 (US$35 million equivalent) and became effective on July 22, 2013. The Project is the continuation of a long-term stable cooperation in the Health Sector between the World Bank and the Republic of Armenia, and builds upon previous support to health sector reforms in health financing, primary health care and hospital modernization and optimization. The Project supports the Government’s National Non-communicable Disease (NCD) strategy that focuses on prevention and control of diseases contributing to high morbidity and mortality. The PDO is to improve: (i) Maternal and Child Health (MCH) services and the prevention, early detection, and management of selected non-communicable diseases at the Primary Health Care (PHC) level; and (ii) the efficiency and quality of selected hospitals in Armenia. Progress toward achieving the PDO has been rated as satisfactory since effectiveness, with overall implementation progress (IP) also rated as satisfactory. The amounts disbursed under the Project as of February, 2015 are as follows: (a) Credit 5222 – SDR 3.67 million has been disbursed, representing 16.1 percent of the total credit of SDR 22.8 million equivalent. Commitments (contracts signed) are around US$3.04 million; and (b) under the Health Results Innovation Trust Funds (HRTF) associated to Component 1 (PBF) of the Project: (i) Grant TF 13103: US$0.40 million has been disbursed, representing 100 percent of the total grant of US$0.40 million. Commitments represent US$83,000. (ii) Grant TF 14138-US$0.18 million has been disbursed, representing 10 percent of the total grant. The national program for screening of NCDs (hypertension, diabetes, and cervical cancer) supported by the Project has been launched, and primary health care providers have been trained to implement the screening program. Work to rehabilitate the national Hematology Center to provide modern health care services, including the creation of a Bone Marrow Transplantation Unit, is underway. The design of a new national oncology inpatient facility and radiotherapy center has also been initiated and is expected to result in increased access by the population to quality cancer treatment services. Procurement administration is rated as “Unsatisfactory”, due to irregularities identified in early 2014 in the bidding and contracting process for the construction of the Vanadzor Medical Center (US$ 8.1 million), which led to the declaration of mis-procurement without cancellation of US$8.1 million by the Regional Vice President by notice to the Borrower dated September 11, 2014. The justification for not cancelling the US$8.1 million was that: (a) no Credit funds had been spent on the activity in question; (b) the new Government was appointed after the violations had occurred and was therefore not aware of the violations and the circumstances leading to them; and (c) the new Government committed to undertaking its own investigation into the situation and taking remedial actions. The Government’s letter outlining the findings of their investigation was sent to the Bank on December 8, 2014, in which the following actions were also stated: (i) supervising of all civil works financed under the Project by an independent company in addition to the normal supervision carried out by the HPIU (already Page 6 of 21 in practice as of May 2014); (ii) following the Bank’s no objection to civil works bidding documents, the HPIU visits the work site to ensure no works have been initiated prior to contract signing; (iii) the HPIU has taken steps to increase awareness among construction companies of tender announcements to ensure wide participation and competition, including notifying foreign embassies and professional associations of tenders; and (iv) the Government requests the Bank’s support in improving procurement capacity for the HPIU staff on contract management. The Financial Management (FM) arrangements at the HPIU, including planning and budgeting, accounting, financial reporting, external audit, and funds flow are satisfactory and acceptable to the Bank. The level and timeliness of government co-financing is satisfactory. Environmental Safeguards. The Project’s rating on safeguards compliance is Satisfactory. An Environmental Management Framework developed and adopted for guiding site-specific environmental work is being followed through. C. Proposed Changes Development Objectives/Results Project Development Objectives Original PDO The Project development objective is to improve (i) Maternal and Child Health (MCH) services and the prevention, early detection, and management of selected Non-Communicable Diseases (NCD) at the Primary Health Care (PHC) level; and (ii) the