Document of The World Bank FOR OFFICIAL USE ONLY Report No: 122567-MD RESTRUCTURING PAPER ON A PROPOSED PROGRAM RESTRUCTURING OF HEALTH TRANSFORMATION OPERATION CREDITS 5469-MD AND 5470-MD MAY 22, 2014 TO THE REPUBLIC OF MOLDOVA October 31, 2018 Regional Vice President: Cyril E. Muller Global Practice Vice President: Annette Dixon Country Director: Satu Kristiina Kahkonen Practice Manager: Tania Dmytraczenko Task Team Leader(s): Volkan Cetinkaya ABBREVIATIONS AND ACRONYMS CNAM National Health Insurance Fund DLI Disbursement-linked Indicators ESSA Environmental and Social System Assessment HCW Health Care Waste HCWM Health Care Waste Management IPF Investment Project Financing MHI Mandatory Health Insurance MoHLSP Ministry of Health, Labor and Social Protection MTR Mid-term Review NCD Non-communicable Disease NPHA National Public Health Agency NTCP National Tobacco Control Program PBF Performance-based Financing PDO Project Development Objective PforR Program-for-Result PHC Primary Health Care 2 REPUBLIC OF MOLDOVA HEALTH TRANSFORMATION OPERATION CONTENTS A. DATA SHEET B. SUMMARY OF PROPOSED CHANGES C. PROGRAM STATUS D. PROPOSED CHANGES ANNEX 1: RESULTS FRAMEWORK AND MONITORING ANNEX 2: DISBURSEMENT LINKED INDICATORS, DISBURSEMENT ARRANGEMENTS AND VERIFICATION PROTOCOLS 3 REPUBLIC OF MOLDOVA HEALTH TRANSFORMATION (P144892) ECA Region GHN03 . . A. DATA SHEET Program ID: P144892 Lending Instrument: Program for Results Regional Vice President: Cyril E. Muller Current Approval Date: May 22, 2014 Country Director: Satu Kristiina Kahkonen Current Closing Date: March 30, 2019 Practice Manager: Tania Dmytraczenko Report No: 122567-MD Team Leader: Volkan Cetinkaya . Borrower: Republic of Moldova Responsible Agency: Ministry of Health, Labor and Social Protection (MoHLSP) . Restructuring Type Approval Authority: Country Director Restructuring Level: Level 2 Explanation of Level 2 Approval Authority: If Level One: Explanation: . Financing Information Key Dates Effectiveness Current Program Ln/Cr/TF Status Approval Date Signing Date Revised Closing Date Date Closing Date P144892 IDA-5469 Effective 22-May-2014 14-Jul-2014 05-Apr-2015 30-Mar-2019 31-Dec-2020 P144892 IDA-5470 Effective 22-May-2014 14-Jul-2014 05-Apr-2015 30-Mar-2019 31-Dec-2020 Disbursements (in Millions) Program Ln/Cr/TF Status Currency Current Revised Cancelled Disbursed Undisbursed % Disbursed P144892 IDA-5469 Effective XDR 18.6 18.6 0.0 9.300 9.300 50 P144892 IDA-5470 Effective XDR 1.4 1.4 0.0 0.762 0.638 54 . Policy Waivers Does the Program require any waivers of Bank policies applicable to Program- Yes [ ] No [X] for-Results operations? 4 Explanation Has the waiver(s) been endorsed or approved by Bank Management? Yes [ ] No [ ] Explanation: not applicable . B. Summary of Proposed Changes Change in Program’s Development Objectives Yes [ ] No [X] Change in Program Scope Yes [ X ] No [ ] Change in Results Framework Yes [X] No [ ] Change in Legal Covenants Yes [ ] No [X] Change in Loan Closing Date(s) Yes [X] No [ ] Cancellations Proposed Yes [ ] No [X] Change to Financing Plan Yes [ ] No [X] Reallocation between and/or Change in DLI Yes [X] No [ ] Change in DLI Verification Protocol Yes [X] No [ ] Change in Key Parameters (Disbursement Arrangements, Institutional Arrangements, Yes [ ] No [X] Technical, Fiduciary, and Environmental and Social aspects) Change in Program Action Plan Yes [X] No [ ] Other Change(s) Yes [ ] No [ X] C. Program Status 1. The Credit was approved on May 22, 2014, for a total amount of SDR 20 million (US$30.8 million equivalent), of which SDR 18.6 million (US$28.7 million equivalent) for the Program part and SDR 1.4 million (US$2.1 million equivalent) for the IPF component and became effective on April 8, 2015. The Health Transformation Operation (HTO) is a Program-for-Results (PforR), which was developed to be implemented over a four-year period. The HTO supports the Government of Moldova to address a part of the health system challenges through the Program part of the Credit (Program Credit No. 5469-MD), which is a subset of the government health sector work plan. The HTO also includes an IPF component (Project Credit No. 5470-MD) for technical assistance and institutional capacity building activities for the attainment of the Program objectives and its sustainability. Ten Disbursement- linked Indicators (DLIs) were selected to address the bottlenecks along the results chain that require incentivizing while ensuring both ambition and feasibility. The share of IDA financing allocated to each DLI corresponds to the level of effort required for Program achievement and/or the prominence of its role in the attainment of the Program Development Objective (PDO), which remains relevant, of contributing to reducing key risks for non- communicable diseases and improving efficiency of health services in Moldova. 2. Progress toward achieving the PDO (DO) and Implementation Progress (IP) have been rated no less than moderately satisfactory for the past 12 months. The amounts disbursed under the HTO as of October 2018 are as follows: (a) Program, Credit 5469-MD: SDR 9.3 million has been disbursed, representing 50 percent of the total credit of SDR 18.6 million; and (b) IPF component, Credit 5470-MD: SDR 762,000 has been disbursed, representing 54.4 percent of the total credit of SDR 1.4 million. 5 3. The proposed restructuring results from the outcomes of the mid-term review (MTR), which took place in September-October 2017. The MTR has provided the opportunity to thoroughly assess progress in achieving the Disbursement-linked Indicators (DLIs), and indicators in the Result Framework (RF). As such, it has identified inconsistencies between the Program Appraisal Document (PAD) and Supplemental Letter #2 on Key Performance Indicators of July 11, 2014 (which is part of the legal documents negotiated in April 2014). It has, therefore, been agreed that a Program restructuring will be undertaken to modify and reconcile the documents, but, more importantly, to reflect contextual changes in the country and in the health sector in the Program content (DLIs, Program Action Plan, and RF) since its preparation in 2013-2014 while ensuring that any of those changes would continue to appropriately measure the achievement of the PDO. The restructuring of the HTO will (i) adjust the Program scope to evolving circumstances; (ii) amend the results framework; (iii) reallocate funds among DLIs and between one DLI (#9) and a new IPF component within the Program Credit to provide for additional technical assistance and software; and (iv) extend the closing date by 21 months to December 31, 2020, due to delays because of the Government reorganization and multiple changes within the MoHLSP management. 