Disclosable Version of The ISR Moldova Health Transformation Project P144892 Sequence No 12

Public Disclosure Authorized
The World Bank Implementation Status & Results Report

Moldova Health Transformation Project (P144892)
EUROPE AND CENTRAL ASIA | Moldova | Health, Nutrition & Population Global Practice | Requesting Unit: ECCEE | Responsible Unit: HECHN
IBRD/IDA | Program-for-Results Financing | FY 2014 | Team Leader(s): Volkan Cetinkaya
Seq No: 12 | ARCHIVED on 13-Jul-2019 | ISR37950 | Created by: Volkan Cetinkaya on 28-Jun-2019 | Modified by: Volkan Cetinkaya on 10-Jul-2019
Program Development Objectives
Program Development Objective (from Program Appraisal Document)

The Program Development Objective is to contribute to reducing key risks for non-communicable diseases and improving efficiency ofhealth
services in Moldova.
Overall Ratings
Name Previous Rating Current Rating
Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory

Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory
Implementation Status and Key Decisions

The Project has achieved progress towards key indicators, including PDO Indicator 5, “average length of stay in acute care hospitals”, and recorded
improvements in the disbursement level reaching 53.5% for the Program part and 80% for the technical assistance part of the Operation. So far, the
Program part of this operation has disbursed four out of the ten Disbursement-linked Indicators entirely, while other indicators have demonstrated
good progress (partially achieved).
A further improvement in the implementation of the hospital sector reforms is foreseen over the coming year. The Ministry of Health, Labor and
Social Protection has expressed its commitment to improve efficiency of hospital sector and quality of services provided to the population. The Bank
team will continue providing immediate technical assistance to support the development of consensus among stakeholders on the vision and the
implementation of the regionalization of hospital care based on international best practices.
Data on Financial Performance

Disbursements (by loan)
Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed
P144892 IDA-54690 Effective USD 28.70 28.70 0.00 13.80 12.02 53%
P144892 IDA-54700 Effective USD 2.10 2.10 0.00 1.55 0.40 80%
Key Dates (by loan)

Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date
P144892 IDA-54690 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Dec-2020

P144892 IDA-54700 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Dec-2020
7/13/2019 Page 1 of 11
Program Action Plan

Action Description 6. Adoption of sanction mechanisms against hospitals with confirmed informal payment cases
Source DLI# Responsibility Timing Timing Value Status
Technical Client Recurrent Continuous Completed
Completion There is a regulatory framework in place that allows non-payment by CNAM of inpatient case treated by hospital if
Measurement there is a proof of out-of-pocket payments for drugs or medical services. The number of such cases decreasing.
Comments
Action Description 7. Implementation of annual audit of Diagnosis Related Group (DRG) payment for hospitals
Technical Client Recurrent Yearly Completed
CNAM is conducting verification of DRG coding by means of IT application which helps cross-check and identify
Completion
suspicious cases, after which more detailed verification takes place. The DRG audit report is submitted to the Bank
Measurement
by April each year.
Comments
Action Description 2. Annual tobacco excise duty increase as per the roadmap in the tobacco control legislation
Technical Client Recurrent Yearly In Progress
Completion The GoM adopts 3-year (rolling) fiscal policy framework based on which tobacco excise taxes are being defined. In
Measurement 2018 the 3% ad valorem tax was added to the non-filter cigarettes, however a greater tax unification is needed.
For 2017 – 2019 period of time and in compliance with the Association Agreement between the Republic of Moldova
Comments and European Union, the Government has approved the gradual annual growth of the excise duty on tobacco
products.
Action Description 3. Filling the vacancies in the MOH Policy Analysis and Monitoring Unit
Technical Client Other 2016 Completed
Completion completed early during project implementation and maintained since then.
Measurement
Comments
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Action Description 4. Completion of stakeholder analysis related to key health reforms supported by the Program
Technical Client Other 2016 Completed
Completion completed early during project implementation.

