Document of The World Bank FOR OFFICIAL USE ONLY Report No: PAD3083 INTERNATIONAL DEVELOPMENT ASSOCIATION PROGRAM APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 7.3 MILLION (US$10 MILLION EQUIVALENT) A PROPOSED GRANT IN THE AMOUNT SDR 7.3 MILLION (US$10 MILLION EQUIVALENT) AND A MULTI-DONOR TRUST FUND GRANT IN THE AMOUNT OF US$17 MILLION EQUIVALENT TO THE KYRGYZ REPUBLIC FOR A PRIMARY HEALTH CARE QUALITY IMPROVEMENT PROGRAM May 7, 2019 Health, Nutrition & Population Global Practice Europe And Central Asia Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Exchange Rate Effective March 31, 2019 Currency Unit = Kyrgyz Som (KGS) KGS 69.80 = US$1 US$ 1.388 = SDR 1 FISCAL YEAR January 1 - December 31 Regional Vice President: Cyril E. Muller Practice Group Vice President: Annette Dixon Country Director: Lilia Burunciuc Practice Manager: Tania Dmytraczenko Task Team Leader(s): Ha Thi Hong Nguyen ABBREVIATIONS AND ACRONYMS ADP Additional Drug Package BETF Bank-Executed Trust Fund BM Budget Measures BSC Balance Score Card CGPs Centers for General Practice CIF Clinical Information Form CME Continuous Medical Education CPD Continuous Professional Development CPF Country Partnership Framework DALY Disability Adjusted Life Year DDD Defined Daily Dose DLI Disbursement Linked Indicators DLR Disbursement Linked Results EF Expenditure Framework ESSA Environmental and Social System Assessment EUR Euro FAP Feldsher-midwifery post FM Financial Management FMCs Family Medicine Centers FSA Fiduciary System Assessment GDP Gross Domestic Product GEN03 ECA Environment Unit GFSM Government Finance Statistics Manual 2001 GGOEE Europe Central Asia East Governance Unit GGOPC Europe Central Asia Procurement Unit GHN03 Europe Central Asia Health Nutrition and Population Unit GHN04 Latin America Caribbean Health Nutrition and Population Unit GHN07 West/Central Africa Health Nutrition and Population Unit HbA1C Hemoglobin A1c (HbA1c) Test for Diabetes HCWM Health Care Waste Management HCW Health Care Waste HMIS Health Management Information System HRH Human Resource for Health IA Internal Audit ICRC Independent Complaints Review Commission IDA International Development Association IFAC International Federation of Accountants IHME Institute for Health Metrics and Evaluation INN International Nonproprietary Name IPF Investment Project Financing IR Intermediate Result IRR Internal Rate of Return ISA International Standards on Auditing IT Information Technology IVA Independent Verification Agent JFs Joint Financiers KfW German Development Bank KR Kyrgyz Republic LEGLE Legal Department MBTF Medium-Term Budget Framework MCH Maternity and Child Health MDTF Multi-Donor Trust Fund MHI Mandatory Health Insurance MHIF Mandatory Health Insurance Fund MoH Ministry of Finance MOU Memorandum of Understanding MTBF Medium-Term Budget Framework NCD Non-Communicable Disease NPV Net Present Value OECD Organization for Economic Cooperation and Development OHS Occupational Health and Safety OOP Out-of-Pocket OP Operational Policy OPRC Operational Procurement Review Committee PAD Program Appraisal Document PAP Program Action Plan PBB Program-Based Budgeting PDO Program Development Objective PEFA Public Expenditure and Financial Accountability PFM Public Finance Management PforR Program for Results PHC Primary Health Care POM Program Operation Manual PPD Public Procurement Departments PPL Public Procurement Law QI Quality Improvement QOC Quality of Care RBF Result-Based Financing RETF Recipient-Executed Trust Fund SB Supervisory Board SCD Systematic Country Diagnosis SDC Swiss Agency for Development and Cooperation SDG Sustainable Development Goals SDR Special Drawing Right SGBP State Guaranteed Benefit Package SORT Systematic Operations Risk-rating Tool SPHD State Program for Health Development 2030 SNSC State National Security Committee STEPS STEPwise approach to surveillance SWAp Sector-Wide Approach TA Technical Advisory TB Tuberculosis TOR Terms of Reference TSA Treasury Single Account UHC Universal Health Coverage UNDP United Nations Development Program US$ United States Dollar WA Withdrawal Application WBG World Bank Group WDI World Development Indicators WHO World Health Organization The World Bank Primary Health Care Quality Improvement Program (P167598) KYRGYZ REPUBLIC PRIMARY HEALTH CARE QUALITY IMPROVEMENT PROGRAM TABLE OF CONTENTS I. STRATEGIC CONTEXT .................................................................................................... 12 A. Country Context ................................................................................................................ 12 B. Sectoral and Institutional Context .................................................................................... 13 C. Relationship to the CPF and Rationale for Use of Instrument .......................................... 19 II. PROGRAM DESCRIPTION............................................................................................... 21 A. The State Program of Health Development 2030 ............................................................. 21 B. The Scope of the Primary Health Care Quality Improvement Program (Program PforR) 22 C. Program Development Objective(s) (PDO) and PDO Level Results Indicators ................. 26 D. Disbursement Linked Indicators and Verification Protocol .............................................. 27 III. PROGRAM IMPLEMENTATION ...................................................................................... 38 A. Institutional and Implementation Arrangements ............................................................. 38 B. Results Monitoring and Evaluation ................................................................................... 40 C. Disbursement Arrangements ............................................................................................ 41 D. Capacity Building ............................................................................................................... 43 IV. ASSESSMENT SUMMARY .............................................................................................. 45 A. Technical Assessment ....................................................................................................... 45 B. Fiduciary ............................................................................................................................ 50 C. Environmental and Social .................................................................................................. 55 D. Climate Change Co-Benefit ............................................................................................... 58 E. Risk Assessment................................................................................................................. 60 ANNEX 1. RESULTS FRAMEWORK ........................................................................................ 63 ANNEX 2. DISBURSEMENT LINKED INDICATORS, DISBURSEMENT ARRANGEMENTS AND VERIFICATION PROTOCOLS .................................................................................................. 79 ANNEX 3. TECHNICAL ASSESSMENT SUMMARY .................................................................... 93 ANNEX 4. FIDUCIARY SYSTEMS ASSESSMENT SUMMARY ................................................... 114 ANNEX 5. ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT SUMMARY ..................... 133 ANNEX 6. PROGRAM ACTION PLAN ................................................................................... 138 ANNEX 7. IMPLEMENTATION SUPPORT PLAN .................................................................... 143 MAP IBRD 33430 6 The World Bank Primary Health Care Quality Improvement Program (P167598) BASIC INFORMATION Is this a regionally tagged project? Financing Instrument No Program-for-Results Financing Bank/IFC Collaboration Does this operation have an IPF component? No No Proposed Program Development Objective(s) The Program Development Objective is to contribute to improving the quality of primary health care services in the Kyrgyz Republic. Organizations Borrower : Kyrgyz Republic Implementing Agency : Ministry of Health Mandatory Health Insurance Fund Ministry of Finance COST & FINANCING FIN_SUMM_WITH_IPF SUMMARY (USD Millions) Government program Cost 1,470.00 Total Operation Cost 414.18 Total Program Cost 414.18 Total Financing 414.18 Financing Gap 0.00 Financing (USD Millions) Counterpart Funding 377.18 Borrower/Recipient 377.18 7 The World Bank Primary Health Care Quality Improvement Program (P167598) International Development Association (IDA) 20.00 IDA Credit 10.00 IDA Grant 10.00 Trust Funds 17.00 Program-for-Results Support MDTF 17.00 Expected Disbursements (USD Millions) Fiscal Year 2019 2020 2021 2022 2023 2024 2025 Absolute 0.00 6.25 2.75 5.00 3.00 2.00 1.00 Cumulative 0.00 6.25 9.00 14.00 17.00 19.00 20.00 INSTITUTIONAL DATA Practice Area (Lead) Health, Nutrition & Population Contributing Practice Areas Climate Change and Disaster Screening Yes PRI_PUB_DATA_TBL Private Capital Mobilized No Gender Tag Does the program plan to undertake any of the following? a. Analysis to identify Project-relevant gaps between males and females, especially in light of country gaps identified through SCD and CPF Yes 8 The World Bank Primary Health Care Quality Improvement Program (P167598) b. Specific action(s) to address the gender gaps identified in (a) and/or to improve women or men's empowerment Yes c. Include Indicators in results framework to monitor outcomes from actions identified in (b) Yes SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance  High 2. Macroeconomic  Substantial 3. Sector Strategies and Policies  Moderate 4. Technical Design of Project or Program  Substantial 5. Institutional Capacity for Implementation and Sustainability  Substantial 6. Fiduciary  High 7. Environment and Social  Moderate 8. Stakeholders  Substantial 9. Other  Low 10. Overall  Substantial COMPLIANCE Policy Does the program depart from the CPF in content or in other significant respects? [ ] Yes [✔] No Does the program require any waivers of Bank policies? [ ] Yes [✔] No 9 The World Bank Primary Health Care Quality Improvement Program (P167598) Safeguard Policies Triggered Safeguard Policies Yes No Projects on International Waterways OP/BP 7.50 ✔ Projects in Disputed Areas OP/BP 7.60 ✔ Legal Covenants Sections and Description The Recipient shall maintain, throughout the implementation of the Program, an independent verification agent with qualifications and experience and under term of reference acceptable to the Bank to verify the data and other evidence supporting the achievement of one or more DLIs Sections and Description The Recipient, through MoF, MoH and MHIF, shall carry out the Program in accordance with the Program Operation Manual. Sections and Description The Recipient, through MoH, shall furnish to the Association each Program Report not later than one month after the end of each calendar semester, covering the calendar semester. Conditions Type Description Effectiveness The MoF, MoH and MHIF have signed a Memorandum of Understanding in a manner satisfactory to the Association. Type Description Effectiveness The Recipient, through MoH, has contracted an independent verification agency (the Independent Verification Agent) under terms and conditions satisfactory to the Association, including terms of reference satisfactory to the Association. Type Description Effectiveness The Recipient, through MoH and MHIF, has adopted a POM in form and substance satisfactory to the Association. 10 The World Bank Primary Health Care Quality Improvement Program (P167598) TASK TEAM Bank Staff Name Role Specialization Unit Team Leader(ADM Ha Thi Hong Nguyen GHN03 Responsible) Procurement Specialist(ADM Irina Goncharova GGOPC Responsible) Financial Management Garik Sergeyan GGOEE Specialist(ADM Responsible) Social Specialist(ADM Kristine Schwebach GSU03 Responsible) Alaa Mahmoud Hamed Team Member GHN07 Abdel-Hamid Asel Sargaldakova Team Member GHN03 Baktybek Zhumadil Team Member GHN03 Gabriel C. Francis Team Member GHN03 Ian Forde Team Member GHN03 Iryna Postolovska Team Member GHN03 Jasna Mestnik Team Member Finance Officer WFACS Javaid Afzal Environmental Specialist GENEC Johanne Angers Team Member GHN03 Kathleen E. Krackenberger Team Member TF Coordinator GHNGE Meerim Sagynbaeva Team Member ECCKG Mohirjon Ahmedov Team Member GHN03 Ruxandra Costache Counsel LEGLE Extended Team Name Title Organization Location German Kust Environmental Specialist Consultant Moscow, Financial Management Nodar Mosashvili Consultant Tbilisi,Georgia Specialist Tihomir Strizrep Health Finance Management Consultant Zagreb,Croatia 11 The World Bank Primary Health Care Quality Improvement Program (P167598) I. STRATEGIC CONTEXT A. Country Context 1. The Kyrgyz Republic is one of the poorest countries in the Europe and Central Asia region, with a gross national income per capita of 1,130 US$ in 2017. Its population of 6.2 million (in 2017) is growing rapidly at 2.0% per year.1 The country’s economy and society are considered the most open in Central Asia, but the country has witnessed political and social instability during the last decade. While a new constitution was approved by referendum to shift from presidential to a parliamentary system, frequent changes in government and rapid turnover of senior officials have slowed progress. Economic growth was averaged at a modest 4.4% per year over the period of 2008-2017. Although significant progress was made in poverty reduction, it is estimated that one in four citizens lived below the national poverty line in 2017. 2 Going forward, the government of the Kyrgyz Republic projected average gross dometic product (GDP) growth of 3.8% per year for the period of 2018-2021. However, growth projections assume continuing efforts to maintain macroeconomic stability, to address institutional weaknesses, and to improve infrastructure. Failure to do so would reduce growth prospects and result in added fiscal pressure. 2. Like in many post-Soviet countries, the population of the Kyrgyz Republic enjoys almost universal access to basic education and health. Some 97% of children under age 17 attend school, and only around 2% of the population in 2015 was reported not having access to health services. However, equal access to services is likely undermined by significant variation in the quality of these services across geographical and social divisions in the population. For instance, the under-five mortality rate is more than 50% higher among the bottom 40 than among the top 60% of the population, at 37.4 and 24.0 deaths per 1,000 live births respectively.3 Likewise, learning outcomes in education vary widely across residence, social categories, and types of institutions. Children in poor families—regardless of gender—have lower educational attainment compared with the nonpoor, indicating the presence of a vicious cycle of poverty. 3. Although the Kyrgyz Republic has made some progress towards the twin goals of the World Bank Group to eliminate extreme poverty and promote shared prosperity, vulnerability remains widespread with a large majority of the population being clustered near the poverty line . The population, therefore, face high risks of falling back into poverty given the high exposure to shocks and insufficient safety nets. Moreover, economic growth relies on remittances and heavy exploitation of the country’s natural resources, which do not translate into labor force growth. In fact, jobs have not been created in the formal sector, and most of the employment that took place in the informal sector, estimated to be around 50% of GDP, is unproductive and undynamic. 1 World Development Indicators (WDI) (2016) 2 National Statistics Committee 3 National Statistical Committee of the Kyrgyz Republic (NSC), Ministry of Health [Kyrgyz Republic], and ICF International. 2013. Kyrgyz Republic Demographic and Health Survey 2012. Bishkek, Kyrgyz Republic, and Calverton, Maryland, USA: NSC, MoH, and ICF International. 12 The World Bank Primary Health Care Quality Improvement Program (P167598) 4. A recovery is underway as outlined in the government’s National Development Strategy 2040 . The Government has made the commitment to improve the access to and quality of social services (especially health and education) while addressing the regional disparities and inequities among the different income and cultural segments of the society. The Strategy 2040 sets forth three main goals, namely: (i) economic well-being of the people; (ii) social welfare; and (iii) security and favorable environment for the lives of citizens. 5. To complement the National Development Strategy, the government has put in place an action plan for the coming three years to guide the efforts of stakeholders . The action plan has identified several areas of priorities, among which is the human development area where education, health, and social protection are cornerstones. Under the healthcare dimension, the government is planning to promote several health awareness campaigns, improve the quality of health services, improve the financing system of the health sector, and build the capacity of health personnel. 6. In summary, the country is faced with significant challenges that could affect the realization of its priority given to the social sectors. The challenges are associated with the struggle of the young democracy to build strong and stable public institutions as a foundation for economic and social development. This is in the background of a low revenue base due to the slow economic development and small-sized formal sector. These constraints affect policies and fiscal space for the social sectors, despite the government’s commitment to human development as a key priority. Going forward, the country needs a new development model to tackle the sources of low overall productivity. At the same time, maximizing the efficiency of public policies and the quality of social services have been identified as important steps to help achieve the government goals as set forth in the National Development Strategy 2040. B. Sectoral and Institutional Context 7. Health has traditionally been a priority in the Kyrgyz Republic and the country has achieved better health outcomes compared to other countries with similar income level (Table 1) . The population enjoys a longer life expectancy, from 66.5 years in 1996 to 71.0 years in 2016, due partly to the significant progress in reducing under-5 mortality from 65.8 deaths per 1,000 live births in 1990 to 21.1 in 2016. Improvements in undernourishment have been dramatic over the past decade, and the prevalence of tuberculosis was halved between 2000 and 2012. In 2015, the country was declared as having achieved the Millennium Development Goal No. 4 on reducing mortality among children under five. 13 The World Bank Primary Health Care Quality Improvement Program (P167598) Table 1: Key Health Indicators (2016) Lower Kyrgyz Middle Republic Income Countries Life expectancy at birth 71.0 68.4 Under-5 Mortality rate (per 1,000 live births) 21.1 40.0 Infant mortality rate (per 1,000 live births) 18.8 30.8 Total Fertility Rate (number of children per women) 3.1 3.2 Prevalence of moderate and severe stunting* 12.9 23.1 Proportion of women receiving at least 4 antenatal care consultations 94.6 82.6 Proportion of births attended by skilled health personnel (%)* 98.4 84.1 Contraceptive prevalence rate (% of women aged 15-49)* 42.0 47.8 Proportion of 1-year-old children fully immunized against diphtheria (%) 96.0 84.6 Proportion of 1-year-old children immunized against measles (%) 97.0 84.2 Source: World Development Indicators (2018) *Data are from 2014. 8. The prioritization of health is also evident by the relatively high levels of health spending (Figure 1 and Figure 2). Between 2000 and 2015, current health spending increased from 4.4% of GDP to 8.2%. Despite substantial increases in government health spending in nominal terms, the composition of health spending has not changed substantially, and the health system is still predominantly financed by out-of- pocket (OOP) spending. Although OOP declined substantially between 2000 and 2007, the trend appears to have been reversed, with OOP spending increasing from 38.1% in 2009 to 48.2% of current health spending in 2015. Figure 1. Current health spending (% of GDP) vs gross Figure 2. OOP share of current health spending (%) vs Public national income per capita, 2015 spending on health as a share of GDP (%), 2015 Source: World Development Indicators and WHO Global Health Expenditure Database (2018) 14 The World Bank Primary Health Care Quality Improvement Program (P167598) 9. Kyrgyz Republic is featured highly in the international literature as a pioneer among the Central Asian and former Soviet Union countries in health system reforms. The country has adopted successive health reforms, from Manas (1996-2005) to Manas-Taalimi (2006-2011), and most recently Den Sooluk (2012-2018). Among early health reform features that made the country a pioneer in the region are: (a) An establishment as early as 20 years ago of a single purchaser of services, the Mandatory Health Insurance Fund (MHIF), which pools funds at the national level to purchase a standardized package of services across rich and poor regions; (b) An establishment of a basic benefits package (the State Guaranteed Benefits Package - SGBP) that guarantees the whole population with a minimum package of health services focusing on primary health care (PHC) and health prevention, at no or minimal cost; (c) A reform of the service delivery model to promote family medicine practice at PHC and to rationalize the excess hospital capacity inherited from the Soviet Union time; (d) An appreciable financing priority is given to the health sector, evidenced by a significant share of total government spending devoted to health; and (e) Strong coordination among donors to support a government-led health reform agenda, underpinned by a Sector-Wide Approach (SWAp) mechanism. 10. Despite early successes, the reform agenda remains largely unfinished and universal entitlement to the SGBP does not translate to effective universal access to quality service that contributes to improving population health outcomes. At a maternal mortality ratio of 76/100,000 live births in 2015,4 Kyrgyz Republic is far from its Millennium Development Goal no. 5 target for maternal mortality of 15.7/100,000. Although having performed better than neighboring Tajikistan and Turkmenistan in the early 1990s, in 2015 Kyrgyz Republic had the highest incidence in both neonatal and maternal disorders among the Central Asian and Caucasus countries. The burden of non-communicable diseases (NCDs) is on the rise. Disability Adjusted Life Year (DALY) loss due to chronic liver diseases nearly doubled from 705/100,000 population in 1990 to 1,268/100,000 in 2015 and stood at the highest level among Central Asian and Caucasus countries in 2015.5 Cardiovascular diseases have become the largest cause of death among the general population, accounting for 48% of all deaths in 2016. 4 WHO World Health Statistics (model estimate) 5 Global Burden of Diseases (2015) 15 The World Bank Primary Health Care Quality Improvement Program (P167598) Figure 3. Maternal Mortality per 100,000 live births (2015) Figure 4. Causes of death as a share of total death (2016) Source: WHO World Health Statistics Source: Institute for Health Metrics and Evaluation 11. While many factors outside the health sector could be responsible for health outcomes, the situation could be explained to a large degree by gaps in the performance of the sector, particularly with regards to quality of care. Given the fact that access to health services is widespread, poor performance in health outcomes points to weaknesses in the clinical quality of care. This has been seen with the persistently high maternal mortality. On the same note, about half of deaths among children under-five occur within 28 days of birth, and about 80% of neonatal deaths occur within the first seven days. Considering advances in medicine, most neonates who die during the first month of birth in health facilities are likely to die from the poor quality of care provided during deliveries and the immediate postnatal period. 12. There are several shortcomings in the structure and process of care that could lead to suboptimal outcomes in the quality of care spectrum. Specifically: (a) Structural aspect of quality of care: throughout the country, it has been recognized that health infrastructure and equipment for the most part are rundown and poorly maintained, especially at the PHC level. With a shortage of funding, the amount spent on essential inputs such as drugs is negligible. For example, only 1.7% of public health financing is devoted to the Additional Drug Package (ADP) – the package of outpatient drugs for the insured population. The SGBP, although covering diabetes, does not include HbA1c – the test considered the best practice to monitor blood glucose in diabetic patients. The effective monitoring and control of blood glucose is critical for prevention of the costly irreversible long-term diabetes complications. Furthermore, challenges of the human resources within the health sector are critical with issues in availability, distribution, qualification, and motivation of personnel. During 2014-2015, primary care facilities 16 The World Bank Primary Health Care Quality Improvement Program (P167598) were understaffed by 39%, and 41% of medical personnel in rural areas were close to retirement age. (b) Process of care: although the country has produced a large number of clinical guidelines, adherence to guidelines and protocols remains low. For example, a survey of district hospitals conducted by the World Bank in 2014 revealed that less than 6% of normal deliveries followed clinical protocol. For all important delivery complications, clinicians in surveyed hospitals were unable to identify key signs and symptoms, as well as appropriate management techniques. Reliable and valid data on quality of primary care services is much more limited. While extensive anecdotal evidence and expert opinions suggest substantial gaps in quality of care in the primary care, lack of quality of care data in the health system limits systematic evaluation of quality and action. 13. Shortcomings in the structure and process of quality can be traced back to various challenges and bottlenecks in service delivery, strategic purchasing, and governance arrangements in the primary health sector. In particular: (a) Service delivery: although family medicine was introduced as part of the early reform to decrease the utilization of hospital services, the health system remains heavily hospital-centric: about 66% of government spending is devoted to the hospital sector. There is clear evidence of excess bed capacity and health facility redundancies in many areas. Care coordination and integration are almost non-existent. Although PHC should play a gatekeeping role, it remains largely unattractive to the population, which leads to widespread bypassing practice. While utilization of PHC has increased since 2000,6 so has the use of inpatient care. PHC facilities are also rather ineffective in the early detection and management of chronic diseases. For example, only 15% of diabetic patients in centers for general practitioners were reported to have an HbA1c test (mainly performed in private labs). Among hypertensive patients taking medications, about half still had suboptimal blood pressure. The high hospitalization rates for chronic conditions, such as hypertension and diabetes also point to inefficiencies and gaps in quality at the PHC level. (b) Strategic purchasing: MHIF as a single purchaser has not been able to exercise strategic purchasing to ensure high quality of services. Until mid-2018, it used unadjusted capitation for PHC and case-based payment for hospitals, further aggravating the incentives for low use of PHC and increased hospitalization. Hospitals are not allowed to provide outpatient services under SGBP, making it necessary for patients to be hospitalized for at least 2-3 days for services that could easily be done in an outpatient setting. Capitation payments in primary care do not facilitate improvements in coverage for preventive services and best practices in the management of chronic conditions. The utilization of evidence-based interventions for non-communicable 6Utilization of outpatient care has been increasing since 2000, particularly in rural areas and among the poor. The proportion of population using outpatient services increased from 9 % in 2000 to 13 % in 2014. Among those who utilized outpatient services, almost 30 % family medicine centers (FMCs) or polyclinics, 29 % sought care at family group practices (FGPs), and 21 % sought care at feldsher-midwifery posts (FAPs). Only 9 % of individuals sought outpatient care at private facilities. 17 The World Bank Primary Health Care Quality Improvement Program (P167598) conditions, thus, is believed to be suboptimal. There is no systematic and evidence-based process for reviewing and revising the services and drugs to be included in the SGBP. The MHIF does not receive direct detailed reports from PHC facilities on clinical activities, and neither the MHIF nor MoH has the capacity to analyze clinical data to identify outliers and provide feedback to the providers. (c) Sector stewardship and governance: throughout, a system for monitoring, analyzing, and improving quality of care is largely absent, with the unclear division of roles and responsibilities between the MoH and MHIF. The MoH has an evidence-based medicine unit which is staffed with one consultant and which has limited effectiveness in guiding decisions on the SGBP. There is also an accreditation unit which is supposed to evaluate both public and private facilities on structural aspects rather than clinical care aspects. Staffed with only 75 full-time employees at the central level, MoH’s reach to the regions is limited. The role of regional health coordination in reform implementation described in various policy documents has not been realized in practice. Despite its important role in the health sector, managing some 80% of public spending on health, the MHIF has little authority to make decisions and exercise its strategic purchasing functions. The MHIF is obliged to contract all public providers and has little say over who can receive copayment exemption and what should be included in the benefit packages. Moreover, the MoH and MHIF have not effectively collaborated towards a common objective of improving quality of care. 14. Over the last two years, some positive developments have taken place toward improving quality of care and rationalizing health services toward PHC. Specifically: (i) in 2017, an Action Plan for optimization of tuberculosis (TB) care was adopted, which envisioned restructuring the network of TB hospitals and expanding outpatient TB treatment to ensure access and safety of service. TB service is gradually integrated into PHC and a new payment method for TB, per treated case, is being piloted at the PHC level; (ii) From the second half of 2018, 10% of the MHIF budget is set aside to pay for quality in both hospitals and PHC facilities, with quality being measured based on a Balance Score Card (BSC). The decision was inspired by a successful pilot of Result-Based Financing (RBF) in rayon hospitals supported by the World Bank, and positive experience in the PHC RBF pilots supported by the World Bank and the Swiss Agency for Development and Cooperation (SDC). This is a significant shift in the government’s take on health financing where domestic resources are mobilized to improve quality through strategic purchasing using evidence-based practices. 15. Going forward, the government is committed to steering health reforms in the right direction. A decision was made to increase significantly earnings of PHC family medicine doctors from the end of 2018, conditioned on performance. This policy is a welcomed step and is expected to attract more physicians into primary care. In parallel, the government is also keen on continuing the unfinished agenda of rationalizing secondary hospital network. Under the current World Bank supported Second Health and Social Protection Project (SWAp2), the MoH is procuring consulting service for developing a master plan for service delivery. Once completed, the master plan will provide recommendations on future infrastructure investments in the health sector and a framework for an integrated, patient-centered health service configuration. 18 The World Bank Primary Health Care Quality Improvement Program (P167598) 16. On this background, the government has prepared a new health sector program which sets priorities and draws the attention of different stakeholders to key issues in the health sector. The new program - The Program of the Kyrgyz Republic Government on Public Health Protection and Health Care System Development for 2019-2030 – adopted the moto “Healthy Person - Prosperous Country” to emphasize the importance of health as an investment to achieve economic development. The program has identified priority areas including improving primary health care and public health, rationalization of hospital and ambulance services, and strengthening the different building blocks of the health system. The program serves as a guiding document for the sector and an instrument to mobilize and harmonize development partners’ support, including the support from the upcoming PforR. It was approved by the Government Decree number 600 on December 20, 2018. C. Relationship to the CPF and Rationale for Use of Instrument 17. The World Bank has established twin goals to anchor its overarching mission, and to galvanize international and national efforts in this endeavor to (i) end extreme poverty at the global level within a generation, and (ii) promote shared prosperity which is defined as a sustainable increase in the wellbeing of the poorer segments of the society. The operation will contribute to the achievement of both goals, as it aims to improve health service quality with a focus on the PHC level which will bring about the best value for public financing. 18. The World Bank has recently completed a Country Partnership Framework (CPF) for the period of calendar years 2018-2022 to agree with the government of the Kyrgyz Republic on the areas in which the World Bank has a comparative advantage to guide the future engagements [Report No. 130399-KG, Board discussion on November 8, 2018]. Stakeholder consultation as part of the CPF exercise revealed popular concern about the quality of the social services (health and education), as well as the efficiency and governance of the health systems. The Program thus fits under the Bank’s overall engagement in the country, in the areas of increasing the value for money of public expenditures, addressing the quality deficit in the provision of social services, and improving targeting in social protection programs. 19. The Bank has had a long and productive partnership with Kyrgyz Republic in its support of national health sector reforms. The Health Sector Reform Project (Health I, 1996-2002) and the Second Health Sector Reform Project (Health II, 2001-2006) supported key elements of the Manas Program (1996- 2005). Both projects had satisfactory outcomes, succeeding in strengthening elements of the health system and carrying out first-generation reforms with a view to achieving improved services and better outcomes more efficiently. 20. Since 2005, Bank’s health system support has been in the form of SWAp, pooling its financing with other donors and government in a common basket to support national health reform programs. The Bank has been the lead agency in two consecutive SWAps (SWAp1: 2005-2015 and SWAp2: 2014- 2019). From 2014, the Bank has also supported the MHIF and MoH to pilot an RBF scheme to improve quality of maternal and neonatal health services in district hospitals. Preliminary impact evaluation results showed significant and positive effects of the intervention on newborns’ Apgar score and mothers’ blood 19 The World Bank Primary Health Care Quality Improvement Program (P167598) loss, as well as blood supply, drug availability and quality, and provider’s motivation. The RBF program in the Kyrgyz Republic is one of the most successful among some 35 country programs supported in the Bank’s health RBF portfolio and is the first that starts reaching institutionalization with full domestic financing. 21. The new operation will build on the successful experience of the two ongoing operations, RBF and SWAp. It will prepare Kyrgyz Republic for the new stage toward effective and sustainable Universal Health Coverage (UHC), the agenda that the Bank is strongly committed to at the global level. Various discussions over the last years among national stakeholders and development partners, including the current Joint Financiers (JFs) of the SWAp – German Development Bank (KfW) and SDC - revealed a strong interest for the Bank’s continued leading role in supporting the health sector in the Kyrgyz Republic. With its convening power, comparative advantages in health system strengthening, strong fiduciary support, multi-sectoral engagement, and proven record in successful operations, the Bank is deemed well positioned to help the government realize catalytic measures, which could advance the country significantly on the road toward UHC. The two JFs of the current SWAp have committed to continue co- financing Bank’s operation in the next phase of engagement. 