4. The MTR acknowledges progress to date in the implementation of the HTO. Out of ten DLIs under the Program, four have fully been achieved and ahead of schedule, while the other six DLIs are in progress. Other DLIs are not accounted due to being linked to either technical assistance, or the STEPS survey, results of which will validate achievement of target values for some DLIs. 5. The first part of the PDO is being addressed by: (a) the implementation of the 2015 Tobacco Control Law, which restricts smoking in public places and premises (starting 2016), prohibits artificial flavor additives in cigarettes (starting 2018), introduces traceability for cigarettes packs (starting 2018) and requires the labeling of at least 65 percent of cigarettes packs with health warning messages (starting 2018); (b) the increased excise tax on tobacco for filter and non-filter cigarettes since 2017 and onwards; (c) the update of the National Program on Tobacco Control in 2017-2021; and (d) improvements in health care provided to patients with hypertension, the increase in the reimbursement rate of compensated essential drugs (8 INNs) for patients with hypertension, and the inclusion of indicators covering better management of hypertensive patients in the performance-based payment scheme for primary care. The second part of the PDO is being addressed by: (a) implementation of the updated scheme for performance-based payment at the primary care level; (b) the development of performance indicators for hospitals; (c) an increase in the proportion of payments in CNAM contracts with hospitals that are based on diagnosis-related groups (DRG); and (d) the implementation of costing study for customization of DRG prices based on country data. The IPF component is progressing fairly well with most of the planned technical assistances (TA) being under implementation. 6. Program Action Plan (PAP). Overall, most of the actions identified in the PAP are on track to be completed by the current Closing Date of March 30, 2019. However, some actions (#9 and #10) must be reformulated to reflect current context. The two key actions included in the PAP and pertaining to the Environmental and Social Safeguards Assessment (ESSA) relate to the development of a Feasibility Study and a four-year HCWM action plan (action #9) and the annual monitoring of the said action plan (action #10). The reformulation of these two actions have been discussed and agreed with the Regional Safeguards Advisor and are reflected in the revised ESSA, which can be shared upon request. 7. Overall, the HTO is an important vehicle for necessary transformations and reforms of the health system in Moldova. It contributes to the strengthening of primary care and better management of NCDs, and it also supports important actions towards deep reforms in the hospital sector. The views of the various key stakeholders (Prime Minister’s Office, Parliamentary Committee on Health and Social Protection, MoHLSP, CNAM, World Health Organization, Swiss Development Cooperation) are aligned with the importance and necessity of key healthcare reforms. However, the ongoing reorganization of the GoM, particularly the merger of the Ministry of Health with the Ministry of Labor, Social Protection and Family, the internal restructuring of CNAM, and the pre-election period (parliamentary elections are scheduled for end 2018), will likely slow down the implementation of the hospital reform. In this context, the MTR has recommended taking stock of the existing studies and reports, and the development of a feasibility study to provide options for hospital reform and their implications on service 6 delivery. This task would also support the government’s commitment to the regionalization of hospital care while providing the necessary analysis (including health needs assessment) to further justify rightsizing of the hospital sector. This recommendation is reflected with the proposed changes and reformulation of the DLI #9. 8. Financial Management (FM). FM is rated Satisfactory. The HTO complies with the financial management covenants. The program audits for FY 2016 and 2017 have been received and did not reveal any significant issues in the Programs’ fiduciary systems. The Program budget is prepared with due regard to relevant policies and executed in an orderly and predictable manner. The audit report for the project financial statements as of December 31, 2017, has unqualified opinion without any matters noted by the auditors. The HTO financial reporting is done on a timely basis, and in line with the requirements. The accounting records under the IPF component were reviewed and no deficiencies were noted. The relevant supporting and payment documents were of adequate quality and duly approved. Arrangements, including planning and budgeting, accounting, financial reporting, external audit, and funds flow and procurement administration of the operational support team of the MoHLSP are satisfactory and acceptable to the Bank. The level and timeliness of government co-financing is satisfactory. 9. Procurement. Procurement management is rated as satisfactory under the IPF component, which follows the World Bank procedures and guidelines on the selection of consultants. The component is progressing well with most of the planned technical assistance being under implementation. All issues identified during the MTR and relating to ongoing contracts have been addressed. 