efficiency and quality of selected hospitals in Armenia. Change in Project's Development Objectives Change in Results Framework Explanation: Some PDO indicators are revised due to changes in the age-group of targeted population for the screening program from 40-74 to 35-68 age-group in order to better reflect the population at risk for NCDs. The target values are also revised to be more realistic based on new baselines. PDO indicator on bed occupancy rate is now related to the Artashat Medical Center (MC) instead of the Vanadzor MC. A number of Intermediate Results Indicators are dropped and or revised to reflect, among others, the changes to the Impact Evaluation design and the PBF verification mechanisms. Clarification from the HRITF administrators on the activities that could be financed by the Bank-executed impact evaluation fund, indicate that activities such as financing an independent group to conduct an ex-poste counter-verification of services under the PBF scheme are not eligible as previously understood. Further, hiring of an independent entity such as a survey firm to counter-verify performance results would not be cost-effective given the PBF scheme which is already implemented country-wide, is quite unified with no variation in its implementation across regions. Although it is not possible to have an independent counter-verification Entity (this also requires changes to the legal covenants), ex-poste counter-verification would still be done as further explained below. Following an assessment of key gaps in the current national PBF scheme, it was agreed with the client that the current system of ex-ante verification of performance results will be further enhanced through additional in-depth reviews that will be undertaken by a special Working Group consisting of competitively recruited local experts. This will ensure more through checking of PHC facility performance results prior to release of payments. In order to provide a more realistic basis for assessing the progress of the Project activities, some end-of-Project targets are also adjusted. One indicator is added to reflect the proposed Project support to the establishment of a new integrated model of health care services at the Sevan MC (See Annex 1 for more details on the changes to the Results Framework). Page 7 of 21 Change in Legal Covenants Explanation: As the State Health Agency’s (SHA) capacity to perform verification and technical reviews of the PBF scheme is being strengthened under the Project by a special Working Group consisting of competitively selected local experts; the covenants related to the Independent Counter-verification Entity will be removed as part of the Project restructuring. The HPIU and the Working Group would instead conduct ex-poste counter-verification checks through face- to face meetings with and phone calls to randomly selected patients to verify if services were actually received. In addition patient records in PHC facilities would be reviewed, and the annual Project audit would also review a sample of PBF payments made to PHC facilities. A telephone hot-line will also be established to get feedback from the population on services provided by the PHC facilities, and periodic focus group discussions would also be conducted with providers and patients. Finance Ln/Cr/T Date Recurre Frequenc Agreement Description of Covenant Status Action F Due nt y Reference The Recipient, no later than 30 days after Effectiveness Date, shall create and thereafter maintain: the SC consisting of the Project representatives of the Steering MoH and other key Committee IDA-522 stakeholders, with the 15-Aug- Complie No (SC) 20 responsibility of guiding 2013 d with Change established and coordinating the and implementation of the maintained Program, defining TOR, participating in technical evaluations and working directly with consultants on arrangements of strategic TA. The Recipient, no later than 30 days after the Effectiveness Date, shall create and thereafter maintain a PHC PHC Coordinating Committee, Coordinating with membership and IDA-522 Committee 15-Aug- Complie No composition acceptable 20 established 2013 d with Change to the Associations, and including representatives maintained of the relevant MOH departments and units, SHA and the HPIU, with the responsibility of supervise and guide the Page 8 of 21 implementation of PBF Scheme. The Recipient shall not x later than six months after effectiveness, select and contract an independent counter-verification entity with experience Independent and qualifications in the Marked IDA-522 Counter-verifi health and social sectors 31-Dec-2 Not yet for 20 cation Entity acceptable to the 