22. An Implementation Completion and Results Report of SWAp-1 (2015) and mid-term review of SWAp-2 (2016) provide an opportunity to reflect on the strengths and weaknesses of the input-based SWAp model as an instrument for engagement. Major positive aspects include (i) alignment of donors funding around national programs which helps to focus on country’s own priorities; (ii) ability to maintain regular policy dialogues on important issues regarding UHC; and (iii) concerted efforts to strengthen the country system, including the fiduciary capacity of the health sector. Nonetheless, some critical issues are noted, namely: (i) there is a major challenge in building and sustaining capacity within the MoH due to staff and consultant turnover; (ii) high level policy dialogues sometimes are not followed through in a concrete manner; and most importantly, (iii) there is a lack of concrete results and tangible benefits delivered to the population from the JF’s basket funding due to the ambition to support all aspects of the health system. 23. The lessons from the past and experience from other countries with SWAp history are valuable for determining a relevant content and instrument for the upcoming operation in the Kyrgyz Republic. Moving forward, several major changes compared to the two preceding SWAp operations will be instituted, most importantly: (i) a shift from a broad-based whole-sector support to a small number of carefully selected areas to allow for a focused approach and assure best chance for success; and (ii) use of Program for Results (PforR) instrument to encourage client’s ownership and assure concrete results. In parallel, implementation support and capacity building will be provided, through accompanying measures provided by KfW in its position as a JF of the operation, and a Bank-Executed Trust Fund (BETF) to be created as part of the arrangement with the JFs. 24. The PforR instrument is deemed appropriate for the operation as it would help the government in improving the efficiency and effectiveness of the health system by financing the achievement of key 20 The World Bank Primary Health Care Quality Improvement Program (P167598) results rather than supporting a large number of inputs . This instrument links disbursement to the achievement of well-defined results. More specifically: (a) By linking disbursements to the achievement of results that are tangible, transparent, and verifiable, PforR can be an effective instrument to shift focus towards the achievement of results, rather than financing inputs as in the case of Investment Project Financing (IPF) instrument; (b) The PforR instrument is well placed to support the government’s own programs to improve local service delivery by leveraging domestic financing at the central and local government levels; (c) The PforR instrument will enable Bank financing to support efficiency gains in the government’s programs, strengthen institutions, and build implementation capacity; and (d) The PforR instrument will also allow for improvements, as necessary, in the implementation of governments’ own technical, fiduciary and safeguard systems. II. PROGRAM DESCRIPTION A. The State Program of Health Development 2030 25. The upcoming PforR (or the Program) will support the program of the Kyrgyz Government on Public Health Protection and Health Care System Development for 2019-2030 “Healthy Person - Prosperous Country,” or State Program of Health Development 2030 (SPHD2030), approved in December 2018. The development of the program started in early 2017 and involved multiple consultations at the national and regional levels. SPHD2030 outlines key directions for health sector reform in 2019-2030 and builds on achievements and lessons from the three earlier programs (‘Manas’, ‘Manas-Taalimi’ and ‘Den Sooluk’). The program is in line with the government’s international commitments in health (i.e. Sustainable Development Goals – SDGs and Health 2020). The five-year estimate of the program cost (2019-2023) is US$ 1.47 billion.7 26. Improved health outcomes and quality of services, reduced inequities in health outcomes and financial protection, and strengthened public health are some of the stated program goals. Although the program provides overall health sector goals for 2030, its implementation is divided into two phases. The current version of the program provides an action plan for the first five years (2019-2023). An action plan for the second phase will be determined based on outcomes and lessons from the first phase. 27. Overall, the program SPHD2030 has identified ten main areas . Four areas focusing on issues related to specific care include public health, primary care, hospital, and ambulance service. The remaining six areas are cross-cutting in nature and include laboratory services, medicines and medical devices, human resources, e-health, governance, and financing. Each program area is further divided into sub-areas with priority actions and indicators for monitoring progress. Key program objectives for primary 7The cost was estimated based on the health sector budget as reflected in the Medium-Term Budget Framework 2019-2021 and extrapolated for 2022-2023. 21 The World Bank Primary Health Care Quality Improvement Program (P167598) care, for instance, include capacity building, quality improvement, care coordination and strengthening primary care for prevention, early detection and case management of chronic conditions. The list of up to five activities and outputs for each objective are also identified to highlight the priority actions. Highlighted priority actions for primary care include, among others, revising of the SGBP to better target high burden NCDs, improving alignment of payments with results, coverage, and quality of care, strengthening referral systems, and improving access to medical information for health workforce. Figure 5. Service-specific and cross-cutting areas in the SPHD2030 1. Public 2. Development 3. 4. Development Health of primary Improvement of ambulance Service health care and service specific rationalization of the hospitals 5. Laboratory service 6. Medicines and medical devices Cross-cutting 7. Modernization of the health governance areas 8. Human resources for health system 9. Development of electronic health 10. Development of the financing system 28. The SPHD2030 program provides for the monitoring and evaluation system based on the Indicators Logframe, considering the SDGs. The Program Indicators Logframe was developed based on the availability of routine data collection and harmonization with existing systems of national and departmental statistics. This log frame of indicators includes baseline, medium-term or interim milestones/outputs, and target indicators/outcomes, in addition to annual indicators to be developed at the initial stage of program implementation. The Indicators Logframe will be amended based on the results of a mid-term review of the program to be conducted five years after implementation begins. 29. The SPHD2030 sets out a wide-ranging and ambitious program for improving health and healthcare for the Kyrgyz Republic. It will require skilled management, significant investment and bold decision making by parliament and several ministries. It will also require strengthening the capacity of the MoH and MHIF to ensure successful implementation. B. The Scope of the Primary Health Care Quality Improvement Program (Program PforR) 30. The boundary for the PforR within the government program SPHD2030 has several dimensions. First, the PforR aims to support the first five years of implementation of the SPHD2030. Second, it will focus on PHC among the four care specific areas. Zooming in one area helps to focus the program attention and resources to the type of support where the potential for achieving the PDO is optimized. By contributing to improving quality of care at PHC, the Program will also help to assure effectiveness in 22 The World Bank Primary Health Care Quality Improvement Program (P167598) public and private financing and to provide better financial protection for the majority of the population. A pictorial representation of the PforR boundary within SPHD2030 is shown below. Figure 6. The boundary of PforR within the government program SPHD2030 (in bold and shaded area) 2. Public 2. Development 3. 4. Development Health of primary Improvement of ambulance Service health care and service specific rationalization of the hospitals 5. Laboratory service 6. Medicines and medical devices Cross-cutting 7. Modernization of the health governance areas 8. Human resources for health system 9. Development of electronic health 10. Development of the financing system 31. The decision to focus on PHC in the service delivery system is justified on several grounds. Primary health care is the fundamental foundation of the health system and strengthening PHC in the case of the Kyrgyz Republic is the precondition for many reform efforts at the higher level. For example, to develop day hospitalization, a service delivery model that has a great potential for improving efficiency and has become popular in more advanced health systems, PHC needs to be capable of handling post- operative cases, which is not the case currently. Primary health care reaches the largest share of the population and most services at the PHC are free or have a low copayment. Investing in PHC thus will have a strong indirect effect on equity, as it will be more likely to benefit the poor even in the absence of an explicit poverty targeted intervention.8 32. Even though optimization of hospital services will likely bring about efficiency gains, at this stage, the country and the upcoming operation are not ready to tackle the hospital sector in a systematic manner. The Master Plan for service delivery will not be completed until the end of 2019. Furthermore, given the relatively low implementation capacity of the health sector stakeholders and the lack of experience with a PforR instrument, it is advisable to start with a relatively simpler level – the PHC – before embarking on a more complex hospital sector. At mid-term, if the Program progresses well, capacity of the sector is strengthened, and if there is additional financing, there could be a possibility to restructure the Program to support the optimization of hospital services. 8 The economic case for PHC is corroborated in a recent scoping review which found convincing evidence linking primary care to improved health outcomes, health system efficiency and health equity (WHO, 2018: Building the economic case for primary health care: a scoping review). 23 The World Bank Primary Health Care Quality Improvement Program (P167598) 33. The cross-cutting areas of the SPHD2030 are included in the PforR to the extent that they relate directly to PHC. For example, a significant element of quality at PHC level is the competence of family medicine doctors, which is included in the Human Resources for Health (HRH) component. The PforR will seek to improve the competence of family medicine doctors but will not attempt to address a full array of issues related to HRH. Likewise, it will support the development of a system for collecting and analyzing PHC quality data but will not attempt to comprehensively address the eHealth agenda, which will require significantly more targeted efforts and investment. By the same logic, there could be some overlapping with public health and hospitals in elements that directly relate to the quality of PHC. 34. The vision for PHC set in the SPHD2030 document is a modernized, high quality, and patient- centered primary care model to be achieved through several main areas of activities . Most notably, the document envisions development and implementation of quality standards, ensuring access of medical workers to the approved clinical guidelines and protocols, revising the SGBP to prioritize high burden diseases while adopting evidence-based medicine practice, improving PHC payment incorporating RBF, introducing patient electronic medical cards at the PHC level, fostering care integration with other levels by realization of the master plan, and developing of a quality management system for PHC health services and its continuous improvement. 35. Based on the SPHD2030 vision, the Program focuses on the following three areas identified as the key weaknesses in improving PHC quality and where the Bank’s engagement is likely to make a significant impact: Result area 1: Integrating sustainable quality improvement mechanisms into service delivery Result area 2: Strengthening strategic purchasing for the quality of care Result area 3: Strengthening health sector stewardship and governance for quality improvement 36. The Program is thus focusing on establishing and strengthening systems for quality of care monitoring, purchasing, and governance in order to build and strengthen foundations for sustainable systemwide quality improvement. As such, the first result area will support the establishment of: (a) a system for routine collection of quality of care data and continuous feedback to providers on quality gaps through development of an electronic platform and required structures and processes for collecting and reporting quality of care data; (b) a system that improves access to quality continuing professional development (CPD) materials, facilitates delivery of targeted CPD materials addressing quality gaps, and permits monitoring of effectiveness of targeted CPD efforts through development of an electronic platform for CPD learning and strengthening required structures and processes, such as capacity building for sustainable online CPD content development. 37. The second result area will support improvement in payment mechanisms to facilitate strategic purchasing of quality through, for example, activities aimed at revising payment mechanisms to consolidate existing multiple payment schemes. In addition, under this result area, the government will 24 The World Bank Primary Health Care Quality Improvement Program (P167598) institutionalize a process for benefits revision, and medications within the insurance drugs benefit program (the ADP) and the SGBP will be revised to improve coverage for selected maternal and child health (MCH) and NCD conditions. 38. The third result area will aim to establish a national level structure and mechanism to ensure coordinated efforts to improve quality of care in the country . Establishment of a quality improvement unit within the MoH, setting up a national coordination committee on quality, dissemination of regular quality of care reports, and clinical guideline development are some of the activities that will be supported in this area. The third result area will also support the adoption and execution of price regulation under the ADP – to address the largely unregulated pharmaceutical market in the country. 39. Although the PforR focuses on primary care, its positive spillover effects will strengthen other elements of the health system as illustrated in Figure 6. Routine reporting of quality metrics and renewed attention to CDP, for example, will support a culture of continuous quality improvement across all health care levels. Likewise, modernizing payment systems in primary care, to reward outcomes and incentivize integration, will help instill patient-centered care, transparency, and accountability across the health system. 40. The committed total financing for the Program for the five-year period 2020-2024 is estimated at US$414.18 million. Of this amount, expenditure from the Republican Budget of the government is estimated at US$377.18 million.9 In accordance with the IDA 18 financing terms, US$20 million has been committed from IDA, comprising of US$10 million to be provided as grant and US$10 million as credit. Co- financing from the SDC and KfW will be included in a Multi-Donor Trust Fund (MDTF) managed by the World Bank that has a BETF and a Recipient-Executed Trust Fund (RETF). Based on the amount tentatively committed (pending signing of Administration Agreement) for the PforR from SDC and KfW (US$9 million and EUR9 million respectively), the first phase of financing for RETF in the MDTF amounts to US$17 million.10 This makes the total contribution for the Program from the three financiers (World Bank, SDC, KfW) US$37 million, which is the amount appraised for the PforR. The remaining amount in the MDTF will be contributed towards the BETF. 41. Due to the different commitment timelines of the two donors, the Administration Agreement (AA) between the World Bank and KfW and between the World Bank and SDC to govern their respective contribution to the MDTF will be signed after negotiation. It is expected that the AA with SDC will be signed at the end of April 2019, before the planned approval date of May 30, 2019, while the AA with KfW will be signed by the end of calendar year (CY) 2019 or early CY 2020. Funding from the SDC will be 9 This assumes an exchange rate of 69.8 Kyrgyz som for 1 US$ (as of March 31, 2019). This same rate is used by the government of the Kyrgyz Republic for 2019 budget as stated in the Explanatory Note to the Budget. See the section of Expenditure Framework Analysis for more details on government financing. 10 Under German Financial Cooperation, EUR9 million have been committed to the PforR, subject to satisfactory appraisal of the final program design by KfW and approval by the German Federal Ministry for Economic Cooperation and Development. The remaining commitment of EUR10 million will be considered by the German Government in the context of government negotiations in 2019 and funding can be available by 2022. Commitment from SDC will also come in two phases: US$9 million for 2020-2022, and US$3 million for 2023-2024. 25 The World Bank Primary Health Care Quality Improvement Program (P167598) transferred to the World Bank in three tranches over the course of three years, and funding from KfW will be transferred to the World Bank in full as soon as the AA is signed between the two institutions. If, for some unforeseen reasons, funding from one or both donors does not materialize as planned, the Program will be restructured to commensurate with the reduced amount unless additional funding from IDA can be sought. The disbursement schedule (table 3) is developed so that payments in Year 1 (advance and disbursement) will rely only on IDA financing, allowing time for the Bank to restructure the Program if needed. Table 2. Program Financing, CY 2020-2024 (US$ million) Source Amount already committed Potential additional commitment Government of the Kyrgyz Republic 377.18 World Bank (IDA) 20.00 IDA Credit 10.00 IDA Grant 10.00 MDTF – 1st round (CY 2020-2022)* 17.00 MDTF – 2nd round (~CY 2022-2024)* 13.00 Total Program Financing 414.18 13.00 *The amount denotes the RETF portion of the MDTF only. 42. In addition, it is expected that KfW will commit another EUR10 million (funding can be available in CY 2022) and SDC will commit another US$3 million (funding can be available in CY 2023), which will increase the RETF portion of the MDTF by US$13 million. When such funding materializes, the Program will be restructured with additional financing to allow for one or more options as followed: (i) magnifying the value of the current disbursement-linked indicators (DLIs); (ii) expanding the size of the Program by adding DLIs; or (iii) incorporating new areas, one of which could be the hospital sector as mentioned in paragraph 32. 43. Exclusions from the Program are major constructions and high-risk activities. These include activities which: (a) are judged to likely have significant adverse impacts that are sensitive, diverse or unprecedented on the environment and/or affected population; and (b) involve procurement of goods, works and services under high-value contracts. High-value contracts are specified as followed: (i) works, estimated to cost US$10 million equivalent or more per contract; (ii) goods and non-consulting services, estimated to cost US$5 million equivalent or more per contract; or (iii) consulting services, estimated to cost US$3 million equivalent or more per contract. C. Program Development Objective(s) (PDO) and PDO Level Results Indicators 44. The Program development objective is to contribute to improving the quality of primary health care services in the Kyrgyz Republic. 26 The World Bank Primary Health Care Quality Improvement Program (P167598) 45. The PDO will be achieved through strengthening of key quality improvement systems that have been identified as significant gaps in quality improvement interventions globally 11 and as highly relevant in the country context. The quality improvement systems to be supported by the Program are mapped to the three result areas: (i) service delivery; (ii) strategic purchasing; and (iii) stewardship and governance. Progress toward achievement of the PDO in the first result area will be monitored by improvement in quality of services delivered for selected tracer MCH and NCD conditions (antenatal and diabetic care). Under the second area, progress toward PDO will be measured by the availability and affordability of drugs reimbursed under the health insurance drug package for selected high burden conditions (diabetes, anemia, and hypertension). Finally, progress toward the PDO under stewardship and governance result area will be measured by an establishment and functioning of a quality improvement unit within the MoH. 46. The list of PDO indicators is as followed: PDO 1: Increase in the percentage of pregnant women who received hemoglobin test and urine analysis for bacteriuria during the first trimester in a public PHC facility; PDO 2: Increase in the percentage of diabetic patients (type I and II) who received recommended care (an HbA1C test at least once a year) in a public PHC facility; PDO 3: Increase in drug coverage for priority conditions (diabetes, anemia, hypertension) under the Additional Drug Program, as measured by the number of prescriptions reimbursed by insurance for: (a) Test strips for monitoring blood sugar (b) Iron supplement (c) Hypertension drugs; and PDO 4: A unit fully designated to quality improvement is established and functioning within the Ministry of Health. D. Disbursement Linked Indicators and Verification Protocol 47. Nine DLIs are being proposed under the Program . With the ultimate goal to help set up a sustainable national quality of care improvement system, most DLIs aim to target key processes and outputs needed to establish selected key foundational blocks of a national system for quality improvement. The verification for these DLIs will rely mostly on documentation review. However, several DLIs aim to capture progress on tracer quality indicators to confirm that different key elements of the quality improvement systems supported by the Program are fully operational and are having an impact on quality of care. These DLIs will require additional verification steps. For example, the two clinical process DLIs (DLI 3 and 4) will require verification through crosschecking with other data sources, such as laboratory logbooks and patient phone interviews. 48. A single Independent Verification Agent (IVA) will be contracted by the MoH with qualifications and experience and under term of reference acceptable to the Bank, to verify the data and other 11Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., ... & English, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 27 The World Bank Primary Health Care Quality Improvement Program (P167598) evidence supporting the achievement of one or more DLIs as described in the DLIs matrix (Annex 2) . The IVA will be maintained throughout the implementation of the Program and will: (i) carry out verification and process(es) in accordance with the Verification Protocol at least annually; and (ii) submit to the Bank the corresponding verification reports in a timely manner after the verification of compliance of the DLIs/DLRs in form and substance satisfactory to the Bank. It has been agreed that the IVA will be contracted before the Program becomes effective. A list of DLIs by result area is elaborated below. Result area 1: Integrating sustainable quality improvement mechanisms into service delivery DLI 1: A national e-platform for collecting and reporting quality of care indicators from PHC facilities is established and functioning Description: 49. Continuous quality of care measurement and monitoring are the foundational blocks of national quality improvement systems. However, establishing national quality of care data collection systems is a challenging task. This DLI will support the government in setting up a national quality of care data collection and monitoring system to inform and guide quality improvement decisions. 50. Kyrgyz Republic has national data collection systems for health statistics and health insurance, both of which are partially automated and have had limited use for quality improvement. The proposed quality of care e-platform will anchor on these existing data collection systems to collect, monitor, and report on quality of care. 51. The setting up of the new quality of care data collection and monitoring system requires several key elements such as an e-platform, automated data collection from primary care, data exchange systems/capabilities. These elements are highlighted and emphasized in the Program as DLI milestones. 52. Technical specifications, including data exchange standards, for the quality of care analytics and the clinical information form (CIF) based primary care data collection platforms will be developed and officially approved. A quality of care dashboard will be publicly available on the MoH website, including data visualization tools. The two platforms will be designed to ensure data exchange with the MHIF database. The Quality Improvement unit staff and designated staff within the MHIF, MoH, and PHC facilities will have access to the quality of care analytics platform (role-based access). CIF will be revised to incorporate new quality of care indicators. An individual-level patient data reporting form for FAPs will be developed and approved. The patient level data collected from FAPs will be incorporated into the CIF based primary care data collection platform. 53. The e-platform is expected to collect relevant data from the two data collection systems (health statistics and insurance) and apply data analytics techniques to identify and report on trends, patterns, and relationships. Benchmarking and reporting on provider performance have been shown to improve quality of care, particularly among poor performers. Eight quality indicators (outlined in Annex 3) will be 28 The World Bank Primary Health Care Quality Improvement Program (P167598) tracked for routine collection and reporting to ensure that the newly set up quality of care data collection and monitoring system is fully operational. The indicators are preliminary; they can change over time to reflect national health priorities and quality of care trends/dynamics in the country and globally. Measurement and verification: 54. Measurement of achievement of the DLI and its milestones will be based on the documentation review with attention to both processes and outputs. For example, for the milestone on the development of technical specifications (output) to be considered achieved, the specifications should be developed to the satisfaction of the Bank and approved by the MoH and/or MHIF (process). The developed quality of care e-platform (output) should be in line with the technical specification (process). The platform outputs such as reports and descriptive statistics will be reviewed as part of the documentation review. The reporting of the eight indicators by PHC facilities will be measured and verified using the e-platform outputs, such as descriptive statistics on quality indicators by health facilities. Theory of change: 55. Quality improvement is a multifaceted continuous process which requires routinely collected data to guide quality improvement decisions. Automated data collection, monitoring, and reporting systems are essential to the sustainability of quality improvement systems in resource-constrained settings. DLI 2: A national in-service training e-platform is established and functioning Description: 56. This DLI builds on the following key quality improvement concepts: (a) Provider competency is a key contributor to quality of care; (b) Continuous access to quality and up to date medical information is essential to sustainable quality improvement; (c) Big data analytics could facilitate effective learning and improved quality of care through targeted/tailored CPD activities. 57. Access to quality and up to date medical information for physicians in Kyrgyz Republic is a major challenge and bottleneck to improving quality of care. Most physicians in Kyrgyz Republic do not speak English, while quality up to date medical materials in Kyrgyz and Russian languages are very limited. Furthermore, the national CPD framework mostly relies on face-to-face didactic learning methods, where the quality of training may vary widely from one lecturer to another. Within the current didactic CPD framework, those who are based outside the two major cities (Bishkek and Osh) are disadvantaged due to the added costs of travel and accommodation while on training. The training costs are rarely reimbursed fully. This DLI aims to facilitate the development of a national medical e-learning system by supporting the development of an online platform for CPD and a system for quality e-content development. The online CPD platform will be integrated into the existing national CPD framework. 29 The World Bank Primary Health Care Quality Improvement Program (P167598) Measurement and verification: 58. Measurement of achievement of the DLI and its milestones will be based on the documentation review with attention to both processes and outputs. For example, for the milestone on the development of the technical specification for the online platform (output) to be considered achieved, the specifications should be developed to the satisfaction of the Bank and approved by the MoH (process). The developed CPD platform (output) should be in line with the technical specification (process). The platform outputs, such as reports and descriptive statistics, will be reviewed as part of the documentation review. 59. The achievement of the milestone on the amendments to the CPD regulations will be verified by revision of the official documents. The milestones on meeting CPD requirements for online credit hours by PHC physicians will be measured using the CPD platform outputs, such as descriptive statistics on e- materials and credit hours by PHC physicians. In addition, for these milestones, 10% of physicians who are reported as meeting CPD requirements will be randomly selected and contacted by the IVA to verify the reported data. An acceptable margin of error will be set at 10%. Theory of change: 60. The national online CPD platform aims to improve quality of care through improving access to quality up-to-date medical materials and learning. The quality of learning provided will be improved by: (a) setting minimum standards for the e-learning materials, (b) ensuring that various learning styles are accommodated, including adult learning principles, (c) enabling continuous evaluation and feedback on the quality of learning and materials, (d) enabling targeted learning whereby the recommended/required learning is tailored to the existing deficiencies in quality of care both at the individual provider and health facility levels. 61. The CPD platform will improve access to high-quality learning for all physicians, and in particular for those based outside the two major cities, as the platform is online. DLI 3: Number of pregnant women who received hemoglobin test and urine analysis for bacteriuria during the first trimester in a PHC facility Description: 62. A systems approach taken by the program aims to improve quality of care by addressing various essential elements of a national quality improvement framework. Progress will be measured for two tracer disease-specific quality indicators, one of which is compliance with the recommended diagnostic tests during the first Antenatal Care visit. Physician compliance with clinical guideline recommendations is an important aspect of quality that leads to improved health outcomes. The compliance can be improved by quality improvement interventions such as those supported by the Program: measurement, feedback, improving provider knowledge/competency, and incentive. 30 The World Bank Primary Health Care Quality Improvement Program (P167598) Measurement and verification: 63. Measurement of achievement of the DLI and its milestones will be based on the documentation review with the verification of the reported data for a random sample. In the early stages of the Program implementation, regular reports and data from the e-Health Center will be used to measure and verify achievement of the DLI targets. After the e-platform on quality of care becomes operational, the platform will become the main source for measurement and verification. 64. The accuracy and validity of the reported data will be verified by cross-checking a random sample of data with the laboratory data (aggregate data and individual data from logbooks) and contacting patients via phone. Five percent of the PHC facilities will be randomly selected for verification. The IVA will randomly select 10% of patients in each randomly selected facility who are reported as having had the two tests during the current calendar year. The sample data will be individually cross-checked against the laboratory logbooks to verify the reported data. The pregnant women from the sample who are in the first and second trimester of the pregnancy at the time of a site visit will be contacted to verify the data. An acceptable margin of error for laboratory verification would be 10% and for the direct verification with the pregnant women – 10% (excluding those out of reach). Theory of change: 65. Continuous measurement and reporting of quality indicators and strengthening physician knowledge/competency are considered important quality improvement interventions. It is expected that routine measurement and reporting of compliance rates with the recommended Antenatal Care diagnostic testing to providers as well as focused CPD activities will lead to improvements in compliance rates. DLI 4: Number of diabetic patients (type I and II) who received HbA1C test at least once a year in a public PHC facility Description: 66. Compliance with a recommended diagnostic test (HbA1c) in diabetes management is another tracer condition that will be used to track progress in quality improvement. Diabetes is a high prevalence and high-cost condition. In 2018, there were 57,000 registered diabetic patients in Kyrgyz Republic (prevalence of <1%), which is likely a significant underestimate, as the WHO STEP wise approach to surveillance (STEPS) estimates put the prevalence in Kyrgyz Republic at above 6%. 67. Significant cost savings and quality of life improvements could be achieved by improving the quality of diabetes management. Regular HbA1c testing is key to evaluation and monitoring of quality of diabetes management and is considered essential to high-quality diabetes care. In Kyrgyz Republic, however, the test is rarely performed in the public sector and is not considered a part of routine practice. 68. At the PHC level, patients are referred to private laboratories which charge some 500 Kyrgyz som (US$ 7.5) per test, significantly higher than the actual cost of the test (≈ US$1). The consequences of the current state are multifold: (a) the high cost may deter patients from adhering to the recommended 31 The World Bank Primary Health Care Quality Improvement Program (P167598) practice of testing for HbA1c, thus hampering the ability to monitor and properly manage diabetes, and prevent serious and costly complications in future; (b) patients adhering to recommended practice suffer from high financial burden; and (c) trust in PHC’s credibility and ability to serve the population is eroded, thus deferring people further from seeking care in PHC. 69. This DLI incentivizes public PHC facilities to perform the test, resulting in a significant increase in the number of diabetic patients tested for HbA1C. The test values will inform the decision makers of the quality of the diabetes management in the country and guide future quality improvement interventions. Measurement and verification: 70. Measurement of achievement of the DLI and its milestones will be based on the documentation review with the verification of the reported data for a random sample. In the early stages of the Program implementation, regular reports and data from the e-Health Center will be used to measure and verify achievement of the DLI targets. After the e-platform on quality of care becomes operational, the platform will become the main source for measurement and verification. 