Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Health System Resiliency Strengthening (P150481) MIDDLE EAST AND NORTH AFRICA | West Bank and Gaza | Health, Nutrition & Population Global Practice | Special Financing | Investment Project Financing | FY 2015 | Seq No: 7 | ARCHIVED on 02-Oct-2017 | ISR28255 | Implementing Agencies: Ministry of Health, Ministry of Finance Key Dates Key Project Dates Bank Approval Date:21-Jan-2015 Effectiveness Date:16-Feb-2015 Planned Mid Term Review Date:15-May-2017 Actual Mid-Term Review Date:17-Jul-2017 Original Closing Date:30-Jun-2020 Revised Closing Date:30-Jun-2020 Project Development Objectives Project Development Objective (from Project Appraisal Document) The project PDO is to support the Palestinian Authority in securing continuity in healthcare service delivery and building its resilience to withstand future surge in demand for effective healthcare coverage. Has the Project Development Objective been changed since Board Approval of the Project Objective? No PHRPDODEL Components Name Component 1: Emergency and Rapid Response Window:(Cost $2.00 M) Component 2: Rationalizing Outside Medical Referrals:(Cost $3.50 M) Component 3: Supporting health coverage to strengthen sector resilience:(Cost $2.00 M) Component 4: Project Management and Capacity Building:(Cost $1.00 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO  Satisfactory  Satisfactory Overall Implementation Progress (IP)  Satisfactory  Satisfactory Overall Risk Rating  Substantial  Substantial 10/2/2017 Page 1 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Implementation Status and Key Decisions The Project has made good progress towards achieving its overall Project Development Objective (PDO): “to support the Palestinian Authority in securing continuity in health care service delivery and building its resilience to withstand future surges in demand for effective healthcare coverage”. In terms of disbursements, the project has disbursed approximately US$4.0 million out of the original grant amount of US$8.5 million, representing 47 percent disbursement rate with close to 50 percent of the project period having elapsed. In terms of implementation progress by component: Component 1 (Emergency and Rapid Response Window) has been the most successful: Project resources allocated to this emergency component have been fully utilized and successfully met the intended purpose in response to the 2014 Gaza war. Moving forward, and to help address the continued dire health care situation in Gaza, the Bank is willing to consider supporting the Ministry of Health (MoH) and the development partners in identifying key measures to further strengthen the emergency response in such a highly volatile environment. Component 2 (Rationalizing Outside Medical Referrals): has been progressing well on several aspects including on the development and cabinet endorsement of the referrals master plan, the development of Memorandums Of Understanding (MOUs) for Outside Medical Referrals (OMRs) with non-Ministry of Health (MoH) hospitals, the development of referral guidelines, the strengthening of the Service Purchasing Unit institutional capacity (SPU), the strategic purchasing of hospital equipment, and the development of an Integrated Government Health Insurance Management System (GHI MIS). On the rationalization of contracts, the Strategic Purchasing Unit (SPU) and USAID/Intrahealth have achieved substantial progress with the signing of 12 MoUs with hospitals both in Israel and the West Bank in addition to 4 abroad. This comes as an initial step prior to the formulation of the solid and comprehensive contracts, awaiting the finalization of the one pricing national schedule currently being developed by a World Bank international consultant, in close coordination with MoH. The referral master plan was developed and endorsed in September 2016 and has served as an excellent reference for the clarification of roles and responsibilities among the various stakeholders in the health sector. With regard to the referrals information system, the project is supporting the development of an Integrated Government health Insurance Management System (GHI MIS). A very well prepared and highly informative report was produced and approved by the MoH technical committee. The consultant is now in the process of producing the general architectural, functional and logical design of the GHI MIS in addition to the related ToRs. The document will also include recommendations for the GHI MIS implementation phase. However, the mission acknowledged that a full-fledged system is far too ambitious to be finalized under the project given the current limitations of the systems in place. Therefore, the mission recommends to reduce the scope of this activity by supporting an agile, phased approach, rather than the adoption of a full complex system. Furthermore, the progress on the development and finalization of the pricing schedule for OMRs has been slow due to the lack of essential data at the Ministry. To move forward, MoH needs to make key decisions on issues such as the price scheduling classification (opting for an International Diagnosis Related Group ([DRG] system versus the Israeli system). As soon as MOH is clear about the way forward, an action plan will be developed to move ahead and complete the national pricing, which will subsequently allow for the development of the solid and comprehensive contracts with the health providers This component has also supported the enhancement of SPU performance through the recruitment of a medical auditor who has been on board since August 1, 2017 and that of two financial auditors expected to join shortly. With regard to the Strategic Purchasing of Equipment for hospitals, the project has so far provided: 1) six operating rooms to Alia Hospital that are currently fully functional. The impact of this addition has been very positive as it has increased the number of surgeries conducted in the hospital; decreased the waiting time; improved the working environment and medical team morale. 