014 due Deletion selected Association, in accordance with terms of reference satisfactory to the Association, for the carrying out of technical reviews of agreed results during project implementation. The Recipient shall cause the Independent Counter-verification Independent entity to carry out at least Counter-verifi two technical reviews per Marked IDA-522 cation Entity year during Project Not yet Yearly for 20 technical implementation, and due Deletion reviews thereafter prepare a carried out report of such scope and in such details the Association shall reasonably request. The Recipient shall Independent furnish to the Association Counter-verifi as soon as available, the Marked IDA-522 cation Entity Not yet reports of the Yearly for 20 reports due independent Deletion furnished to counter-verification Association entity The Recipient shall as soon as possible after the Effective Date, Verification established a Verification IDA-522 Working Working Group Not yet Yearly New 20 Group comformed by members due established with experience and qualifications in the health and social sectors acceptable to the Page 9 of 21 Association, pursuant to the provisions of Section III of this Schedule and in accordance with terms of reference satisfactory to the Association, for the carrying out of technical reviews of agreed results during Project implementation, particularly focused on the compliance with the verification protocols included in the PBF Manual. The Recipient shall cause the Verification Working Group to carry out the verification of quantity and quality of primary care services piror to the Verification release of the PBF Working payments on a IDA-522 Group Not yet Semi-ann semi-annual basis, and in New 20 verification due ually accordance with the done criteria set forth in the semi-annually PBF Manual; and thereafter prepare a report of such scope and in such details the Association shall reasonably request. The Recipient shall Verification furnish to the SHA and Working the Association as soon IDA-522 Group Reports Not yet Semi-ann as available, the reports New 20 furnished to due ually of the Verification the Working Group referred Association to in paragraph (b) above. The Recipient shall enter into an agreement with each of the Eligible PHC PHC facilities (“PHC IDA-522 Performance Performance Complie No Yearly 20 Agreements Agreements”), under d with Change entered terms and conditions approved by the Association and elaborated in the PBF Page 10 of 21 Manual, setting forth the technical, administrative and fiduciary aspects of their participation in the implementation and use of funds under Part 1(a) of the Project. The Recipient shall operate and maintain, until the completion of the Project, an implementation unit Health Project within MOH, to be IDA-522 Implementatio responsible for the Complie No Yearly 20 n Unit (HPIU) overall coordination of d with Change maintained the Project (the “HPIU”). Such unit shall have staff in adequate numbers and with qualifications and experience satisfactory to the Association. The Recipient, not later than 30 days after the Effectiveness Date, shall have executed the Project Co-financing Agreement IDA-522 Operational Complie No and all conditions Yearly 20 Manual d with Change precedent to its (POM) effectiveness or to the right of the Recipient to make withdrawals under it have been fulfilled. The Recipient shall carry Performance-b out the Project in IDA-522 ased Financing accordance with the Complie No Yearly 20 Manual Performance-Based d with Change (PBFM) Financing (PBF) Manual dated February 12, 2013. Financing Reallocations Explanation: Project funds would be reallocated between components and disbursement categories as the construction of the Vanazdor MC (original allocated amount of US$8.1 million) is cancelled. It is proposed that these funds be used to strengthen current PBF-related activities and carry out a nationwide survey for the development of the Health Sector Performance Assessment Report for the year 2015 under Component 1 (estimated at SDR 516,000) and support the hospital modernization effort at the Artashat, Sevan, and Megri Medical Centers under sub-component 2.1 of Component 2 (estimated at SDR 5,233,161). Page 11 of 21 Exchange rate: SDR 1 = 1.4089 (as of February 11, 2015) Current Category of Disbursement % (Type Ln/Cr/TF Currency Allocation Expenditure Total) Current Proposed Current Proposed GD, CS, TRNG, TF-14138 USD 243,000.00 243,000.00 100.00 100.00 Workshops, IOC Perform.based 1,557,000.0 1,557,000.0 100.00 100.00 finan.under Part 1(a) 0 0 Designated Account 0.00 0.00 0.00 0.00 1,800,000.0 1,800,000.0 Total: 0 0 G, CW, non-CS, IOC 21,180,000. IDA-52220 XDR 20,664,000. 