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: 8 | ARCHIVED on 26-Jan-2018 | ISR31318 | Implementing Agencies: Ministry of Health, Ministry of Finance, World Health Organization, USAID/Intrahealth Project 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 1/26/2018 Page 1 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Implementation Status and Key Decisions A mid term evaluation mission was conducted in July 2017 to assess the project performance and the need to make any adjustments to the project's scope, activities and or indicators. Based on thorough consultations with the Ministry officials and the Project Implementation Unit, it was agreed that a number of Project indicators would need to be revised so as to render them more attainable during the remaining period of the Project life. The proposed changes on the results framework indicators are as follows: 1 . Revising the PDO indicator “utilization rates in the hospitals of Shifa and Rafedia do not deteriorate or improve up to 10% compared to a baseline end September 2014” to include Alia Hospital. Since the Project has provided substantial assistance to Alia Hospital through the strategic purchasing of necessary equipment (amounting to USD 850,000), it is important that the Project captures the impact of this contribution on the utilization rates. 2 . Revising the PDO indicator “the total cost of referrals reduced by 15% by end of the project” to read instead as follows “average annual growth of total expenditure in OMRs of a four-year period lower than the proposed baseline which is the period 2012-2015 (<13.19%)”. Due to factors beyond MOH’s control (population growth; the volatile emergency situations; complex and costly services …etc.), and despite the substantial progress in revamping the referral management system, the cost of referrals remains very difficult to be contained, at least for the remaining period of the Project. Accordingly, the indicator has been revised to reflect the average annual growth of total expenditure which should be more attainable. 3 . Revising the end target of the intermediate indicator “health facilities constructed, renovated and/or equipped” from 5 to 2. The reduction in the end target is being proposed to capture the substantial support extended to Alia Hospital. Six operating rooms were fully equipped – an intervention that contributed to an increase in the number of conducted surgeries; decrease in the waiting period for surgical operations; increase in public satisfaction as well as medical staff morale. In addition to Alia, the project supported Beit Jala hospital through the provision of much needed equipment: a) ultrasound Doppler and b) Sterilizer. It is worth noting that both Alia and Beit Jala Hospitals serve the Southern governorates population and based on the MoH’s request, enhancing the quality of services provided by these two hospitals is highly needed – otherwise stretching aid to 5 facilities would reduce the impact of the contributions. 4 . Amending the intermediate result indicator “a consolidated health information system (HIS) for referrals, billing and health insurance in both the West Bank and Gaza is fully operational “to read instead as “a consolidated health information system for referrals and health insurance operational”. Based on the Government Health Insurance (GHI MIS) business analysis completed in September 2017 which clearly highlights MoH’s processes weaknesses, the need to reduce the scope of the GHI MIS activity was highlighted. The Project should focus on achievable activities during the life of the project to improve the health insurance system by introducing some key features such as: a) electronic services; b) a set of benefit packages with detailed and separate provisions; c) electronic inter-operationality between the HIS and other MOH IT systems and so forth. 5 . Revising the end target of the intermediate result indicator “new referral contracts/MOUs negotiated with all outside providers” from 40 to 30. One of MoH’s adopted strategies to enhance the referral management system including cost and quality control is to reduce the number of contracted service providers. Hence the end target of this indicator is being revised to capture this strategy. An official request from the Ministry was received into that effect which was formally approved by the Bank. 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 1/26/2018 Page 2 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) 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, Rafedia and Alia Hospital 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: occupancy: 87.6%; Alia occupancy: 87.6%; Alia occupancy: 85%, Alia 136% 136% occupancy: Obstetrics Shifa:96% Obstetrics Shifa:96% 136% Shifa occupancy: 89%, Obstetrics Rafedia: Obstetrics Rafedia: Obstetrics Rafedia occupancy: 85% 81.5% 81.5% Shifa: 76% - Obstetrics Shifa: 76% Obstetrics Alia: 105% Obstetrics Alia: 105% Obstetrics Value Obsetrics Rafedia: 94% Outpatient Shifa: OC= Outpatient Shifa: OC= Rafedia: 94% - Outpatient Shifa: 578,646 190187, ER= 231621 190187, ER= 231621 Obstetrics Alia: Outpatient Rafedia: Oupatient Rafedia: Oupatient Rafedia: 105% 163,262 168037 168037 Outpatient Outpatient Alia: Outpatient Alia: Shifa: 578,646 - OC=102046, OC=102046, Outpatient ER=108704 ER=108704 Rafedia: 163,262 - Outpatient Alia: 102046 Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 31-Dec-2019 PHINDPDOTBL  Average annual growth of total expenditure in OMRs of a four-year period lower than the proposed baseline which is the period 2012-2015 (<13.19%) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 13.19% 13.19% 13.19% <13.19% Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 31-Dec-2019 1/26/2018 Page 3 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) 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 1:7:1 1:15:1 Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 Overall Comments Intermediate Results Indicators PHINDIRITBL  Utilization rates (outpatient, emergency, and obstetrics) in the hospitals of Shifa, Rafedia and Alia 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: Shifa occupancy: 92% 87.6% Rafedia occupancy: Alia occupancy: 136% 87.6% Obstetrics Shifa: 96% Shifa occupancy:89% - Obstetrics Shifa: 96% Obstetrics Rafedia: Same ratio as Nasser occupancy: 74% Obstetrics Rafedia: 81.5% baseline or Value European Gaza Hospital: 81.5% Obstetrics Alia: 105% improve up to 79% outpatient Shifa: OC= outpatient Shifa: OC= 10% 190187, ER= 231621 190187, ER= 231621 Outpatient Rafedia: Outpatient Rafedia: 168037 168037 Outpatients Alia: 102046, ER: 108704 Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 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 5.00 5.00 10.00 Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 1/26/2018 Page 4 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  A consolidated Government Health Information System (HIS) for referrals and health insurance is operational (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target A web-based system Value 0.00 not operational not operational operational in all hospitals taking referrals Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 31-Dec-2019 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-Sep-2017 18-Jan-2018 31-Dec-2019 PHINDIRITBL  Health facilities constructed, renovated, and/or equipped (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 2.00 2.00 2.00 Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 31-Dec-2019 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 53.00 1/26/2018 Page 5 of 9 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 12.00 30.00 Date 25-Jan-2015 28-Dec-2017 18-Jan-2018 31-Dec-2019 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 Functional Functional Functional Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 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 90.00 90.00 90.00 Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 PHINDIRITBL  Direct project beneficiaries (no), of which female (%) (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 45.00 45.00 50.00 Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 1/26/2018 Page 6 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) PHINDIRITBL  External audit (medical and financial) (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value Not available Functional Functional Functional Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 PHINDIRITBL  Health personnel receiving training (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 150.00 150.00 500.00 Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 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-Sep-2017 18-Jan-2018 31-Dec-2019 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 workshops were workshops were workshop conducted conducted conducted Date 25-Jan-2015 13-Sep-2017 18-Jan-2018 31-Dec-2019 Overall Comments 1/26/2018 Page 7 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P150481 TF-18986 Effective USD 8.50 8.50 0.00 4.03 4.47 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 ,Level 2 Approved on 17-Jan-2018 1/26/2018 Page 8 of 9 Public Disclosure Copy Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Resiliency Strengthening (P150481) Related Project(s) There are no related projects. 1/26/2018 Page 9 of 9 Public Disclosure Copy