2) A Doppler to Beit Jala Hospital which has been used so far to conduct 154 operations thus reducing the need for costly outside medical referrals. It is estimated that the savings resulting from this purchase are at around USD 150,000. 3) A Sterilizer for Beit Jala Hospital which is currently underway. The existing sterilizer is no condition to continue to function and is highly hazardous to the safety of both the personnel and the patients. Component 3 (Supporting Health Coverage Reform to Strengthen Sector Resilience) is the component where progress has been slowest compared to the others, with much of the funding remaining undisbursed. Progress was slow due to the lack of an agreement and vision on the longer term and more comprehensive reform related to the pooling and separation of financing functions. The mission found that more evidence and data are needed to justify such reform efforts and to guide planning activities for Universal Health Coverage (UHC) beyond just health financing. The Project will provide the necessary institutional support to facilitate the generation of such evidence, and health financing, but also human resources for health (HRH) which is closely interlinked. This will entail the consideration of an alternative mode of implementation for this specific component. Component 4 (Project Management and Capacity Building) is generally progressing satisfactorily. However, more efforts need to be exerted to achieve further progress on the capacity building activities relating to project management and monitoring and evaluation (M&E). A communication strategy consultant is currently on board assisting the Ministry with the development of a two-year communication strategy. Training programs for medical personnel on four top priority referral conditions are presently being designed by the Project Management Unit (PMU) in close coordination with the MoH experts. In consultation with the client during the Mid-Term Review, it was agreed that a few modifications will be introduced to some of the Project envisaged activities as well as key indicators that can be more realistically achieved. 10/2/2017 Page 2 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance  --  High  High Macroeconomic  --  High  High Sector Strategies and Policies  --  High  High Technical Design of Project or Program  --  High  High Institutional Capacity for Implementation and Sustainability  --  High  High Fiduciary  --  Substantial  Substantial Environment and Social  --  Substantial  Substantial Stakeholders  --  Moderate  Moderate Other  --  --  -- Overall  --  Substantial  Substantial Results Project Development Objective Indicators PHINDPDOTBL  Utilization rates (out-patient, emergency and obstetrics) in the hospitals of Shifa, and Rafedia do not deteriorate or improve up to 10% compared to a baseline end-September, 2014 (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Shifa occupancy: Shifa occupancy: 92%, Shifa occupancy: 92%, 89%, Rafedia Rafedia occupancy: Rafedia occupancy: Shifa occupancy: 89%, occupancy: 87.6% 87.6% Rafedia occupancy: 85% 85%Obstetrics Obstetrics Shifa:96% Obstetrics Shifa:96% Obstetrics Shifa: 76% Shifa: Obstetrics Rafedia: Obstetrics Rafedia: Value Obsetrics Rafedia: 94% 76%Obsetrics 81.5% 81.5% Outpatient Shifa: 578,646 Rafedia: Outpatient Shifa: OC= Outpatient Shifa: OC= Outpatient Rafedia: 94%Outpatient 190187, ER= 231621 190187, ER= 231621 163,262 Shifa: Oupatient Rafedia: Oupatient Rafedia: 578,646Outpati 168037 168037 ent Rafedia: 163,262 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 10/2/2017 Page 3 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDPDOTBL  The total cost of referal reduced by 15% (by end of the project) relative to baseline (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 144.00 197.00 197.00 120.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments The team, in consultation with the client, proposes that this indicator be revised to focus on the growth rate of referrals rather than the cost as the latter is not inclusive of all factors that might lead to cost increase. This will be taken into account in the upcoming restructuring. PHINDPDOTBL Gap in geographic equity for referral cost (between the West Bank and Gaza) reduced by 80 percent relative to baseline (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.7:1 -- 1:7:1 1:15:1 Date 25-Jan-2015 -- 13-Sep-2017 31-Dec-2019 Comments The continued blockade on Gaza and the potential increase in health expenditures hinders any objective comparison between the two areas. Furthermore, the sensitive political split between the West Bank and Gaza renders the compilation of accurate data very challenging. In consultation with the client, the team proposes to drop this indicator in the upcoming restructuring. Having said that, the Project will continue to track progress in Gaza with the monitoring tools available. Overall Comments Intermediate Results Indicators 10/2/2017 Page 4 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  Utilization rates (outpatient, emergency, and obstetrics) in the hospitals of Shifa and Rafedia do not deteriorate or improve by up to 10% compared to a baseline end September 2014 (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Shifa occupancy: 92% Rafedia occupancy: 87.6% Shifa occupancy:89% - Obstetrics Shifa: 96% Same ratio as Nasser occupancy: 74% Obstetrics Rafedia: baseline or Value European Gaza Hospital: -- 81.5% improve up to 79% outpatient Shifa: OC= 10% 190187, ER= 231621 Outpatient Rafedia: 168037 Date 25-Jan-2015 -- 13-Sep-2017 31-Dec-2019 PHINDIRITBL  Referral protocols and procedures for the ten costliest conditions defined and rendered operational (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3.00 5.00 10.