80.00 80.00 ,TR, CS, AUDIT 00 00 Perform.based 1,620,000.0 2,136,000 100.00 100.00 finan.under Part 1(a) 0 .00 Designated Account 0.00 0.00 0.00 0.00 22,800,000. 22,800,000. Total: 00 00 Disbursement Estimates Change in Disbursement Estimates Explanation: As the new activities can only begin after approval of the restructuring by both the Bank and the Government, there will be a slight lag in disbursement for this calendar year. Fiscal Year Current (USD) Proposed (USD) 2014 3,300,000.00 850,000.00 2015 5,000,000.00 4,650,000.00 2016 8,000,000.00 8,000,000.00 2017 10,200,000.00 13,000,000.00 2018 5,000,000.00 5,000,000.00 2019 2,500,000.00 2,500,000.00 2020 1,000,000.00 1,000,000.00 Total 35,000,000.00 35,000,000.00 Components Change to Components and Cost Explanation: The US$8.1 million initially allocated for the construction of the Vanadzor MC would be utilized to strengthen Project activities in Component 1 (PBF) and support the hospital modernization effort in Page 12 of 21 sub-component 2.1 of Component 2 as follows: Component 1 (increased allocation of US$727,000; total revised allocation of SDR 2,136,000): (a) an additional US$250,000 is allocated to the Performance-based payments for maternal and child health (MCH) and NCD subcomponent 1.1 to cover incentive payments to Primary Health Care (PHC) providers who may exceed the initial screening targets set by the Project; (b) an additional US$40,000 to support additional short term trainings for PHC providers on the NCD screening guidelines under sub-component 1.2; (c) an additional US$90,000 for the implementation of a nation-wide Health Sector Performance Assessment Survey for the year 2015; (d) an additional US$15,000 for advanced trainings of Obstetricians and Gynaecologists on colposcopy, including the provision of limited number of medical equipment to hospitals for the management of early stages of cervical cancer; and (e) an additional US$332,000 for the provision of IT equipment for about 350 PHC facilities. This activity will support implementation of the Integrated Health Information System in Armenia. Component 2 (reduced allocation of US$727,000; total revised allocation of SDR 20,664,000): The construction of Vanadzor MC under sub-component 2.1 (renamed as: “Modernization of Marz Hospital Network”) is deleted and replaced with: (a) rehabilitation of and provision of medical equipment, medical furniture and supplies to Artashat MC in Ararat Marz (US$4,148,000 million); (b) the construction of, and provision of medical equipment, medical furniture and supplies to a new medical center in Sevan and its merger with the Sevan CJSC polyclinic (US$2,450,000 million); and (c) provision of medical equipment, medical furniture and supplies to Megri regional MC (US$775,000). The allocation for: (i) medical and waste management equipment for the new Vanadzor MC; (ii) the provision of training to clinical staff and hospital administration,; and (iii) the financing of angiographs at the Gyumri hospital and Nork-Marash specialized cardiology and cardiac surgery center, remain valid as per the original project sub-component 2.1 (i.e. will be financed as originally planned from the other project funds, and not the reallocated funds). Current Component Proposed Component Current Proposed Action Name Name Cost Cost (US$M) (US$M) 1. Performance-based 4.30 5.03 Revised incentives to improve MCH and NCD services in primary care facilities 2. Hospital 38.90 38.17 Revised Modernization 3. Project Management 1.80 1.80 No Change Total: 45.00 45.00 Risk Category Rating 1. Political and Governance Low 2. Macroeconomic Low 3. Sector Strategies and Policies Low 4. Technical Design of Project or Program Low 5. Institutional Capacity for Implementation and Sustainability Moderate 6. Fiduciary Moderate 7. Environment and Social Low 8. Stakeholders Low 9. Other OVERALL Low Page 13 of 21 Annex 1: Results Framework and Monitoring REPUBLIC OF ARMENIA DISEASE PREVENTION AND CONTROL PROJECT Revisions to the Results Framework Indicator definition Comments/ Rationale for Change PDO Current (PAD) Proposed The original Project Continued Development Objective (PDO) is to improve (i) MCH services and the prevention, early detection, and management of selected non-communicable diseases at the PHC level; and (ii) the efficiency and quality of selected hospitals in Armenia. PDO indicators Current (PAD) Proposed change* 1. Percentage of antenatal care Continued Number of ANC visits The percentage is calculated (ANC) attendees screened for in which these 3 tests according to: the number of glycosuria, hypertension and were done X 100/Total pregnant women