71. As the first step, the CIF will need to be revised to incorporate information on HbA1c testing (i.e. whether the test is performed, the value of the test, and location where it was performed). The information collected from the revised CIF will be used to measure the achievement of the target values. 72. The accuracy and validity of the reported data will be verified by cross-checking a random sample of data with the laboratory data (aggregate data and individual data from the logbooks) and contacting patients via phone. Five percent of the PHC facilities will be randomly selected for verification. The IVA will randomly select 10% of patients in each randomly selected facility who are reported as having received the test during the respective calendar year. The sample data will be individually cross-checked against the laboratory logbooks to verify the data. The patients from the sample will also be contacted by phone to verify the data. An acceptable margin of error for laboratory verification would be 10% and for the direct verification with the patients - 10% (excluding those out of reach). Theory of change: 73. Providing free HbA1C test in PHC will increase PHC capacity in disease management, provide information to evaluate the state of diabetes care, enable course-correction of disease management, and thus improve patient outcomes. Continuously reported data on HbA1c test will also inform quality improvement interventions at the provider and national levels. Result area 2: Strengthening strategic purchasing for the quality of care DLI 5: The benefit package (SGBP) is revised to improve effective coverage for priority conditions at the primary care level Description: 32 The World Bank Primary Health Care Quality Improvement Program (P167598) 74. The SGBP is the main instrument guiding what structural aspects of care should be available in the public facilities (drugs, tests, procedures, etc.). Defining the benefit package is a continuous process requiring regular revisions to continuously align the package to changing health system challenges and priorities. It should include identification and prioritization of the specific topics or technologies, technical evaluation, consideration of the evidence, decision making, and implementation activities. The SGBP revision process has to be supported by well-established structures. Changes to the SGBP should be informed by changes in the burden of disease, the demographic profile of the population and the evidence on cost-effectiveness and efficacy of health treatments, interventions and technology development locally and internationally. Overall, the policy should develop an innovative model for the future refinements of the SGBP. 75. This DLI supports the following: (i) establishing a structure and methodology for revising the SGBP; and (ii) at least one revision of the SGBP for PHC using an adopted structure and methodology within the timeframe of the Program. The revision will take into account gaps in coverage for priority conditions, such as HbA1C in the list of basic laboratory and diagnostic tests for diabetic patients. Measurement and verification: 76. The establishment of a structure for revising the SGBP will be verified based on the administrative/regulatory document specifying the institution(s), roles and responsibilities of different stakeholders responsible for the task. The regulation on SGBP revision methodology will define SGBP related decision-making process (e.g. evidence-based medicine, process, frequency, health technology assessment, budget impact analysis, etc.) according to international best practice and acceptable to the Bank. 77. The content of the SGBP will be revised at least once during the Program period using the adopted methodology. Gaps in coverage for priority conditions will be addressed to the extent that the budget allows. To the least, these should include HbA1C test for diabetes for all diabetic patients and antihypertensive drugs for uninsured patients at the same level of benefits as the insured. All documents submitted for verification should be developed to the satisfaction of the World Bank. Theory of change: 78. To ensure effective coverage for cost-saving and cost-effective interventions in priority areas, the SGBP content and scope need to be refined so that the benefits are aligned with the country’s current and future health needs and priorities, available financial resources and up to date medical knowledge. Filling in critical gaps will contribute to a reduction in preventable complications from chronic conditions and other health outcomes. DLI 6: The provider payment mechanism for PHC is revised to improve quality and effective coverage for priority services Description: 33 The World Bank Primary Health Care Quality Improvement Program (P167598) 79. In Kyrgyz Republic, until very recently, PHC was funded prospectively according to a simple unweighted capitation model. The risks associated with pure capitation include under-provision of services on both quantity and quality fronts. Furthermore, the MHIF does not have information to assess the adequacy of services provided because providers do not report on services and procedures performed in PHC. 80. The MHIF has started several schemes to incorporate performance indicators into the PHC payment, including the rollout of the PHC Balance Score Card, pay for TB treated cases, and stimulation package for family medicine doctors. These are welcomed steps towards a more sophisticated, blended capitation payment. However, such schemes need to be consolidated and the payment method needs to be improved to incentivize quality and coverage of priority high burden conditions. 81. This DLI supports the adoption and implementation of a blended capitation payment mechanism for PHC, whereby: (a) Part of the funding will be earmarked for selected priority services to improve utilization rates (structural aspect of quality). Such services can potentially include certain procedures and tests; procedure classification for PHC will be developed, implemented, captured and reported through the e-platform; and (b) All performance-based initiatives will be consolidated into one scheme for incentivizing quality (process and outcome aspects of quality). Measurement and verification: 82. For achievement of the new payment mechanism design, a Resolution of the government is required, which formally adopts revisions to the current capitation payment, namely: (a) introduction of fee-for-service for selected priority and/or preventive services; and (b) revision of performance and quality indicators. Thereafter, MHIF contracts stipulating the revised payment signed by PHC facilities will serve as proof of implementation. 83. For the development and application of the PHC procedure classification, verification requires: (a) a list of PHC procedures and corresponding codes (based on the International Classification of Primary Care), approved by a joint order between the MoH and MHIF or equivalent; (b) an adoption of the revised reporting forms to capture such classification. Theory of change: 84. This DLI contributes to transforming the MHIF from a passive to a strategic purchaser of services. It helps to incentivize quality and adequacy of provided services for priority conditions (effective coverage). DLI 7: The Additional Drug Package (ADP) for insured population is revised and its budget is increased to improve effective coverage for priority conditions at the primary care level Description: 34 The World Bank Primary Health Care Quality Improvement Program (P167598) 85. Availability of medications is essential to provision of quality of care. In Kyrgyz Republic, the ADP provides an outpatient drug benefit for the insured, roughly 75% of the population. However, some items in the ADP are not justified based on the latest cost-effectiveness evidence. Furthermore, the ADP is too small to provide effective coverage for targeted conditions. In 2017, spending on the ADP accounted for less than 1.8% of MHIF spending and only 900,000 prescriptions were dispensed (for an insured population size of roughly 4.5 million). MHIF imposes a budget cap (a normative per person of 70 som, or ~ US$ 1 per year), which necessitates rather strict provider-level rationing. 86. This DLI supports the revision and increases in the ADP spending/budget. Specifically: (a) Funding allocated to the ADP will be increased so that more prescriptions will be reimbursed by the MHIF. It is expected that the approved budget will increase by 15% each year; and (b) The list of medications covered by the ADP will be revised to better align the Program with evidence-based practices and to maximize coverage for priority conditions, cost-saving, and cost- effective interventions. A ministerial order (developed jointly by MoH and MHIF) will formally adopt the ADP revision methodology, action plan, roles and responsibilities of different stakeholders, and timeline for the development and implementation of the regulation on ADP revision. The regulation on ADP revisions methodology will define ADP related decision-making process (e.g. evidence-based medicine, process, frequency, health technology assessment, budget impact analysis, etc.) according to best international practices and acceptable to the Bank. Measurement and verification: 87. Measurement of achievement of the DLI and its milestones will be based on the documentation review with attention to both processes and outputs. For achievement of this DLI, the following documents are required: (a) The MHIF order(s) to formally adopt a revised ADP and annual increase of the ADP budget by 15%; (b) A ministerial order (by the MoH or MoH-MHIF jointly) formally adopting ADP revision methodology, action plan, roles and responsibilities of different stakeholders, and timeline for the development and implementation of the regulation(s) on ADP revision; 88. All documents submitted for verification should be developed to the satisfaction of the World Bank. Theory of change: 89. Medications represent an important structural aspect of quality of care and are key to quality management of conditions in primary care. Limited availability of the medications is likely to reduce adherence to the treatment protocols and thus negatively impact quality of care and patient outcomes. Improving the availability of the drugs covered by health insurance, thus, will contribute to improved quality of care and outcomes. The revised content of the ADP will also contribute to effective coverage by facilitating the use of cost-saving and cost-effective interventions by incorporating the latest evidence on cost-effectiveness. Result area 3: Strengthening health sector stewardship and governance for quality improvement 35 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI 8: Price regulation mechanisms for the Additional Drug Package for insured population are developed and implemented Description: 90. Under the ADP, MHIF contracts with private pharmacies to dispense drugs to beneficiaries. The reimbursement rate is set by the MHIF at 50% of the median wholesale price. Patients pay the difference between the retail price of the drugs and the amount of compensation. Effectively, the compensation is often much less than 50% of the retail price because the retail markups are not capped, and competition is limited. Anecdotal evidence reveals that the retail price of some drugs in the pharmacies in the Kyrgyz Republic is higher than the price of the same drugs in significantly wealthier countries. Neither the MHIF nor the MoH have any mechanism in place to control price, regulate mark-up, and enforce generic prescription. The situation adversely affects people with NCDs due to the need to take medications on a regular basis and it could jeopardize adherence to treatment protocols. 91. This DLI supports the adoption and implementation of a mechanism to regulate price, prescription, and reimbursement of medications under the ADP to improve availability of evidence-based medications in the public sector. Although the ADP accounts for a small share of the market, it is only feasible to start with the ADP because the MHIF has a contracting mechanism for it, which is supported by an electronic prescription database. With an annually increasing envelope for the ADP (DLI 7), MHIF’s market leverage will increase and will enable it to exercise price control in the contracting pharmacies. Measurement and verification: 92. Measurement of achievement of the DLI and its milestones will be based on the documentation review with attention to both processes and outputs. Adoption of ADP drug pricing, prescription, and reimbursement with an order from the MoH, or joint order between the MoH and MHIF, will serve as proof of regulation. The Order will specify an action plan, roles and responsibilities, and timeline for implementing the regulation and should be developed to the satisfaction of the World Bank. 93. Evidence of achievement of the implementation will also include: (a) Revised MHIF contract with pharmacies to enforce new pricing and reimbursement model, with a penalty clause for violation; (b) Prescription slips to specify the price patients should pay; (c) The price patients should pay have to be the same per defined daily dose (DDD) for all drugs under the same International Nonproprietary Name (INN); (d) Price list to be published in contracting pharmacies: and (e) Public campaigns on new drug pricing and reimbursement policy to be conducted. Theory of change: 94. Effective control of price and reimbursement will reduce the financial burden on the population and improve the availability of the covered medications for insured groups. Increased availability of medications will likely facilitate increased adherence to treatment protocols for covered conditions and improved patient outcomes. 36 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI 9: A unit fully designated to quality improvement (QI unit) is established within the MoH and functioning Description: 95. Quality improvement is a complex, multifaced, and continuous process that requires concerted efforts along various dimensions of health care. In Kyrgyz Republic, there are many standalone quality improvement initiatives conducted by the government and developing partners with little coordination of efforts/resources and unified vision. A newly established QI unit within the MoH will take over key functions essential to establish and sustain a national quality improvement framework in the country. A set of key functions such as coordination, analytics, and clinical guidance development are listed as milestones for disbursement. A Coordination Committee, comprised of key quality of care experts and decision makers from the MoH and MHIF, will be established to ensure coordinated and concerted quality of care efforts between MoH and MHIF. Its roles and responsibilities will be detailed in the ToR (to be established with the Program). Measurement and verification: 96. Measurement of achievement of the DLI and its milestones will be based on the documentation review with attention to both processes and outputs. For example, for the milestone on the development of technical specifications for the QI Unit and Coordination Committee (output) to be considered achieved, the specifications should i) provide an overview of key functions and deliverables such as analytic reports and list of activities; ii) be developed to the satisfaction of the World Bank; and iii) officially approved/endorsed by the MoH (process). The documentation submitted for review will include the terms of reference for the QI Unit and Coordination Committee, MoH orders, analytical reports, and clinical guidance documents. All documents submitted for verification should be developed to the satisfaction of the World Bank. Theory of change: 97. National level governance is an essential component of a national quality improvement framework. The QI unit is expected to take over the quality improvement governance tasks and improve quality of care by setting quality improvement vision, strategy, and roadmap, as well as coordinating and governing all quality improvement efforts in the country. The result chain for the Program is depicted in the figure below. 37 The World Bank Primary Health Care Quality Improvement Program (P167598) Figure 7. A Theory of Change for the Primary Health Care Quality Improvement Program III. PROGRAM IMPLEMENTATION A. Institutional and Implementation Arrangements 98. The Program implementation will be supervised at the national and regional levels using the existing institutions, capacities, and supervision practices, which are deemed adequate to provide implementation support, stewardship and oversight to the Program. At the national level, two key existing structures used to provide stewardship on health care issues requiring the involvement of multiple ministries and agencies will be utilized to support the Program implementation. The first structure, Supervisory Board on Mandatory Health Insurance and Health system (SB), is hosted within the Cabinet of Ministers and chaired by the Vice-Prime Minister. The SB is used as a forum for discussions and decision-making on health care issues that are multisectoral in nature and involve various government ministries and agencies in implementation or impact. The MoH, MHIF, and MoF form the core of the SB, while other ministries and agencies are involved on an as-needed basis. In the Program implementation, the SB will provide overall supervision of the program by facilitating strategic decision making and ensuring cross-agency coordination. The SB will be primarily used to address the issues requiring high- level multisectoral decision making. It will meet at least once a year to discuss the progress in the Program implementation and will involve senior management from the MoF, MHIF, and MoH. The MoF will provide political and budget support to the Program. It will receive the DLI linked funding and allocate the funds to the MoH and MHIF in line with respective DLIs and prespecified arrangements outlined in relevant documents. The MoH and MHIF will be responsible for the actual implementation of the Program and ensuring that the PDOs and DLIs are met in a timely manner. A Memorandum of Understanding among MoF, MoH, and MHIF will be signed before the start of the Program to govern roles and responsibilities 38 The World Bank Primary Health Care Quality Improvement Program (P167598) in assuring smooth implementation. Any change in the institutional arrangement will need to be agreed with the Bank in advance. Box 1. Key players at the national level: Vice-Prime Minister (for the social sector) – leads and coordinates activities in selected areas such as the health sector, education, labor, and social development. MoH – a lead state health agency responsible for health system governance, including development of health policies, strategies, regulations, as well as coordination, and oversight; will take the lead in the overall coordination of the Program, implementation, and supervision of the activities in data reporting, CPD, quality improvement interventions, and governance. MHIF - a state agency with financial autonomy subordinated to the Prime Minister’s office; the single purchaser of health services in the country responsible for pooling contributions, managing health insurance funds and purchasing of services through contracts with providers; will take the lead in activities related to the SGBP, provider payment reforms and drug benefits/reimbursements. MoF – a lead state agency responsible for state fiscal budget and its execution; will be responsible for receiving and timely allocation of the DLI linked finances to the MoH and MHIF. 99. The second structure, an interagency working committee (Committee on Health Policy), serves as a forum for discussion and decision-making on issues requiring coordination between the MoH and MHIF. The same structure will be utilized within the Program for oversight, discussion, and decision- making on implementation issues not requiring central government policies. The Committee on Health Policy meetings on Program implementation and supervision activities will also involve representatives from the MoF. The committee will meet at least once a year to discuss the progress in Program implementation. The Committee on Health Policy will establish a sub-committee working group that brings together heads of departments of respective institutions on a more frequent basis to address routine operational issues in program implementation, supervision, and reporting. The sub-committee working group will meet at least on a quarterly basis and can invite representatives from various line-units and institutions involved in Program activities. In the current form, the interagency working committee does not involve MoF representatives in its meetings and is not structured to have sub-committee working groups. The terms of reference for the Committee on Health Policy will be updated prior to the launch of the Program to accommodate the two recommended changes. 100. At the national level, the MoH and MHIF are the primary benefactors and will be jointly responsible for the national level day-to-day supervision, technical guidance, fiduciary arrangements and actual implementation of the Program. The MoH Department on Strategic Planning and Project Implementation will be the main focal point to interact with the Bank team, report and ensure timely achievement of the PDOs and DLIs. Procurement and financial management (FM) will be carried out by the MoH and MHIF for the Program activities each is respectively responsible for and be coordinated by the MoH for the overall Program. Within each agency, a unit will be designated to lead agency efforts in project implementation and supervision with regard to relevant PDO indicators and DLIs; the staff will be 39 The World Bank Primary Health Care Quality Improvement Program (P167598) complemented by additional technical and fiduciary consultants as needed. Within the MoH, the implementation and supervision of the project activities will be carried out by the Quality Improvement Unit (to be established) within the Department of Health Services and Pharmaceutical Policy. Within the MHIF, the Department of Strategy, Analysis, and Quality of Health Services will be the designated leading unit. The MoH and MHIF teams will work closely to ensure timely implementation and achievement of the PDOs and DLIs. With regard to fiduciary aspect, the MoH will still need to rely on accounting and IT support consultants, who have been providing critical support to the sector’s accounting and financial reporting system both at national and regional level. These consultants are currently funded by the Bank’s SWAp2 project and retention of the consultants in adequate number is necessary to assure adequate fiduciary functioning of the Program. 101. At the regional level, MHIF regional office teams, comprised respectively of the Head of the regional MHIF branch and two key staff members, will be responsible for the implementation of the Program at the regional and facility levels. Within the MoH framework, a regional health coordinator and a team comprised of 2-3 key staff members will be responsible for the implementation and supervision of the relevant activities at the regional level. At the health facility (district) level, a team comprised by the Head of the primary care facility and 2-3 key staff members (including selected members of the facility Quality Committee) will be responsible for the implementation and supervision of the relevant indicators at the health facility level. The guiding documents for the project implementation, supervision and reporting will be the Program Operation Manual, detailing the PDOs, intermediate result indicators (IRs), DLIs, verification protocol and standard fiduciary, PforR Core Principles, implementation, and monitoring and evaluation (M&E) requirements. B. Results Monitoring and Evaluation 102. For monitoring purposes, the Program indicators (PDO, intermediate indicators, and DLIs) can be divided into those that can be tracked and monitored using the existing routine data reporting systems and those that rely on other data sources. There are two main routine health data reporting systems in the country - health statistics, and mandatory health insurance. The MHIF collects hospital data directly from hospitals through its web-based data reporting platform and receives the primary care data from the e-Health Center in Bishkek. The MoH (e-Health Center) collects the health statistics data from both primary care facilities and hospitals using a combination of paper and electronic reporting modes. The e-Health Center primary care data reporting system will be used to monitor progress in Program implementation. 40 The World Bank Primary Health Care Quality Improvement Program (P167598) Box 2 National primary care data reporting system The health statistics primary care data are mainly collected using a patient level clinical reporting form (CIF). The form is used to report on each episode of care/encounter (i.e. the first visit and any follow-ups within a week). A typical CIF data reporting flow in primary care facilities is as follows: for each patient-physician encounter, a CIF is filled out by a physician or a nurse. CIFs contain demographic, administrative, and limited clinical data, such as diagnoses, medications, and selected tests. CIFs are regularly submitted to a facility health statistics unit. The frequency of submission greatly varies among health facilities from daily to monthly submissions. In a facility health statistics unit, CIF data are routinely entered into the Access-based desktop application. The software generates mandatory statistical reporting forms aggregating CIF data, which then can be submitted as paper forms and electronic files to a respective regional e-Health Center branch. The aggregated regional data are then reported to the e-Health Center in Bishkek, where the regional data are consolidated to produce national level data. 103. Milestones for PDOs 1 and 2, DLIs 1, 3, and 4 will be monitored using the routine primary care data reporting system managed by the e-Health Center. In early stages of the Program implementation, the CIF database at the e-Health Center will be used for monitoring purposes. Once the quality of care e- platform is operational, the Program monitoring will rely on the e-platform. The remaining indicators will use documentation review and periodic reports for monitoring purposes. For example, ADP budget target milestones in DLI 7 will be monitored by reviewing MHIF budget reporting documents, while selected DLI 2 target milestones (% physicians meeting CPD credit hour requirements) - via the online in-service training platform. Detailed information on data sources and monitoring processes are provided in Annex 1 and 2.2. 104. The MoH focal point team (the Department on Strategic Planning and Project Implementation) will be responsible for timely collection of all documentation supporting achievement of the indicator milestones and ensure that the respective institutions responsible for each DLI have documented and verified the indicators. The MoH focal team will also consolidate all Program activity and fiduciary reports as required, review them, and prepare a progress report on a semi-annual basis. The Progress report will include information on progress achievement of the Program indicators, highlighting bottlenecks and proposed corrective measures. The MoH will submit the monitoring data and progress reports to the Bank on a semi-annual basis. Independent measurement and verification reports will be prepared by the IVA as DLIs are achieved, but no more than twice a year and at least on an annual basis. The IVA will be selected competitively and contracted by the MoH before the Program becomes effective. As a part of the Program, the routine data reporting systems will be strengthened as needed to enhance the timeliness and quality of data. C. Disbursement Arrangements 105. The Program will rely on the country treasury system, and the Program’s IDA and MDTF funds will be disbursed upon achievement of the DLIs. Evidence of achievement will be based on the MoH’s and/or the MHIF’s respective technical documentation and will be verified by the IVA following the 41 The World Bank Primary Health Care Quality Improvement Program (P167598) Verification Protocol. The Bank will review the documentation submitted and will reserve the right for further due diligence on the robustness of data as needed. After the World Bank formally considers the DLI(s) met, it will then issue an official letter to the government confirming the achievement of the DLI targets and the value of disbursement. The MoH then will submit a Withdrawal Application (WA) for the disbursement of the respective amount. For some DLIs, for which the achievement relates to calendar year (such as number of diabetic patients receiving HbA1C test at least once a year), the verification will take place during the first quarter of the subsequent calendar year, and disbursement will be made during the second quarter of the subsequent year. Overall, disbursements for the Program will be made twice a year as applicable. 106. The achievement of time-bound DLIs must happen by the deadline for achievement as outlined in the DLI matrix (Annex 2). For non-scalable DLIs, the World Bank will disburse the DLI value only upon full achievement of the DLI targets. For scalable DLIs, the World Bank will disburse against the formulas as set out in the DLI matrix. 107. To ensure timely availability of the Program funds to the MoH and MHIF, upon achievement of DLIs and their verification, satisfactory to the Bank, the Program funds will be transferred by the Bank to the Treasury Single Account of the MoF. Upon receipt of the funds, the MoF, based on the MoH request, will convert the received US$ funds into equivalent amount in local currency and transfer the funds in full to the MoH and MHIF. In order to enable the MoH year-end balances of unspent funds to be carried over the next fiscal year, the MoF proposed using a special account to be opened at the Treasury for the MoH, to which the respective part of the Program funds will be transferred. Given that as per the MHIF budget law, the year-end balances of unspent funds will remain at MHIF disposal, there is no need to have a similar special account for the MHIF. It was agreed that the MoF will ensure that the transfer of the Program funds to the MoH and the MHIF in corresponding amounts is made within a reasonable time after the Program funds are received to the MoF treasury account. 108. Disbursements against the achievement of DLIs 1-8 will be equally split between the MoH and MHIF, while disbursements against the achievement of DLI 9 will be fully made available to the MoH. Following the effectiveness of the legal agreements, the Bank will make available in total of US$ 5 million as an advance payment: US$2.5 million from the IDA grant and US$2.5 million from the IDA credit, respectively. It was further agreed that the advance will be equally split between the MoH and MHIF. The need for the advance is driven by the constrained fiscal environment and the need to kick-start Program implementation by carrying out initial activities (such as developing technical specifications for several e- platforms). This is particularly important because the Program effectiveness is planned for the beginning of a calendar year (CY 2020), when tax collection is typically low and the government is faced with a cash constraint situation. 109. When the DLIs are achieved, the amount of the advance will be deducted (recovered) from the amounts due to be disbursed under such DLIs. The advance amount recovered by the Bank will be then available for additional advances (“revolving advance”). The Bank requires that the Borrower refunds, no later than six months after the legal agreement(s) closing date, any advances (or portion of advances) if 42 The World Bank Primary Health Care Quality Improvement Program (P167598) the DLIs have not been met (or have been only partially met) by the PforR Program closing date. At the end of the Program, any amount disbursed under DLIs that will exceed the actual expenditures level for the whole Program period till the Program closing date, will be reimbursed to the Bank. 110. Summary of disbursement schedule by DLI and for the whole Program is provided in table 3 below and more details are presented in Annex 2 (DLI Matrix) . Table 3 also clarifies the source of financing for each Disbursement Linked Results (DLR), necessary because of the different commitment schedule by IDA and the two donors to the MDTF as described in paragraph 41. Table 3. Overview of disbursement schedule (US$ million) DLIs (short name) Year 1 Year 2 Year 3 Year 4 Year 5 Total DLI 1: National e-platform for quality of 1 1 0.75 1 3.75 care data DLI 2: National in-service training e- 1 1 0.5 0.5 3 platform DLI 3: Number of pregnant women 1 1 1 1 1 5 receiving tests in the first trimester DLI 4: Number of diabetic patients receiving 0.25 0.75 1 1.25 1.5 4.75 HbA1C test DLI 5: SGBP revision 1 4 5 DLI 6: Provider payment mechanisms for 1 2 3 PHC DLI 7: ADP revision 1 1 1 1 1 5 DLI 8: ADP price regulation 1 1 1 0.5 0.5 4 DLI 9: QI unit within the MOH 1 1 0.5 0.5 0.5 3.5 Total financing 6.25 8.75 11.75 4.25 6 37 IDA grant IDA credit MDTF (SDC) MDTF (KfW) D. Capacity Building 111. Capacity building for Program implementation will be built on a long-standing engagement the Bank has in the country through the SWAp and RBF projects and on its analytic and advisory service work program. In particular, on the technical side, the Bank has been: (a) supporting the MoH in evidence- based medicine with a consultant based in the MoH financed by the SWAp; (b) providing technical support to the MHIF to roll out the BSC nationally and at all levels since July 2018; and (c) conducting a review of international experience with mixed capitation payment to inform the formulation of the respective DLI. On the fiduciary aspect, intensive hand-holding on-the-job coaching and classroom training has been provided by the Bank’s fiduciary team of staff and consultants to the MoH. Under KfW Accompanying 43 The World Bank Primary Health Care Quality Improvement Program (P167598) Measures, the SWAp supported the development of a long-term procurement strategy for the health sector, a fiduciary capacity assessment, and activities to strengthen the internal audit of the MoH and MHIF. 112. Nevertheless, it is acknowledged that capacity of the key institutions, especially of the MoH and its subordinate units, remains weak. The decision not to set up a Program implementation unit, as well as the anticipation that the upcoming operation will not support a large number of national consultants working in the MoH like in the SWAp project, will exacerbate the challenges. At the same time, implementing the Program without an implementation unit provides an opportunity to support the capacity of the implementing agencies involved (MoH, MHIF, e-Health center, and Postgraduate Institute) in a more sustainable manner. In team meantime, the fiduciary assessment identified that the MoH will need to continue reliance on and ensure retention of adequate level of accounting and IT support consultants’ support to the Program, currently providing critical support to the sector’s accounting and financial reporting system both at national and regional level. There is also a need for certification of procurement specialists, as required by the public procurement law (see Annex 6: Program Action Plan). 113. As part of the technical assessment for the Program preparation, several areas have been identified as important for targeted capacity building and institutional strengthening, including (a) content development for e-learning; (b) development and revision of the clinical guidelines; (c) revisions of the SGBP and the ADP, including evidence-based medicine, health technology assessment, and budget impact analysis; (d) revision of the provider payment methods; (e) terms of reference (TOR) development and operation of the to-be-established QI unit within the MoH; and (f) monitoring and evaluation. Depending on the nature of the task, capacity building activities can take the form of just-in-time technical assistance, knowledge and experience exchange with other countries, or long term advising, potentially through a small number of international consultants embedded within the MoH and MHIF. 114. Implementation support and capacity building will be provided through KfW Accompanying Measures and the BETF. A program of work is being developed in which some support could be made available even before effectiveness to give the Program an advanced head start. Furthermore, the team will assure synergy with the support from various development partners. Some relevant examples include WHO’s support in the areas of quality improvement, pharmaceutical policies, and clinical guidelines, GiZ’s support in e-Health, and SDC’s facility support through the Provider Autonomy Project. 