10. Environmental and Social Safeguards. The HTO’s rating on safeguards compliance is Moderately Satisfactory. . D. Proposed Changes . . Development Objectives/Results Program Development Objectives Original PDO: The PDO is to contribute to reducing key risks for non-communicable diseases and improving efficiency of health services in Moldova. Current Program Development Objectives, if any Current PDO Change in Program's Development Objectives Explanation: not applicable Proposed New PDO Change in Program Scope Explanation: It is proposed to add an IPF component to the Program Credit (Cr. 5469-MD) to finance technical assistance (TA) to support the MoHLSP in carrying out, inter alia, the necessary analytical work for hospital rightsizing/optimization, including Health Care Waste Management (HCWM), and in purchasing software for strengthening CNAM in data collection and monitoring. The amount not allocated to DLI #9 of SDR 714,500 is, therefore, reclassified to finance the TA/software under the Program Credit. This new IPF component would follow the same procurement and disbursement procedures as in the case of the Project Credit (Credit 5470-MD). The reclassification of SDR 714,500 is reflected under a new Category for the Program Number 11 (Goods and consultant 7 services under Section 1.6 of Schedule 1 to the amended Financing Agreement) and is required due to constraints in the MoHLSP’s budget in financing in a timely fashion these additional TA. Change in Results Framework (see Annex 1 for details) Explanation: Modifications to the Results Framework are proposed to align the PDO and intermediate results indicators with the proposed modifications of the DLIs, but more importantly, to reflect contextual changes since the HTO was approved in 2014. The following are the key modifications: PDO Indicators: • PDO Indicator 1 (Smoking prevalence among adults) is revised to specify age group, disaggregation by gender, and frequency of measurements. Reference to “disaggregated by population quintile� is deleted since the STEPS survey does not provide this data. The baseline is updated to the 2013 STEPS survey. Given that the Tobacco Control Law was only introduced in 2016, there is not enough time to observe changes. A STEPS survey is planned for 2018 with field work starting in November 2018 to coincide with the 2013 STEPS survey. • PDO Indicator 2 (controlled hypertension) is revised to specify age group and type of intervention, disaggregation by gender, and frequency of measurements. The baseline is updated to reflect the 2013 STEP survey data. The source of verification of this exercise is the 2019 STEP survey data. Intermediate Results Indicators: • Intermediate Results Indicator 3 is revised to align with revised PDO indicator 2. • Intermediate Results Indicators 4, 5, and 6 are deleted as they duplicate DLIs #6, 7, and 8, respectively. • Intermediate Results Indicators 8 and 9 are deleted and replaced by a new Intermediate Results Indicator 11 to reflect the revised DLI #9 related to hospital reform: “Consolidation of departmental hospitals under the MoHLSP authority�. • New Intermediate Results Indicators is added to reflect citizen engagement mandate for all World Bank-financed operations. Accordingly, a new indicator is added to measure beneficiary feedback mechanism as follows: “Percentage of citizen satisfied with quality of health services.� . Change in Legal Covenants Explanation: not applicable Finance Loan No. Agreement Description of Covenant Date Due Status Recurrent Frequency Action Reference . Financing Change in Loan Closing Date(s) Explanation: An extension of the Closing Date by 21 months from March 30, 2019 to December 31, 2020 is necessary to ensure absorption of funds (i.e. verification and validation of DLIs) and the delivery of the government’s hospital reform agenda, while supporting the government in hospital restructuring/optimization beyond the planned Parliamentary elections of end 2018. In addition, the merger of the Ministry of Health with the Ministry of Labor, Social Protection and Family, the establishment of a National Public Health Agency and the restructuring of CNAM will affect the timely implementation of the HTO. 8 Proposed Closing Loan No. Status Current Closing Date Current Closing Date Previous Closing Date(s) Date 5469-MD Effective 30-Mar-2019 30-Mar-2019 31-Dec-2020 n/a 5470-MD Effective 30-Mar-2019 30-Mar-2019 31-Dec-2020 n/a Cancellations Proposed Explanation: not applicable Current Amount (in Cancelled Amount (in Total Proposed Amount (in Loan No. Status Currency currency) currency) currency) Change in Financing Plan (USD) Explanation: not applicable Source(s) Currency At Approval Current (from AUS) Proposed Total Reallocation between and/or Change in DLI (see Annex 2 for details) Explanation: A reallocation of SDR 323,500 from DLI #1.1 to DLIs #2.1 and #2.2 for the amounts of SDR 259,000 and SDR 64,500, respectively is proposed. The following presents the rationale for the changes to the DLIs: DLI #1: reformulated from “smoking prevalence amongst adults� to “smoking prevalence amongst adults (age between 18-69); a) men; b) women�. This DLI is affected by the following key factors: (i) enforcement of anti-tobacco legislation and implementation of specific measures set out in the Tobacco control program; and (ii) increase in tobacco excise taxes which make cigarettes less affordable for population. Although the tobacco legislation on imposing smoking ban in public places has been adopted in 2016 and an increase in tobacco taxation has been implemented in 2017, the other important tobacco control measures will come into effect before the end of calendar year 2018 (particularly, cigarette labeling requirements). Consequently, it is proposed that formulation and targets for DLI #1 be revised given that the STEP survey results will only be made available at the earliest in early 2019. Data collection (field work) is planned (October - November 2018) to coincide with the 2013 STEP survey. It is also revised to specify age group and disaggregation by gender and update the number of measurements and the baseline. Intermediate action (DLI 1.1) is included in Year 3 (2018) and is linked to the “Sanitary regulation on health warnings and labeling of tobacco products�, which is also included in the Tobacco Control Strategy 2017 -2020 (clause no. 23). The following DLI 1.1 is therefore proposed as follows: “Starting 2018, all imported and locally produced cigarettes in the market are in line with the tobacco labelling regulation.