at 38 week of proteinuria in at least three number of ANC visits gestation registered with the antenatal visits in the last year obstetrician-gynecologist who passed three antenatal visits (urine and blood tests 3 times) within the reported period at 36-38 week of gestation X 100 / total number of pregnant women at 38 week of gestation registered with the obstetrician-gynecologist within the reported period 2. Percentage of population Revised to “Percentage of New definition: The age-group is revised to aged 40-74 screened for population aged 35-68 screened for 35-68 in order to better reflect Number of adults aged hypertension at least once in hypertension at least once in the the population at risk regarding 35-68 screened for the last year last year NCDs. The target values are hypertension at least a) female b) male” also revised to be more realistic once in the last year X based on new baselines 100/Total number of people in this age group (by gender) 3. Percentage of population Revised to “Percentage of New definition: The age-group is revised to aged 40-74 screened for population aged 35-68 screened for 35-68 in order to better reflect Number of adults aged diabetes mellitus at PHC level diabetes mellitus at PHC level at the population at risk regarding 35-68 screened for at least once during the last 3 least once during the last 3 years NCDs. The target values are diabetes mellitus for at years a) female b) male” also revised to be more realistic least once in the 3 based on new baselines years X 100/Total number of people in this age group 4. Percentage of women aged Continued Number of women aged 30-60 screened for cervical 30-60 screened for cancer at least once during the cervical cancer at least last 3 years and received the once and received the Page 14 of 21 Revisions to the Results Framework Indicator definition Comments/ Rationale for Change results results in the 3 years X 100/Total number of women in this age group 5. Bed occupancy rate at the Revised to “ Bed occupancy rate at The percentage of The indicator is revised to Bed new Medical Center in the new Medical Center in available beds which Occupancy Rate at new Medical Vanadzor Artashat” have been occupied over Center in Artashat based on a given period. This restructuring of the project, with indicator is used to Vanadzor no longer a project measure increase in bed activity. occupancy rate. 6. Quality of care in a) MCH; Dropped Level of Quality of The indicator is dropped due to and b) NCD provided by Care of doctors as the changes in the Impact doctors measured by clinical measured by clinical Evaluation design vignettes vignettes Intermediate Results indicators Current (PAD) Proposed change* Component 1: Performance-based Financing 1.1. % of PHC facilities in Dropped Number of PHC The indicator is dropped due to Group 1 of the study receiving facilities receiving the changes in the Impact verifications of results, independent Evaluation design supervision and feedbacks by verifications of results SHA within two months after on time every 6 months the end of every semiannual X 100/Number of PHC period facilities in the agreed sample size 1.2. % of patient in the sample Revised to An indicator is revised to the size receiving independent “Proportion of PHC facilities new one in order to be more verifications of results within undergoing enhanced verification compliant with the results two months after the end of of results by the SHA/Working verification performed by SHA every semiannual period Group” and Working group which will enhance the results verification process 1.3. % of eligible PHC Continued Number of PHC facilities receiving incentives facilities receiving within two months after the independent end of every semi-annual verifications of results period on time every 6 months X 100/Number of PHC facilities in the agreed sample size 1.4. Level of awareness among Continued, but baseline values are The percentage of adults Baseline values are changed to adults in key N CD risk factors changed to reflect HSPA 2012 who are aware about reflect 2012 HSPA survey data a) high blood pressure; b) high survey data mentioned NCD risk cholesterol level; c) high salt factors. The indicator is intake; d) obesity; e) high used to assess success glucose level of health promotion interventions 1.5. Health facilities Continued, but moved to This indicator measures Baseline and target values are constructed, renovated, and/or Intermediate Results Indicator the cumulative number changed to reflect only those equipped section 2 for Component B. of health facilities facilities that are supported by (number) Baseline and target values are constructed, renovated