44 The World Bank Primary Health Care Quality Improvement Program (P167598) IV. ASSESSMENT SUMMARY A. Technical Assessment Strategic Relevance and Technical Soundness 115. The Program supports the areas under the government health program (SPHD 2030) that are aligned with the targeted areas under the CPF for calendar years 2018-2022, such as improving the quality of care and creating opportunities for adult life-long learning through application of new technologies. The key bottlenecks identified in the most recent Systematic Country Diagnosis are reflected in the Program objectives and results. A lack of comprehensive, cohesive and long-term quality improvement framework in the country is a key contributor to inefficiencies in the system and poor health outcomes. The Program aims to improve primary care quality by supporting the government in establishing national systems, structures, and policies on continuous quality of care data collection, reporting, feedback, and actions to improve quality. 116. Addressing quality of care at the national level is a challenging endeavor. Despite various studies, pilots, and initiatives supported by development partners over the past two decades, there has been little attempt to tackle the issue of quality at primary care in a systematic, wholistic, and sustainable manner. Quality of care improvement is a complex long-term process that requires concerted health systems level changes to create a sustainable quality improvement culture in the health system. Sustainable quality improvement systems are hard to establish and often require extensive technical and political support. The Bank and JFs’ engagement are critical because no other partner would have comparative advantages, pooled resource envelope, political clout, and commitment to support such a long-term and focused agenda. 117. The proposed operation builds on the current evidence base on quality improvement efforts and good practices from other countries taking the health care and socio-economic context in Kyrgyz Republic into account. Sustainable quality improvement systems require foundational blocks such as a) reliable and valid context specific quality of care measures, b) health information or data management systems to collect, manage, analyze, and report quality of care data, c) quality of care improvement methods and interventions integrated into the health system; and d) national governance and organizational structures/mechanisms. The PforR interventions aim to strengthen these areas and are aligned with best global practices, which suggest that a focus on processes and system building is more 45 The World Bank Primary Health Care Quality Improvement Program (P167598) effective in improving the quality of care than structural one-off interventions.12,13,14,15,16 The proposed Program will aim to strengthen the quality from three perspectives by setting up systems to (a) improve various aspects of service delivery, (b) strengthen capacity for strategic purchasing, and (c) govern for quality improvement. Expenditure Framework Analysis 118. The Program expenditure is situated against a relatively positive fiscal outlook of the Kyrgyz Republic.17 Real GDP growth was projected to be 4.9% in 2019 and averaged at 4.6% during 2019-2022. Current health spending is estimated at 8.2% of GDP and government health spending accounts for 11% of total government spending.18 Economic growth is typically associated with a disproportionately higher increase in government spending on health (growth in health spending is higher than economic growth). However, the potential for the government to increase health spending faster could be limited given that the Kyrgyz Republic has the highest debt to GDP ratio among all Central Asia countries. Nevertheless, there are good opportunities for raising additional revenue through increasing taxes on harmful consumption goods such as tobacco, alcohol, sugary beverages and fatty foods. Such measures also have the potential to decrease future health expenditure and promote economic growth through their positive effects on health, assuming that the tax is high enough to affect consumption.19 119. In essence, the SPHD2030 is an enhancement of the current health sector program and costing of SPHD was estimated as additional to the current spending in the sector. The SPHD2030 cost estimate is also not exhaustive - it includes additional activities by concerned stakeholders involved in the SPHD2030’s program of action but does not take into account the full cost needed to achieve the vision of SPHD2030. For example, for one of the proposed activities – revising the SGBP– SPHD2030 costing reflects the timing of the technical working group in charge of the revision only, it does not estimate what the cost of the revised SGBP itself will be. This limitation is understandable given the lack of data on many aspects and the ambition to project health sector activities over the period of 12 years. At the same time, the implication of such limitation is that the expenditure framework analysis will focus almost exclusively on the PHC content of the health sector budget as reflected in the government budgeting and execution cycle, as well as in the Medium-Term Budget Framework (MTBF) for 2019-2021. 12 Quality of care encompasses three dimensions: structure (that is, inputs), clinical processes (that is, interaction between health workers and patients), and patient outcomes (that is, clinical outcomes, morbidity, and mortality). 13 Smith, O., & Nguyen, S. N. (2013). Getting better: improving health system outcomes in Europe and Central Asia. The World Bank. 14 National Academies of Sciences, Engineering, and Medicine (2018). Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. 15 WHO, OECD, and World Bank (2018). Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization, Organisation for Economic Co-operation and Development, and The World Bank. 16 Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., ... & English, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 17 International Monetary Fund (2018) Kyrgyz Republic, IMF Country Report No. 18/53. February 2018 18 WHO (2018) Global health Expenditure Database 19 The World Bank (2018) Fiscal Space for Health in the Kyrgyz Republic. Background Report. Unpublished 46 The World Bank Primary Health Care Quality Improvement Program (P167598) 120. Government health expenditure in the Kyrgyz Republic is managed by two main entities: the MoH and MHIF. As a Single Purchaser of health services in the country, MHIF manages 80% of the domestic public financing for health (not including infrastructure investment), contracting with 261 health institutions providing health care services at all levels. Expenditure by the two institutions over the last three years experienced a high execution rate - over 95% for MHIF and 83%-91% for MoH. 121. Starting in 2019, Program-Based Budgeting (PBB) will be piloted in two sectors – health and transport. In the health sector, the PBB provides an additional budget classification method: budgets of the MoH and MHIF are classified into 8 main programs (4 under the MoH and 4 under the MHIF – figure 8). Mapping the three Result Areas of the PforR into the PBB structure helps delineating the financial boundary for the Program, which consists of budget programs under the MHIF (delivery of PHC services) and under the MoH (organization of delivery of health services; medical education and human resource management in health care; and planning, management, and administration). The biggest among these is the “delivery of PHC services” under the MHIF, which largely represents MHIF’s purchase of services from PHC providers. Based on the expenditure pattern prevailing in the previous years, about 75% of this funding will be spent on salary, and the remaining for utility, maintenance, drugs and supplies. Neither big constructions nor major procurement contracts are included in the Program. Figure 8. Program Based Budgets for the health sector (Preliminary 2019 budget) 122. The detailed budget for MoH and MHIF under the Program is provided in table 4 and 5 respectively below. 47 The World Bank Primary Health Care Quality Improvement Program (P167598) Table 4. Excerpt from MoH’s PBB with budget measures directly related to the PforR (thousand Kyrgyz Soms, 2017-2021) Budgetary programs and budget measures (BM) 2017 2018 2019 2020 2021 Program 1: Planning, governance & administration BM 7: Provision of monitoring, analysis & strategic planning/stewardship of health sector 3,058 4,223 5,088 5,088 5,088 BM 8: Implementation of online systems and databases 24,822 26,929 28,276 28,276 28,276 Program 3: Organization of health care services delivery BM 1: Improvement of quality of health services delivery at PHC level 65,883 67,373 70,741 73,571 75,578 BM 4: Provision of accessibility of drugs and medical devices at healthcare organizations 0 9,069 120,000 124,885 128,272 Program 4: Medical Education & Management of HRH BM 3: Improvement/upgrading of qualification of health care workers 113,071 143,424 149,161 154,597 158,483 Total budget mapped to the Program 206,834 251,018 373,266 386,397 395,697 Total MoH budget 3,211,742 3,319,867 4,602,619 3,773,924 3,857,948 Program budget as % of MoH budget 6% 8% 8% 10% 10% Source of data: MoF (MoH’s Program Based Budget approved on November 29 2018); Note: 2017 and 2018 figures were retrofit to the PBB classifications. 2017 figures are actual expenditure while 2018-2021 figures are planned budgets Table 5. Excerpt from MHIF’s PBB with budget measures directly related to the PforR (thousand Kyrgyz Soms, 2017-2021) Budgetary programs and budget measures (BM) 2017 2018 2019 2020 2021 Program 2. Delivery of PHC services BM 2: Provision of basic health services at PHC for the whole population (SGBP) 3,532,949 3,467,193 4,341,818 3,738,016 3,797,824 BM 3: Provision of TB care in PHC 456 30,000 33,372 35,000 35,000 BM 4: Drugs reimbursed under the SGBP for the whole population 35,856 55,000 55,000 55,000 55,000 BM 5: Drugs reimbursed under the ADP for insured population 228,560 264,435 276,070 280,000 290,000 BM 6: Provision of fee-based services beyond the SGBP 57,196 75,539 77,291 73,280 76,944 BM 7: Provision of non-medical & other services by the HCOs, operating under the Single Payer System 181,007 275,106 239,280 266,882 280,226 BM 8: Incentives for Family Group Practices based on quality performance 3,500 4,500 100,000 100,000 100,000 Total budget mapped to the Program 4,039,524 4,171,773 5,122,831 4,548,178 4,634,994 Total MHIF budget 13,064,861 14,230,326 15,030,944 14,640,465 14,932,071 Program budget as % of MHIF budget 31% 29% 34% 31% 31% Source of data: MoF 48 The World Bank Primary Health Care Quality Improvement Program (P167598) Note: 2017 and 2018 figures were retrofit to the PBB classifications. 2017 figures are actual expenditure while 2018-2021 figures are planned budgets 123. The magnitude of Joint Financiers’ commitment to the PforR is compared to the government budget channeled through the MoH and MHIF over the lifetime of the proposed operation, 2020-2024 (table 6). Based on budget data during 2017 – 2021, it is assumed that the MoH and MHIF nominal budget under the Program will be increased during 2022-2024 at a rate of 3% and 4.2% annually respectively. The 5-year budget for the MoH and MHIF is thus estimated at 2,040.9 and 24,286.5 million Kyrgyz soms respectively, giving a total of more than US$ 377.18 million.20 With this, Joint Financiers’ commitment constitutes nearly 9% of the total Program’s budget. Table 6. Estimated five-year budget for the Program (CY2020-CY2024) Kyrgyz som (thousand) US$ (million) MoH MHIF MoH MHIF Joint Financiers* CY 2020 386,398 4,548,178 5.54 65.16 6.25 CY 2021 395,697 4,634,994 5.67 66.40 8.75 CY 2022 407,419 4,829,231 5.84 69.19 11.75 CY 2023 419,489 5,031,608 6.01 72.09 4.25 CY 2024 431,915 5,242,465 6.19 75.11 6.00 Total 2020-2024 2,040,918 24,286,476 29.24 347.94 37.00 Government budget 377.18 Program budget 414.18 Source of data: PBBs for the health sector, MoF. * Joint Financiers disbursement schedule is based on table 3 and is subject to change. Economic Rationale 124. Targeted investment in human capital development is needed in the Kyrgyz Republic. A child born today in the Kyrgyz Republic will be 58% as productive when she grows up as she could be if she enjoyed complete education and full health. In addition, the Kyrgyz Republic only holds 27.5% of its total wealth as human capital. This is far below ECA low- and middle-income peers (37.0%), global lower middle-income countries (50.6%) and global low-income countries (40.8%). The relative deficit of human capital in the Kyrgyz Republic is an important preliminary economic justification for the PforR, given its focus on improving health (a core component of human capital) across the life course, particularly in working age adults. 125. There is a strong economic rationale for investing in strengthening primary care services. Conditions that could be prevented or better managed by stronger primary care (such as diabetes or 20This assumes an exchange rate of 69.8 Kyrgyz som for 1 US$. This rate is used by the government of the Kyrgyz Republic for 2019 budget as stated in the Explanatory Note to the Budget 49 The World Bank Primary Health Care Quality Improvement Program (P167598) cardiovascular disease) exert a substantial macro-economic impact because of lost productivity due to early death, inability to participate in the workforce and/or “presenteeism,” where the ill individual is present at work but unable to contribute fully. A WHO/UNDP report estimated that the indirect costs to the Kyrgyz Republic’s economy from lost productivity are 14.6 billion som (US$ 209m). Adding indirect costs to health care costs means that the total cost of NCD to the Kyrgyz Republic economy is 19.9bn som (US$ 284mn) per year, equivalent to almost 4% GDP. Poor outcomes from maternity care also carry a high cost: neonatal complications are the second most important cause of death and disability in the country, with a life-long impact on individuals and families. 126. Taking action through the PforR can be expected to tackle these issues and yield direct economic benefit through increased efficiency in health spending (by shifting care from the hospital to the primary care sector); improved health status (due to averting premature deaths and DALYs through improved access and quality of primary care and maternity services, improved prevention and management of NCDs, and improved management of vaccine preventable diseases as well as some others such as TB, respiratory, skin and gastrointestinal infection); and, improved financial protection (due to reduced financial risk, reduced catastrophic health spending, reduced precautionary savings for health, and increased investment/spending in other economic activities). In addition, spillover effects from strengthening purchasing and data systems etc. can be expected to generate substantial benefits across the health system. 127. A cost-benefit analysis focused on a) the efficiency gains from shifting care for NCDs from hospitals to primary care and b) the health gains from strengthened primary care, was conducted. The full cost of the PforR was assumed to be distributed across 2020-2034 as if all DLIs were achieved. Benefits were estimated from the literature, or similar World Bank Group investments, and projected out to 2034. The combined net present value of the PforR from analyses a) and b) is estimated to be $216.4 million. The combined benefit-cost ratio for the PforR is estimated to be 1.97 and the internal rate of return 4% (Table 7). Table 7. Summary of economic benefit of the Program Lower impact Higher impact Default Scenario Scenario Scenario Combined gain in Benefit cost ratio 1.97 1.76 2.59 efficiency and in Internal rate of return (IRR) 4% 1.5% 8% health status Net present value (NPV) $ 216,449,000 $ 135,570,000 $ 369,447,000 B. Fiduciary 128. The Program fiduciary systems, in general, are adequate to support the Program and provide overall reasonable assurance that the Program financing proceeds will be used for intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability, subject to implementation of fiduciary actions as defined in the Program Action Plan (PAP). The Program fiduciary responsibilities will be carried out by the MHIF and the MoH (for their parts of the Program) and be coordinated by the MoH for the overall Program. The Fiduciary risk rating is High. 50 The World Bank Primary Health Care Quality Improvement Program (P167598) 129. In general, the Program budgeted expenditures are prepared with due regard to relevant government policies and will be executed overall in an orderly and predictable manner. The planning and budgeting capacity at both the MoH and the MHIF is relatively better than in other government bodies, which also is expressed by the fact that the MoH has been chosen to be one of two pilots (together with the Ministry of Transport and Roads) to implement program-based budgeting (PBB) in parallel with conventional budgeting. Meanwhile the planning and budgeting capacity at some PHC facilities (mostly at small PHCs located in regions) is weak due to weak staff capabilities. In the meantime, there is still a need for enhancing capacity at the MoH to cope with challenges associated with the introduction of PBB. Given that 2019 will be the first year of piloting for the sector, the expectation is that the learning curve will improve during subsequent years when relevant experience and knowledge is accumulated. For better implementation of PBB, there is a need to develop and implement PBB based resource planning software. The Bank, within the ongoing Second Capacity Building in Public Finance Management (PFM) project, plans to provide necessary support in strengthening the PBB process and legal framework, improving training materials and conduction of training to the MoF and line ministries. The support will also include the review of functional requirements on development of information system for PBB planning process, midterm and annual budget planning as well as enhancement of e-Government Procurement (e-GP). 130. It was agreed that the Program funds will be reflected in the republican budget under separate functional classification for the MoH and MHIF. The MoH will prepare a detailed implementation plan based on the indicated disbursement schedule to ensure that the approved budget incorporates the annual planned DLI disbursements. During the formation of the subsequent year’s republican budget (as per the budget calendar), the expected amounts of cash flow under the Program will be reflected in the income and expenditure parts of the republican budget. The budget would later be revised in case of unavailability of some part of the Program funds during the year. 131. There is overall acceptable procurement planning capacity at the MoH and PHC facilities. However, in certain PCH facilities there is a shortage of certified procurement specialists, while in some others the procurement function is assumed by accountants. The MHIF has no role in procurement planning for the health sector. Major part of the Program funding will finance salary payments (including statutory tax and social payments). The Program will also finance renovation and minor repairs, goods contracts, which will include pharmaceuticals, medical equipment, various consumables and materials, as well as consultancy services including audit and verification. The procurement activities to be undertaken under the program will be noncomplex low value activities below the Operational Procurement Review Committee (OPRC) thresholds. 132. Exclusions from the Program are major constructions and high-risk activities. These include activities which: (a) are judged to likely have significant adverse impacts that are sensitive, diverse or unprecedented on the environment and/or affected population; and (b) involve procurement of goods, works and services under high-value contracts. High-value contracts are specified as followed: (i) works, estimated to cost US$10 million equivalent or more per contract; (ii) goods and non-consulting services, 51 The World Bank Primary Health Care Quality Improvement Program (P167598) estimated to cost US$5 million equivalent or more per contract; or (iii) consulting services, estimated to cost US$ 3 million equivalent or more per contract. 133. Since May 14, 2015, all public procurements in the Kyrgyz Republic are been done electronically , which means a complete transition to e-Procurement. The official e-Portal is in operation and a single uniform system of Public Procurement has been created. The introduction of the e-Portal helped to ensure transparency, openness and public access to information on the opening of the bids, procurement procedures and competitive award of contracts. The conditions for suppliers and contractors have also been made uniform, and any party registered on the e-Portal can participate in a tender announced on the e-Portal, on equal footing with all others, except when domestic preference is used. Standard bidding documents exist for goods, works, consulting and non-consulting services, and secondary legislations are available on the e-Portal to all procuring entities, suppliers, and contractors. 134. There are difficulties for foreign pharmaceutical companies to participate in tender process. According to the local legislation (Law #165 dated August 2, 2017 “On pharmaceuticals” of the Kyrgyz Republic), foreign pharmaceutical companies should be registered in the License Department of the MoH before participation in a tender. In 2017 and 2018, 11,621 tenders were conducted by health procurement entities in the country. Only one foreign company was registered before tender. This confirms that there is no attraction for foreign companies to register before awarding the contract and market competition is compromised. 135. A complaint handling mechanism exists, but there is concern over its sustainability. An order of the MoF on October 14, 2015 approved the regulation on the procedures of the Independent Complaints Review Commission (ICRC). The ICRC was established six months later, in March 2016, with a mandate to ensure fair resolution of any procurement related complaints. Unreliable suppliers can be included for non-fulfilment of their contractual obligations, and for violation of the rules of participation in the Public Procurement Law (PPL) by the ICRC. Currently complaints are reviewed by a panel of experts who have completed the mandatory procurement training. When a complaint is received, an automated computer program randomly selects one expert from each of the three groups to review and decide on the complaint. The selected member from each group reviews the complaint and any accompanying documentation online and then submits their response through the e-Portal. While existing complaint review mechanism is sufficient, there is risk of sustainability/quality of complaint review due to the fact that the panel of experts is working on a voluntary basis. 136. The fiduciary system assessment indicated that there is a need to improve internal controls in the health sector. The Program will largely finance salary payments (including statutory tax and social payments), estimated to be around 75% of the Program expenditures (see Table 4.1 in Annex 4). Although there is overall acceptable level of payroll controls at the central, MoH and MHIF level, the level of payroll controls at PCH facility needs to be improved. Internal and external audit reports of on-going Bank- financed projects in the health sector identified cases of inaccuracies (due to low capacity of staff), overriding of controls, delayed payments as well as improper segregation of duties at local level. 52 The World Bank Primary Health Care Quality Improvement Program (P167598) 137. In general, there are adequate contract management arrangements at the MoH level, with some minimal contract management arrangements in place at PHC facilities, which however need to be improved. During the assessment, cases of delayed payments for goods accepted were observed, which were due to unclear payment terms or lack of payment deadline specification in the contract (the contract only indicates that payment will be made upon provision of financing from the budget). The MoH should ensure that the contracts specify clear deadlines for payments. 138. PHC facilities have their own systems to monitor the usage of goods and materials. While each PHC facility operates an inventory monitoring system, it is not connected to the general ledger or accounting system. In eleven PHC facilities sampled for the assessment, goods acceptance procedures were not clear and could lead to increased fiduciary risks. There is overall adequate control at the PHC and MHIF level over medication prescription and payment scheme under the state guaranteed drug benefit packages, while the registration and distribution scheme at PHC facility level for medication procured locally and to be used in-house at PHC facility should be improved. To reduce the risk, with the support of KfW Accompanying Measures, internal instructions for acceptance of medical goods have already been developed, and it is expected that the MoH will approve and disseminate the instructions to PHC facilities for execution. Additionally, the MoH and MHIF internal auditors will conduct a sample physical verification of medication distributed to patients. 139. There is overall adequate IA function at both the MoH and the MHIF, while no IA function exists at PHC facility level. The professional qualities of the staff to conduct audits are overall adequate, and the audits are conducted as per annual audit plans and cover health institutions, including PHC facilities with higher risks determined based on the size of the institution’s budget and issues identified during previous years’ audits. To ensure stricter control at PHC facility level, it has been agreed that within the Program, the IA units of the MoH and the MHIF will combine their resources and will conduct joint audits of the PHC facilities, including test of control systems on achievement of results (such as sample based physical verification of service delivery to patients). The annual plans of the IA units of the MoH and MHIF will also include the review of implementation of the activities under the Program. The annual audit plans of the MoH and the MHIF will ensure that each PHC facility is audited at least once in a three-year period, with more regular audits of health institutions with higher risks. During the IA audit, particular attention should be paid to payroll controls at PHC facility level, sample physical verification of medical services delivered to patients, review of control system over medication and drug prescription registration and distribution. The IA units of the MoH and MHIF will agree with the Bank the annual audit plans, terms of reference and the audit scope. Also, the audit reports and findings will be shared with the Bank. 140. The FSA confirmed that in general, the accounting and financial reporting systems of the MoH, MHIF and PHC facilities are appropriate with adequate records to be maintained for the Program. The major risk to the accounting and financial reporting systems is the staff low capacity and high turnover. For purposes of the Program accounting and financial reporting, the Bank will rely on the existing government accounting and financial reporting arrangements, and the MoH will be responsible for submission of Program annual audited financial statements to the Bank. The Program annual financial statements to be audited will be consolidated by the MoH based on inputs provided by MHIF, and will 53 The World Bank Primary Health Care Quality Improvement Program (P167598) include: (i) a summary of Program funds received (separately indicating those received under each DLIs) and a summary of Program Expenditures under the Program headings, both for the current fiscal year and accumulated to-date; and (ii) Notes, comprising a summary of significant accounting policies and other explanatory notes. Modified cash basis accounting is used in the health sector, with 1C accounting software installed at each PHC facility. However, as indicated above, there are still cases observed when the software is not fully utilized due to lack of sufficient software skills and high turnover of the accounting staff due to low salary level. 141. The Program audit arrangements will rely on the existing independent auditing arrangements under the Bank-financed on-going projects implemented by the MoH. By the time of the assessment there were no due audits under those projects, although delays in the submission were observed for FY2017 audits. The audit of the Program annual financial statements will be conducted (i) by independent private auditors, acceptable to the Bank, on the Terms of Reference acceptable to the Bank and procured by the MoH, and (ii) according to the International Standards on Auditing (ISA) issued by the International Auditing and Assurance Standards Board of the International Federation of Accountants (IFAC). The audited financial statements of the Program will be presented to the Bank within 9 months after the end of each reporting period and at the end of the Program. The Recipient has agreed to disclose the audit reports for the Program within one month of their receipt from the auditors and acceptance by the Bank, by posting the reports on the MoH web sites. Following the Bank's formal receipt of these reports from the Recipient, the Bank will make them publicly available according to World Bank Policy on Access to Information. 142. The audit of the Program procurement will be conducted by independent private firm, including a thorough review of the procedures and processes followed by the procuring entities and the contracts selected for verification. The review of contracts will include (i) an overview of the documentation available in the files of the procuring agencies, (ii) visits to facilities for quality inspection and the number of goods, works and services delivered. Where required, compare prices with similar contracts in the country and region and international market prices for the items of interest. The audit report also will include information about average length of procurement, time for bid evaluation, percent of contracts (by value) awarded on a sole source basis and bidders’ participation and timeliness of payments. The Program procurement audit will be procured by the MoH, on the terms of reference agreed with the Bank, and the report will be presented to the Bank within 9 months after the end of each reporting period, and at the end of the Program. 143. There is an intense anti-corruption agenda in the country. The government and concerned state bodies are active in setting anti-corruption measures. However, the effectiveness of anti-corruption measures remains low since anti-corruption functions are dispersed among too many authorities, sometimes duplicating each other. To address the possible cases of fraud and corruption associated with the Program implementation, the Program will rely on the respective country systems, and the MoH anti- corruption Commissioner will be the responsible staff for the implementation of the Program anti- corruption measures as outlined in the Summary of Fiduciary Systems Assessment (Annex 4). 54 The World Bank Primary Health Care Quality Improvement Program (P167598) 144. Fiduciary risk mitigation measures are proposed in the Program Action Plan (Annex 6). During the Program implementation, the Bank’s fiduciary team will (i) review the implementation progress and working with the task teams to examine the achievement of Program results and/or legal covenants/PAP that are of a fiduciary nature; (ii) help the Recipient to resolve implementation issues and carry out institutional support; (iii) monitor the performance of fiduciary systems and audit reports, including the implementation of the PAP; and (iv) monitor changes in fiduciary risks to the Program and, as relevant, compliance with the fiduciary provisions of legal covenants capacity building. Further details of the implementation support plan are provided in the Integrated Fiduciary System Assessment. C. Environmental and Social 145. The Environment and Social Systems Assessment (ESSA) report was prepared in consultation with major stakeholders and from review of earlier reports on Health Care Waste Management (HCWM) and data provided by several Government departments. Interventions in thematic areas identified under the Program boundary, which focuses on PHC, are likely to bring positive environmental and social effects to the health sector. It is expected that project activities will provide significant social benefits as improvement in the quality of PHC will manifest throughout the country, including in more remote areas. It is expected that the Program will differentially benefit women and children through specific target on antenatal care, including improved clinical process of care (DLI3) and availability and affordability of drugs (DLI7). 146. ESSA review for HCWM in the country indicates that the environmental regulatory framework is well-developed and has multilevel legislation and regulations. The country also has adequate institutional hierarchy to support the health care system, including HCWM. Despite significant progress in development of multilevel and hierarchical system of epidemiological, environmental and infection control, the systemic gaps remain in the organization of public health. The environmental and sanitary pollution, and occupational health risks therefore remain significant at PHCs right from diagnostics to treatment of diseases. Data on HCW related incidence registration, for example, remains incomplete. The registration of disease at the PHCs is largely and primarily based on requests for medical assistance while epidemiological surveillance and identification of patients with infectious diseases including outbreaks are not the parameters/bases for disease registration. 147. There is a critical shortage of specialists at PHCI for ensuring occupational health and safety (OHS) of the staff and patients. Existing and available professional staff, especially in remote rural areas, has insufficient skills in conducting analysis, assessment, prediction and prevention of the sanitary and epidemiological situation. Analysis of the existing information is weak and is of little use to improve the system and assess risks at PHC. Training personnel in risk assessment and preventive methods does not consider modern international approaches and requirements. Accounting, collection and analysis of information is manual and is based on paper trail. Modern information technologies are not widely used to generate electronic records for analysis, reporting, information exchange and decision support. 55 The World Bank Primary Health Care Quality Improvement Program (P167598) 148. The government of the Kyrgyz Republic is preparing to launch additional innovative practices to expand the reach of primary care services to underserved population. These includes: (a) introducing health caravans with mobile laboratory equipment; (b) employing home visiting nurses for child health services and nurse check-ups; (c) conducting community outreach and awareness campaigns; and (d) increasing the prestige of and material benefits for family practitioners. These innovative practices, if implemented consistently and with systemic consultations involving various stakeholders, can strengthen the primary health-care sector and contribute to building a patient-centered health system. However, further measures could be adopted to make services more available and improve patient satisfaction with PHC. 149. Gap analysis of the HCWM system led to the identification of the following issues: (i) Hardware: lack of adequate HCW handling (collection and transportation) equipment and disposal infrastructures at the PHCs, inadequate processing and recycling of some medical plastic disposable devices (except syringes), inefficient handling and storage of medical devices and products are some key features observed in terms of hardware required for HCWM. In addition, expensive waste transportation system, lack of proper storage systems for HCW, and lack of incinerators increases the burden on PHC facilities. (ii) Systemic: existing HCWM model is overloaded and revolves around secondary health care level (mainly hospitals). HCW processing is established at hospitals, which also receive HCW from PHC facilities. Hospitals can refuse taking waste from the PHC facilities. Harmonization of some of the existing laws and standards with clearly assigned roles and responsibilities could result in better coordination though amongst the responsible agencies. Many private PHC facilities do not follow state regulations on HCWM due to gaps in the legislation. (iii) Staff Training: There is no systematic approach in the training of medical and nursing personnel for HCWM. This has resulted in occupational health and safety risks for medical staff, the public, and the environment. Existing system for capacity building and training of specialists in remote areas is weak. Independent experts also note the lack of trained personnel, knowledge, experience, skills, and capability in all areas of infection control and HCWM. 150. The overall conclusion is that current practices in place for HCWM at the PHCs in the country are still far from appropriate and require major overhaul of the system to become compatible with international standards for HCWM. 151. The ESSA recommends the following actions in the PAP to address some of the key challenges identified above: Recommended Actions 152. Reviewing and updating legislation, sector standards and policies. The Government will update legislation, sector policies and standards on integrated infection and pollution control and on processing, utilization, and final disposal of HCW generated by PHC facilities. 