� Verification of compliance would apply to products sold in the market that have been imported (or locally produced) in the country after January 2018. This means that sale of inventory stock which was imported or produced before legislation enters in force is allowed until June 30,2018. It is proposed that the verification process for labelling compliance be insured by a reputable independent entity with adequate capacity and technical expertise. The DLI #1.2 “smoking prevalence amongst adults: baseline minus 2 percentage points� would apply to each male and female. In addition, a reallocation of SDR 323,500 from DLI #1.1 to DLIs #2.1 and 2.2 is 9 proposed given that the enforcement of key tobacco control regulations is late in the project lifetime and that the risk of not entirely fulfilling DLI 1.1 is relatively high. DLI #2: reformulated from “Adults with hypertension whose blood pressure is under control� to “Increase in the percentage of people with cardiovascular diseases (CVDs) benefitting from compensated medications for treatment of CVDs�. This DLI fits in the strategic importance of the PDO on reducing NCDs risks, yet it significantly extends the scope of intervention to a wider disease group as many of cardio-vascular events are accompanied by hypertension and are often caused by not keeping high blood pressure under control. Appropriate lifestyle modifications are a fundamental step to prevent hypertension, which is the strongest risk factor for CVDs, however, not all risk factors for CVDs are avoidable. CVDs represent the leading causes of death globally with an estimated 17.3 million deaths in 2013; representing about a quarter of all global mortality.1 Approximately 80% of these deaths occur in low- and middle-income countries (LMICs).2 Ischemic heart disease and stroke are the first and third causes of death, respectively, according to the Global Burden of Disease estimates of 2013. Mortality from CVDs in Moldova are still almost twice as high as the average for the WHO European Region. The age-standardized death rate (per 100,000 population) in non-EU countries in WHO European region ranged from 255 men in Israel to 1545 men in Ukraine, and from 195 women in Israel to 1087 women in Kyrgyzstan. Moldova has one of the highest age-standardized death rate for CVDs in the region for both men and women: 1380 men and 1072 women. Similarly, the number of DALYs attributable to CVDs (per 1,000 individuals) for Moldova is significantly higher than countries with similar socio-economic status in the region: Moldova (143), Croatia (95), Estonia (110), Kyrgyzstan (76), and Romania (125).3 Population-wide public health approaches alone will not have an immediate tangible impact on cardiovascular morbidity and mortality and will have only a modest absolute impact on the disease burden.4 By themselves they cannot help individuals at high risk of developing CVDs or with an established CVDs. A combination of population-wide strategies and strategies targeted at high risk individuals is needed to reduce the CVDs burden. Improving access to medicines for CVDs is an essential component of treatment for CVD. The new formulation for DLI#2 is cross-supporting and reinforcing DLI#5 (revision of the outpatient drug benefit package with regards to anti-hypertensive drugs). The revised outpatient drug benefit package now includes first line generic anti-hypertensive medications and increases the compensation share from 50% to 70% (DLI #5 was achieved and disbursed in November 2015). DLI# 2.1 and DLI# 2.2 should read “Increase in the percentage of people with CVDs benefitting from compensated medications for treatment of CVDs by 5 percentage point from the baseline�, and “Increase in the percentage of people with CVDs benefitting from compensated medications for treatment of CVDs by 10 percentage point from the baseline�. Amounts reallocated within DLI #2 and from the SDR 323,500 reduced amount against DLI #1.1 result in the proposed allocation for: DLI 2.1: SDR 1,294,000; DLI 2.2: SDR 1,617,500. Verification of compliance from CNAM database will be done by the Court of Accounts. DLI #3: The description of the DLI is revised to remove inconsistencies between the indicator statement and the description of its achievement in the PAD, which makes reference to “admissions� instead of “discharges� (acute care discharges as defined by OECD). 1 GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385:117–171 2 World Health Organization. Global status report on noncommunicable diseases 2010. Geneva, Switzerland: World Health Organization; 2011. 3 Townsend, Nick & Wilson, Lauren & Bhatnagar, Prachi & Wickramasinghe, Kremlin & Rayner, Mike & Nichols, Melanie. (2016). Cardiovascular disease in Europe: Epidemiological update 2016. European Heart Journal. 37. ehw334. 10.1093/eurheartj/ehw334. 4 Lopez AD et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367(9524):1747–57. 10 DLI #6: “Revision and implementation of the Performance-based Incentive (PBI) scheme in primary care�. An updated Program for Performance (P4P) scheme by CNAM and MoH have started implementation in 2017. However, issues have been identified by the Bank team during the visit to the Primary Healthcare Clinics with regards to the indicators and calculation mechanism. While most indicators are adequate with regards to the burden of disease in Moldova, these are mostly clinical indicators that are provider centric. A better balance between provider and patient-based approach in the selection of the indicators should have been considered to contribute to the improvement of the performance of the PHC system. Therefore, further revisions of the P4P indicators are proposed to assess the following dimensions: (1) patient experience and perceived quality of care; (2) care coordination between different levels of care providers; (3) supportive supervision and mechanisms for continuous learning of health care providers; (4) avoidable hospital admissions; (5) access to care after hours. Consequently, it is proposed that DLIs #6.3 and #6.4 be reformulated to include further “revision of the P4P scheme� to address these issues and “implementation of the revised contracts with providers of primary care� in Years 3 and 4, respectively. DLI #9: “Percentage of public hospitals in Chisinau which are under common management, from a baseline of 0%�. This indicator is changed to measure progress in terms of number of hospitals rather than percentage of hospitals. However, the MoHLSP indicated during the MTR that though the draft law on centralization of hospitals was approved in the first reading (a second reading is planned followed by promulgation of the law), there remain several critical steps before consolidation of hospital network can be achieved, including the (a) elaboration of a feasibility study on hospital rightsizing; and (b) the development of a national masterplan for hospital consolidation and rationalization. Consequently, it was agreed that DLIs #9.2 