The World Bank Report No: ISR10575 Implementation Status & Results Armenia Health System Modernization Project (APL2) in Support of the Second Phase of the Health Sector Reform Program (P104467) Public Disclosure Copy Operation Name: Health System Modernization Project (APL2) in Support of Project Stage: Implementation Seq.No: 13 Status: ARCHIVED Archive Date: 06-Jul-2013 the Second Phase of the Health Sector Reform Program (P104467) Country: Armenia Approval FY: 2007 Product Line: IBRD/IDA Region: EUROPE AND CENTRAL ASIA Lending Instrument: Adaptable Program Loan Implementing Agency(ies): Key Dates Board Approval Date 08-Mar-2007 Original Closing Date 31-Dec-2012 Planned Mid Term Review Date Last Archived ISR Date 03-Dec-2012 Effectiveness Date 06-Jun-2007 Revised Closing Date 31-Dec-2014 Actual Mid Term Review Date 17-May-2010 Project Development Objectives Project Development Objective (from Project Appraisal Document) The overall objective of the HSRP Program remains unchanged: to improve the organization of the health care system in order to provide more accessible, quality and sustainable health care services to the population, in particular to the most vulnerable groups, and to better manage public health threats. This Project aims at: (i) scaling up family medicine based primary health care reform by expanding the renovation of primary health care facilities and upgrading of the medical equipment in the remaining marzes; (ii) optimizing and upgrading hospital networks in the remaining marzes; (iii) strengthening Government's capacity to develop and monitor effective health sector policies in the area of health financing, resource allocation and provider payments; and (iii) expanding investment in human resources to include formal and continuous education in health (medical, nursing, auxiliary health professionals). Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost COMPONENT A: FAMILY MEDICINE DEVELOPMENT 10.15 Public Disclosure Copy COMPONENT B: HOSPITAL NETWORK OPTIMIZATION 37.77 COMPONENT C: INSTITUTIONAL STRENGTHENING 4.82 COMPONENT D: PROJECT MANAGEMENT 2.20 Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Satisfactory Overall Implementation Progress (IP) Satisfactory Satisfactory Overall Risk Rating Low Low Page 1 of 8 The World Bank Report No: ISR10575 Implementation Status Overview All activities planned under the original credit of the Project are fully completed with the credit fully disbursed. Key activities under the Additional Financing (AF) in support of the Project Development Objectives are completed and or are ongoing. These include the development of the Health System Performance Assessment Report and of the National Health Accounts Report for 2011, with their publication expected end of May 2013. Other activities that are taken place include the retraining of family physicians and family nurses, which Public Disclosure Copy are financed under State Budget. All planned civil works are ongoing and will be completed at the latest May 2014. Population satisfaction with PHC and hospitals care services has shown positive trends as follows (combined urban and rural marzes): PHC services: from 53.6% in 2009 to 68.7% in 2012; hospitals: from 64.6% in 2009 to 69.3% in 2012. Locations Country First Administrative Division Location Planned Actual Armenia Syunik'i Marz Tegh Armenia Syunik'i Marz Tat'ev Armenia Vayots' Dzori Marz Surenavan Armenia Ararati Marz Noyakert Armenia Syunik'i Marz Goris Armenia Ararati Marz Burastan Armenia Ararati Marz Aygezard Armenia Vayots' Dzori Marz Areni Armenia Ararati Marz Ararat Armenia Ararati Marz Urts'adzor Armenia Ararati Marz Ararati Marz Armenia Syunik'i Marz Syunik'i Marz Armenia Vayots' Dzori Marz Vayots' Dzori Marz Armenia Shiraki Marz Horrom Public Disclosure Copy Armenia Armaviri Marz Margara Armenia Aragatsotni Marz Zovuni Armenia Geghark'unik'i Marz Vaghashen Armenia Aragatsotni Marz Ushi Armenia Aragatsotni Marz Ujan Armenia Geghark'unik'i Marz Tsovazard Page 2 of 8 The World Bank Report No: ISR10575 Country First Administrative Division Location Planned Actual Armenia Geghark'unik'i Marz