153. Developing and strengthening the information management framework. The Government will strengthen the information management framework for preventing infectious diseases and 56 The World Bank Primary Health Care Quality Improvement Program (P167598) environmental pollution at PHC level, including indicators for infection prevention and control, health care waste management, and water quality. 154. Developing and piloting a capacity building system. Develop systems for capacity building on infection prevention and control and health care waste management for PHC-level personnel. 155. Piloting HCWM models. The Government will pilot and implement health care waste management models in selected districts and PHC facilities, with adequate budget allocated, and a committee designated to provide adequate oversight of the full HCWM cycle. 156. Adopt institutional and financial changes to make primary health-care facilities more accessible and attractive for citizens. Several options can be explored for making primary health care more attractive to patients such as assigning specific services that can be received only in primary health care (such as sick-leave certificates) or extending working hours or introducing shifts for family doctors to increase public access. In working to improve patient satisfaction, investigating what patients and providers expect from primary health care may be relevant. Similarly, information campaigns to inform and engage the public and to closely engage local governments should be given priority. 157. Implementation arrangements for recommended actions: At national level, focal point set up by MoH will be responsible for the implementation of recommended actions in the ESSA. A detailed action plan for each of four key actions will be drawn up at the program start, based on the recommendations made by the ESSA. At regional level, MHIF will help in the implementation of PAP. In consultation with MoH and MHIF, a coordination and implementation committee on HCWM will be set up adopting members from SAEPF and SIET to formulate PAP recommendations into actions. The Bank team will help setting up annual capacity development program by involving project partners like KfW, Swiss Agency and WHO (with previous experience to help GoK on HCWM) to train relevant staff at select PHCIs and FAPs in infection control, OHS and waste management. The coordination committee will monitor the progress on the implementation of recommended action in the PAP. The Bank team will continue providing implementation support on the ESSA recommended actions for PAP during the program implementation. 158. ESSA Consultation and disclosure: The ESSA was prepared in consultation with major stakeholders in the country, including relevant Government departments, representatives of international donors in the health sector, civil society, academia and citizen. The draft report was presented in a workshop on 15 February 2019 in Bishkek with the participation of these groups. Prior to organizing the workshop, the ESSA report was translated into Russian and disseminated among key stakeholders. Both Russian and English versions were also uploaded at the MoH website.21 and published on World Bank website on Apirl 9, 2019. 159. Significant gender differences exist in premature mortality related to NCDs in the Kyrgyz Republic. According to estimates from 2015, a citizen of the Kyrgyz Republic has about a one in four 21http://www.med.kg/ru/dok/obsuzhdenie-npa/997-kyrgyzskaya-respublika-orientirovannaya-na-rezultat-programma- zdravookhraneniya-v-kyrgyzskoj-respublike-p167598-otsenka-ekologicheskoj-i-sotsialnoj-sistem.html 57 The World Bank Primary Health Care Quality Improvement Program (P167598) chance (24%) of dying before the age of 70 from one of the four main NCDs (cardiovascular, diabetes, chronic obstructive pulmonary disease, and cancer), but the probability is almost twice as high for men than women (32% versus 17%, respectively). On this background, the Program will monitor its effects on men and women separately for the NCD tracer indicator (DLI 4: Number of diabetes patients type I and II who received HbA1C test at least once a year in a public PHC facility). While the estimated prevalence of diabetes is slightly higher among men than women ages 45-64 (10.1% versus 9.4% respectively), 22 almost 60% of registered diabetic patients are female.23 This is likely a result of different care seeking patterns by gender, as women are more likely to seek outpatient care.24 Differences in care seeking patterns are also seen in the diabetes registry: 37% of registered diabetic women received an HbA1C test compared to 28% of men. The breakdown of registered diabetic patients receiving HbA1C tests by gender will be reported as intermediate result (IR) indicator No.4. Activities will be undertaken to raise providers’ awareness of the gender gap, including gender sensitive training of health care staff to be introduced as part of the online training platform (DLI 2) and training of PHC Quality Committee on quality improvement (IR 12). 160. Citizen engagement is highly relevant to the Program given that patient perception is an important aspect of care but is often overlooked. During preparation, intensive discussions were held to explore different tools for engaging citizens on a continuous basis, which could lead to improved quality of care. As the result, an immediate result indicator (IR 13. Number of PHC facilities that pilot a new mechanism to collect patient experience information regularly) is included in the result framework (Annex 1). This will raise attention from the health sector’s leadership to the patient experience issue and encourage PHC service providers make an effort to improve it. As part of the implementation support, the Bank also plans to provide technical assistance to design and expand the pilot for collecting patient experience information on a regular basis and incorporate such information into service delivery. D. Climate Change Co-Benefit 161. This Program has been screened for short- and long-term climate change and disaster risks and the overall risk rating is Low. Nevertheless, the Kyrgyz Republic is vulnerable to climate change. The main associated climate risks include rising temperatures, drought conditions with decreased precipitation, decrease in snow cover, as well as potential glacier melting and lake outburst floods. The mean annual temperature is projected to increase by 1℃ by 2050 with similar projected rate of warming for all seasons. A temperature rise of 1℃ is projected to increase the number of heatwaves by 100% to 180%. These changes are expected to lead to deleterious health effects, including increased mortality and injuries from heat stress, as well as floods and wildfires. There is also a potential for changes in infectious disease patterns which will affect the project’s target population (e.g. increased incidence of diarrhea particularly among young children). 22 World Health Organization (2017). Prevention and control of noncommunicable diseases in Kyrgyz Republic: The case for investment. http://www.euro.who.int/__data/assets/pdf_file/0006/349683/BizzCase-KGZ-Eng-web.pdf 23 In total 49,606 patients were registered in the diabetes registry in 2017, of which 19,733 were men and 29,873 were women. 24 World Health Organization (2016). Long trends in financial burden of health care seeking in Kyrgyz Republic, 2000–2014. http://www.euro.who.int/__data/assets/pdf_file/0019/329221/Long-term-trends-KGZ.pdf 58 The World Bank Primary Health Care Quality Improvement Program (P167598) 162. Climate adaptation and mitigations measures supported by the Program include the followings : 163. DLI1 (US$1 million from IDA) and DLI 2 (US$2 million from IDA) support the establishment and functioning of e-platform for quality of care indicators and continuous professional development respectively. As part of the the technical specifications development for the e-platforms, a backup system will be elaborated to safeguard against potential impact of climate change-induced natural disasters, such as flooding and over-heating. The backup system will help assuring that functionality of the platform and the server will stay intact in extreme weather conditions. 164. DLI3 (US$3 million from IDA) and DLI4 (US$3.5 million from IDA) incentivize the provision of necessary tests to pregnant women and diabetic patients. As part of the activities to fulfil the DLIs, the MoH will conduct centralized procurement of lab equipment and supplies to be distributed to the PHC facilities. The procurement will adopt climate smart approach toward reducing embedded carbon foorprint in manufacturing processes. Energy efficiency will be explicitly included in the bidding document. 165. DLI9 (US$2.5 million from IDA) supports the establishment and functioning of a quality unit within the MoH. Among others, the quality unit will produce guidelines to health facilities on climate issues, including but are not limited to requirements on energy efficiency standard in quality improvement activities. Under the coordination of the quality improvement unit, at the PHC level, patients will not only receive critical essential health care services but also climate relevant health information. Health worker training will include climate sensitive topics and the Quality Committee of the PHC will discuss climate related health issues in their quarterly meetings. 166. It is expected that the total financing from the Program (US$20 million from IDA) will be used not only to fulfil the DLI requirement but to make further improvement to the structural quality at the PHC. To this aim, the MoH will make annual plan to use Program financing for buying equipment and refurbishing facilities. The Program will provide incentives to the government of the Kyrgyz Republic to improve infrastructures in a way that the structures can better withstand the expected impact of climate change, i.e. extreme heat stress, floods, etc. As part of the guidelines produced by the Quality Unity (DLI 9) and Program Operation Mannual (to be developed), energy saving and climate resilience requirements in capital investment will be elaborated. 167. The Program adopts important mitigation measures to reduce net greenhouse gas emissions in the health sector. Specifically: 168. DLI1 (US$1 million from IDA) supports an establishment and functioning of a national e-platform for collecting and reporting quality of care indicators from PHC facilities. By shifting the practice of data recording and reporting from paper-based to electronic-based, the e-platform contributes to climate mitigation measures in two ways: (1) it eliminates the need for a large number of PHC facilities to make trips to the district level for submitting reports, hence reducing significantly the net greenhouse gas 59 The World Bank Primary Health Care Quality Improvement Program (P167598) emission; and (2) it reduces significantly the use of paper, hence contributing to preserving the environment and also increasing the absorption of CO2. 169. DLI2 (US$2 million from IDA) supports an establishment and functioning of a national e-platform for continuous professional development (CPD). It enables a large number of PHC workers to fulfil the CPD requirements in an online mode. Similar to DLI1, this DLI also helps offsetting trips to the capital and other big cities for attending in-person training and helps reducing use of papers, leading to reducing the climate footprint of the health sector. This DLI will benefit some 6,000 physicians working in PHC. Assuming that 20% of the trips by these physicians to big cities will be averted each year by having access to online education and the average distance from their home to the training centers is 20km, it is estimated that during years 2-5 of the Program, a total of 192,000 kilometers of travel will be averted. 170. DLIs 3-6 (total US$8.5 million from IDA) are expected to lead to significant improvements in disease prevention, early detection, and effective management of diseases at the PHC level. Strengthening PHC will reduce the need for more energy-intensive services at the hospital level, thereby reducing the carbon footprint of the health sector. This focus on PHC level of care will also help to offset trips by patients to seek higher level care by providing patients with better quality services near their home. This reduction in the number of trips will also lead to emissions reductions. In the Kyrgyz Republic, 874,000 admissions to hospital took place in 2017. Assuming that 5% of these admissions could be averted with the strengthening of PHC and the average distance from patient home to the hospital is 10 kilometers, a total of 3,496,000 kilometers of travel would be avoided during years 2-5 of the Program. E. Risk Assessment 171. Based on the integrated risk assessment, the overall risk of the operation is considered substantial. 172. Political and governance risk is rated high. Political risks arise partly from external factors: the security environment in Central Asia and Afghanistan and the narcotics trade, as well as shifts in regional relationships; and partly from internal factors: residual social and ethnic tensions, and a history of frequent changes of government. These risks are being tempered by a shift in power from the President towards a cabinet system of government, with accountability to a rigorous and assertive parliament. The first peaceful transition of presidential power and continuity in the government are stabilizing factors. Governance risks stem from political-business ties, still-weak (though slowly improving) institutions, and deficiencies in the investment environment, which is insufficiently rules-based. The World Bank Group’s support to business climate reforms will play a major role in improving governance. Building capacity and incentive structures for implementation will help address the risks. 173. The technical design of the Program is rated as having substantial risk. The proposed design of the Program represents a significant simplification compared to the existing project SWAp2 and the preceding SWAp1, both attempting to provide support to the entire health sector. The Program chooses to focus intensively on PHC and approach other cross-cutting system areas from the angle of PHC. This design helps to focus resources and attention on one area rather than stretching government and Bank’s 60 The World Bank Primary Health Care Quality Improvement Program (P167598) resources too thinly across many aspects. The technical design is also based on extensive knowledge of the team derived from analytical work and policy dialogues. The design, however, remains ambitious enough to represent a substantial risk toward the PDO. It entails several fundamental changes in the health sector setup and practices, including shifting the purchasing practice of the Single Purchaser from passive to active with a brand-new focus on quality of care and establishing a new quality improvement mechanism involving the active participation of two key players (MoH an MHIF). To mitigate the risk, consultations were held with key stakeholders on the result areas and the DLIs to assure that the focus is sound and the DLIs are deemed achievable. 174. The risk in institutional capacity for implementation is rated substantial. The biggest lesson learned from the past and on-going engagement is that the implementation capacity of the MoH remains low. In the upcoming PforR, the second implementing agency MHIF is deemed to have better capacity. Also, unlike the MoH, the MHIF has branches at the regional level, which helps with the implementation on the ground. Nevertheless, both institutions will need substantial capacity building. The decision not to have a Bank’s implementation unit will create some difficulty during implementation. However, this is a deliberate decision made to enable better capacity building and assure institutional sustainability. Moving from the input-based SWAp model to a PforR represents a significant change in accountability and expose the government counterparts with the risk of not receiving funding if the DLIs are not achieved. PforR is also a new instrument for both the government and the Bank team, as this is the first PforR in Kyrgyz Republic. To mitigate this risk, during preparation, an implementation plan has been preliminarily agreed upon with the two implementing agencies. A detailed Program Operation Manual will be developed before effectiveness. Technical assistance and implementation support will be provided throughout the operation with funding from the KfW Accompanying Measures and BETF. 175. The stakeholders risk is rated substantial taking into account the unclear division of roles, responsibilities and collaboration between the MoH and MHIF. In the context of the Program, this is further aggravated by the fact that achievement of most DLIs require joint efforts of both institutions. The decision to equally split the Program disbursements for DLIs 1-8 will help making sure that the two institutions collaborate closely for the smooth implementation of the Program. Stakeholder risk will further be addressed during the participatory process of developing the Program Operation Manual, which will take place immediately after Board approval of the Program. 176. As per paragraphs 40 and 41, there could be a risk that co-financing from KfW and SDC will not materialize in full or in time for the operation because the AA with SDC will be signed after negotiations and with KfW will be signed after Board’s date respectively. However, this risk is minimal as both KfW and SDC have a credible tracked record of supporting the Kyrgyz Republic, have had a long-standing engagement with the World Bank in the Kyrgyz Republic and other countries, have co-financed the existing health operation (SWAp2), and have already submitted to the World Bank letters of intent, specifying their respective commitment amounts. The disbursement schedule has built in safeguard against the risk by frontloading IDA financing in the first year of implementation, so that the team has adequate time to process restructuring if such need arises. 61 The World Bank Primary Health Care Quality Improvement Program (P167598) 177. The Program’s fiduciary risk rating remains high. Several fiduciary risks were identified during the fiduciary system assessment, including but are not limited to: (a) shortages of human resources and limited capacities for key FM functions in the sector; (b) weak internal controls, particularly at PHC levels; and (c) delayed availability of funds for spending at the beginning of the fiscal year. Procurement risks identified include: (a) lack of sustainability of the complaint review mechanism; (b) weak contract management practice; (c) conflict of interests between procurement and payment functions; (d) lack of procurement capacity; (e) difficulties of the foreign pharmaceutical companies to participate in tender process; and (f) payment delays in PHC. A number of fiduciary related risk mitigation measures are included in the Program Action Plan to be monitored throughout the process of implementation (Annex 6). 178. The overall environmental and social risk rating is considered Moderate. It is not expected that the Program will require involuntary land acquisition. On the environment, with the objective of improving quality of PHC, the proposed operation will likely lead to an increase in the number of patients, thus possibly resulting in increased healthcare waste. The ESSA indicates that the country has relevant laws and bodies although the health care waste management practice varies between areas and with significant gaps. . 62 The World Bank Primary Health Care Quality Improvement Program (P167598) ANNEX 1. Results Framework Results Framework COUNTRY: Kyrgyz Republic Primary Health Care Quality Improvement Program Program Development Objective(s) The Program Development Objective is to contribute to improving the quality of primary health care services in the Kyrgyz Republic. Program Development Objective Indicators by Objectives/Outcomes RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Program objective is to contribute to improving the quality of primary health care services. PDO 1: Increase in the percentage of pregnant women who received hemoglobin test and urine DLI 3 16.00 22.00 29.00 36.00 42.00 50.00 analysis for bacteriuria during the first trimester in a public PHC facility (Percentage) PDO 2: Increase in the percentage of diabetic patients (type I and II) who received DLI 4 0.00 8.00 20.00 25.00 30.00 35.00 recommended care (an HbA1C test at least once a year) in a public PHC facility (Percentage) PDO 3: Increase in drug (i) 3,149 (i) 3,500 (i) 7,400 (i) 11,800 (i) 16,700 (i) 22,200 coverage for priority DLI 7 (ii) 169,480 (ii) 190,000 (ii) 404,000 (ii) 645,000 (ii) 917,000 (ii) 1,224,000 conditions under the ADP, as 63 The World Bank Primary Health Care Quality Improvement Program (P167598) RESULT_FRAME_T BL_ PD O Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 measured by number of (iii) 333,545 (iii) 376,000 (iii) 800,000 (iii) 1,279,000 (iii) 1,819,000 (iii) 2,429,000 prescriptions reimbursed for (i) Test strips, (ii) Iron supplements and (iii) Hypertension drugs (Text) PDO 4: A unit fully designated to quality improvement is established within the Ministry DLI 9 No No Yes Yes Yes Yes of Health and functioning (Yes/No) . 64 The World Bank Primary Health Care Quality Improvement Program (P167598) . Intermediate Results Indicator by Results Areas RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Integrating sustainable quality improvement mechanisms into service delivery Number of online learning curriculum on priority conditions (including MCH, CVD, diabetes) developed and approved for use in Continuous DLI 2 0.00 0.00 2.00 7.00 15.00 25.00 Professional Development (CPD) online platform (Number) Number of PHC physicians who meet requirement of credit 0.00 0.00 0.00 200.00 500.00 900.00 hours for CPD to be obtained in online mode (Number) Number of pregnant women who received hemoglobin test and urine analysis for 24,000.00 34,000.00 78,000.00 132,000.00 196,000.00 270,000.00 bacteriuria during the first trimester in a public PHC facility (Number) Number of diabetic patients (type I and II) who received HbA1C test at least once a year 0.00 5,000.00 20,000.00 40,000.00 65,000.00 95,000.00 in a public PHC facility (Number) Number of men (Number) 0.00 1,700.00 7,200.00 14,600.00 24,100.00 36,100.00 Number of women (Number) 0.00 3,300.00 12,800.00 25,400.00 40,900.00 58,900.00 People who have received essential health, nutrition, and 0.00 270,000.00 540,000.00 810,000.00 1,080,000.00 1,350,000.00 population (HNP) services (CRI, 65 The World Bank Primary Health Care Quality Improvement Program (P167598) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Number) Number of children 0.00 270,000.00 540,000.00 810,000.00 1,080,000.00 1,350,000.00 immunized (CRI, Number) Strengthening strategic purchasing for quality of care The SGBP is revised to improve coverage for selected priority DLI 5 No No No Yes Yes Yes conditions at PHC (Yes/No) Revised payment mechanism is implemented that includes pay for quality and fee-for-service DLI 6 No No Yes Yes Yes Yes for selected priority services (Yes/No) The drugs list under the ADP program is revised to prioritize spending on evidence-based No No Yes Yes Yes Yes generic medications (Yes/No) Strengthening health sector stewardship and governance for quality improvement Number of meetings by the Coordination Committee of the QI unit to discuss quality issues 0.00 0.00 4.00 8.00 12.00 16.00 and actions (at least quarterly) (Number) Number of clinical guidelines revised or developed by the QI 0.00 0.00 0.00 10.00 20.00 30.00 unit (Number) Number of PHC facilities* receiving reports from the QI Unit on their own performance 0.00 0.00 40.00 80.00 120.00 160.00 with benchmarking (at least quarterly) (Number) Number of PHC facilities* 0.00 0.00 40.00 80.00 120.00 160.00 66 The World Bank Primary Health Care Quality Improvement Program (P167598) RESULT_FRAME_T BL_ IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 whose Quality Committee receives training on quality improvement (at least once a year) (Number) Number of PHC facilities* that pilot a new mechanism to collect patient experience 0.00 0.00 0.00 7.00 14.00 21.00 information regularly (Number) . 67 The World Bank Primary Health Care Quality Improvement Program (P167598) . Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection This indicator serves as a proxy for the quality of antenatal care. Numerator: Number of pregnant women during the year who received hemoglobin test and urine Clinical Information analysis for bacteriuria Form (CIF) database at PDO 1: Increase in the percentage of E-Health (microscopic and/or e-Health Center and e-Health Center and pregnant women who received Center and qu culture) during the first Annual hospital discharge Quality Improvement hemoglobin test and urine analysis for ality of care e- trimester in a PHC facility. database at MHIF until (QI) Unit bacteriuria during the first trimester in a platform quality of care e- public PHC facility Denominator: Number of platform is established. pregnant women during the year (estimated backwards from the deliveries in the following year). Targets are annual. This indicator serves as PDO 2: Increase in the percentage of E-Health proxy for the quality of Data compiled from CIF diabetic patients (type I and II) who Center and e-Health Center and QI diabetic care. Annual until the quality of care received recommended care (an HbA1C quality of care Unit e-platform is established test at least once a year) in a public PHC e-platform Numerator: Number of facility diabetic patients (type I 68 The World Bank Primary Health Care Quality Improvement Program (P167598) and II) who received HbA1C test at least once a year in a PHC facility. Denominator: Number of registered diabetic patients (type I and II) as recorded in the Diabetic Registry. As noted, diabetes in Kyrgyz Republic is likely under- detected. It is expected that the number of patients in the Registry will increase as detection improves, especially when the Program starts providing the HbA1C test for free. The denominator will be reviewed every year and possibility is open for revising indicator target at midterm depending on the magnitude of the change in the Registry patient volume. The targets are annual. PDO 3: Increase in drug coverage for This indicator measures the MHIF ADP e- Data compiled from the priority conditions under the ADP, as accessibility of drugs/tests Annual prescription MHIF ADP e-prescription MHIF measured by number of prescriptions for the three priority database database reimbursed for (i) Test strips, (ii) Iron conditions (diabetes, supplements and (iii) Hypertension drugs anemia, hypertension) for 69 The World Bank Primary Health Care Quality Improvement Program (P167598) individuals covered under the Additional Drug Package (ADP). Specifically, the indicator monitors the annual number of reimbursed prescriptions for (i) test strips for monitoring blood sugar; (ii) iron supplements; and (iii) hypertension drugs. Targets are cumulative. The Quality Improvement Unit within the Ministry of Health will be deemed as functioning when its TOR has been developed and endorsed by an MoH Order MoH will submit the ToR and the QI unit has been and supporting MoH established within the MoH documentation structure, QI PDO 4: A unit fully designated to quality with at least 4 staff. The indicating that the QI Annual Unit TOR, and MoH improvement is established within the responsibilities of the QI Unit has been activity Ministry of Health and functioning Unit will include producing established and reports reports from online functioning (e.g. MoH system, revising evidence- organogram, reports). based medicine guidelines, coordinating among quality players, and implementing selected activities from the quality strategy and . roadmap. 70 The World Bank Primary Health Care Quality Improvement Program (P167598) . Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection This indicator tracks the number of online learning materials on priority conditions (including MCH, CVD, and diabetes) developed and approved for use in the online CPD platform. Institute for Learning materials within Number of online learning curriculum on Postgraduate Medical the Program are defined Institute for priority conditions (including MCH, CVD, CPD Education will submit as: (i) a set of self-learning Annual Postgraduate Medical diabetes) developed and approved for use platform/MoH supporting materials materials that include a Education and QI Unit in Continuous Professional Development (e.g. links to learning pre-test assessment, (CPD) online platform materials). learning materials (i.e. lecture, reading materials, audio-visual materials) and a post-test assessment; or (ii) a set of disease specific clinical vignettes with detailed explanation of answer choices. The targets are cumulative. This indicator will monitor Institute for Number of PHC physicians who meet CPD platform/ Statistical reports from the annual number of PHC Annual Postgraduate Medical requirement of credit hours for CPD to be MoH the CPD platform physicians (including Education and QI Unit obtained in online mode specialists) who meet the 71 The World Bank Primary Health Care Quality Improvement Program (P167598) credit hour requirement for Continuous Professional Development by taking the online course through the Continuous Medical Education (CME) platform. The physician will have to meet all the requirements specified in the online course (including passing an assessment if applicable) to count towards this indicator. The targets are cumulative. This indicator monitors the number of pregnant Statistics reported to e- women who received e-Health Number of pregnant women who Health Center and hemoglobin test and urine Center and e-Health Center and QI received hemoglobin test and urine Annual through the quality of analysis for bacteriuria quality of care Unit analysis for bacteriuria during the first care e-platform (when it during the first trimester in e-platform trimester in a public PHC facility is functional) a public PHC facility. Targets are cumulative. This indicator monitors the number of diabetic Statistics reported to e- e-Health patients (type I and II) who Health center and Number of diabetic patients (type I and II) Center and e-Health Center and QI received HbA1C test at Annual through the quality of who received HbA1C test at least once a quality of care Unit least once a year in a public care e-platform (when it year in a public PHC facility e-platform PHC facility. To comply is functional) with World Bank’s corporate gender 72 The World Bank Primary Health Care Quality Improvement Program (P167598) requirements, this indicator is disaggregated by gender to enable gender-disaggregated monitoring. Targets are cumulative. Statistics reported to e- e-Health Health Center and Center and e-Health Center and QI Annual through the quality of Number of men Targets are cumulative. quality of care Unit care e-platform (when it e-platform is functioning) e-Health Statistics reported to e- Center and Health Center and e-Health Center and QI Annual quality of through the quality of Number of women Targets are cumulative. Unit care e- care e-platform (when it platform is functioning) Statistics reported by the Republican Center for Immuno-prophylaxis; Republican e-Health Center; and QI Center for Unit (when it is People who have received essential Immuno- functional). The Annual MoH health, nutrition, and population (HNP) prophylaxis; e- composite CRI will have services Health Center; the same value as the QI Unit breakdown CRI “Number of children immunized”. If a child is immunized more than once per year, only the number of 73 The World Bank Primary Health Care Quality Improvement Program (P167598) children who received immunization is recorded and not the number of immunizations. Targets are cumulative. Number of children Republican under 5 immunized. If a Center for child is immunized more Immuno- Annual than once per year, only MoH Number of children immunized prophylaxis, e- 1 immunization is Health center, recorded. Targets are QI Unit cumulative. A methodology will be developed for SGBP revisions. This indicator will track whether the SGBP has been revised based on the new methodology to incorporate new benefits SGBP decree, revised The SGBP is revised to improve coverage Annual MHIF MHIF for the population. The SGBP for selected priority conditions at PHC revised SGBP will include, among others, HbA1C test for all diabetic patients and antihypertensive drugs for uninsured patients at the same level of benefits as the insured. Revised payment mechanism is For achievement of new Annual MHIF MHIF contracts using the MHIF implemented that includes pay for quality payment mechanism revised payment 74 The World Bank Primary Health Care Quality Improvement Program (P167598) and fee-for-service for selected priority design, a Resolution of the mechanism services government is required, which formally adopts revisions to the current capitation payment, namely: (a) introduction of fee-for-service (FFS) for selected priority and/or preventive services; and (b) revision of pay for performance indicators (P4P). A methodology will be developed for Additional Drug Package (ADP) MoH/MHIF Order, The drugs list under the ADP program is revisions. This indicator will Annual MHIF revised ADP, MHIF MHIF revised to prioritize spending on track whether the ADP has Budget evidence-based generic medications been revised based on the new methodology and budget for the ADP is increased by 15% annually. This indicator monitors the number of meetings by the Coordination Committee of the QI Unit. The meetings Number of meetings by the Coordination Minutes from the should be conducted at Committee of the QI unit to discuss Annual MoH/QI Unit Coordination Committee QI Unit, MoH least once per quarter. The quality issues and actions (at least meeting Coordination Committee quarterly) will meet to discuss quality of care issues and reports and provide recommendations to the 75 The World Bank Primary Health Care Quality Improvement Program (P167598) MoH collegium and MHIF. Targets are cumulative. From Year 3 to Year 5, at least 10 clinical guidelines on priority conditions (MCH, CVD, and diabetes) Revised clinical Number of clinical guidelines revised or Annual MoH/QI Unit QI Unit, MoH will be revised or guidelines developed by the QI unit developed and endorsed annually. Targets are cumulative. This indicator monitors the number of PHC facilities that receive reports from the QI Unit on a quarterly basis. The reports will be based on the quality of care e-platform and will include information on the Number of PHC facilities* receiving facility’s performance as Quality of care e- reports from the QI Unit on their own well as benchmarking with Annual MoH/QI Unit platform statistical QI Unit, MoH performance with benchmarking (at least other comparable facilities report quarterly) (e.g. by type of PHC facility or location). The reports will be delivered in an electronic form via email and/or quality of care e- platform. Targets are cumulative. 