and 9.3 would be revised while DLI #9.4 deleted with an allocation of SDR 678,000 for each DLI. Given the fact that an advance of SDR 404,050 has already been disbursed as advance payment against DLI #9.1 out of a total of SDR 517,500, DLI 9.1 will remain as stated (it is also achievable, but at a later stage), but under the following formulation: “Three public hospitals in Chisinau under common management�. DLI #9 is reformulated as follows: “Consolidation of public hospital network under the MoHLSP authority�. The amount not allocated to DLI #9 of SDR 714,500 is reclassified to a new IPF component under the Program Credit (Credit No. 5469-MD) for additional TA and for the provision of software as mentioned under “Change in Program Scope� Section above. Changes in DLI Verification Protocol Explanation: See Annex 2 for details. Change in Key Parameters (Disbursement Arrangements, Institutional Arrangements, Technical, Fiduciary, Environmental and Social Explanation: Environmental and Social Systems Assessment (ESSA). The two key actions included in the Program Action Plan (PAP) and relevant to the ESSA relate to the development of a Feasibility Study and a four-year HCWM action plan (action #9) and the annual monitoring of the said action plan (action #10). However, these two actions are no longer relevant. In view of the proposed changes made in the PAP, the ESSA presented in the Program Appraisal Document for the HTO has been revised to reflect current context and the proposed new actions. The revised ESSA approved by the Regional Safeguards Advisor was disclosed with public consultation on March 29, 2018. It is filed in the project file. Change in Program Action Plan Explanation: Actions #9 (Development of: (i) a feasibility study on the options, costs and technical issues of the creating regional networks for Health Care Waste Management (HCWM); and (ii) a four-year HCWM action plan) and #10 (Annual monitoring of the implementation of HCWM action plan) are reformulated to reflect current context with regards to the development of a comprehensive hospital reform planning, which will include environmental recommendations set out in the revised ESSA (cleared by the Regional Safeguards Advisor) and latest developments and standards in this area. The following two actions are proposed in replacement of the current ones: (i) Action #9: 11 The MoHLSP will develop technical guidelines and sanitary regulation for Health Care Waste Management; and (ii) Action #10: The MoHLSP will set up an efficient mechanism for close cooperation among the key institutions that have attributions in HCWM, including, but not limited to, the Ministry of Environment, Academy of Science, UNDP. Other Change(s) Explanation: Not applicable. 12 ANNEX 1: RESULTS FRAMEWORK AND MONITORING Table 1: Revised Results Framework Matrix Program Development Objective: The PDO is to contribute to reducing key risks for non-communicable diseases and improving efficiency of health services in Moldova. Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection PDO Level Results Indicators PDO Indicator 1: Revised 1 Percentage 25.4; Starting in Baseline Twice STEPS survey MoHLSP Smoking a) 43.7%; b) 2018, all minus 2 during prevalence 5.7% imported and percentag program among adults (2013) locally e points period (disaggregated produced by cigarettes gender: a) men; sold in b) the market women) are in line with the tobacco labelling regulation Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection PDO Indicator 2: Revised 2 Percentage 5.1%; a) Increase Twice STEPS survey MoHLSP Adults (age 45- 2.9%; b) 7% from during 59) with (2013) baseline to program hypertension at least period whose blood 10% pressure is under control because of antihypertensive medication; (disaggregated by gender: a) men; b) women) PDO Indicator 3: No 3 Number 17.6 (2011) 17.0 16.5 16.0 15.6 Annual Administrativ MoHLSP Annual acute change during e data care hospital Program discharges per period 100 persons PDO Indicator 4: No 4 Number 17,586 17,000 16,500 16,000 15,000 Annual Administrativ MoHLSP Acute care change (2012) during e data hospital beds Program period PDO Indicator 5: No Number of 8.0 (2012) 7.8 7.6 7.4 7.2 Annual Administrativ MoHLSP Average length change days during e data of stay in acute Program care hospitals period 14 Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection Intermediate Results Area 1: Reducing NCD Risks Intermediate No 1 Yes/No No Yes Once Self-reported MoHLSP Results change during data Indicator 1: Program Approval of the period new tobacco control legislation Intermediate No Yes/No No Yes Once Self-reported CNAM Results change during data Indicator 2: Program Revision of the period outpatient drug benefit package with regard to antihypertensive drugs Intermediate Revised 2 Percentage 32.4 (2015) 39 Twice Household MoHLSP Results during survey with Indicator 3: Rate Program blood of registered period pressure patients with measurement hypertension on antihypertensive treatment with value of maintained arterial 15 Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection tension of <140/90 mm Hg Intermediate Results Area 2: Improved efficiency of health services Intermediate Dropped Text No revision Revision of Performance- Performance- Performance- Annual Self-reported CNAM Results of incentive based based based during data Indicator 4: performance- scheme for incentive incentive incentive Program Revision and based family agreements agreements agreements period implementation incentives in medicine signed with signed with signed with of the family all primary all primary all primary performance- medicine care centers care centers care centers based incentive contracted contracted contracted scheme in family by CNAM in by CNAM in by CNAM in medicine Year 2 Year 3 Year 4 Intermediate Dropped Text No Design of Pilot of the Evaluation of Performance- Annual Self-reported CNAM Results performance incentive scheme in at the pilot and based during data Indicator 5: based scheme for least 3 revision of incentive Program Introduction of incentives for hospitals multiple- the scheme agreements period performance- hospitals profile design signed with based incentives hospitals all multiple- to improve (i) profile efficiency; and hospitals (ii) quality of care in hospitals Intermediate Dropped Text DRG DRG DRG DRG DRG Annual Self-reported CNAM Results accounting accounting accounting