Measurement
Comments
5. Annual public awareness and communication campaigns on health reforms on the basis of the completed
Action Description
stakeholder analysis under Action 4
Technical Client Due Date 31-Dec-2020 In Progress
For 2019, the Mass Media Information and Communication Service has proposed to include several actions related to
Completion
the communication campaigns. Above mentioned Service is going to develop the Communication Strategy of the
Measurement
MHLSP for 2019-2021.
Comments
Action Description 1. Provision of sufficient Program annual budget
Fiduciary Systems Client Recurrent Yearly Completed
Completion At the time of monitoring, there was no information on the lack of budget allocated to PforR-related activities.
Measurement
Comments
8. Training conducted by hospital management consultants for all managers of hospitals under common management
Action Description
structures on reengineered business processes and workflows
Technical Client Due Date 31-Dec-2020 In Progress
Completion Firm responsible for the assignment is revising the content of the report in light with MoHLSP’s comments.
Measurement
Comments
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Action Description 9. Development of technical guidelines and sanitary regulation for Healthcare Waste Management (HCWM)
Environmental and Social

Client Due Date 31-Dec-2020 In Progress
Systems
Completion This action was reformulated as part of restructuring completed in November, 2018.
Measurement
No technical guidelines developed yet.

The regulation framework on health-care waste management, "Sanitary regulation on health-care waste
Comments management", has been approved by the Government Decision no.696 of 11.07.2018.
10. Setting up of an efficient mechanism for close cooperation among key institutions that have attributions in HCWM,
Action Description
including, but not limited to, the Ministry of Environment, Academy of Science, UNDP
Environmental and Social

Client Due Date 31-Dec-2020 In Progress
Systems
This action was reformulated. The MoHLSP will set up an efficient mechanism for close cooperation among the key
Completion
institutions that have attributions in HCWM, including, but not limited to, the Ministry of Environment, Academy of
Measurement
Science, UNDP.
Comments
Risks
Systematic Operations Risk-rating Tool
Risk Category Rating at Approval Previous Rating Current Rating
Political and Governance -- Substantial Moderate

Macroeconomic -- Substantial Substantial
Sector Strategies and Policies -- Substantial Substantial
Technical Design of Project or Program -- Substantial Moderate
Institutional Capacity for Implementation and
Sustainability
-- Substantial Substantial
Fiduciary -- Moderate Moderate
Environment and Social -- Moderate Moderate
Stakeholders -- Substantial Substantial
Other -- -- --
Overall -- Substantial Substantial
7/13/2019 Page 4 of 11
RiskComments
Comments
The "Political Governance" risk is lowered from "Substantial" to "Moderate" since a new government was established in June, 2019 after the last
parliamentary election.
The "Technical Design of Project" risk is lowered from "Substantial" to "Moderate" since the project implementation has been progressing well after
the completion of restructuring.
Results
PDO Indicators by Objectives / Outcomes
Reducing key risks for NCDs

IN00725674
►PDO Indicator 1: Smoking prevalence among adults (Percentage, Custom)
Baseline Actual (Previous) Actual (Current) End Target

Value 25.40 25.40 25.40 23.40
Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

The current value reflects 2013 STEPS survey data due to the fact that there was no other STEPS survey
Comments conducted in the meantime. It will be updated after 2019 STEPS survey is completed.
IN00725747
Smoking prevalence among adults, Male (Percentage, Custom Breakdown)

Value 43.70 43.70 43.70 42.00

IN00725749
Smoking prevalence among adults, Female (Percentage, Custom Breakdown)

Value 5.70 5.70 5.70 5.20

IN00725750
►PDO Indicator 2: Adults (age 45-59) with hypertension whose blood pressure is under control because of antihypertensive
medications (Percentage, Custom)
Value 5.10 5.10 5.10 10.00