DPC project changed to reflect only those and/or equipped through facilities that are supported by DPC the Bank-financed project project. Component 2: Improving Efficiency and Quality of Selected Hospitals 2.1. Number of hospitals Dropped This indicator measures The indicator is dropped Page 15 of 21 Revisions to the Results Framework Indicator definition Comments/ Rationale for Change constructed/renovated and/or the cumulative number because an indicator that equipped of hospitals constructed, measures the cumulative renovated and/or number of hospitals equipped through the constructed, renovated and/or Bank-financed project. equipped through the Bank-financed project is already included in the results framework 2.2. % of pediatric patients Continued, but targets timeline is Number of pediatric As Hematology center will be newly diagnosed with revised to be more realistic patients newly acting since 2016, it is more onco-hematology conditions diagnosed with realistic to shift the targets by the Hematology Center who onco-hematology timelines forward by a year received treatment overseas in conditions by the the past year Hematology Center in the past year who received treatment overseas X 100/ Number of pediatric patients newly diagnosed with onco-hematology conditions by the Hematology Center in the past year 2.3. Number of new clinical Dropped Number of new CPG The indicator is dropped as the practice guidelines for hospitals developed following B4 (# of hospital developed for hospitals and adopted health workers receiving training in a set of new clinical practice guidelines) and B5 (% of public hospitals at marz level i mplementing Quality Improvement Program) indicators requires that clinical guidelines will be developed 2.4. Number of hospital Continued, but targets timeline is Key health workers are The process of developing health workers receiving revised to be more realistic supposed to be trained guidelines will be started in training in a set of new clinical once during the project 2015 and the guidelines will be practice guidelines and the target is ready for use by the end of cumulative 2015. 2.5. % of public hospitals at Continued, but targets timeline is The percentage of The implementation of the marz level implementing revised to be more realistic public hospitals Quality Improvement Program Quality adopting continuous in marz hospitals will be Improvement Program Quality Improvement effective in 2016 mechanism 2.6. %of quarterly project Dropped %of quarterly project Indicator dropped as it does not progress reports submitted on progress reports add any value to the results time submitted within 2 framework. weeks after the end of each quarter 2.7. Sevan Medical Union New indicator Sevan Medical Union as Implementation of integrated operational an integrated service service delivery model delivery model Page 16 of 21 A. Revised Project Results Framework Project Development Objective (PDO): The objective of the Project is to improve (i) MCH services and the prevention, early detection, and management of selected non-communicable diseases at the PHC level; and (ii) the efficiency and quality of selected hospitals in Armenia. Cumulative Target Values 2 End Target Frequency Responsibility PDO Level Results UOM Baseline 2014 2015 2016 2017 2018 (2019 Data Source/ for Data Comments Core 1 Indicators Year Year Year Year Year Year) Methodology Collection 1. Percentage of □ antenatal care (ANC) attendees screened for glycosuria, % 0.00 0.00 40.00 60.00 75.00 85.00 85.00 Annual HMIS SHA hypertension and proteinuria in at least three antenatal visits 2. Percentage of □ a) a) population aged a)22.5 % a)2 35 40 a) a)50 35-68 screened for b)17.8 % 5% % % 45% a) 55% % %b) Annual HMIS SHA hypertension at least (2013 b)2 b) b) b) b) 50% 45% once in the last year: data) 0% 30 35 40% a) female; b) male % % 3. Percentage of □ population aged 35-68 screened for a)9.8% a)12.0 a)22. a)32.0 a)52.0 diabetes mellitus at b)7.5% % 0% % a)42.0% % a) 55.0% % b)50.0 Annual HMIS SHA PHC level at least (2013 b)10.0 b)20. b)30.0 b)40.0% b) 55.0% once during the last 3 data) % 0% % % years: a) female; b) male 4. Percentage of □ There are no women aged 30- baseline data 60 screened for available via cervical cancer at least HMIS as once during the last 3 PAP test was % 8.5 10.00 20.00 35.00 50.00 50.00 Annual HMIS SHA years and received the 50.00 not 1 UOM = Unit of Measurement. 