76 The World Bank Primary Health Care Quality Improvement Program (P167598) *Includes Centers for General Practice (CGPs), Family Medicine Centers (FMCs), and Family Group Practices (FGPs) but not Feldsher-midwifery Posts (FAPs). This indicator monitors the quality of care training delivered to PHC facility Quality Committee members under the coordination of the QI Unit. Topics for training may vary from year to year but should include a session on Training agenda, Number of PHC facilities* whose Quality review and discussion of materials, list of Annual MoH/QI Unit QI Unit, MoH Committee receives training on quality quality reports. participants, and improvement (at least once a year) attendance sheets. Targets are cumulative. *Includes Centers for General Practice (CGPs), Family Medicine Centers (FMCs), and Family Group Practices (FGPs) but not Feldsher-midwifery Posts (FAPs) A patient experience Data collected from the Number of PHC facilities* that pilot a new questionnaire will be Annual MoH/MHIF piloted patient MoH/MHIF mechanism to collect patient experience developed/adapted and experience information regularly piloted in a selected questionnaires 77 The World Bank Primary Health Care Quality Improvement Program (P167598) sample of PHC facilities (CGPs, FMCs, and legally independent FGPs). Targets are cumulative. *Includes Centers for General Practice (CGPs), Family Medicine Centers (FMCs), and Family Group Practices (FGPs) but not Feldsher-midwifery Posts . (FAPs). 78 The World Bank Primary Health Care Quality Improvement Program (P167598) . ANNEX 2. Disbursement Linked Indicators, Disbursement Arrangements and Verification Protocols . Disbursement Linked Indicators Matrix DLI_T BL_MATRI X DLI 1 A national e-platform for collecting and reporting quality of care indicators from PHC facilities is established and functioning Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Text 3,750,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 Technical specifications developed and approved 1,000,000.00 for (i) the online quality of care analytics; and (ii) CIF-based primary care data collection platforms by end of Year 2 Year 2021 CIF based primary care data collection and online 1,000,000.00 quality of care analytics platforms developed and fully functioning by end of Year 3 Year 2022 Data from PHC facilities (all but FAPs) are in the 750,000.00 50%-89% of PHCs: 0.25M; 90% of quality of care platform PHCs or >: another 0.5M Year 2023 0.00 Year 2024 Data from at least 20% of FAPs are incorporated 1,000,000.00 in the quality of care platform. 79 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI_T BL_MATRI X DLI 2 A national in-service training e-platform is established and functioning Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Text 3,000,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 Technical specifications developed and approved 1,000,000.00 for (i) the online CPD platform; and (ii) integration of CPD and HRH platforms by end of Year 2. Year 2021 Online CPD platform (including a mobile 1,000,000.00 application) developed and fully functional by end of Year 3. Year 2022 10% PHC physicians meet CPD credit hour/points 500,000.00 $50,000 per 1 pp increase in PHC requirements for online learning. physicians up to $0.5M Year 2023 0.00 Year 2024 25% PHC physicians meet CPD credit hour/point 500,000.00 $20,000 per 1 pp increase in PHC requirements for online learning. physicians up to $0.5M DLI_T BL_MATRI X Number of pregnant women who received hemoglobin test and urine analysis for bacteriuria during the first trimester in a DLI 3 public PHC facility Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 5,000,000.00 Period Value Allocated Amount (USD) Formula 80 The World Bank Primary Health Care Quality Improvement Program (P167598) Baseline 24,000.00 Year 2020 34,000.00 1,000,000.00 0.1M per 1000 women receiving tests (over 24,000) up to 1M Year 2021 44,000.00 1,000,000.00 0.1M per 1000 women receiving tests (over 34,000) up to 1M Year 2022 54,000.00 1,000,000.00 0.1M per 1000 women receiving tests (over 44,000) up to 1M Year 2023 64,000.00 1,000,000.00 0.1M per 1000 women receiving tests (over 54,000) up to 1M Year 2024 74,000.00 1,000,000.00 0.1M per 1000 women receiving tests (over 64,000) up to 1M DLI_T BL_MATRI X DLI 4 Number of diabetic patients (type I and II) who received HbA1C test at least once a year in a PHC facility Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output Yes Number 4,750,000.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Year 2020 5,000.00 250,000.00 50,000 for each 1000 patients up to a max amount of 0.25M Year 2021 15,000.00 750,000.00 50,000 for each 1000 patients up to a max amount of 0.75M Year 2022 20,000.00 1,000,000.00 50,000 for each 1000 patients up to 81 The World Bank Primary Health Care Quality Improvement Program (P167598) a max amount of 1M Year 2023 25,000.00 1,250,000.00 50,000 for each 1000 patients upto a max amount of 1.25M Year 2024 30,000.00 1,500,000.00 50,000 for each 1000 patients up to a max amount of 1.5M DLI_T BL_MATRI X DLI 5 The benefit package (SGBP) is revised to improve effective coverage for priority conditions at the primary care level Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 5,000,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 0.00 Year 2021 The structure, process, and methodology for 1,000,000.00 SGBP revision developed and approved by end of Year 2 Year 2022 Revised SGBP based on the new structure and 4,000,000.00 methodology is approved that includes, among others, HbA1C test for all diabetic patients and antihypertensive drugs for uninsured patients at the same level of benefits as the insured by end of Year 3. Year 2023 0.00 Year 2024 0.00 82 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI_T BL_MATRI X DLI 6 The provider payment mechanism for PHC is revised to improve quality and effective coverage for priority services Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 3,000,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 0.00 Year 2021 (i) Provider capitation payment mechanism 1,000,000.00 (i) 0.5M; (ii) 0.5M revised and endorsed(ii) Procedure classification developed by end of Year 2. Year 2022 Revised capitation payment mechanism is 2,000,000.00 implemented that includes pay for quality and fee-for-service for selected priority services by end of Year 3. Year 2023 0.00 Year 2024 0.00 DLI_T BL_MATRI X The Additional Drug Package (ADP) for insured population is revised and its budget is increased to improve effective DLI 7 coverage for priority conditions at the primary care level Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 5,000,000.00 Period Value Allocated Amount (USD) Formula Baseline None 83 The World Bank Primary Health Care Quality Improvement Program (P167598) Year 2020 (i) ADP approved budget for CY 2020 is increased 1,000,000.00 (i) 0.5M; (ii) 0.5M by 15% compared to CY 2018 (ii) Regulation on ADP revision methodology approved by end of Year 2 Year 2021 (i) ADP approved budget for CY 2021 is increased 1,000,000.00 (i) 0.5M; (ii) 0.5M by 15% compared to CY 2020 (ii) Adopt the revised ADP based on the new methodology by end of Year 3 Year 2022 ADP approved budget for CY 2022 is increased by 1,000,000.00 15% compared to CY 2021 Year 2023 ADP approved budget for CY 2023 is increased by 1,000,000.00 15% compared to CY 2022 Year 2024 ADP approved budget for CY 2024 is increased by 1,000,000.00 15% compared to CY2023 DLI_T BL_MATRI X DLI 8 Price regulation mechanisms for the Additional Drug Package for insured population are developed and implemented Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 4,000,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 Regulation on pricing, prescribing, and 1,000,000.00 reimbursement of drugs under ADP approved by end of Year 2 84 The World Bank Primary Health Care Quality Improvement Program (P167598) Year 2021 (i) 2 public campaigns conducted; (ii) 5% of 1,000,000.00 (i) 0.5M; (ii) 0.5M contracted drug dispensing points randomly checked by MHIF for compliance by end of Year 2. Year 2022 (i) 2 public campaigns conducted; (ii) 5% of 1,000,000.00 (i) 0.5M; (ii) 0.5M contracted drug dispensing points randomly checked by MHIF for compliance by end of Year 3. Year 2023 5% of contracted drug dispensing points 500,000.00 randomly checked by MHIF for compliance by end of Year 4. Year 2024 5% of contracted drug dispensing points 500,000.00 randomly checked by MHIF for compliance by end of year 5. DLI_T BL_MATRI X DLI 9 A unit fully designated to quality improvement (QI unit) is established within the MoH and functioning Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Output No Text 3,500,000.00 Period Value Allocated Amount (USD) Formula Baseline None Year 2020 Official approval of an establishment of the QI 1,000,000.00 unit and its TOR with at least 4 staff by end of Year 2 Year 2021 National QI strategy with action plan and 1,000,000.00 85 The World Bank Primary Health Care Quality Improvement Program (P167598) roadmap developed by the QI unit and endorsed Year 2022 Report on quality of care developed and 500,000.00 distributed to key decision makers and PHCs on a quarterly basis by end of Year 3. Year 2023 Report on quality of care developed and 500,000.00 distributed to key decision makers and PHCs on a quarterly basis by end of Year 4. Year 2024 Report on quality of care developed and 500,000.00 distributed to key decision makers and PHCs on a quarterly basis by end of Year 5. . 86 The World Bank Primary Health Care Quality Improvement Program (P167598) . Verification Protocol Table: Disbursement Linked Indicators DLI_T BL_VERIFICATI ON A national e-platform for collecting and reporting quality of care indicators from PHC facilities is established and DLI 1 functioning Technical specifications, including data exchange standards, for the quality of care analytics and CIF based primary care data collection platforms will be developed and officially approved. A quality of care dashboard will be publicly available on the MoH website, including data visualization tools. The two platforms will be designed to ensure data exchange with the MHIF database. The QI unit staff, and designated staff within the MHIF, MoH and PHC facilities will have access to the quality care analytics platform (role-based access). CIF will be revised to incorporate new quality care indicators. An individual-level Description patient data reporting form for FAPs will be developed and approved. The patient level data collected from FAPs will be incorporated into the CIF based primary care data collection platform in the final year. Year 1: Technical specifications, including data exchange standards, for (i) online quality of care analytics and (ii) CIF-based primary care data collection platforms developed to the satisfaction of WB and approved by the MoH. Year 2: CIF based primary care data collection and online quality of care analytics platforms developed to the satisfaction of WB and fully functioning. Year 3: Data from PHC HFs (all but FAPs) are in the quality of care e-platform. Data source/ Agency MoH Quality of Care e-platform Verification Entity IVA Year 1: The MoH approved technical specifications for the online quality of care analytics and CIF based primary care data collection platforms submitted to the WB Year 2: Platform screenshots and platform generated outputs (reports) submitted to the WB Procedure Year 3: Platform generated reports (summary statistics) by PHC providers submitted to the WB Year 5: Platform generated report (summary statistics) by FAPs submitted to the WB. DLI_T BL_VERIFICATI ON DLI 2 A national in-service training e-platform is established and functioning Target values are annual (not cumulative). Year 1: Technical specifications for the (i) the online CPD platform; and (ii) integration of CPD and HRH platforms are developed to the satisfaction of WB. Year 2: Online CPD platform (including a Description mobile application) developed to the satisfaction of WB and fully functional. Year 3: 10% PHC physicians meet CPD credit hour/points requirements for online learning. 87 The World Bank Primary Health Care Quality Improvement Program (P167598) Data source/ Agency MoH, Online CPD platform (Quality Improvement Unit/MoH) Verification Entity IVA Year 1: The MoH approved technical specifications for the online CPD platform and integration of CPD and HRH platforms submitted to the WB Year 2: the CPD platform screenshots and platform generated outputs (reports) submitted to the WB Procedure Year 3 and 5: Platform generated reports (summary statistics) on number of credit hours/points received by providers submitted to the WB. The IVA will reach out to randomly selected physicians to verify the data reported by the platform. DLI_T BL_VERIFICATI ON Number of pregnant women who received hemoglobin test and urine analysis for bacteriuria during the first trimester in a DLI 3 public PHC facility This indicator is included among the 8 quality indicators to be reported on a routine basis to the online quality care platform (DLI 1). Before the platform is functioning, a report from the e-Health Center aggregating oblast level data will be used. The Description target values are annual (not cumulative). The DLRs are scalable (as specified in the formulas) and timebound. Year 1-5: pregnant women who received the hemoglobin test and urine analysis for bacteriuria (microscopic and/or culture) during the first trimester in a public PHC facility Data source/ Agency MoH, Quality of Care e-platform (QIUnit/MoH) Verification Entity IVA Before e-platform is operational, regular reports and data from the e-Health Center will be used to measure and verify achievement of the DLI targets. After the quality of care e-platform becomes operational, it will become the main source for measurement and verification. The accuracy and validity of the reported data will be verified by cross-checking a random sample of data with the laboratory data (aggregate data and individual data from logbooks) and contacting patients via phone. Five percent of the Procedure PHC facilities will be randomly selected for verification. The IVA will randomly select 10% of women in each randomly selected facility who are reported as having had the two tests during the current calendar year. The sample data will be individually cross-checked against the laboratory logbooks to verify the reported data. The pregnant women from the sample who are in the first and second trimester of the pregnancy at the time of a site visit will be contacted to verify the data. An acceptable margin of error for laboratory verification would be 10% and for the direct verification with the pregnant women – 10% (excluding those out of reach). 88 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI_T BL_VERIFICATI ON DLI 4 Number of diabetic patients (type I and II) who received HbA1C test at least once a year in a PHC facility This indicator is included among the 8 quality indicators to be reported on a routine basis to the online quality care platform (DLI 1). Before the platform is functioning, a report from e-Health Center aggregating oblast level data will be used. The Description target values are yearly (not cumulative). The DLRs are scalable (as specified in the formulas) and timebound. Year 1-5: diabetic patients (type I and II) received at least one HbA1C test per year at public PHC facility. Data source/ Agency MoH, quality of care e-platform (QI Unit/MoH) Verification Entity IVA Before the quality of care e-platform is operational, regular reports and data from the e-Health Center will be used to measure and verify achievement of the DLI targets. After the quality of care e-platform becomes operational, it will become the main source for measurement and verification. The accuracy and validity of the reported data will be verified by cross-checking a random sample of data with the laboratory data (aggregate data and individual data from the logbooks) and contacting patients via phone. Five percent of Procedure the PHC facilities will be randomly selected for verification. The IVA will randomly select 10% of patients in each randomly selected facility who are reported as having had the test during the respective calendar year. The sample data will be individually cross-checked against the laboratory logbooks to verify the data. The patients from the sample will also be contacted by phone to verify the data. An acceptable margin of error for laboratory verification would be 10% and for the direct verification with the patients - 10% (excluding those out of reach). DLI_T BL_VERIFICATI ON DLI 5 The benefit package (SGBP) is revised to improve effective coverage for priority conditions at the primary care level The DLRs are timebound. Year 2: The regulation on SGBP revisions methodology is adopted, which defines SGBP related decision-making process (e.g. evidence-based medicine, process, frequency, health technology assessment, budget impact analysis, etc.) according to international practices and acceptable to the Bank. Year 3: The content of SGBP is revised using Description adopted methodology. Gaps in coverage for priority conditions are be addressed to the extent that the budget allows. To the least, these should include HbA1C test for all diabetic patients and antihypertensive drugs for uninsured patients with the same level of benefits as the insured. 89 The World Bank Primary Health Care Quality Improvement Program (P167598) Data source/ Agency MHIF Verification Entity IVA Year 2: Government Decree to adopt the Regulation on SGBP revisions methodology submitted to the World Bank Year 3: Government Decree to adopt the revised SGBP submitted to the World Bank. Procedure DLI_T BL_VERIFICATI ON DLI 6 The provider payment mechanism for PHC is revised to improve quality and effective coverage for priority services The DLRs are timebound. Year 2: Milestone 1: The current capitation payment method for PHC is revised and endorsed. Revisions include: (a) introduction of fee-for-service (FFS) for selected priority and/or preventive services; and (b) revision of pay for performance indicators (P4P). Milestone 2: Procedure classification with the list of PHC procedures and Description corresponding codes is developed. Year 3: New payment mechanism that includes P4P and FFS for selected priority and/or preventive services is implemented. All primary health care facilities are contracted and paid based on the new payment mechanism. Data source/ Agency MHIF Verification Entity IVA Year 2: Milestone 1: Copy of joint MoH/MHIF order to adopt the revised payment mechanism submitted to the WB. Milestone 2: Copy of joint MoH/MHIF order to adopt the PHC procedure classification submitted to the WB. Procedure Year 3: Copies of the signed contracts between PHC facilities and MHIF submitted to the WB. MHIF payments to the PHC facilities based on the new payment method verified by the IVA. DLI_T BL_VERIFICATI ON The Additional Drug Package (ADP) for insured population is revised and its budget is increased to improve effective DLI 7 coverage for priority conditions at the primary care level Year 1-5: Approved budget for the ADP is increased each year by 15% compared to the preceding year (or compared to CY Description 2018 of Year 1). Evidence of achievement is based on the last amendment of the approved budget for the year in question. Year 1: Milestone 2: Methodology for the revision of ADP with the definition of roles and responsibilities of different 90 The World Bank Primary Health Care Quality Improvement Program (P167598) stakeholders, and methods which will be used in the decision process (e.g. health technology assessment, budget impact analysis) is approved by end of Year 2. This is a timebound DLR. Year 2: Milestone 2: the ADP is revised based on the approved methodology by end of Year 3. This is a timebound DLR. Data source/ Agency MHIF Verification Entity IVA Year 1-5: MHIF budget for the subsequent year and for the preceding year submitted to the WB. Year 1: Milestone 2: Copy of joint MoH/MHIF order to adopt methodology for the revision of ADP submitted to the WB Procedure Year 2: Milestone 2: Copy of Government Decree to adopt revised ADP submitted to the WB. DLI_T BL_VERIFICATI ON DLI 8 Price regulation mechanisms for the Additional Drug Package for insured population are developed and implemented The DLRs are timebound. Year 1: Regulation on pricing, prescribing, and reimbursement of the drugs under ADP is approved. Years 2 and 3: Milestone 1: Public campaigns are conducted to inform population on the new ADP policy. Years 2 Description and 3: Milestone 2: 5% of drug dispensing points are randomly checked by MHIF for compliance with the new ADP policy. Years 4 and 5: 5% of drug dispensing points are randomly checked by MHIF for compliance with the new ADP policy. Data source/ Agency MHIF Verification Entity IVA Year 1: Copy of Government Decree to adopt regulation on pricing, prescribing, and reimbursement of the drugs under ADP submitted to the WB. Years 2 and 3: Milestone 1: Public campaign strategy; contracts with the public campaign partners; campaign materials submitted to the WB. Procedure Milestone 2: Reports on randomly checked pharmacies by MHIF submitted to the WB. 5% of randomly checked pharmacies are inspected by the IVA. Years 4 and 5: Reports on randomly checked pharmacies by MHIF submitted to the WB. 5% of randomly checked pharmacies are inspected by the IVA. 91 The World Bank Primary Health Care Quality Improvement Program (P167598) DLI_T BL_VERIFICATI ON DLI 9 A unit fully designated to quality improvement (QI unit) is established within the MoH and functioning The DLRs are timebound. Year 1: Official approval by a Minister’s Order of an establishment of the QI unit with at least 4 staff. The Order should approve also a TOR for QI unit and Coordination Committee (among others, TOR includes producing reports from online system, revision of evidence-based medicine guidelines/protocols, MoH and MHIF coordination in Description revising SGBP, ADP, Balance Score Card (BSC), and BSC verification). This is a timebound DLR and has to be achieved by end of Year 2. Year 2: National QI strategy with action plan and roadmap is developed and endorsed. Year 3-5: Reports using facility reported data through the online quality care platform on at least 8 quality of care indicators developed and distributed to key decision makers and PHCs on a quarterly basis. Data source/ Agency MoH Verification Entity IVA Year 1: Copy of the Government Decree or Ministerial Order on establishment of QI unit and on TORs for QI unit and CC. The TORs for QI Unit and CC are developed to allow for an effective coordination role and are deemed satisfactory by the Bank. Procedure Year 2: Official document on National QI Strategy with action plan and roadmap issued by the MoH. Year 3 - 5: copy of reports submitted to the WB. . 92 The World Bank Primary Health Care Quality Improvement Program (P167598) ANNEX 3. TECHNICAL ASSESSMENT SUMMARY Primary Health Care Quality Improvement Program A. The Government Program SPHD2030 and the PHC Service Specific Area of the SPHD2030 1. The SPHD2030 builds on 20 years of health reform in the Kyrgyz Republic and is designed in parallel with other planning processes at the government level - the National Development Strategy for 2018-2040 and Government Program for Country Development for 2018-2022 “Unity. Trust. Creativity.” The program is the fourth document that defines major directions for further health care system. It defines the goals and objectives of health care system development until 2030. The ways to achieve these goals and objectives of the program have been developed for the next five years. 2. The formulation process of the SPHD2030 followed an important principle of active participation of all stakeholders and from all regions of the Kyrgyz Republic. The civil society representatives, promoting the interests of recipients of health services also actively participated in the process. The active involvement of the Jogorku Kenesh (Parliament) members, representatives of other government sectors, and local self-governing bodies was an indispensable condition for the development of the program. International and national expertise of the program was provided. Following the broad public consultations in all regions, approval by members of the intersectoral and Thematic Groups, the draft program was reviewed and approved by the Committees of the Jogorku Kenesh on Social Affairs, Education Culture and on budget and finances, and was submitted to the Government of the Kyrgyz Republic observing the procedure. 3. Development of the modernized high-quality primary care is a key element of the strategy. This will be founded on an integrated approach designed to meet the needs of the population and will include the following: (a) Create an efficient model of PHC that incorporates services for prevention, early detection of diseases and case management guided by the quality standards and other government commitments to secure the right to health. (b) Improve the continuity and coordination between PHC and secondary and tertiary level organizations in provision of comprehensive, integrated and patient-oriented services. (c) Improve the quality and coverage of PHC services with a focus on improving health outcomes and on the principles of fair, equitable access for the entire population. (d) Strengthen the staff capacities for provision of qualified PHC services. 93 The World Bank Primary Health Care Quality Improvement Program (P167598) 4. To achieve these goals, the SPHD2030 envisions several interrelated measures and activities, the most important ones include: (a) Development and implementation of the list of services under the SGBP oriented to priority, widespread diseases and conditions, guided by evidence-based medicine; (b) Improvement of PHC health care organizations’ activity payment, taking into account the extended tasks and functions, as well as demographic indicators, results-based financing and service quality improvement services. (c) Implementation of the patient electronic medical cards at the PHC level, integrated into all levels of healthcare, in order to ensure integrated patient management and provision of integrated services. (d) Ensuring access of medical workers to the approved clinical guidelines / protocols in all regions, with use of electronic databases and libraries. (e) Development and implementation of a quality management system for PHC health services and its continuous improvement, regardless of ownership of providers. (f) Creation of educational and methodological centers in PHC organizations, with access to the electronic database of clinical guidelines and protocols, electronic scientific and medical library, and to educational organizations as part of continuous professional training. 5. Development of the PHC will be implemented in tandem with several measures aimed at improving efficiency in the hospital sector. The measures include optimizing hospital network with an aim to reinforce care integration, modernization of infrastructure and introduction of modern approaches to effective management, increase the role of tertiary-level organizations in delivery of high-tech services to the population following the principles of equal access, conducting methodical and scientific developments in priority areas, providing methodological assistance to PHC healthcare organizations and secondary level institutions. B. The Program for Results Focus Areas 6. The first result area will aim to integrate into service delivery key quality improvement elements, namely a) quality of care data collection and reporting, and b) bringing quality CPD to the ‘bedside’ through improving access and tailoring the content to the gaps. The second result area activities will focus on strengthening strategic purchasing capacity within the MHIF by a) supporting coverage of evidence-based practices for selected conditions within SGBP; b) introducing blended payment mechanisms to increase utilization of selected evidence-based practices; and finally, c) realigning the government’s drug reimbursement package with the evidence-based practices and priority high burden conditions. The final result area will aim to support the establishment of national governance structures and mechanisms and policy support for drug price regulation. 94 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area 1: Integrating sustainable quality improvement mechanisms into service delivery 7. Quality improvement activities within the service delivery result area will support two important components needed for building a sustainable national quality improvement system. Availability of quality of care data for continuous quality monitoring and decision making is a key element. The set of proposed activities will improve the availability of quality of care data for decision making by establishing a unified national quality of care e-platform with the data analytics and reporting functions. Eight quality indicators on priority MCH and NCDs will be selected for routine collection and reporting as preliminary tracer indicators, one of which (vi) will be linked to disburement. The proposed set of indicators is as follows: (a) Number of patients with diabetes (type 1 and type 2) who had at least one HbA1c test performed in PHC during the preceding calendar year (b) Percentage of patients with diabetes (type 1 and type 2) who had HbA1c test during the preceding calendar year (c) Percentage of patients with diabetes (type 2) whose most recent HbA1c level was higher than 9.0% among those tested during the preceding year (d) Percentage of patients with blood pressure reported among patients who had an office visit to PHC (50-year-old and older) (e) Percentage of patients with hypertension and taking antihypertensive medications whose blood pressure was adequately controlled (<140/90) during the most recent measurement (f) Percentage of pregnant women who received selected antenatal care services (hemoglobin measurement and urine microscopy) during the first trimester (g) Percentage of patients with chronic stable coronary artery disease who were recommended an antiplatelet agent during the preceding year (h) Percentage of patients with heart failure who were recommended angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy during the preceding year 8. Strengthening physician knowledge and competencies is the second area to be addressed within this result area. An in-service training online platform will be developed to improve access to training materials, enforce unified quality standards for training materials, improve relevance to quality gaps, and facilitate the integration of online learning activities with the existing CPD framework. 9. These activities map into the PBB of the MoH as shown in the Expenditure Framework Analysis above. In particular, the sub-program budget measures include development of an online database, availability of drugs and medical devices, and improving qualification of health workers, detailed in the Technical Annex’s section on Expenditure Framework Analysis (table A3.5). Result area 2: Strengthening strategic purchasing for the quality of care 10. The result area on strategic purchasing will support the introduction of blended payment mechanisms, revision of SGBP, and revision of the government drug reimbursement package. 95 The World Bank Primary Health Care Quality Improvement Program (P167598) 11. The blended payment mechanisms will be developed and introduced for primary care services to increase utilization of the selected evidence-based services such as HbA1c testing for diabetes patients and strengthen purchasing of quality. The revision of the SGBP will be supported to align the benefits with the evidence-based cost-saving and cost-effective practices and increase coverage for selected evidence-based priority services. 12. Strategic purchasing operations will also support the revision of the Additional Drug Package program funded by the MHIF. The medication list covered by the reimbursement program will be revised to maximize coverage for priority conditions selected for quality improvement and to better align the program with evidence-based cost-effective practices. 13. These activities squarely fall under the program 2 in the PBB of the MHIF (providing PHC services) as shown in the Expenditure Framework Analysis and detailed in table A3.6. Result area 3: Strengthening health sector stewardship and governance for quality improvement 14. National coordination and governance mechanisms for quality improvement are essential to building an efficient, effective and sustainable national quality improvement framework in the country. Although, there are staff within the MoH working on various elements of quality improvement (evidence- based medicine, accreditation, licensing), a designated unit and staff tasked with improving quality are lacking. The governance activities will aim to establish a QI unit with clear terms of reference and expanded role for quality improvement by consolidating existing staff and structures into a single unit. Capacity will be built within the unit for quality measurement and improvement techniques and methodologies. 15. Regulation of medication prices and prescription practices can strengthen quality through improved coverage. There were several initiatives to develop and implement price regulation in the country, however, none has come to be endorsed and implemented. The Program activities will support the government in development and implementation of price regulation policies for the ADP. 16. These activities fall under Budget Measure 7 in program 1 of the MoH’s PBB , detailed in the Technical Annex’s table A3.5 (Provision of monitoring, analysis and strategic planning, stewardship of the health sector). 96 The World Bank Primary Health Care Quality Improvement Program (P167598) C. Strategic Relevance and Technical Soundness of the Proposed PforR Strategic Relevance 17. The proposed Program’s focus on the quality of PHC will constitute an important step to help to advance the country toward the global and its own commitment to UHC. UHC means that all people and communities should have access to high-quality health services they need without facing financial hardship. Delivering quality health services is high on the agenda and is considered essential to UHC. 25 Although Kyrgyz Republic has committed to UHC and has an SGBP that provides universal entitlement to basic services, it does not have effective universal coverage in a sense that the services of high quality are not available to the whole population at low cost. Improvements in the quality of services in primary care will fill in this gap. It will increase the attractiveness and effectiveness of PHC, thus reduce unnecessary services and hospitalizations with much higher costs to the system and the population. It addresses a structural bottleneck on the pathway toward the ultimate goals of the health system, which are improving health outcomes and providing financial protection relating to health care. 18. The Program objectives are well aligned with the Bank’s twin goals of reducing poverty and sharing prosperity. The Program supports the areas under the government health program (SPHD 2030) that match the strategic directions outlined in the CPF for calendar years 2018-2022. The CPF objective on the development of skilled human capital aims to raise the quality of health care and opportunities for adult life-long learning through application of new technologies, which will be the focus of the Program. Quality of education/learning, relevance critical gaps and policy priorities are highlighted as key areas for action within CPF, which are incorporated into the Program within the context of quality of care improvement. 19. The bottlenecks identified in the most recent SCD are considered in developing the Program objectives and results.26 The quality deficit in social services, including health services, is highlighted as one of 11 constraints to advancing the Bank’s twin goals. A lack of comprehensive, cohesive and long- term policy frameworks in various public service areas is noted as a key missing area. The Program aims to improve quality of care by supporting comprehensive sustainable policy and implementation frameworks by establishing systems, structures, and policies on continuous quality of care data collection, reporting, feedback and action. 20. There is a strong justification for the Bank and JFs to support PHC . Globally, investing in PHC has been considered the most cost-effective intervention that has a large potential for generating positive externalities. Yet it is also observed that PHC has not received adequate attention and priority it deserves. 25 Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization, Organization for Economic Co-operation and Development, and The World Bank; 2018. 26 The World Bank Group (2018) Kyrgyz Republic: From Vulnerability to Prosperity. A Systematic Country Diagnostic. 