Comments conducted in the meantime. It will be updated after 2019 STEPS survey is completed.
IN00725751
Adults with hypertension whose blood pressure is under control, Female (Percentage, Custom Breakdown)
7/13/2019 Page 5 of 11
Value 7.00 7.00 7.00 11.30

IN00725752
Adults with hypertension whose blood pressure is under control, Male (Percentage, Custom Breakdown)

Value 2.90 2.90 2.90 7.10
Improving efficiency of health services

IN00725675
►PDO Indicator 3: Annual acute care hospital discharges per 100 persons (Number, Custom)

Value 17.60 13.70 13.60 15.60
Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020
Comments
IN00725746
►PDO Indicator 4: Acute care hospital beds (Number, Custom)

Value 17,586.00 13,632.00 13,206.00 15,000.00
Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020
Comments
IN00725748
►PDO Indicator 5: Average length of stay in acute care hospitals (Days, Custom)

Value 8.00 7.60 6.90 7.20
Date 27-May-2014 20-Nov-2018 05-Jul-2019 31-Dec-2020
Comments
Intermediate Results Indicators by Results Areas
Intermediate Results Area 1: Reducing NCD risks

IN00725753
►Intermediate Results Indicator 1: Approval of the new tobacco control legislation (Yes/No, Custom)

Value No Yes Yes Yes
7/13/2019 Page 6 of 11
Date 27-May-2014 23-Nov-2018 23-Nov-2018 31-Dec-2020
Comments
IN00725754
►Intermediate Restults Indicator 2: Revision of the outpatient drug benefit package with regard to antihypertensive drugs
(Yes/No, Custom)

Starting February 1, 2019, citizens can request free of charge medications (only one from each INN, the
cost of which falls within the compensated amounts established quarterly by CNAM), according to Order No.
Comments 96/20A dated January 24th, 2019 signed by the Ministry of Health, Labor and Social Protection and the
National Health Insurance Company (CNAM).
IN00725756
►Intermediate Results Indicator 3: Rate of registered patients with hypertension on antihypertensive treatment with value of
arterial tension of <140/90 mm Hg (Percentage, Custom)
Value 32.40 23.80 32.40 39.00
Date 31-Mar-2015 19-Oct-2018 05-Jul-2019 31-Dec-2020

This indicator was revised as part of restructuring process completed in November, 2018. Actual of 23.80%
is measurement of previous indicator before the revision.
Comments
conducted in the meantime. It will be updated after 2019 STEPS survey is completed.
IN00725759
Adults with hypertension receiving treatment, Male (Percentage, Custom Breakdown)

Value 15.90 15.90 15.90 23.00
Date 27-May-2014 19-Oct-2018 19-Oct-2018 31-Dec-2020

IN00725761
Adults with hypertension receiving treatment, Female (Percentage, Custom Breakdown)

Value 32.50 32.50 32.50 37.60
Intermediate Results Area 2: Improved efficiency of health services

IN00725760
►Intermediate Results Indicator 4: Approval of the revised national health strategy which includes hospital rationalization
measures (Yes/No, Custom)
7/13/2019 Page 7 of 11
Comments
IN00725764
►Intermediate Results Indicator 5: Annual hospitalizations through referrals by family medicine providers (Percentage,
Custom)
Value 36.00 40.00 40.00 44.00
Date 31-Dec-2011 19-Oct-2018 05-Jul-2019 31-Dec-2020
Comments
IN00725765
►Intermediate Results Indicator 6: Consolidation of departmental hospitals under the MoHLSP authority (Yes/No, Custom)

Value No No No Yes
Date 19-Oct-2018 19-Oct-2018 05-Jul-2019 31-Dec-2020
Comments
IN00725766
►Intermediate Results Indicator 7: Percentage of citizen satisfied with quality of health services (Percentage, Custom)

Value 62.60 62.60 62.60 70.00
Date 19-Oct-2018 19-Oct-2018 05-Jul-2019 31-Dec-2020
Comments
Disbursement Linked Indicators