Tsovagyugh Public Disclosure Copy Armenia Ararati Marz Sis Armenia Geghark'unik'i Marz Sarukhan Armenia Armaviri Marz Samaghar Armenia Armaviri Marz Pshatavan Armenia Armaviri Marz P'arak'ar Armenia Kotayk'i Marz Nor Geghi Armenia Kotayk'i Marz Mrgashen Armenia Armaviri Marz Mrgashat Armenia Shiraki Marz Mets Mant'ash Armenia Kotayk'i Marz Meghradzor Armenia Armaviri Marz Khoronk' Armenia Aragatsotni Marz K'uch'ak Armenia Aragatsotni Marz Kosh Armenia Aragatsotni Marz Kasakh Armenia K'aghak' Yerevan K'anak'erravan Armenia Ararati Marz Kanach'ut Armenia Geghark'unik'i Marz Gavarr Public Disclosure Copy Armenia Tavushi Marz Ijevan Armenia Kotayk'i Marz Hrazdan Armenia Armaviri Marz Armavir Armenia Shiraki Marz Gyumri Armenia Lorru Marz Jrashen Armenia Armaviri Marz Dalarik Armenia Kotayk'i Marz Buzhakan Page 3 of 8 The World Bank Report No: ISR10575 Armenia Armaviri Marz Aygeshat Armenia Geghark'unik'i Marz Astghadzor Public Disclosure Copy Armenia Aragatsotni Marz Arteni Armenia Armaviri Marz Arshaluys Armenia Armaviri Marz Arevik Armenia Lorru Marz Arevashogh Armenia Kotayk'i Marz Aramus Armenia Aragatsotni Marz Aparan Armenia Armaviri Marz Apaga Armenia Shiraki Marz Akhurik Armenia Tavushi Marz Azatamut Armenia Tavushi Marz Artsvaberd Armenia Aragatsotni Marz Nor Sasunik Armenia Ararati Marz Darakert Armenia Aragatsotni Marz Aragatsotni Marz Armenia Armaviri Marz Armaviri Marz Armenia Geghark'unik'i Marz Geghark'unik'i Marz Armenia Kotayk'i Marz Kotayk'i Marz Armenia Lorru Marz Lorru Marz Public Disclosure Copy Armenia Shiraki Marz Shiraki Marz Armenia Tavushi Marz Tavushi Marz Armenia Armaviri Marz Arratashen Armenia Geghark'unik'i Marz Lusakunq Results Project Development Objective Indicators Page 4 of 8 The World Bank Report No: ISR10575 Indicator Name Core Unit of Measure Baseline Current End Target Proportion of Armenian Population covered by Text Value 47% 91% 95% qualified family medicine practices Date 31-Dec-2006 17-May-2013 31-Dec-2014 Public Disclosure Copy Comments Exceeded against APL2 target (90%). On track against AF target Increased utilization of a) out-patient services; Text Value a) 3.9%; b) 3.1% a) 3.8%; b) 5.1% Increased Utilization and b) in-patient services by the poorest Date 22-Nov-2011 30-Dec-2011 31-Dec-2014 income quintile Comments Slight decrease. Data for year 2011; Data for year 2012 will be available in November 2013 Health Sector Performance Report issued once Text Value HSPA for 2006 year published HSPA report for 2011 HSPA published every two every two years developed year Date 01-Sep-2007 17-May-2013 31-Dec-2014 Comments HSPA will be published end May 2013 Perceived quality of care in marzes increased Text Value 64.3% a) PHC: urban: 65.1%; rural: Improvement from baseline 73.2%; b) hospitals: urban: 73.7%; rural: 66.8% Date 30-Dec-2007 17-May-2013 31-Dec-2014 Comments Both urban/rural marzes: Target on track. Same PHC: 53.6% in 2009; indicators in 2010 shows: a) Hospitals: 64.6% in 2009. PHC: urban: 49.5%; rural: 57.5%; b) hospitals: urban: 56.4%; rural: 74.9%. Important improvement from 2010 for PHC, but decrease observed on rural hospitals. Both urban/rural marzes: PHC: 68.7% (2012); Public Disclosure Copy hospitals:69.3% (2012) ALOS in marz hospitals decreased close to Text Value 7.7 6.5 6.5 OECD average Date 01-Dec-2006 17-May-2013 31-Dec-2014 Comments Target achieved under APL2 (target was 7.0); Target achieved under AF Page 5 of 8 The World Bank Report No: ISR10575 National Health Accounts report published Text Value 2006 NHA report distributed NHA for 2011 developed Annual annually 2007 Date 31-Dec-2006 17-May-2013 31-Dec-2014 Public Disclosure Copy Comments NHA report will be published end of May 2013 Public hospitals in project sites that have Text Value 0 0 13 published financial audit reports from Date 31-Dec-2006 17-May-2013 31-Dec-2014 independent audits Comments MoH to finance FY11 For FY11 and FY13 independent audit in 2013 out of State budget Proportion of patients with a) hypertension who Text Value a) 42%; b) 33% a) 61%; b)57% Increased had at least one ECG annually; b) ischemic Date 31-Dec-2006 17-May-2013 31-Dec-2014 heart disease who had at least one Comments Indicators status shows set totalcholesterol test annually back from previous status. Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Number of certified FDs trained Text Value 633 1654 1750 Date 01-Dec-2006 17-May-2013 31-Dec-2014 Comments 22 FD are undergoing Target for AF is 100; Target retraining which will be for APL2 is 1650 completed Oct. 2013 Number of certified FNs trained Text Value 568 1770 1950 Date 01-Dec-2006 17-May-2013 31-Dec-2014 Comments 34 FN are undergoing Target for AF is 120; Target retraining which will be for APL2 is 1650 completed in May 2013 Reduction of sq. meters of hospital space Text Value 0% 65.3% 85% (percent of original) in all marzes Date 31-Dec-2006 17-May-2013 31-Dec-2014 Public Disclosure Copy Comments (68,997 sqm out of 105,609 sqm) . Gvt Decree RA N-1911 Health personnel receiving training (number) Number Value 1201.00 3456.00 3700.00 Date 01-Jan-2009 17-May-2013 31-Dec-2014 Comments The APL 2 continues training Exceeded for APL2. This is Target for AF if 400. Target of doctors and nurses started cummulative figure. This for APL2 is 3300 under the previous two Bank's includes FD and FN re- investment project. training mentioned above, and 19 narrow specialists and Page 6 of 8 The World Bank Report No: ISR10575 13 nurses (trained in Q4 of CY12). Health facilities constructed, renovated, and/or Number Value 0.00 86.00 89.00 equipped (number) Public Disclosure Copy Date 01-Jan-2008 17-May-2013 31-Dec-2014 Comments Target on track Proportion of health budget allocated to PHC Percentage Value 35.50 34.70 43.00 Date 31-Dec-2006 02-Nov-2012 31-Dec-2014 Comments Not achieved under APL2 target (41%). Approved 2013 budget All project hospitals apply updated Text Value No Yes Yes environmental management guidelines Date 01-Jan-2007 17-May-2013 31-Dec-2014 Comments Target met State Medical University has a revised students Text Value No revision has been done No Yes examination system in line with EU countries Date 31-Dec-2006 17-May-2013 31-Dec-2014 Comments Discussions with Rector Target to be met at the confirmed that this will be closing of AF achieved by June 2014 Increased number of admission in project Text Value 29,668 38,960 40,000 hospitals Date 01-May-2009 02-Nov-2012 31-Dec-2014 Comments Includes APL2 and AF Target met against APL2 target of 35,000 Proportion of key management staff in project Text Value 0 0 39 key management staff or hospitals trained on financial management after 100% the results of performed independent audits Date 31-Dec-2006 17-May-2013 31-Dec-2014 Comments Delayed. Awaiting 3 staff in 13 hospitals = 39 independent audits of public key management staff hospitals for FY11 to assess issues before deciding on Public Disclosure Copy content of training. MoH to finance out of State budget. Reduction in out-of-pocket payments for Text Value a) 35.4% (out-patient); b) a) 38.4% (out-patient); b) 37% Reduction essential health services 47.1% (in-patient) (in-patient Date 31-Dec-2009 02-Nov-2012 31-Dec-2014 Comments Baseline data will be available 2011 data. Data for 2012 will in November 2011 be available in November 2013 Data on Financial Performance (as of 03-Jun-2013) Page 7 of 8 The World Bank Report No: ISR10575 Financial Agreement(s) Key Dates Project Ln/Cr/Tf Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P104467 IBRD-79870 Effective 20-Dec-2010 26-Jan-2011 08-Jun-2011 31-Dec-2014 31-Dec-2014 Public Disclosure Copy P104467 IDA-42670 Closed 08-Mar-2007 09-Mar-2007 06-Jun-2007 31-Dec-2012 31-Dec-2012 Disbursements (in Millions) Project Ln/Cr/Tf Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P104467 IBRD-79870 Effective USD 19.00 19.00 0.00 10.55 8.45 56.00 P104467 IDA-42670 Closed USD 22.00 21.96 0.04 22.87 0.00 104.00 Disbursement Graph Public Disclosure Copy Key Decisions Regarding Implementation not applicable Restructuring History There has been no restructuring to date. Related Projects P121728-Additional Financing for the 2nd Health System Modernization Project (APL2) in Support of the 2nd Phase of the Health Sector Reform Page 8 of 8