97 The World Bank Primary Health Care Quality Improvement Program (P167598) In many countries, PHC is typically underfunded while elite capture often draws public resources toward hospitals. In the case of Kyrgyz Republic, although the government has announced a strong intention to focus more on PHC, how it will operationalize the promise has yet to be seen given the country’s resource constraint situation. This operation supports the government’s effort to focus on PHC while emphazing the importance of having a holistic approach in service delivery. This is also an area where other private investors and new donors are unlikely to come in. 21. Addressing quality of care at the PHC is a challenging endeavor which the Bank is uniquely qualified to support. Despite various studies, pilots and initiatives supported by DPs, none has attempted to tackle the issue of quality at primary care, or quality in general, in a systematic and comprehensive manner. Quality of care improvement is a complex long-term process that requires concerted health systems level changes to create a sustainable quality improvement culture. Sustainable quality improvement systems are difficult to establish and often require extensive technical and political support. The proposed operation, approaching quality from multiple angels - service delivery, strategic purchasing, and governance – will help to move the system to the next stage. The Bank and JFs’ engagement is critical because no other partner would have comparative advantages and the necessary resource envelop to support such a long-term and focused agenda. Technical Soundness 22. The proposed operation builds on current evidence base on quality improvement efforts and good practices from other countries considering the health care and socio-economic context in Kyrgyz Republic. Sustainable quality improvement systems require, at a minimum, reliable and valid quality of care measures, health information or data management systems to collect, manage, analyze and report quality of care data, quality of care improvement methods and interventions integrated into the health system and national governance and organizational structures/mechanisms. The PforR interventions are aligned with best global practices, which suggest that a focus on processes and systems rather than structural interventions is more effective in improving the quality of care. 27,28 The three recent reports on the quality of care29,30,31 highlight several categories of interventions for quality improvement, including setting standards; sharing information and education for health workers, managers, and policymakers; engaging and empowering patients, families and communities; use of continuous quality improvement 27 Quality of care encompasses three dimensions: structure (that is, inputs), clinical processes (that is, interaction between health workers and patients), and patient outcomes (that is, clinical outcomes, morbidity, and mortality). 28 Smith, O., & Nguyen, S. N. (2013). Getting better: improving health system outcomes in Europe and Central Asia. The World Bank. 29 National Academies of Sciences, Engineering, and Medicine (2018). Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. 30 WHO, OECD, and World Bank (2018). Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization, Organisation for Economic Co-operation and Development, and The World Bank. 31 Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., ... & English, M. (2018). High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 98 The World Bank Primary Health Care Quality Improvement Program (P167598) programs and methods; establishing performance-based incentives; and legislation and regulation. As highlighted in the Lancet Global Health Commission on High Quality Health Systems in the SDG Era, governance is a critical component of high-quality systems and forms the basis of any quality intervention. The Commission recommends the development of policies and guidelines for quality and the compilation of an open-access health system dashboard for monitoring progress toward a high-quality health system. This PforR is built around two of the key universal actions for improving quality of care as outlined in the Commission’s report: govern for quality and transform the health workforce through competency-based clinical education. 23. The Kyrgyz Republic has extensive health and insurance data collection systems, but the systems are not integrated, collect limited quality of care data and do not have the capacity for quality of care monitoring and action. A comprehensive quality improvement governance at the national level is extremely limited with various governance functions partially carried out by different players with little overall coordination and cohesion. For instance, the MHIF is involved in purchasing for quality with limited role and capacity to develop quality measures and design/implement improvement interventions. The MoH has staff that is responsible for various siloed components of quality improvement such as evidence- based medicine or provider accreditation. A national body responsible for quality improvement as a concept that commissions situational analyses, identifies priorities and indicators, implements interventions and sets the long-term strategic vision for the country is missing. 24. Physician knowledge and competencies in evidence-based practices are critical to sustainable quality improvement. National CME frameworks that build on adult life-learning principles and match existing critical gaps are considered as best practices. The Kyrgyz Republic has a longstanding CPD framework that is mostly based on didactic learning, but also ready to accommodate and internalize new concepts in CPD. Currently, according to the national CPD requirements, all physicians are required to obtain 250 hours learning credits (50 hours a year) every 5 years to maintain ‘license’ to practice. Credit hours could be obtained by attending training provided by the Institute for Postgraduate Medical Education or other certified training. Many courses eligible for the credit hours are offered at the Institute or its branches, which limits geographical and financial access. Furthermore, the data and systems are lacking that can link learning content and mode to existing gaps and various learning styles. 25. The Program operations will focus on building a holistic sustainable system for quality improvement in primary care. Selected high burden MCH and NCD conditions will be part of the model building exercise that will be used in all three result area activities; the set of indicators could be revised and/or expanded in future to align with the priorities. D. Program Expenditure Framework 26. In essence, the SPHD2030 is an enhancement of the current health sector program and costing of SPHD was estimated as additional to the current spending in the sector. SPHD2030 cost estimate is 99 The World Bank Primary Health Care Quality Improvement Program (P167598) also not exhaustive - it includes additional activities by concerned stakeholders involved in the SPHD2030’s program of action but does not take into account the full cost needed to achieve the vision of SPHD2030. For example, for one of the proposed activities – revising the State Guaranteed Benefit Package (SGBP) – SPHD2030 costing reflects the timing of the technical working group in charge of the revision only, it does not estimate what the cost of the revised SGBP itself will be. This limitation is understandable given the lack of data on many aspects and the ambition to project health sector activities over the period of 12 years. At the same time, the implication of such limitation is that the expenditure framework analysis will focus almost exclusively on the health sector budget as reflected in the government budgeting and execution cycle, as well as in the Medium-Term Budget Framework (MTBF) for 2019-2021. The following will: (1) provide a brief overview of public domestic health expenditure in the Kyrgyz Republic, its principal sources of financing, intermediary agencies that manage public health budget - MoH and MHIF – and their budget programs as specified in the recently adopted Program-Based Budgets (PBBs); (2) assess the Program budget performance; and (3) analyze the PforR expenditures in each Result Area in view of the PBBs. The analysis does not include development budget (infrastructure), which is approved through a completely different process and timeline compared to Republic Budget for the health sector. Government Health Expenditure in the Kyrgyz Republic 27. The Kyrgyz Republic has a rolling 3-year Medium Term Budget Framework (TBF), which provides reasonable predictability in the budget for all sectors. 28. Besides external aids, public expenditure for health in the KR comes from three main sources: Republican (central) budget, local budget, and revenue from mandatory health insurance (MHI). Setting asides development budget (infrastructure), of the three sources, the most significant is Republican Budget, accounting for some 85% of the total public health spending in the last three years. Local Budget accounts for a small and decreasing share, from 10% in 2013 to 2% in 2017. Table A3.1: Share of domestic public expenditures on health, net of development budget 2017 (preliminarily 2015 2016 approved) Republican (%) 84 86 85 Local (%) 6 3 2 MHI (%) 10 11 13 Total (%) 100 100 100 Total (thousand Kyrgyz som) 14,396,300 15,328,500 16,498,300 Source of data: MoF (provided as part of 13% budget target verification) 29. Government health expenditure in the Kyrgyz Republic is managed by two main entities: the MoH and MHIF. As a Single Purchaser of health services in the country, MHIF manages 80% of the 100 The World Bank Primary Health Care Quality Improvement Program (P167598) domestic public financing for health, contracting with 261 health institutions providing health care services at all levels. Table A3.2: Government health expenditure by MoH and MHIF, 2017 (actual) Thousand Kyrgyz som US$ equivalent % MHIF 13,064,888 192,130,700 80 MoH 3,211,742 47,231,494 20 Total MoH and MHIF 16,276,629 239,362,194 100 Source of data: Interim Financial Reports (IFRs) 30. For budget formulation, execution and reporting, a uniform budget classification is used for all levels of the budget system that ensures the unification of the forms of budget statistics and comparability with international practice. The budget classification is part of the Chart of Accounts used for the bookkeeping of operations on the execution of budgets and economic activities of budgetary institutions in the general government sector. The budget classifications are in line with the basic principles of the GFSM 2001. Budget agencies compose their statistical reports on a modified cash basis. The main classification for budget appropriations and budget execution include economic, functional and administrative classification. Budget Performance 31. The budget law allows for some flexibility in adjusting the budget through two amendments in a budget year: before June 1 and before November 1 of the current fiscal year. In-year reallocations of budgetary appropriations between items of the economic classification of expenditures are permitted. In- year reallocations of budgetary appropriations between medical institutions within the limits of one administrator of budgetary funds are also permitted. 32. The Interim Financial Reports (IFRs) distinguish three key concepts when it comes to budget approval and execution: (a) “Approved plan,” or originally approved budget, that is stated in the Law and approved by the Parliament, usually in December of the preceding year; (b) “Distribution plan,” or the budget that is revised during the course of the year and is also approved by the Parliament; and (c) “Cash,” or the actual expenditure. 33. Comparing “cash” with “distribution plan” reveals that the budget execution rate is high for MHIF but lower for MoH, which was only 83% in 2017. Within MHIF, the expenditure on the SGBP at PHC and on the ADP, the two main sub-programs in PHC, have the execution rate in the order of 100%. 101 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A3.3. Execution rate of the Republican Budget, 2015 – 2017 (%) Year Health Sector MoH expenditure MHIF expenditure PHC SGBP ADP 2015 97 91 100 100 92 2016 95 88 96 98 102 2017 92 83 95 95 104 Source of data: IFRs 34. At the same time, comparing “distribution plan” with “approved plan” reveals how much short- term predictability one could obtain with the budget that is originally approved. As presented in table A3.4, the Republican budget for the health sector as a whole was actually revised up during the year of implementation over the last 3 years, indicating that initial budget planning may have erred on the conservative side. This is largely true for sub-programs SGBP and ADP, although there was a dip in ADP in 2017. Table A3.4. Short-term predictability of the Republican Budget, 2015 – 2017 (%) Year Health Sector MoH expenditure MHIF expenditure PHC SGBP ADP 2015 106 104 107 104 100 2016 103 95 105 103 99 2017 104 117 104 101 87 Note: this indicator measures the share of the revised budget in the originally planned budget for the year in question. Source of data: IFRs Mapping the PforR Expenditures by Result Area to the PBB 35. Starting in 2019, PBB will be piloted in two sectors – health and transport. In the health sector, the PBB provides an additional budget classification method: budgets of the MoH and MHIF are classified into 8 main programs (4 under MoH and 4 under MHIF – figure A3.1). One of the main objectives of the PBB is to strengthen managerial and financial independence of health care organizations and increase their responsibility for delivering quality services. For example, by providing certain flexibility on economic classification line items, the PBB provides for retaining of savings within the entities (MoH and MHIF) if they generate efficiency by optimizing on allocative and technical efficiency. 102 The World Bank Primary Health Care Quality Improvement Program (P167598) Figure A3.1: Program Based Budgets for the health sector (Preliminary 2019 budget) 36. Classification of health sector budget by programs as shown in figure A3.1 makes it easy to draw a boundary for the PforR expenditure framework. As shown, purchasing of PHC services is one of the four programs under MHIF. The MoH, while not purchasing the services delivered at the PHC, is in charge of organizing the delivery of services, medical education, management of human resources for health (HRH), and planning and management that includes health information system . Thus, the PHC program under MHIF and three programs under MoH (all but Public Health) together form the expenditure framework that corresponds to the boundary of the PforR (focusing on quality of the PHC – with MHIF being responsible for PHC service specifics and MoH plays the functions of cross cutting areas promoting quality at PHC). 37. The PforR consists of 3 Result Areas: (1) Integrating sustainable quality improvement mechanisms into service delivery; (2) Strengthening strategic purchasing for the quality of care; and (3) Strengthening health sector stewardship and governance for quality improvement. Main activities under Result Area 1 include setting up an online platform for data exchange, developing several databases, developing online training programs, and reporting quality data online by the PHC facilities. These fall largely under different budget measures (BM) in programs 1, 3, and 4 of the MoH’s PBB as shown in table A3.5 below. Specifically, BM 8 under program 1 provides for an implementation of eHealth activities, setting up online systems and databases, etc. Similarly, BM 3 under Program 4 on upgrading qualification of health care workers serves as a basis for the online continuous medical education supported by the PforR. Of note is that the BM 4 under Program 3 “Provision of accessibility of drugs and medical devices at healthcare organizations” applies to both PHC and hospitals and is likely to weigh heavily toward hospitals. Therefore, the amount reported as “directly related to the Program for Results” and its 103 The World Bank Primary Health Care Quality Improvement Program (P167598) corresponding share of the MoH budget is likely to overestimate the actual spending and budgeting for PHC. 38. Result Area 3 proposes to set up a Quality Improvement Unit in the MoH. This will fall largely under BM7 of Program 1, on provision of monitoring, analysis, and strategic planning of health sector. Table A3.5. Excerpt from MoH’s PBB with budget measures directly related to the PforR (thousand Kyrgyz Soms, 2017-2021) Budgetary programs and budget measures (BM) 2017 2018 2019 2020 2021 Program 1: Planning, governance & administration BM 7: Provision of monitoring, analysis & strategic planning/stewardship of health sector 3,058 4,223 5,088 5,088 5,088 BM 8: Implementation of online systems and databases 24,822 26,929 28,276 28,276 28,276 Program 3: Organization of health care services delivery BM 1: Improvement of quality of health services delivery at PHC level 65,883 67,373 70,741 73,571 75,578 BM 4: Provision of accessibility of drugs and medical devices at healthcare organizations 0 9,069 120,000 124,885 128,272 Program 4: Medical Education & Management of HRH BM 3: Improvement/upgrading of qualification of health care workers 113,071 143,424 149,161 154,597 158,483 Total budget mapped to the Program 206,834 251,018 373,266 386,397 395,697 Total MoH budget 3,211,742 3,319,867 4,602,619 3,773,924 3,857,948 Program budget as % of MoH budget 6% 8% 8% 10% 10% Source of data: MoF (MoH’s Program Based Budget approved on November 29, 2018); Note: 2017 and 2018 figures were retrofit to the PBB classifications. 2017 figures are actual expenditure while 2018-2021 figures are planned budgets 39. The PforR’s Result Area 2 (Strengthening strategic purchasing for the quality of care) falls squarely under the Program 2 (delivery of PHC services) of the MHIF (Table A3.6). All budget measures under Program 2 are relevant to the PforR except for emergency care (not shown in the table). In the Result Area 2, the main activities include revising the and increasing financing for the drug lists under the SGBP and Additional Drug Package (ADP), as well as revising the provider payment to incorporate performance-based indicators. As shown in table 6 below, budget related to the PforR accounts for 90%- 91% of MHIF’s budget for PHC, and 29%-31% of MHIF’s total budget. 104 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A3.6. Excerpt from MHIF’s PBB with budget measures directly related to the PforR (thousand Kyrgyz Soms, 2017-2021) Budgetary programs and budget measures (BM) 2017 2018 2019 2020 2021 Program 2. Delivery of PHC services BM 2: Provision of basic health services at PHC for the whole population (SGBP) 3,532,949 3,467,193 4,341,818 3,738,016 3,797,824 BM 3: Provision of TB care in PHC 456 30,000 33,372 35,000 35,000 BM 4: Drugs reimbursed under the SGBP for the whole population 35,856 55,000 55,000 55,000 55,000 BM 5: Drugs reimbursed under the ADP for insured population 228,560 264,435 276,070 280,000 290,000 BM 6: Provision of fee-based services beyond the SGBP 57,196 75,539 77,291 73,280 76,944 BM 7: Provision of non-medical & other services by the HCOs, operating under the Single Payer System 181,007 275,106 239,280 266,882 280,226 BM 8: Incentives for Family Group Practices based on quality performance 3,500 4,500 100,000 100,000 100,000 Total budget mapped to the Program 4,039,524 4,171,773 5,122,831 4,548,178 4,634,994 Total MHIF budget 13,064,861 14,230,326 15,030,944 14,640,465 14,932,071 Program budget as % of MHIF budget 31% 29% 34% 31% 31% Source of data: MoF; Note: 2017 and 2018 figures were retrofit to the PBB classifications. 2017 figures are actual expenditure while 2018-2021 figures are planned budgets 40. As shown in table A3.6, the most important budget measure in the PHC program by MHIF is the provision of the basic health services for the whole population, representing the SGBP at PHC (BM 2). Five- year trend shows a gradual increase in nominal term except for a dip in 2018. Similar trend is observed for the ADP (BM5). Special attention is warranted for BM8, which shows a significant increase planned for 2019-2021, demonstrating the government intention to roll out the performance-based payment scheme for PHC under the scheme to improve salary for family medicine physicians. 41. The expenditure patterns over the last two years reveal that most of the MoH and MHIF budget was spent on staff, leaving very little for goods, services, or maintenance (table A3.7) . Specifically, roughly 66% of MoH’s budget and 75% of MHIF’s budget within the Program was spent on salary and social contribution. Under MHIF, about 20% of the total expenditure under the program “Delivery of PHC services” went to goods and services, a large part of this is for pharmaceuticals. 105 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A3.7. Breakdown of MoH and MHIF budget under the Program by major economic classification, 2017-2018 (%) MoH MHIF 2017 (actual) 2018 (estimate) 2017 (actual) 2018 (estimate) Salary 56% 54% 66% 65% Social Payment 10% 9% 11% 11% Goods and services 34% 35% 19% 20% Others 1% 1% 4% 4% Total 100% 100% 100% 100% Source of data: MoH and MHIF 42. The magnitude of Joint Financiers’ commitment to the PforR is compared to the government budget channeled through the MoH and MHIF over the lifetime of the proposed operation, 2020-2024 (table A3.8). Based on budget data during 2017 – 2021, it is assumed that the MoH and MHIF nominal budget under the Program will be increased during 2022-2024 a rate of 3% and 4.2% annually respectively. The 5-year budget for the MoH and MHIF is thus estimated at 2,040.9 and 24,258.5 million Kyrgyz soms respectively, giving a total of more than US$ 377.18 million.32 With this, Joint Financiers’ commitment constitutes nearly 9% of the total Program’s budget. Table A3.8. Estimated five-year budget for the Program Kyrgyz som (thousand) US$ (million) MoH MHIF MoH MHIF Joint Financiers* CY 2020 386,398 4,548,178 5.54 65.16 6.25 CY 2021 395,697 4,634,994 5.67 66.40 8.75 CY 2022 407,419 4,829,231 5.84 69.19 11.75 CY 2023 419,489 5,031,608 6.01 72.09 4.25 CY 2024 431,915 5,242,465 6.19 75.11 6.00 Total 2020-2024 2,040,918 24,286,476 29.24 347.94 37.00 Government budget 377.18 Program budget 414.18 Source of data: PBBs for the health sector, MoF. * Joint Financiers disbursement schedule is based on table 3 and is subject to change. 32This assumes an exchange rate of 69.8 Kyrgyz som for 1 US$. This rate is used by the Kyrgyz Government for 2019 budget as stated in the Explanatory Note to the Budget 106 The World Bank Primary Health Care Quality Improvement Program (P167598) E. Economic Justification of the Program The cost associated with the Kyrgyz Republic’s health and health care system today There is a relative deficit of human capital in the Kyrgyz Republic 43. Despite a promising macroeconomic background, targeted investment in human capital development is needed in the Kyrgyz Republic. A child born in the Kyrgyz Republic today will be 58 % as productive when she grows up as she could be if she enjoyed complete education and full health. In addition, the Kyrgyz Republic only holds 27.5% of its total wealth as human capital. This is far below ECA low- and middle-income peers (37.0%), global lower middle-income countries (50.6%) and global low- income countries (40.8%). Table A3.9. Per capita wealth by sources in comparison (US$) Per capita wealth (2014 U.S. dollars at market exchange rate) Total Produced Natural Human Human capital as wealth capital capital capital share of total wealth Kyrgyz Republic 24,429 6,159 12,570 6,729 27.5% ECA low- and middle-income 70,530 27,760 19,978 26,116 37.0% Global lower middle-income 25,948 6,531 6,949 13,117 50.6% Global low-income 13,629 1,967 6,421 5,564 40.8% Source: The Changing Wealth of Nations, WBG, 2018 44. The relative deficit of human capital in the Kyrgyz Republic is an important preliminary economic justification for the PforR, given its focus on improving health (a core component of human capital) across the life course, particularly in working age adults. Weak primary care generates substantial societal costs 45. Conditions that could be prevented or better managed by stronger primary care imply a substantial cost to the economy of the Kyrgyz Republic, both directly (through health system spending) and indirectly (through reduced labor productivity, for example). A recent interagency report 33 estimates that some 30% of total public health care spending in the Kyrgyz Republic is directed to the management of chronic non-communicable diseases (NCD), equivalent to 5.3bn som (US$ 76.1m; data taken from Figure A3.1). More specifically, the report estimates that 13.4% (2.4bn som) of public health care spending is directed towards cardiovascular disease (CVD) and 4% on diabetes (0.71bn som), two NCD that appear in the DLI linked to this PforR. It should be noted, however, that GoKR is almost certainly under-spending in this area given the high prevalence of undiagnosed NCD. Chronic illness also exerts a substantial macro- 33Prevention and control of non-communicable diseases in Kyrgyz Republic: the case for investment. WHO Regional Office for Europe, Copenhagen. 107 The World Bank Primary Health Care Quality Improvement Program (P167598) economic impact through indirect means such as early death, inability to participate in the workforce and/or “presenteeism. Adding indirect costs to direct government spending means that the total economic cost of NCD to the Kyrgyz Republic economy is 19.9bn som (US$ 284mn) per year, equivalent to almost 4% GDP. In the absence of stronger primary care, this figure is likely to rise given the Kyrgyz Republic’s growing population and worsening prevalence of NCD risk factors. 46. Improving antenatal care, another focus of the PforR, will also have wider societal benefits. Neonatal complications are the second most important cause of death and disability combined in the country, according to IHME data. The burden of disability due to neonatal complications has risen by 22% in the past decade and has a life-long impact on individuals and families - babies who survive face greater risks of significant health problems throughout their lives, translating into significant increased costs to healthcare and the broader economy. Maternal deaths also have far-reaching and long-standing ramifications, including increased mortality among children whose mothers had died. Difficultly in managing the remaining household is common. Children may be taken out of school, sent away to live with other families or, if girls, married earlier than if their mother had remained alive 34. Each of these steps can further entrench poverty and limit human capital development. 47. There is thus a strong economic case, a priori, for investing in better prevention, early detection and effective management in primary care. The cost-benefit of such interventions is discussed further below. Expected economic benefits of the PforR 48. The PforR comprises complex system interventions that work on service delivery, financing/purchasing, and governance as illustrated earlier in the PAD by Figure 7 (“A theory of change for the Primary Health Care Quality Improvement Program”). Based on this, the expected results and expected economic benefits of the PforR comprise increased efficiency in health spending, by shifting care from the hospital to the primary care sector; improved health status due to averting premature deaths and DALYs, through improved access and quality of primary care; and, improved financial protection, through reduced financial risk, reduced catastrophic health spending, reduced precautionary savings for health, and increased investment/spending in other economic activities. 49. As discussed earlier, spillover effects mean that the program will lead to health system strengthening beyond the PforR’s main focus, the primary care sector . The analysis that follows is restricted to costs and benefits within that sector. It should be noted, however, that PforR activities to support continuous quality improvement, deepen transparency and accountability, and strengthen pharmaceutical price regulation will generate substantial benefits across the health system. 34Miller S and JM Belizán (2015), The true cost of maternal death: individual tragedy impacts family, community and nations. Reprod Health. 2015; 12: 56 108 The World Bank Primary Health Care Quality Improvement Program (P167598) Increased efficiency in health spending 50. In principle, efficiency in health spending will be achieved through multiple channels. The biggest gains are likely to come from optimizing of service delivery - in particular, shifting management of conditions amenable to primary care out of the hospital sector. Efficiency should also be improved by revising primary care payment mechanisms and linking payment more explicitly to the outcomes of care. Revising the SGBP and ADP based on cost-effectiveness considerations will improve the technical and allocative efficiency of government spending, in particular by drawing on international best practice and evidence to support the design of more accessible and efficient packages of care (making the HbA1c test more widely available, for example) and promote the use of generic drugs. Expanding the SGBP and ADP also supports allocative efficiency, by reducing the number of patients paying for services through OOP or informal payments. 51. Finally, improving the quality of care over the long run (by improving the reporting and analysis of health care quality indicators, establishing a national quality monitoring and improvement agency, and strengthening continuing medical education) can be expected to generate savings through better prevention and management of maternity and NCDs, thus avoiding complications. 52. Not all of these anticipated pathways can be quantified. What follows, therefore, is limited to the most important and relevant empirical literature that can guide estimation of the efficiency of this PforR. Efficiency gained by shifting chronic disease management from the hospital sector to primary care 53. There is substantial international evidence that strengthening primary care and reducing dependency on the hospital sector is more efficient for the health system35. Figure A3.1, (“Program- based budgets for the health sector”) shows that half the current government spending on health is directed to hospitals and around a quarter to primary care. This is a typical pattern for less developed health systems. It is not typical, however, for more advanced health systems that have reinvested such that most routine care for maternity and NCD gets provided by a comprehensive and proactive primary care sector. The economic benefit of such a reallocation in the Kyrgyz Republic is modelled below. Efficiency gained by expanding benefits covered by SGBP and ADP, and promoting use of generic medications 54. Wider accessibility of medications in primary care offers gains in both efficiency of service delivery and in population health status. The 2013 STEPS survey36 found that only four in ten adults in the Kyrgyz Republic with diagnosed hypertension were taking medication, and only two in ten if undiagnosed hypertension was included. Many reasons are likely to underlie this under-treatment, but 35 WHO, 2018: Building the economic case for primary health care: a scoping review. WHO publishing, Geneva. 36 WHO Regional Office for Europe (2016). Increasing information on noncommunicable disease risk factors in the Region 109 The World Bank Primary Health Care Quality Improvement Program (P167598) financial barriers are particularly relevant. High out-of-pocket payments for outpatient medicines are the main cause of catastrophic and impoverishing expenditure37, with around 1 in 12 families in the Kyrgyz Republic facing catastrophic health expenditure (defined as more than 15% of household expenditure after food costs) each year38. Paying for treatment for long-term conditions such as hypertension is also problematic for many39. Together, these findings imply that there are substantial health and efficiency gains to be had by widening the accessibility of primary care medications. In addition, the use of generic drugs and centralized procurement has shown to be a big cost saver in other health systems, given that the cost of generic alternatives can be 10% to 90% of the cost of branded drugs. In the EU health care system, the use of generic drugs is estimated to have generated around 25 billion euros of savings each year. Improved health status Improved health status through improved family planning and antenatal care 55. The PforR is will increase the availability and quality of antenatal care, by expanding the provision of iron supplements and folic acid for pregnant women, for example. There is good evidence on the benefit of comprehensive antenatal care on reducing the risk of neonatal complications, the second highest cause of death and disability in the Kyrgyz Republic. A Cochrane Systematic Review40 found that continuous models of antenatal care were associated with reduced risk of preterm birth (relative risk 0.76, 95% CI 0.64 to 0.91) and fetal loss/neonatal death (relative risk 0.84, 95% CI 0.71 to 0.99). Another systematic review and meta-analysis found that enhanced models of antenatal care were associated with a statistically significant 16% reduction in the risk of pre-term birth compared to routine care 41. 56. Regarding maternal outcomes, four studies, one each in Afghanistan, India, Nigeria and Mexico, modelled the health gains of various strategies to reduce maternal mortality 42. All four studies estimated 37 WHO Regional Office for Europe (2016). Long-term trends in the financial burden of health-care seeking in Kyrgyz Republic, 2000–2014; and Pharmaceutical pricing and reimbursement reform in Kyrgyz Republic. 38 WBG, 2014: Kyrgyz Republic: Public Expenditure Review Policy Notes, Health. World Bank Group, Washington D.C. 39 Abdraimova A, Iliasova A, Zurdinova A (2015). Underlying reasons for low levels of seeking medical care in men: policy research document. Bishkek: Health Policy Analysis Center; and Abdraimova A, Urmanbetova A, Borchubaeva G, Azizbekova J (2014). Cost- estimation of medicinal treatment of hypertension in the Kyrgyz Republic with the view of creating possible drug supply mechanisms ensuring free-of charge HTN treatment: policy research paper no. 83. Bishkek: Health Policy Analysis Center. 40 Sandall J, Soltani H, Gates S, Shennan A, Devane D (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. 41 Fernandez Turienzo C, Sandall J, Peacock JL (2016). Models of antenatal care to reduce and prevent preterm birth: a systematic review and meta-analysis BMJ Open 2016;6:e009044. 42 Carvalho N et al (2013), National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan. Health Policy and Planning; Erim D et al (2012), Assessing health and economic outcomes of interventions to reduce pregnancy-related mortality in Nigeria. BMC Public Health2012; Hu D et al (2007). The Costs, Benefits, and Cost-Effectiveness of Interventions to Reduce Maternal Morbidity and Mortality in Mexico; Goldie S et al (2010); Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis. 110 The World Bank Primary Health Care Quality Improvement Program (P167598) that universal pre-natal care would reduce maternal mortality by around 2% in their respective setting. Greater health gains can be achieved by improve family planning, access to safe abortion and access to specialist obstetric services for intrapartum complications. Expansion of these services is estimated to be as cost-effective as childhood immunization or treatment of malaria, tuberculosis, or HIV, with the potential to reduce maternal deaths by 75%. Improved health status through better detection and management of chronic disease 57. Primary care is well-placed to detect and manage NCDs. The economic importance of this is illustrated by the 2013 STEPS survey. The survey, which combines information on individual risk factors (such as blood pressure, cholesterol or smoking status) or history of CVD or diabetes, suggests that almost 1 in 5 adults aged 40–64 years in the Kyrgyz Republic have a probability of 30% or higher of having a fatal or nonfatal cardiovascular event such as a stroke or a heart attack within 10 years. 58. Stronger primary care is critical to meeting this challenge. The Public Health Interventions Cost- effectiveness Database, hosted by the National Institute for Health and Clinical Excellence in the United Kingdom (http://www.crd.york.ac.uk/CMS2Web/), finds that many primary care interventions are highly cost-effective in tackling risk factors such as overweight/obesity, lack of physical activity, or smoking. 59. More detailed estimations, specific to the Kyrgyz Republic , of the cost-effectiveness of interventions to manage or prevent heart attack, stroke or congestive heart failure in both primary and secondary care43 found that most cost-effective interventions were the followings, many of which directly reflect the PforR’s activities: (a) educating people about the benefits of quitting smoking and reducing blood cholesterol level and daily salt intake through mass-media campaigns (b) providing appropriate hypertension-lowering drug treatment to individuals whose systolic blood pressure is over 160 (c) providing aspirin during the acute phase of AMI (d) providing beta blockers, aspirin and angiotensin-converting enzyme inhibitors during the post- acute phase of AMI (e) providing aspirin during the post-acute phase of ischaemic stroke (f) providing diuretics for congestive heart failure (g) providing cardiac rehabilitation for all three conditions. Cost-benefit analysis 43Akkazieva B, Chisholm D, Akunov N, Jakab M (2009). The health effects and costs of the interventions to control cardiovascular diseases in Kyrgyz Republic: policy research paper no. 60. Bishkek: Health Policy Analysis Center . 