DLI_IND_TABLE
►DLI 1 Smoking prevalence among (age between 18 and 69); a) men; b) women (Output, 3,941,000.00, 0%)
Baseline Actual (Previous) Actual (Current) 2019
Value 25.40 25.40 25.40 23.40
Date 22-May-2014 23-Nov-2018 23-Nov-2018 --

The baseline was originally 28% in the PAD. However, the baseline was updated to 25.40% once the results
of the 2013 STEP survey became available.
Comments The current value reflects 2013 STEPS data due to the fact that there was no other STEPS survey conducted
in the meantime.
►DLI 2 Increase in the percentage of people with CVDs benefitting from compensated medications for treatment of CVDs
(Outcome, 3,217,500.00, 0%)
7/13/2019 Page 8 of 11
Value 48.50 48.50 48.50 58.50
Date 22-May-2014 23-Nov-2018 23-Nov-2018 --

This DLI was reformulated from “Adults with hypertension whose blood pressure is under control”. Though the
strongest risk factor for CVDs, not all risk factors for CVDs are avoidable. The reformulation is cross-
Comments supporting and reinforcing DLI 5 (revision of the outpatient drug benefit package with regards to anti-
hypertensive drugs).
►DLI 3 Annual acute care hospital discharges per 100 persons (Outcome, 3,000,000.00, 91%)
Value 17.60 16.50 13.60 15.60
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --
Comments
►DLI 4 Acute care hospital beds (Output, 4,700,000.00, 91%)
Value 17,586.00 16.50 13,206.00 15,000.00
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --
Comments
►DLI 5 Adoption of a revised outpatient drug benefit package for anti-hypertensive drugs (Process, 2,000,000.00, 92%)
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --
Comments
►DLI 6 Revision and implementation of performance-based incentive scheme in primary care (Process, 2,000,000.00, 23%)

Performancebased
incentive
Revision of the agreements signed
Value performance-based In progress. Achieved with all primary care
incentive scheme centers contracted
by CNAM in Year 4:
Yes
7/13/2019 Page 9 of 11
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --

The Pay-for-Performance scheme was amended based on recommendations of the TA consultancy financed
under IPF component. The mid-term review showed the new P4P scheme needs further significant
improvement. The MoHLSP abolished Pay-for-Performance scheme recommended by TA consultancy and
Comments proposed new set of indicators. The Bank approved the revised scheme and agreed to disburse the DLI
entirely. If needed, the Bank team will provide technical support for further revisions in the scheme in the
future.
►DLI 7 Design, piloting, adoption and implementation of a performance-based incentive scheme for hospitals (Process,
2,000,000.00, 23%)

Performance based
No incentive scheme for contracts signed
Value In progress In progress
hospitals with all multiple-
profile hospitals
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --
This DLI was linked to the technical assistance offered under IPF component. The Report with the proposed
scheme developed and approved by the MoHLSP. However, in order to simulate payments under the scheme
for hospitals of various level of care, IT application is required. Consequently, while achievement of DLI target
7.1 confirmed, yet attaining of its further targets requires additional work and are scheduled for end 2019.
Advance payment made in 2015 which was accounted for upon the completion of P4P report under the IPF
component.
Comments To achieve the DLI target, the following shall be urgently completed:
1. Design and development of IT application necessary for processing of large data required for P4P
scheme;
2. Simulation of P4P scheme for 2018;
3. Adjustment of performance indicators;
►DLI 8 Implementation and update of DRG prices for public acute care hospitals (Process, 2,000,000.00, 68%)

