The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Romania Health Program for Results (P169927) EUROPE AND CENTRAL ASIA | Romania | Health, Nutrition & Population Global Practice | Requesting Unit: ECCEU | Responsible Unit: HECHN IBRD/IDA | Program-for-Results Financing | FY 2020 | Team Leader(s): Dorothee Chen, Huihui Wang Seq No: 1 | ARCHIVED on 27-Dec-2019 | ISR39996 | Created by: Dorothee Chen on 15-Dec-2019 | Modified by: Dorothee Chen on 24-Dec-2019 Program Development Objectives Program Development Objective (from Program Appraisal Document) The Program Development Objective (PDO) is to increase the coverage of primary health care for underserved populations and improve the efficiency of health spending by addressing underlying institutional challenges. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO -- Satisfactory Overall Implementation Progress (IP) -- Satisfactory Implementation Status and Key Decisions The Romania Health Program-for-Results (PforR) was approved by the World Bank (WB) Board on September 17, 2019 and the Loan Agreement was signed by the Government of Romania and the WB on September 23, 2019. The ratification law, which is a requirement for effectiveness, is yet to be approved due to the change in Government since the Loan Agreement signing. On the other hand, since then, the key stakeholders and the WB team have agreed on a joint action plan for each Disbursement-Linked Indicator (DLI) over the coming months. The objectives of such action plans are to: (a) ensure a joint understanding, among all stakeholders, of the actions needed to achieve the Disbursement-Linked Results (DLRs) that are expected to be achieved in 2019-20; and, moving forward, (b) confirm jointly if the key stakeholders are on track to achieve the DLRs on time, and inform discussions on corrective measures if needed. The new Government remains committed to achieving the objectives of the Project. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed Not P169927 IBRD-90050 USD 557.20 557.20 0.00 0.00 557.20 0% Effective Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date Not P169927 IBRD-90050 17-Sep-2019 -- -- 31-Dec-2023 31-Dec-2023 Effective 12/27/2019 Page 1 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Program Action Plan Action Description Sufficient allocation of Program funding in the budget and timely remittance of financing to implementing entities Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoPF Recurrent Continuous Not Yet Due Completion Program funding consistent with annual workplans. Measurement Comments Strengthen the enforcement of the existing regulations for medical waste management to handle, collect, record, Action Description store, decontaminate, transport and disposal of waste by developing/updating/revising internal procedures and guidelines at PHC Source DLI# Responsibility Timing Timing Value Status First 2 years of Environmental and Social MoH Other Program Not Yet Due Systems implementation Completion Analysis of MoH internal regulations norms for implementing the procedures for reactive and preventive identified Measurement priorities for medical waste management confirmed Comments Strengthen the capacity to adapt, prevent and react to extreme weather events by developing/updating/revising Action Description internal procedures and guidelines at PHC Source DLI# Responsibility Timing Timing Value Status First 2 years of Environmental and Social MoH Other Program Not Yet Due Systems implementation Completion Analysis of MoH internal regulations/norms for implementing the procedures for reactive and preventive identified Measurement priorities for adaptation to climate change effects confirmed Comments Develop and implement existing communication tools, as may be relevant, to increase public awareness of Program Action Description initiatives in consultation with the World Bank Source DLI# Responsibility Timing Timing Value Status Second and third years Environmental and Social MoH, NIPH, CSO, Other of Program Not Yet Due Systems other implementation 12/27/2019 Page 2 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Completion Findings on the level of public awareness regarding access to basic services package for uninsured Measurement Comments Strengthening a unit of the MoH to ensure integration at the institutional level of strategic planning for primary and Action Description community health care services Source DLI# Responsibility Timing Timing Value Status Technical MoH Due Date 31-Mar-2020 Not Yet Due Completion A ministerial order will be issued to specify the unit staffing, job descriptions and qualifications, overall institutional Measurement mandate, and operational budget. Comments Action Description Determining the benefit package for PHC, including the currently uninsured Source DLI# Responsibility Timing Timing Value Status Technical MoH, NHIH, MoPF Due Date 30-Jun-2020 Not Yet Due Completion Benefit package for PHC determined and incorporated in the Health Care Law 95/2006. Measurement Comments Action Description Issuing government decision and Joint Ministerial Order to establish the state-aid scheme Source DLI# Responsibility Timing Timing Value Status Technical MoH, MoPF Due Date 31-Dec-2019 Not Yet Due Completion Government Decision and Joint Ministerial Order (MoH & MoPF) define the criteria, scope and tools for application Measurement for grants or loans of up to EUR 50,000. Comments Action Description Conducting public expenditure review based on defined scope of work Source DLI# Responsibility Timing Timing Value Status At least 2 times during Technical MoPF Other Not Yet Due Program period Completion PER conducted and results analyzed and used for decision making Measurement 12/27/2019 Page 3 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Comments Maintain records of and track the number of patients, on a sample basis, whom community health workers have Action Description referred to acquire IDs for their registration with family physicians Source DLI# Responsibility Timing Timing Value Status Environmental and Social NHIH, MoH, MoSPJ Recurrent Yearly Not Yet Due Systems Completion Reporting by community health workers on the number of patients who have been referred by community health Measurement workers to acquire an ID for their registration with family physicians Comments Adequate arrangements and technical capacity to prepare Program financial statements and have them timely Action Description audited Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoH Recurrent Continuous Not Yet Due Completion Timely preparation and audit of Program financial statements. Measurement Comments Technical assistance for the establishment of centralized procurement of medical supplies – including systems and Action Description staffing Source DLI# Responsibility Timing Timing Value Status First year of Program Fiduciary Systems MoH/MoPF/ONAC Other Not Yet Due implementation Completion Report on completed review and implementation of report's recommendations – included in annual progress report Measurement Comments Technical assistance for the establishment and maintenance of electronic platforms for collation of procurement Action Description needs of implementing entities to support timely centralized procurement Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoH/MoPF/ONAC Due Date 30-Dec-2022 Not Yet Due Completion Report on system functionalities and roll-out data, including information on capacity building of actual and potential Measurement users – included in annual progress report. 12/27/2019 Page 4 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Comments Action Description Ensuring fund availability for grants under the de minimis aid scheme Source DLI# Responsibility Timing Timing Value Status Technical MoPF Due Date 31-Mar-2020 Not Yet Due Completion Sufficient funds available under the state-aid scheme to achieve Program targets. Measurement Comments Adequate technical capacity to develop and implement de minimis aid scheme and performance-based financing Action Description mechanism Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems MoPF, MoH Recurrent Continuous Not Yet Due Completion Effective systems of internal control and oversight established and maintained - evidenced in annual progress and Measurement audit reports. Comments Conducting training of community nurses and Roma mediators on public community health care in collaboration with Action Description PHC providers Source DLI# Responsibility Timing Timing Value Status Year 2 of Program Technical MoH Other Not Yet Due implementation Completion Training conducted and evaluation report from training participants available. Measurement Comments Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Substantial -- Substantial Macroeconomic Substantial -- Substantial 12/27/2019 Page 5 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Sector Strategies and Policies Moderate -- Moderate Technical Design of Project or Program Substantial -- Substantial Institutional Capacity for Implementation and Sustainability High -- High Fiduciary Substantial -- Substantial Environment and Social Substantial -- Moderate Stakeholders Moderate -- Moderate Other -- -- -- Overall Substantial -- Substantial RiskComments Comments The overall risk remains Substantial. Although a new Government was established in November 2019, the commitment for achieving the Project results was reconfirmed. Results PDO Indicators by Objectives / Outcomes To increase the coverage of primary health care for underserved populations IN00785336 ►Number of the uninsured in Romania who are registered with family physicians and entitled to receive the basic package of PHC services (disaggregated by gender) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 2,000,000.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785338 ►Percentage of adults (40 years old and above) receiving annual medical check-ups from family physicians (disaggregated by gender) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 -- 1.00 20.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. To improve the efficiency of health spending IN00785337 ►Percentage of National Health Insurance House’s annual budget allocated to PHC (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target 12/27/2019 Page 6 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Value 6.50 -- 6.50 10.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785339 ►Proportion of the supplies and devices for emergency medical services (in value) procured under framework agreements by the National Office for Centralized Procurement (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 50.