accounting updated during and Indicator 6: Use for less than for at least for at least for using Program period 16 Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection of updated DRG 40% of total 40% of 50% of total at least country administrative prices for payment by total payment by 60% of data data payment by CNAM to payment CNAM to total CNAM to acute acute care by CNAM acute care payment by care public public to acute public CNAM to hospitals hospitals care public hospitals acute care hospitals public hospitals Intermediate No 10 Yes/No No Yes Once Self-reported MoHLSP Results change during data Indicator 7: Program Approval of period the revised national health strategy which includes hospital Intermediate Dropped Percentage 0 10 20 30 50 Annual Self-reported MoHLSP Results during data Indicator 8: Program Public hospitals period in Chisinau which are under common management 17 Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection Intermediate Dropped Yes/No No Yes Once Self-reported MoHLSP Results during data Indicator 9: Program Establishment period of university hospital Intermediate No 10 Percentage 36 (2011) 38 40 42 44 Annual Administrativ MoHLSP Results change during e data Indicator 10: Program Annual period hospitalizations through referrals by family medicine providers Intermediate New 10 Yes/No No Yes Once Self-reported MoHLSP Results during data Indicator 11: Program Consolidation period of departmental hospitals under the MoHLSP authority Intermediate New Percentage 62.6 70 Once Self-reported MoHLSP Results during data Indicator 12: 18 Unit of Target Values Data Responsibility Indicators Measure Baseline Yr. 1 Yr. 2 Yr. 3 Yr. 4 Yr. 5 Frequency Source/Meth for Data odology Collection Percentage of Program citizen satisfied period with quality of health services 19 ANNEX 2: DISBURSEMENT LINKED INDICATORS, DISBURSEMENT ARRANGEMENTS AND VERIFICATION PROTOCOLS TABLE 1: DISBURSEMENT-LINKED INDICATOR MATRIX Total As % of Achievements to date Indicative timeline for future achievements under the Financing Total under the DLI DLI Status DLIs Allocated to Financing DLI Results Financing Year or Year or Year or Year or DLI Amount Baseline achieved amount Year or Period 4 Period 5 Period 2 Period 3 (in SDR) disbursed Period 1 Modified DLI 1: Smoking prevalence 25.4: a) n/a Starting in Baseline among (age between 18 and 43.7%; b) 2018, all minus 2 69); a) men; b) women 5.7% (2013) imported percentag and locally e points produced (23.4%) cigarettes in the market are in line with the tobacco labelling regulation Allocated amount 2,264,500 13 323,500 1,941,000 Modified DLI 2: Increase in the 48.5% n/a Increase Increase percentage of people with (2017) in the in the CVDs benefitting from percentag percentag e of e of compensated medications for people people treatment of CVDs with with CVDs CVDs benefittin benefittin g from g from compensat compensat ed ed medicatio medicatio ns for ns for treatment treatment 20 of CVDs of CVDs by 5 increases percentag by 10 e point percentag from the e point baseline from the baseline Allocated amount: 2,911,500 16 1,294,000 1,617,500 DLI 3: Decrease in the 17.6 (2011) 17.0 16.5 16.0 15.6 No change number of annual acute care hospital admissions per 100 persons Allocated amount: 1,941,000 11 All 1,941,000 582,000 485,500 485,500 388,000 achieved No change DLI 4: Number of acute 17,586 17,000 16,500 16,000 15,000 care hospital beds (2012) Allocated amount: 3,041,000 17 All 3,041,000 689,000 588,000 588,000 1,176,000 achieved No change DLI 5: Adoption of a No Revised revised outpatient drug benefit benefit package for anti- package: hypertensive drugs yes Allocated amount: 1,294,000 7 No All 1,294,000 1,294,000 achieved Modified DLI 6: Revision and No revision Revision of Performanc Revision of implementation of of incentive incentive e-based incentive Implemen performance-based incentive scheme for scheme for incentive scheme and tation of scheme in primary care family family agreements performanc the medicine medicine signed with e indicators revised all primary for family contracts care centers medicine with contracted providers by CNAM of primary in Year 2 care Allocated amount: 1,294,000 7 Period 1 647,000 323,500 323,500 323,500 323,500 and 2 achieved 21 No change DLI 7: Design, piloting, No incentive Design of Pilot of the Evaluatio Performan adoption, and implementation scheme for incentive scheme in n of the ce-based of the Performance-Based hospitals scheme for at least 3 pilot and contracts Incentive Scheme in hospitals hospitals multiple- revision of signed profile the with all hospitals scheme multi-le- design profile hospitals Allocated amount: 1,294,000 7 Period 1 323,500 323,500 323,500 323,500 323,500 achieved No change DLI 8: Implementation and DRG DRG DRG DRG Preparatio update of DRG prices for accounting accounting accounting accounting n of public acute care hospital for less than for at least for at least for at least updated payments 40% of total 40% of 50% of 60% of DRG payment by total total total prices CNAM to payment by payment by payment by costing public CNAM to CNAM to CNAM to report hospitals public public public using hospitals hospitals hospitals country data for hospitals payments Allocated amount: 1,294,000 7 Periods 970,500 323,500 323,500 323,500 323,500 1,2, and 3 achieved Modified DLI 9: Consolidation of No n/a 3 public Feasibility National departmental hospitals under hospitals in developed strategy the MoHLSP authority Chisinau on and under hospital master common rightsizing plan for managemen hospital t consolidat ion and rationaliza tion adopted Allocated amount: 1,873,500 10 404,050 5 517,500 678,000 678,000 5 The amount of SDR 404,050 represents an advance payment against DLI #9. 22 No change DLI 10: Adoption of the No revised Revised revised National Health strategy strategy System Development approved Strategy, including hospital rationalization measures Allocated amount: 678,000 4 Period 1 678,000 678,000 achieved Total Financing: 17,885,500 6 9,299,500 4,213,500 2,561,500 2,044,000 4,506,500 4,560,000 6 A reclassification of SDR 714,500 from the total amount allocated to the Program component (DLI #9) of SDR 18,600,000 to the IPF component is proposed to support MoHLSP’s commitment towards hospital reforms, including Health Care Waste Management, and CNAM in strengthening its data monitoring and collection tools. 