2 Target values should be entered for the years data will be available, not necessarily annually. Target values are cumulative. If targets refer to annual values, it is indicated in the indicator name and/or in the “Comments” column. Page 17 of 21 Project Development Objective (PDO): The objective of the Project is to improve (i) MCH services and the prevention, early detection, and management of selected non-communicable diseases at the PHC level; and (ii) the efficiency and quality of selected hospitals in Armenia. Cumulative Target Values 2 End Target Frequency Responsibility PDO Level Results UOM Baseline 2014 2015 2016 2017 2018 (2019 Data Source/ for Data Comments Core 1 Indicators Year Year Year Year Year Year) Methodology Collection results included in the performance indicators list 5. Bed occupancy rate □ at the new Medical % Annual Center in Artashat MoH MoH/HPIU 64.00 64.00 64.00 64.00 64.00 70.00 75% 6. Quality of care in a) □ MCH; and b) NCD provided by doctors a) 57%; a) 57%; Every two Impact % a) 63%; measured by clinical b) 60% b) 60% years Evaluation WB/HPIU b) 66% vignettes (IE) DROPPED Intermediate Results and Indicators Cumulative Target Values End Frequency Data Responsibility Intermediate Results Unit of Baseline 2014 2015 2016 2017 2018 target Source/ for Data Comments Core Indicators Measurement Year Year Year Year Year (2019 Methodolog Collection Year) y Intermediate Result 1: Component A: PBF scheme 1. % of PHC □ facilities in Group 1 of the study receiving verifications of a) 100.0 a) 100.0 a)100.0 a)100.0 a)100.0 a) desk SHA M&E results, supervision 0.00 b) 95.0 b) 98.0 b)100.0 b)100.0 b)100.0 Semi-annu SHA/WG review System/IE and feedbacks by % al b) SHA within two supervision months after the end and of every semi-annual period feedback DROPPED (quality Page 18 of 21 Intermediate Results and Indicators Cumulative Target Values End Frequency Data Responsibility Intermediate Results Unit of Baseline 2014 2015 2016 2017 2018 target Source/ for Data Comments Core Indicators Measurement Year Year Year Year Year (2019 Methodolog Collection Year) y assurance within an impact evaluation) 2. Proportion of PHC □ facilities undergoing 50.00 Cumulative Results SHA/WG enhanced verification % 0.00 10.00 20.00 30.00 40.00 45.00 and verification of results by the more SHA/Working Group 3. % of eligible PHC facilities receiving incentives within two □ % months after the end 100% SHA M&E 70% 70/75% 80/85% 90/95% 95/95% 100% Semi-annu SHA of every semi-annual system al period 4. Level of awareness among a)55% b) adults in key NCD 29% c) a) 80%; a)95% 61% d) b) 50%; b)65% a)95%b) risk factors a) high 65% e) c) 65%; c)80% 65% blood pressure; b) □ % Every two HSPA MoH/HPIU 39% d) 70%; d)85% c)80% years high cholesterol d)85% e) (HSPA e) 65% e)80% level; c) high salt 2012 80% intake; d) obesity; e) data) high glucose level 5. Health facilities constructed, renovated, Number and/or equipped (number) MoH/HPIU HPIU The indicator is Annual 0.00 0.00 0.00 1.00 2.00 3.00 moved to Intermediate 4.00 Results Indicators section for Component B Page 19 of 21 Intermediate Results and Indicators Cumulative Target Values End Frequency Data Responsibility Intermediate Results Unit of Baseline 2014 2015 2016 2017 2018 target Source/ for Data Comments Core Indicators Measurement Year Year Year Year Year (2019 Methodolog Collection Year) y Intermediate Result 2: Component B: Improving efficiency and quality of selected hospitals □ 1.Number of hospitals constructed/renovated Annual and/or equipped Number 0.00 0.00 0.00 2.00 3.00 3.00 MoH MoH/HPIU DROPPED 2. % of pediatric □ patients newly diagnosed with onco-hematology conditions by the Hematology Center % 20.00 20.00 20.00 20.00 15.00 10.00 7.00 MoH MoH/HPIU who Annual received treatment overseas in the past year 3. Number of new □ clinical practice guidelines developed Number 0.00 2.00 4.00 6.00 8.00 10.00 Annual MoH MoH/HPIU for hospitals DROPPED 4. Number of hospital □ health workers receiving training in a Number 0.00 0.00 0.00 90.00 210.00 300.00 set of new clinical 300.00 Cumulative MoH MoH/HPIU practice guidelines 5. %of public □ hospitals at marz level 5.00 5.00 25.00 50.00 70.00 90.00 Cumulative implementing Quality 5.00 % Improvement Program MoH MoH/HPIU Page 20 of 21 Intermediate Results and Indicators Cumulative Target Values End Frequency Data Responsibility Intermediate Results Unit of Baseline 2014 2015 2016 2017 2018 target Source/ for Data Comments Core Indicators Measurement Year Year Year Year Year (2019 Methodolog Collection Year) y □ The percentage is calculated 6. % of quarterly within the project progress semi-annual reports submitted on % 0.00 100.00 100.00 100.00 100.00 100.00 Annual PMU HPIU ly project time progress DROPPED reports submitted on time. □ Functional Construct Medical 7. Sevan Medical plan ion Union in developed started operation Union operational and approved Page 21 of 21