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments The following referral procedures protocols have been produced for the following conditions: oncology, ophthalmology, neurology, nephrology and cardiology. PHINDIRITBL  A consolidated Government Health Information System (HIS) for referrals, billing and health insurance in both the West Bank and Gaza is fully operational (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target A web-based system Value 0.00 -- not operational operational in all hospitals taking referrals Date 25-Jan-2015 -- 13-Sep-2017 31-Dec-2019 10/2/2017 Page 5 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Comments This assignment is currently in progress, the consultant is in the process of producing the general architectural, functional, and logical design of the Integrated Government Health Insurance Management System (GHI MIS) PHINDIRITBL  HIS operational in selected hospitals (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 8.00 8.00 10.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 PHINDIRITBL  Health facilities constructed, renovated, and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 1.00 2.00 5.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments Two health facilities were equipped: Alia Hospital and Beit Jala Hospital. PHINDIRITBL  Direct project beneficiaries (no), of which female (%) (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 53.00 53.00 10/2/2017 Page 6 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  New referral contracts/ MOUs negotiated with all outside providers (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 12.00 40.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments The SPU signed 6 MOUs with the Israeli hospitals and 6 with local hospitals. The solid and comprehensive contracts will be developed as soon as the one price national schedule is finalized. PHINDIRITBL  Purchasing agency (either independent or part of the MOH) created, staffed and made operational (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 Functional Functional Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments The Services Purchasing Unit is currently operational but requires further institutional strengthening and support. PHINDIRITBL  People with access to a basic package of health, nutrition or reproductive health services (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 81.00 90.00 90.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 10/2/2017 Page 7 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  Direct project beneficiaries (no), of which female (%) (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 45.00 50.00 Date 25-Jan-2015 -- 13-Sep-2017 31-Dec-2019 PHINDIRITBL  External audit (medical and financial) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Two financial external audits conducted; one Value Not available Functional Functional in 2015 and another 2016 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments The selection of the External Audit Company for 2017 and 2018 is in the process. A medical auditor is currently on board and is conducting regular audits. PHINDIRITBL  Health personnel receiving training (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 150.00 500.00 Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 10/2/2017 Page 8 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  Grievance and Redress Mechanism (GRM) for OMRs and access to Health Care designed and fully operational by end of the project (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Complaints manual Complaints manual and and posters have been posters have been finalized and finalized and Value Not available disseminated. Four disseminated. Four Fully functional workshops conducted workshops conducted at at regional level - two regional level - two remain to be delivered remain to be delivered Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments GRM Database established and piloted in two governorates. 6 GRM training events have been conducted. A GRM case study on the Palestine Medical Complex was conducted. PHINDIRITBL  Communciation strategy on UHC developed and consultation workshops conducted to promote the concept of citizens' engagement (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target One One consultation One consultation consultation Value 0.00 workshop was workshops were workshop conducted conducted conducted Date 25-Jan-2015 13-Apr-2017 13-Sep-2017 31-Dec-2019 Comments A communication strategy consultant is now on board and is in the process of developing a two year communication strategy for MOH. Overall Comments Data on Financial Performance Disbursements (by loan) 10/2/2017 Page 9 of 10 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P150481 TF-18986 Effective USD 8.50 8.50 0.00 3.97 4.53 47% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P150481 TF-18986 Effective 04-Feb-2015 04-Feb-2015 16-Feb-2015 30-Jun-2020 30-Jun-2020 Cumulative Disbursements Restructuring History Level 2 Approved on 07-Sep-2015 Related Project(s) There are no related projects. 10/2/2017 Page 10 of 10 Public Disclosure Copy