23 TABLE 2: DLI VERIFICATION PROTOCOL TABLE DLI status DLI Definition/ Scalability of Status of Protocol to evaluate achievement of the DLI and Description of achievement Disbursemen verification data/result verification ts protocol Data source/agency Verificatio Procedure (Yes/No) n Entity Modified DLI 1: Smoking Prevalence of tobacco use as No No change Data source: survey Reputable Review of survey prevalence among (age percentage of current smokers using the same independent instrument and protocol, between 18 and 69); a) among adults (age 18-69), sampling strategy and entity with primary data and disaggregated by gender and as questions on tobacco sufficient analysis men; b) women measured by a nationally consumption as in the technical representative household survey. 2013 Moldova expertise The sampling strategy of the STEPS survey survey should be the same as the Agency: MoHLSP one used in the 2013 Moldova STEP survey. Modified DLI 2: Increase in the Numerator: number of patients Yes No change Data source: Court of Review of survey percentage of people who receive compensated centralized (online, Accounts instrument and protocol, with CVDs benefitting medicine for CVD real-time) database primary data and that links pharmacies analysis from compensated Denominator: number of people and CNAM and medications for with CVD allows for payment of treatment of CVDs medications compensated under MHI (CNAM DB “compensated medications�) (ii) annual healthcare statistical yearbook compiled by the National Centre for Health Management (before 2017) and the National Agency for Public Health (after 2017). 24 DLI status DLI Definition/ Scalability of Status of Protocol to evaluate achievement of the DLI and Description of achievement Disbursemen verification data/result verification ts protocol Data source/agency Verificatio Procedure (Yes/No) n Entity Agency: MoHLSP No change DLI 3: Annual acute Numerator: Number of hospital Yes No change Data source: National Audit for a random 10% care hospital discharges (OECD definition) Administrative data Bureau of of hospitals with acute discharges per 100 for acute care in the past year as from Statistics or a beds persons reported by health information health information reputable system. Denominator: Mid- system Agency: independent year population x 100 taken MoHLSP entity with from National Bureau of sufficient technical Statistics data. expertise No change DLI 4: Acute care Number of beds in acute-care Yes No change Data source: National Audit for a random 10% hospital beds hospitals contracted by CNAM Administrative data Bureau of of hospitals with acute in a given year. from Statistics or a beds health information reputable system Agency: independent MoHLSP entity with sufficient technical expertise No change DLI 5: Revision of the A joint MOH and CNAM order No No change Ministerial order to MoHLSP Review of Ministerial outpatient drug benefit to formally adopt a revised drug adopt the new benefit order package with regard to benefit package in which the package anti-hypertensive average reimbursement rate for Agency: MoHLSP drugs generic, first line medication for and the three main categories of CNAM anti-hypertensive is at least 70 percent. Modified DLI 6: Revision and For achievement of family No No change Data source: Self- (i) and (iii) (i) Review of report implementation of medicine incentive scheme reported CNAM on the revised performance-based design revision, two results are administrative data 25 DLI status DLI Definition/ Scalability of Status of Protocol to evaluate achievement of the DLI and Description of achievement Disbursemen verification data/result verification ts protocol Data source/agency Verificatio Procedure (Yes/No) n Entity incentive scheme in required: (i) a paper describing Agency: CNAM (ii) MoHLS incentive scheme primary care the revisions of the scheme P (Year 1) satisfactory to the WB which (ii) Review of should include (a) revision of ministerial order to performance indicators and (b) adopt the revised introduction of spot check scheme (Year 1) methods and (ii) a ministerial (iii) Review of annual order to formally adopt such performance-based revisions to the scheme. For incentive agreements annual implementation of the signed with all family revised scheme, there should be medicine providers satisfactory proofs that all (Years 2, 3, 4) primary care facilities contracted by CNAM will have signed annual performance- based incentive agreements. No change DLI 7: Introduction of For achievement of hospital No No change Data source: Self- (i) and (iii) (i) Review of report performance-based incentive scheme design in Year reported CNAM on the revised incentives to improve 1, a paper describing the scheme administrative data (ii) MoHLSP incentive scheme (i) efficiency and (ii) design satisfactory to the WB is Agency: CNAM (Year 1) quality of care in required. For the pilot in Year 2; (ii) Review of hospitals copies of performance-based ministerial order to incentive agreements signed adopt the revised with all pilot hospitals are scheme (Year 1) required. For pilot evaluation in (iii) Review of annual Year 3, a report on (i) pilot performance-based evaluation and (ii) updated incentive agreements scheme design is required. For signed with all multi- implementation of the scheme in profile hospitals (Year 4) Year 4, there should be copies of performance-based incentive agreements signed with all multi-profile hospitals. 26 DLI status DLI Definition/ Scalability of Status of Protocol to evaluate achievement of the DLI and Description of achievement Disbursemen verification data/result verification ts protocol Data source/agency Verificatio Procedure (Yes/No) n Entity No change DLI 8: Use of updated For annual implementation of No No change Data source: Self- (i) (i) Review of annual DRG prices for the updated DRG prices in the reported Reputable hospital payment data payment by CNAM to first three years, a reputable administrative data independen (Years 1, 2 and 3) (ii) public acute care Agency: CNAM t entity with Review of report on independent entity will review hospitals sufficient DRG costing study annual hospital payment data and confirm share of updated technical using country data DRG in total CNAM payment for expertise (Year 4) (ii) CNAM public hospitals. For achievement of updating DRG prices in Year 4, a DRG costing report using country data satisfactory to the WB is required. Modified DLI 9: Consolidation Self- explanatory No Modified Data source: Self- (i) MoHLS (i) Review of proof of 3 of departmental reported P public hospitals in hospitals under the administrative data (ii) CNAM Chisinau under common MoHLSP authority Agency: MoHLSP management; (ii) feasibility study on hospital rightsizing satisfactory to the Bank developed; and (iii) national strategy and master plan for hospital consolidation and rationalization satisfactory to the Bank adopted by MoHLSP No change DLI 10: Approval of A copy of the strategy No No change Data source: copy of MoHLSP Review of strategy and the National Health (translated into English) and strategy in English and official gazette Strategy which proof of government’s formal proof of government includes hospital approval of the strategy sent to 27 DLI status DLI Definition/ Scalability of Status of Protocol to evaluate achievement of the DLI and Description of achievement Disbursemen verification data/result verification ts protocol Data source/agency Verificatio Procedure (Yes/No) n Entity rationalization the WB. Strategy should address adoption of the measures the following hospital strategy rationalization measures, among Agency: MOHLSP others: (i) regionalization of hospitals (ii) common management for public hospital in Chisinau; and (iii) establishment of a university hospital. 28 TABLE 3: BANK DISBURSEMENT TABLE DLI Bank Status of Of which Deadline for Minimum DLI Maximum DLI Determination of financing disbursement Financing DLI value to be value(s) Financing Amount to allocated to arrangements available Achievement1 achieved to expected to be be disbursed against the DLI for Prior trigger achieved for achieved and verified results disbursements of Bank DLI value(s) Bank Financing disbursements purposes Starting in 2018, 2 percent point Formula: Disbursement all imported and reduction from amount is SDR 323,500 locally produced baseline for all cigarettes in the cigarettes packaging market are in line starting in 2018 meet with the tobacco tobacco labelling regulation; and SDR labelling regulation 1 2,264,500 Continued June 30, 2020 1,941,000 for 2 percentage point reduction of prevalence from the previous survey, for a maximum of SDR 2,264,500 in total disbursement. 5 percentage point 10 percentage Formula: Disbursement increase from point increase amount is SDR baseline from baseline 1,294,000 for DLI 2.1 for 5 percentage point increase from the baseline; and SDR 2 2,911,500 Continued June 30, 2020 1,617,500 for 10 percentage point increase from the baseline, for a maximum of SDR 2,911,500 in total disbursement. 29 DLI Bank Status of Of which Deadline for Minimum DLI Maximum DLI Determination of financing disbursement Financing DLI value to be value(s) Financing Amount to allocated to arrangements available Achievement1 achieved to expected to be be disbursed against the DLI for Prior trigger achieved for achieved and verified results disbursements of Bank DLI value(s) Bank Financing disbursements purposes 3 1,941,000 Reduction by 0.1 Reduction by 2 Formula: Disbursement Continued discharge for acute discharges for amount is SDR 388,000 care per 100 acute care per to SDR 582,000 for persons in the past 100 persons in every reduction by year compared to the past year 0.1 discharge for acute preceding year compared to care per 100 persons in the past year compared June 30, 2020 baseline to preceding year, for a maximum of SDR 1,941,000 in total disbursement. Disbursement is once a year, when verified results are available Reduction by one Reduction by Formula: Disbursement acute care hospital 2,586 acute care amount is SDR 714,500 bed compared to hospital beds for every reduction by the preceding year compared to one acute care hospital baseline bed compared to the preceding year, for a 4 3,041,000 Continued June 30, 2020 maximum of SDR 3,041,000 in total disbursement. Disbursement is once a year, when verified results are available Continued Revision of drug N/A Disbursement amount is benefit package SDR 1,294,000 and 5 1,294,000 June 30, 2020 made when this result is achieved and verified 30 DLI Bank Status of Of which Deadline for Minimum DLI Maximum DLI Determination of financing disbursement Financing DLI value to be value(s) Financing Amount to allocated to arrangements available Achievement1 achieved to expected to be be disbursed against the DLI for Prior trigger achieved for achieved and verified results disbursements of Bank DLI value(s) Bank Financing disbursements purposes Continued Achievement of N/A Disbursement amount agreed milestones is SDR 323,500 million per each of the four milestones Disbursement for the 6 1,294,000 June 30, 2020 first milestone is made whenever the first milestone is achieved, Disbursement for the other three is made once a year, when verified results are available Continued Achievement of N/A Disbursement amount is agreed milestones SDR 323,500 per each of the four milestones Disbursement for the first milestone is made 7 1,294,000 June 30, 2020 whenever the first milestone is achieved. Disbursement for the other three is made once a year, when verified results are available. Continued Achievement of N/A Disbursement amounts agreed milestones are SDR 323,500 per 8 1,294,000 June 30, 2020 each of the four milestones. 31 DLI Bank Status of Of which Deadline for Minimum DLI Maximum DLI Determination of financing disbursement Financing DLI value to be value(s) Financing Amount to allocated to arrangements available Achievement1 achieved to expected to be be disbursed against the DLI for Prior trigger achieved for achieved and verified results disbursements of Bank DLI value(s) Bank Financing disbursements purposes Disbursement for the first milestone is made whenever it is achieved. Disbursement for the other two is made once a year, when verified results are available. Continued Achievement of N/A Disbursement amounts agreed milestones are SDR 517,500, SDR 678,000, SDR 678,000 respectively for milestones 1, 2 and 3. 9 1,873,500 404,050 June 30, 2020 Disbursement for the first milestone is made whenever it is achieved. Disbursement for the other two is made once a year, when verified results are available. Continued Approval of the N/A Disbursement amount is new strategy SDR 678,000 and made 10 678,000 June 30, 2020 when this result is achieved and verified Total 17,885,500 404,050 1 Six months prior to the proposed Closing Date of December 30, 2020. 32 33