DRG accounting for less
than 40 percent of total DRG updated using
Value In progress In progress
payment by CNAM to country data
public hospitals
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --
DLI#8.1, DLI#8.2, and DLI#8.3 have been accomplished. DLI #8.4 is not yet achieved due to delay in the TA
supporting the DLI.
The contract with the EuroHealth consulting company expired on February 28, 2019. The report no-3 with
methodology for DRG cost calculation was included in this report and approved. Currently, the report no-4 is
Comments being discussed within the working group and is expected to be approved by end August 2019. Application of
new DRG costs simulation was conducted.
►DLI 9 Consolidation of departmental hospitals under the MoHLSP authority (Process, 4,000,000.00, 0%)
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Value 0.00 0.00 0.00 50.00
Date 22-May-2014 23-Nov-2018 05-Jul-2019 --

The DLI #9.1 was disbursed as advance payment. The draft Government decision on the merger of three
hospitals dd 2016 is still pending. However, given that the hospital reform concept is not yet adopted and
taking into account that the Government brought under the MoHLSP few departmental hospitals (namely,
Comments Railway hospitals) in 2018, there is high probability of this indicator to be achieved till project closure. The
team is monitoring DLI # 9 status.
DLI #9.2, 9.3, 9.4 are restructured to allocate more support for hospital reform design and implementation.
►DLI 10 Adoption of the revised National Health System Development Strategy which includes hospital rationalization
measures (Process, 1,000,000.00, 96%)

Strategy has not been
Value Achieved Achieved --
revised and approved
Date 22-May-2014 23-Nov-2018 23-Nov-2018 --
DLI # 10 achieved and accounted.

Comments
7/13/2019 Page 11 of 11

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Public Disclosure Authorized

The World Bank Implementation Status & Results Report

Moldova Health Transformation Project (P144892)

Program Development Objectives

Program Development Objective (from Program Appraisal Document)

Name Previous Rating Current Rating

Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory

Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory

Implementation Status and Key Decisions

Data on Financial Performance

Disbursements (by loan)

Key Dates (by loan)

P144892 IDA-54690 Effective 22-May-2014 11-Jul-2014 08-Apr-2015 30-Mar-2019 31-Dec-2020

Program Action Plan

Source DLI# Responsibility Timing Timing Value Status

Technical Client Recurrent Continuous Completed

Source DLI# Responsibility Timing Timing Value Status

Technical Client Recurrent Yearly Completed

Source DLI# Responsibility Timing Timing Value Status

Technical Client Recurrent Yearly In Progress

Source DLI# Responsibility Timing Timing Value Status

Technical Client Other 2016 Completed

Source DLI# Responsibility Timing Timing Value Status

Technical Client Other 2016 Completed

Completion completed early during project implementation.

Source DLI# Responsibility Timing Timing Value Status

Technical Client Due Date 31-Dec-2020 In Progress

Action Description 1. Provision of sufficient Program annual budget

Source DLI# Responsibility Timing Timing Value Status

Fiduciary Systems Client Recurrent Yearly Completed

Source DLI# Responsibility Timing Timing Value Status

Technical Client Due Date 31-Dec-2020 In Progress

Source DLI# Responsibility Timing Timing Value Status

Environmental and Social

No technical guidelines developed yet.

Source DLI# Responsibility Timing Timing Value Status

Environmental and Social

Systematic Operations Risk-rating Tool

Risk Category Rating at Approval Previous Rating Current Rating

Political and Governance -- Substantial Moderate

PDO Indicators by Objectives / Outcomes

Reducing key risks for NCDs

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Smoking prevalence among adults, Male (Percentage, Custom Breakdown)

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Smoking prevalence among adults, Female (Percentage, Custom Breakdown)

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Baseline Actual (Previous) Actual (Current) End Target

Value 7.00 7.00 7.00 11.30

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 19-Oct-2018 05-Jul-2019 31-Dec-2020

Improving efficiency of health services

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020

Baseline Actual (Previous) Actual (Current) End Target

Date 27-May-2014 20-Dec-2018 05-Jul-2019 31-Dec-2020

Baseline Actual (Previous) Actual (Current) End Target