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. Intermediate Results Indicators by Results Areas Improving coverage for underserved population IN00785342 ►Number of underserved communities covered by community health care in collaboration with PHC (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 300.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785343 ►Difference between the counties with the highest and lowest coverages of children who have received one dose of measles vaccination at 12 months old (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 48.6% Highest coverage: 100% Value -- 48.6% 41% Lowest coverage: 51.4% Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785346 ►Percentage of uninsured who are aware they are entitled to receive the same PHC basic benefit package as the insured (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Not applicable because Value -- Not applicable 90% they are not entitled yet Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 12/27/2019 Page 7 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785349 ►Number of community health care workers (community health nurses and Roma health mediators) trained (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 2,000.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785353 ►Percentage of women living in communities covered by community health care receiving at least one annual visit from a community health care provider (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 70.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. Hospital-centric health system rebalanced towards effective primary care IN00785341 ►Percentage of metformin prescriptions initiated at the PHC level (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 30.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785344 ►Number of family physicians receiving grants and loans to improve the supply of PHC (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 2,500.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785347 ►Number of family doctors incentivized through grants to improve supply of PHC in underserved areas (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 400.00 12/27/2019 Page 8 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785350 ►Number of communication tools applied for universal access to PHC, de minimis aid scheme, and framework contract modification (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 12.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785352 ►Number of public expenditure reviews conducted (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 3.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. Improving fiscal efficiency by addressing cristical cost drivers IN00785340 ►Percentage change in claims detected as unacceptable (unnecessary care, non-optimized laboratory tests, intentional or unintentional errors, …) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 0.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785345 PHC claims (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 20.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 IN00785348 Hospital claims (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 20.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 IN00785351 12/27/2019 Page 9 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Laboratory tests (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 30.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 IN00785354 ►Percentage of healthcare providers that automatically share data to the central EHR (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 0.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785355 PHC practices (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 90.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 IN00785356 Hospitals (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 60.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 IN00785357 ►Community health care information system upgraded to share data with the EHR (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No -- No Yes Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785358 ►Annual international price comparisons for all medicines with registered shortages in Romania (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No -- No Yes Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785359 12/27/2019 Page 10 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) ►Management Entry Agreement signed for 50% of newly assessed patented drugs with conditional entry decision through HTA methodology (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 0.00 50.00 Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785360 ►Clawback tax regulation revised to improve access to cost-effective drugs (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value Clawback tax not revised -- No revision Clawback tax revised Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. IN00785361 ►Revision of the list of drugs reimbursed by NHIH (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target List of drugs reimbursed by HNIH not revised using List of drugs No revision in HTA/list Value updated HTA -- reimbursed by NHIH of drugs methodology / HTA revised Methodology not updated Date 01-May-2019 -- 15-Dec-2019 31-Dec-2023 The value for this indicator will be updated after the next Implementation Support Mission once the required Comments institutional arrangements and reporting systems are in place. Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 Access to the basic package of PHC services among the uninsured (Outcome, 75,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 At least 2 million uninsured registered About 2 million uninsured with PHC providers do not have access to the Legislative change (DLR Value -- (family physicians) basic package of PHC 1.1) under preparation to receive the basic services package of PHC services Date -- -- 15-Dec-2019 -- The Government seems on track to achieve the DLR 1.1 on time. Comments ►DLI 2 Number of underserved communities receiving public community health care in collaboration with PHC providers (Outcome, 75,000,000.00, 0%) 12/27/2019 Page 11 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) Baseline Actual (Previous) Actual (Current) Year 4 300 underserved communities Community health services Changes in regulations providing public Value not in collaboration with -- (DLR 2.1) under community health in PHC services preparation collaboration with PHC providers Date -- -- 15-Dec-2019 -- The Government seems on track to achieve DLR 2.1 on time. Comments ►DLI 3 Share of the NHIH budget allocated to primary health care (Output, 75,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 a) Share of the NHIH budget allocated to family medicine is 6.5%; b)Provider payment Changes in regulations Share of the NHIF mechanisms for PHC Value -- (DLR 3.1) under budget allocated to providers limits preparation PHC is 10% effectiveness of PHC provision; c) Limited scope of PHC Date -- -- 15-Dec-2019 -- The Government seems on track to achieve DLR 3.1 on time. Comments ►DLI 4 Number of family medicine practices receiving grants and loans for the purpose of increasing and improving the supply of PHC services (Process, 75,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Family medicine practices lack capacity (equipment, New regulation (DLR 4.1) Value supplies, skills) to provide -- -- under preparation quality care, especially in underserved areas. Date -- -- 15-Dec-2019 -- The Government seems on track to achieve DLR 4.1 on time. Comments ►DLI 5 Scope and effectiveness of PHC traced through the share of diabetes medication initiated by PHC providers and proportion of adults (40+) receiving annual medical check up (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Value a) Initiation of diabetes -- Changes in regulations a) 20% of metformin medication at the PHC level affecting DLR 5.1 under prescription (a is 0%; b) Number of adults preparation commonly used (40+) receiving annual diabetes medication) medical check-ups is 1% initiated by PHC providers; b) 20% of 12/27/2019 Page 12 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) adults (40+) receiving annual medical check ups by PHC providers Date -- -- 15-Dec-2019 -- The Government seems on track to achieve DLR 5.1 on time. Comments ►DLI 6 Efficiency of NHIH expenditure improved through data-driven decision making process (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 a) An inter-operable system connects data between PHC providers, NHIH and MoH, to provide regular data cross- checks and inefficient spending 0% (current level of New regulation / data analytics; avoiding unnecessary Value -- procedures (DLR 6.1) b).Efficiency of expenditures used as under preparation health spending baseline) increased by avoiding inefficient NHIH expenditures in an amount equivalent to 2.5% of total projected annual NHIH expenditures Date -- -- 15-Dec-2019 -- The Government seems on track to achieve DLR 6.1 on time. Comments ►DLI 7 Efficiency of expenditure improved through implementation of centralized procurement (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 National Office for Centralized Procurement Changes in regulations Value (ONAC) not operational -- (DLR 7.0) are under -- and not mandated to work preparation in health sector Date -- -- 15-Dec-2019 -- The reform was delayed, and actually requires technical assistance. DLR 7.0 is now expected to be achieve in Comments Q2 of 2020 rather than Q4 of 2020 as initially expected. ►DLI 8 Pharmaceutical measures revised for better efficiency (Outcome, 50,000,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 4 Value Shortcoming of existing -- CHanges in regulations MEA signed by pharmaceutical policy: (DLR 8.0) under initiation NHIH and market 12/27/2019 Page 13 of 14 The World Bank Implementation Status & Results Report Romania Health Program for Results (P169927) a) External authorization reference pricing for holders for 50% of pharmaceutical carried out newly assessed sporadically patented drugs with b) List of drugs the conditional entry reimbursed based on decision using the outdated health technology new HTA assessment (HTA) methodology methodology c) Great potential to expand use of Management Entry Agreements (MEA) Date -- -- 15-Dec-2019 -- The reform has been delayed. It actually requires technical assistance. DLR 8.0 is now expected to be Comments achieved in Q3 of 2020 instead of Q4 of 2019 as initially expected. 12/27/2019 Page 14 of 14