111 The World Bank Primary Health Care Quality Improvement Program (P167598) 60. This section compares the economic costs and benefits of the PforR and estimates whether it is a worthwhile investment for the Bank and the GoKR. 61. It is not possible to quantify all economic benefits potentially generated by the PforR. The economic analysis, therefore, focuses on two areas: (a) efficiency gains from shifting care for NCDs from hospitals to primary care (b) health gains from better prevention or management of conditions within primary care 62. These two analyses are then combined to give a single net present value (NPV) of the proposed PforR investment. 63. The analyses use quantitative information obtained from an extensive literature review. It also relies on several assumptions, in line with previous economic analyses conducted for World Bank projects in the health sector. The cost-benefits were calculated for a 15-year period (2020-2034) using three scenarios (default, lower impact and higher impact). Financial costs (Program costs) and financial savings (from Program interventions) were discounted at 8% to account for future inflation (around 5% according to IMF projections) and the time value of money (set at 3%). 64. The costs of the PforR are considered investment costs and inclusive of both IDA funding and Joint Financiers’ funding (US$37.0 million) plus counterpart GoKR investment (estimated at US$377.18 million). IDA and Joint Financiers’ funding is assumed to be distributed in the tranches specified in Annex 2, as if all DLIs were achieved as specified over the five years of the PforR. For the purpose of the cost- benefit analysis, costs are split 50:50 between arms A and B. 65. For the cost-benefit analysis of the efficiency gains realized by shifting care out of hospitals into a strengthened primary care sector, spending figures on the delivery of hospital services (8999.1mn som; 50.8% total public expenditure on health) and on the delivery of primary care (4887.1mn som; 27.6% total public expenditure on health) were taken from Figure A3.1 “Program-based budgets for the health sector” earlier in the PAD. It was assumed that total public expenditure on health will increase by 3% a year (the projected growth, 2018-2021). Against this background, it was assumed that the share directed towards hospitals will steadily fall to 45.9% under the default scenario by the end of the PforR, and to 35.6% by 2034, and that the share directed towards primary care will steadily increase to 29.9% under the default scenario by the end of the PforR, and to 36.4% by 2034. These trajectories align with those seen in OECD health systems. 66. For the cost-benefit analysis of the gain in health status through strengthened primary care , the monetary value of health gains is calculated based on the potential reductions in disability adjusted life years (DALYs) of conditions amenable to primary care (such as maternity care, non-communicable disease, vaccine-preventable diseases, as well as some others such as TB, respiratory, skin and gastrointestinal infection). DALYs for the Kyrgyz Republic were obtained from the Institute for Health Metrics and 112 The World Bank Primary Health Care Quality Improvement Program (P167598) Evaluation Global Burden of Disease Study for 2016 and were projected until 2033 based on historical trends. The maximum reduction in DALYs attributable to the strengthening of the primary care services was set at 2.5%. In the default and low scenarios, each DALY was valued at GDP per capita ($1,254 in 2018). In the higher impact scenario, we assigned each DALY a value of three times per capita GDP as commonly used in the literature on cost-benefit analysis (Disease Control Priorities; Copenhagen Consensus). The monetary value of the future stream of health benefits (annual DALYs averted) is discounted at 3% based on the recommendations outlined by the WHO and the Disease Control Priorities Project. In the low scenario, the discount rate is set at 5%. Table A3.10. Key inputs and assumptions used for the cost-benefit analysis Key Inputs DEFAULT SCENARIO Sensitivity Analysis Low scenario High Scenario Monetary value of DALY 1 x GDP per capita 1 x GDP per capita 3 x GDP per capita Discount rate of the 3% 5% 3% monetary value of future health benefits Basic discount rate 8% 8% 8% (5% inflation; 3% time-value of money) Annual decrease in hospital 2.5% 2% 2% spending: Annual increase in primary 2% 1.5% 3% care spending: Reduction in DALYs related to Up to 2.5% Up to 2% Up to 3% primary care Results 67. Cost-benefit analysis of the efficiency gains realized by shifting care out of hospitals into a strengthened primary care sector finds that, under the default scenario, the benefit cost ratio is 2.46, with a net present value (NPV) of $67.28 million. Cost-benefit analysis of the gain in health status through strengthened primary care finds that, under the default scenario, benefit cost ratio is 1.47 with an NPV of $149.17 million. 68. Combining the two analyses, NPV of the PforR as a whole is estimated to be $216.4 million. The combined benefit-cost ratio for the PforR is estimated to be 1.97 and the internal rate of return 4%. Table A3.11. The economic benefit of the Program Lower impact Higher impact Default Scenario Scenario Scenario Combined gain in Benefit cost ratio (BCR) 1.97 1.76 2.59 113 The World Bank Primary Health Care Quality Improvement Program (P167598) efficiency and in Internal rate of return (IRR) 4% 1.5% 8% health status Net present value (NPV) $ 216,449,000 $ 135,570,000 $ 369,447,000 ANNEX 4. FIDUCIARY SYSTEMS ASSESSMENT SUMMARY COUNTRY: Kyrgyz Republic Primary Health Care Quality Improvement Program 1. The fiduciary systems assessment (hereinafter referred to as FSA) has been carried out in accordance with the Bank Policy Program-for-Results 44 and the Bank Directive Program-for-Results,45 to determine whether the Program fiduciary (procurement and financial management) systems and governance framework are adequate to support the implementation of the proposed Primary Health Care Quality Improvement Program (hereinafter referred to as the Program). The findings of the FSA conclude that the Program fiduciary systems, in general, are adequate to support the Program and provide overall reasonable assurance that the Program financing proceeds will be used for intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability, subject to implementation of fiduciary actions as defined in the Program Action Plan. 2. The Program’s Fiduciary risk rating is High. The analysis took into consideration the latest Public Expenditure and Financial Accountability Assessment (PEFA 2014), the Bank’s recent assessment of the National Procurement Procedures carried out as part of the implementation of the Bank’s Regulations, the Bank’s knowledge of the health sector, reviews of internal and external audit reports as well as the results of field visits implemented within the assessment frames. The assessment also builds on the lessons from the implementation of the currently ongoing Kyrgyz Second Health and Social Protection project46 (hereinafter referred to as SWAp-2). 3. Several financial management risks were identified during the review, and these include but are not limited to: (i) shortages of human resources and limited capacities for key FM functions in the sector; (ii) weak internal controls, particularly at PHC facility level; (iii) delayed availability of funds for spending at the beginning of the fiscal year. 4. Procurement risks identified include: (i) lack of sustainability of the complaint review mechanism, (ii) weak contract management practice. (iii) conflict of interests between procurement and payment functions (iv) lack of procurement capacity (v) restricted competition due to difficulties of the foreign pharmaceutical companies to participate in tender process, and (vi) payment delays in PHC facilities. 5. The scope of the FSA covers the Program institutional framework, fiduciary capacity and implementation performance, and institutions and systems responsible for governance and anti- corruption aspects within the Program. The FSA, within the context of reviewing the performance of institutions responsible for implementing and management program expenditures, included a sample of eleven PHC facilities to review their fiduciary management capacity. 44 November 10, 2017 45 March 2, 2018 46 P126278 114 The World Bank Primary Health Care Quality Improvement Program (P167598) Planning and Budgeting 6. The assessment confirmed that the Program budgeted expenditures, in general, are prepared with due regard to relevant government policies and will be executed overall in an orderly and predictable manner. The Program will be reflected in the republican and MHIF budgets after the Program effectiveness. The country’s budget system includes republican budget, local governance budgets, Social Fund budget and the budget of MHIF.47 The latter mostly consists of allocations from the republican budget, which is the largest part (around 75%), and the Social Fund budget transfers (around 16% - Data Source: The MHIF FY2019 Budget Law). The budget also includes revenue from for-fee state services, co- pay from population, sales of non-mandatory health insurances and transfers from international organizations. 7. The expectation that the required resources for the Program will be appropriated in the fiscal years, in general, is reasonable given overall adequate level of budget execution of the republican budget during last several years. The actual expenditure out-turn in total republican budget deviated from the originally approved budget by less than 2% percent between FY2011-2013. Since then though the out-turn rates considerable increased, but remained below 10% for 2014-2017 (specifically, for 2017 – 6.3%, for 2016 – 7.0%, for 2015 – 8.7% and 2014 – 6.5%). While total expenditure remained close to the budget, the composition of the expenditure by functional classification deviated considerably (around 15%) for the period (Data Source: PEFA-2014, and Annual budgets and Financial Statements by Central Treasury and Budget Policy Department of the MoF). 8. For health sector budget, the overall out-turn for funds provided from republican budget was between 3-5% for 2016-2018 fiscal years, with 9-17% for MoH, and less than 5% for MHIF allocated funds (Data Sources: IFR, Audit reports for FY2016-17, MHIF/MoH reports for 2018, see also the data in Technical Assessment). No deviations were observed with relation of funding of the MHIF from Social Fund budget for FY2015-17 (Data Source: Social Funds budget execution reports for FY2015-2017). 9. Starting 2018, funds annually allocated to MHIF are governed under a separate law on MHIF Budget, which specifies that any remaining year-end balance at the MHIF accounts, unlike for other government budget holders, would be carried forward to be spent in the next fiscal year. This is an important mechanism for reducing the risk of arears in the Program at least on MHIF side (to be allocated to PHCs), which will be responsible for major part of the Program funds (around 88% - See Table 4.1 below). 10. The planning and budgeting capacity at both the MoH and the MHIF is relatively better than in other government bodies, which also is expressed by the fact that the MoH has been chosen to be one of two pilots (together with the Ministry of Transport and Roads) to implement program-based budgeting (PBB) in parallel with conventional budgeting. The piloting of full cycle of PBB for two ministries including the MoH has started from January 1, 2019. In the meantime, there is still a need for enhancing capacity at the MoH to cope with challenges with introduction of PBB. Given that 2019 will be the first year of piloting for the sector, the expectation is that the learning curve will improve during subsequent years 47 MHIF has a separate budget law starting 2018 115 The World Bank Primary Health Care Quality Improvement Program (P167598) when relevant experience and knowledge is accumulated. The Bank, within the ongoing Second Capacity Building in PFM project, plans to provide necessary support in strengthening the PBB process and legal framework, improving training materials and conduction of training to the MoF, and line ministries. The support will also include the review of functional requirements on development of information system for PBB planning process, midterm and annual budget planning. 11. It was agreed that the Program funds will be reflected in the republican budget under separate functional classification for the MoH and MHIF. The MoH will prepare a detailed implementation plan based on the indicated disbursement schedule to ensure that the approved budget incorporates the annual planned DLI disbursements. During the formation of the subsequent year’s republican budget (as per the budget calendar), the expected amounts of cash flow under the Program will be reflected in the income and expenditure parts of the republican budget. The budget would later be revised in case of unavailability of some part of the Program funds during the year. 12. Procurement Planning. There is overall acceptable procurement planning capacity at the MoH. In general majority of PCH facilities have acceptable procurement planning capacity, however in certain PCH facilities there is a lack of certified procurement specialists, while in some other the procurement function is carried over by accountants. The MHIF has no role in procurement planning for the health sector. Funds for the public procurement contracts are secured from the state budget. An annual procurement plan is prepared on the basis of the annual budget of MoH. All procurement entities prepare procurement plans separately (decentralized). The MoH issues an Order with which the annual procurement plan is approved. In preparing the procurement plan, the MoH collects information with regard to the needs of the various departments within the MoH and also from the various health institutions (state and county hospitals, primary health care departments etc.). It contains information in line with the requirements of the Public Procurement Law, i.e., including the subject matter of procurement and its reference number, estimated value, type of public procurement procedure, including the procedure for awarding of a public service contract, as relevant, information if the public procurement procedure would result in a public procurement contract. The procurement plan is published on the Public Procurement Portal of the MoF immediately after the Order for it is issued, and it is also sent to the Public Procurement Department under the MoF. Only after the budget funds are allocated, the PHC facilities can commence the procurement process. 116 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A4.1. Program Expenditure Framework (2020-2024 total) Estimated Expenditures % Proportion of for 2020-2024 Expenditures Financing In thousand In thousand USD Between the sources KGS equivalent48 MoH and MHIF TOTAL Government funds, of which 26,327,394 377,183 100% to be allocated to the MoH 2,040,918 29,240 8% Government to be allocated to MHIF 24,286,476 347,944 92% TOTAL Donor funds, of which 2,582,600 37,000 100% to be allocated to the MoH 1,413,450 20,250 55% IDA, MDTF to be allocated to MHIF 1,169,150 16,750 45% TOTAL Government and Donor Funds, of which 28,909,994 414,183 100% to be allocated to the MoH 3,454,368 49,490 12% to be allocated to MHIF 25,455,626 364,693 88% Broken down by years (in thousand KGS) – Total Government and Donor funds 2020 2021 2022 2023 2024 Total The MoH 677,813 732,482 827,964 571,304 644,805 3,454,368 MHIF 4,769,793 4,901,979 5,214,876 5,148,522 5,420,456 25,455,626 TOTAL 5,447,606 5,634,461 6,042,840 5,719,826 6,065,261 28,909,994 Broken down by major economic classification (in thousand KGS) - Total Government and Donor funds Expenditure type MoH MHIF Total % share Salary and social payments 2,027,357 19,412,460 21,439,818 74.2% Goods and services (except audit and IVA) 1,297,516 5,002,031 6,299,546 21.8% Other (such as investments in fixed assets) 94,595 1,041,135 1,135,731 3.9% Audit and IVA services 34,900 - 34,900 0.1% TOTAL 3,454,368 25,455,626 28,909,994 Expenditure economic classification at PHC level % Expenditure economic classification at PHC level % 2111 Salary 64.01% 2223 Purchase, sewing and repair of uniform 0.08% 2121 Social payments 10.34% 2224 Purchase of coal and other type of fuel 0.81% 2211 Travel 0.67% 2225 Security Services 0.04% 2212 Communication expenses 0.26% 2226 Bank fees 0.02% 2213 Rental expenses 0.05% 2231 Utility fees 3.89% 2214 Transportation expenses 1.62% 2235 Other utility fees 0.01% 2215 Other goods and services 1.81% 2721 Humanitarian support to population 0.00% 2217 Drugs and medical services 5.82% 2823 Legal fees 0.01% 2218 Food 0.84% 3111 Buildings and constructions 0.50% 2221 Repair expenses 2.45% 3112 Machinery and equipment 3.66% 2222 Inventory for administrative purposes 3.11% TOTAL 100.00% Data Source: the MoH and MHIF 13. Major part of the Program will finance salary payments (including statutory tax and social payments). The Program will also finance minor repairs and renovation, goods contracts, which will include pharmaceuticals, medical equipment, various consumables and materials, as well as consultancy services including audit and verification. The procurement activities to be undertaken under the program 48 This assumes an exchange rate of 69.8 Kyrgyz som for 1 US$. This rate is used by the Kyrgyz Government for 2019 budget as stated in the Explanatory Note to the Budget. 117 The World Bank Primary Health Care Quality Improvement Program (P167598) will be noncomplex low value activities below the OPRC thresholds. Based on conducted procurement analysis for 2016-2017, procurement packages at PHC facilities did not exceed US$700 thousand equivalent. The total amount of all public procurement at PHC facilities level was 911,314,005 KGS (or around US$13 mln) in 2016 and 848,371,582 KGS (or around US$12mln equivalent) in 2017 (Data Source: e-Portal). Budget Execution 14. Treasury Management and Funds Flow. The government operates a treasury system with a Treasury Single Account (TSA) of the Ministry of Finance (the MoF) maintained at the National Bank of the Kyrgyz Republic (NBKR). The NBKR maintains overall adequate operational control over its exchange reserve management. The NBKR has established safeguards in financial reporting and external and internal audits, meanwhile it continues having vulnerabilities in the legal structure, particularly in governance arrangements; the audit committee's authority remains limited, and the NBKR Board is comprised only of executive members (Source: the IMF Staff Country Report - 2018). 15. The State Treasury implements an overall adequate control system, including commitment controls, application of automated transaction processing system and use of TSA, which, in general is adequate for the Program implementation. Cash planning and monitoring has been considerably facilitated by the automated information system - Kazna treasury software, in which all expenditure and revenue are registered as transactions take place, and which prevents the execution of any payment which is not provided for in the budget. However, there is no integrated Treasury Management Information System (TMIS) at the treasury system. While there were several attempts to implement the system during past several years, this has not been done and there is still uncertainty about the authorities’ intentions in regards of implementation of the TMIS system. 16. The MoF initiated the introduction of PBB classification to the Treasury automated system. Relevant IT system functionality for budget execution was developed, and from January 1, 2019, program classification of expenditures is being piloted to be introduced to the automated informational system of budget implementation “IS: Kazna, treasury software” for central government’s ministries and agencies. The central government’s ministries and agencies will be able to fully use the program classification as well as economical, functional and administrative classifications during budget execution, as the system will allow forming reports on actual budget expenditures by budget programs and measures. 17. The Program will rely on the country treasury system, and the Program’s IDA and MDTF funds will be disbursed upon achievement of the DLIs. For details of the funds flow and disbursement arrangements are under the Program refer to Funds Flow and Disbursements Arrangements. 18. The major risk for the Program implementation would be the ability of the treasury to release necessary level of funding for the Project implementation at the beginning of a fiscal year. Recently significant underfunding of the sector was observed for January-February 2019 for MHIF and the MoF funds (Table A4.2), which was sufficient to cover only "protected" category of expenditure (such as salaries, transfers to the social fund). 118 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A4.2. Republican Budget Funding Release Date for Health Sector (in million KGS) MoH MHIF Periods Budget Actual Budget Release % Budget Actual Budget Release % January 202.7 151.0 -25.5% 904.4 633.1 -30.0% 2019 February Not available Not available - 904.4 723.5 -20.0% Quarter1 425.3 343.0 -19.3% 2,537.9 2,537.9 0.0% Quarter2 618.0 549.6 -11.1% 2,537.9 2,537.9 0.0% 2018 Quarter3 628.1 497.7 -20.8% 2,605.9 2,605.9 0.0% Quarter4 1,234.0 1,025.9 -16.9% 2,884.9 2,784.9 -3.5% TOTAL 2,905.4 2,416.2 -16.8% 10,566.7 10,466.7 -0.9% Quarter1 424.5 417.5 -1.6% 1,779.0 1,756.1 -1.3% Quarter2 728.6 596.3 -18.2% 2,641.2 2,664.4 0.9% 2017 Quarter3 736.7 573.1 -22.2% 2,470.4 2,470.1 0.0% Quarter4 1,064.7 884.6 -16.9% 2,670.4 2,589.2 -3.0% TOTAL 2,954.5 2,471.5 -16.3% 9,561.0 9,479.8 -0.8% Quarter1 703.5 427.3 -39.3% 1758.3 1799.0 2.3% Quarter2 766.2 686.0 -10.5% 1852.2 1815.7 -2.0% 2016 Quarter3 569.8 409.1 -28.2% 2202.1 2363.5 7.3% Quarter4 619.9 946.8 52.7% 2722.8 2553.3 -6.2% TOTAL 2659.3 2469.2 -7.2% 8535.4 8531.5 0.0% Source of data: MoH and MHIF 19. Accounting and Financial Reporting: The FSA confirmed that, while in general, the accounting and financial reporting systems of the MoH, MHIF and PHC facilities are adequate with adequate records to be maintained for the Program, the major risk to the accounting and financial reporting systems is the staff low capacity and high turnover. 20. The 2014 PEFA notes that accounting and reporting system in the country still needs to be improved. At the central level detailed monthly budget execution reports are produced by the State Treasury that are compatible with the budget estimates, administratively, economically and functionally but as yet not programmatically. As explained in the above section, the MoF takes necessary steps to improve the system for allowing PBB classification. The reports capture expenditure at the payments stage but not at the commitment stage. Monthly and quarterly in-year budget reports are prepared timely. The Treasury produces also an annual set of financial statements, which are submitted for audit within five months of the end of the financial year as required by the legislation. 21. Public sector accounting and financial reporting is based on the MoF approved respective instruction and manual issued in 2014 with latest update in December 2018. Despite the efforts of the government, the full implementation of national accounting standards in public sector (Kyrgyz Republic Public Sector Accounting Standards - KRPSAS) based on International Public-Sector Accounting Standards (IPSAS), still requires investing substantial resources, in particular, for training and retaining the experienced accounting staff. 22. In the course of the implementation of SWAp2 project, significant resources have been invested for developing accounting and financial reporting systems at PHC facility level. The systems at local level are automated, and all health facilities have installed 1C accounting software, which has major accounting modules such as general ledger, accounts payable and receivable, warehouse (for medications, food, 119 The World Bank Primary Health Care Quality Improvement Program (P167598) payroll), human resources, non-current asset register, etc. The maintenance of the accounting and financial reporting systems at PHC facility level is reliant on a number of accounting and IT support consultants currently being financed under SWAp-2 Project. These consultants provide critical support to the sector’s accounting and financial reporting system by providing timely updates to the accounting software at each PHC facility as well as providing hand on training to the PHC facilities’ accounting staff on any changes in the legislative requirements and reporting forms. As of September 2018, the MoH monitoring indicated the following statistics on the use of the accounting software by health facilities: only 64% of them fully utilize the accounting software, with 3% not using it at all, while the rest is using the software only partially. In addition, only 47% of the accounting staff of health facilities has certification in 1C software (Data Source: the MoH monitoring report). Therefore, given the low capacity and high turnover of the accounting staff at PHC facilities and the MoH, the MoH should ensure that the required minimal level of critical support by the consultants to the system is maintained. Specifically, the MoH should ensure that two consultants at the MoH for FM/Disbursement function, as well as two consultants (accounting and IT support) in the central level for MoH will be retained. Additionally, the relevant staff of the MHIF regional departments will be supported by the IT and accounting consultants at central level and will be responsible for providing support to PHC accounting staff for the upgrade on the 1C accounting software as well as accounting/financial reporting policies, procedures and reporting formats. 23. For purposes of the Program accounting and financial reporting, the Bank will rely on the existing government accounting and financial reporting arrangements, and the MoH will be responsible for submission of Program annual audited financial statements to the Bank. The Program annual financial statements to be audited will be consolidated by the MoH based on inputs provided by MHIF, and will include: (i) a summary of Program funds received (separately indicating those received under each DLIs) and a summary of Program Expenditures under the Program headings, both for the current fiscal year and accumulated to-date; and (ii) Notes, comprising a summary of significant accounting policies and other explanatory notes. 24. Modified cash basis accounting is used in the health sector, with 1C accounting software installed at each PHC facility. However, as indicated above, there are still cases observed when the software is not fully utilized due to lack of sufficient software skills and high turnover of the accounting staff due to low salary level. In particular, due to lack of sufficient knowledge, the accounting staff of some PHC facilities are not aware of the full functionality of the accounting software. The preparation and submission of the financial reports was made without the use of electronic submission through the 1C system but manually with the help of consultants and the staff at the territorial departments of the MHIF. Also, there is a risk of unauthorized access to 1C accounting software due to lack of individual passwords to the system, use of unofficial mail servers for official communication, were observed (Source: External and Internal Audit reports). 25. Procurement Processes and Procedures: The legislative and regulatory framework of Kyrgyz Republic is generally comprehensive and relying on competitive bidding as its default method of procurement. There are different methods of procurement and their conditions of use are outlined in the Public Procurement Law (PPL) enacted in April 2015, which are generally aligned with international good practice, including UNCITRAL Model Law on Procurement, that can be used for goods, works, services and consulting services. The PPL represents the following features: 120 The World Bank Primary Health Care Quality Improvement Program (P167598)  Establishes Independent Complaint Review Commission (ICRC),  Allows challenges in procurement planning, procurement method to contract award,  Mandates publication of intent to go for Direct Contracting,  Introduces modern procurement methods such as Framework Agreement and e-reverse auction,  Mandates development and use of standard bidding documents,  Does not permit splitting of requirements with a view to avoiding competitive procedures,  Requires establishment of the clear criteria for rejecting a bidder from the bidding process,  Introduces the anti-bribery clause, violation of which is among the criteria for inclusion into the database of unreliable suppliers and prohibits bidding that is not included in the procurement plan. 26. Since May 14, 2015, all Public Procurements in Kyrgyz Republic have been done electronically, which means a complete transition to e-Procurement. The official e-Portal is in operation and a single uniform system of Public Procurement has been created. The introduction of the e-Portal helped to ensure transparency, openness and public access to information on the opening of the bids, procurement procedures and competitive award of contracts. The conditions for suppliers and contractors have also been made uniform, and any party registered on the e-Portal can participate in a tender announced on the e-Portal, on equal footing with all others, except when domestic preference is used. 27. Standard bidding documents exist for goods, works. consulting and non-consulting services and secondary legislation are available on the e-Portal to all procuring entities and suppliers and contractors. The guidelines available on the e-Portal are comprehensive covering many elements of the procurement life cycle as detailed in the following table. Table A4.3. Guidelines available on the e-Portal Topic Document Law Procurement in Government organizations, State-Owned Enterprises (SOEs) and Open Joint Stock Companies with Government share more than 51% Code of administrative offences Procurement from societies/organizations of disabled people Secondary Regulations on Government Procurement Department legislation Regulations for centralized procurement Threshold regulations Regulations on how to implement the Law on Procurement from societies/organizations of disabled people Decree on accumulation of savings from procurement Regulations of procurements in national security, defense and state secrets. Orders of the Regulations of e-Procurement for Government entities Ministry of Finance Instructions how to apply domestic preferences in procurement Instructions how to evaluate the bids Instruction for Framework (long-term) contracts SPD’s for Single Stage, Two Stage and Simplified Acquisition Order of the Ministry on the establishment of Independent complaints review committee Guidance on reverse method of procurement Guidance on consultant selection 121 The World Bank Primary Health Care Quality Improvement Program (P167598) Topic Document Program of improvement of Government procurement system Templates for Instruction on bidding documents, advertisement and publishing the results of tenders procurement Template for procurement report planning and other Description and volume of goods produced by society/organizations of disabled people aspects 28. Information pertaining to Public Procurement can be found on the Public Procurement Departments (PPD) e-Portal.49 The web portal is in Russian, Kyrgyz and English (limited coverage). For transparency in Public Procurement in Kyrgyz Republic and to enable open competition, all procurement opportunities must be advertised on the e-Portal and any questions received through the procurement process must be shared with all bidders through the Portal and within a timely manner. The procurement of goods, works and services must be performed using one of the following methods. Table A4.4 Methods used for procurement of goods, works, and services Method Description Single Stage Bidding The key Public Procurement method under the PPL. The number of suppliers/contractor is not limited. Two Stage Bidding The first stage invites bidders to submit initial bids containing their proposals without specifying the bid price. The second stage the procuring entity invites all bidders who didn’t have their initial bid rejected to submit their final bids with specification of prices based on the revised procurement terms. Simplified Simplified acquisition method is used when procuring finished products that do not require Acquisition special manufacturing, as well as works and services with specific description valued less than the thresholds. To ensure competition bids must be considered from at least two contractors. The successful bid shall be an eligible bid with the lowest price that meets the needs of procuring entity. Reverse Auction Procuring entities may conduct electronic Reverse Auction for the procurement of goods and services if such goods and services have established standards of quality and a specific description of services. There must be at least three suppliers to ensure efficient competition. Direct Contracting Direct contracting enables the procuring entity to sign a contract with one supplier after the monitoring of prices. Within two days prior to the Direct Contracting the procuring entity shall publish on the e-Portal information about the procurement. The procuring entity may also Direct Contracting if the additional procurement of goods not exceeding 15% of the awarded contract price or if additional construction works or services do not exceed 25% of original contract price of a contract. 29. While the PPL adopted in 2015 was in line with good international practices, the Government initiated revisions of PPL soon after effectiveness. Amendments to the PPL were signed by the President of KR in January 2019. There amendments did not include any major changes impacting procuring entities and private sector. 49 http://zakupki.gov.kg/popp/home.xhtml 122 The World Bank Primary Health Care Quality Improvement Program (P167598) 30. Preparation of tender documents and technical specifications. The persons involved in the preparation of the specifications are medical doctors and other various experts, depending on the material(s) to be tendered. The preparation of technical specifications and the tender documents is a lengthy process and often takes significant time to accumulate basic information, as it involves numerous consultations with the public institutions for which the joint procurement is conducted, with the business community, and a consultative group comprising various ministries and institutions. The tender documents, including technical specifications are prepared in-house. The technical experts that have prepared the technical specifications usually participate later on in the evaluation process. 31. Opening and evaluation of bids. Tenders are opened in public and minutes of public opening are prepared in a form and content as defined in the above referenced Regulation. A copy of the minutes is made available to all authorized representatives of the tenderers. Evaluation is done in accordance with the evaluation and qualification criteria in the tender documents and is carried out by an evaluation committee. 32. Public Procurement Capacity Building. The Training Centre (TC) of the MoF delivers, on a regular basis, a five-day introductory course on management of public procurement of goods, works and services. In addition to five-day training a two-week advanced course (face-to-face) is offered. And an online version of the introductory course is available on the TC’s website. Certificates are issued for the training. Because Internet connectivity is still unavailable in remote villages, the training course is also distributed in a CDs version. The CD version is to assure that local MoF offices and municipalities as well public organizations have access to the course anytime/anywhere. Mandatory certification is required for conducting public procurement. 33. e-Portal. The introduction of the Governments e-Portal has strengthened the transparency of Public Procurement in Kyrgyz Republic. It has also made the procurement process more effective and efficient. For the moment e-Portal is missing functionality to support selection of consultants and procurement of specialized goods (pharmaceuticals), but actions to fulfil this gap are ongoing and shall be completed by the end of 2019. 34. Eligibility. Open eligibility applies and registration of bidders to the e-Portal does not seem to pose a barrier to participation. The use of domestic preference applies but is used in less than 1% of procurements. Recently prepared amendments to PPL propose mandatory use of domestic preference. In addition, there are difficulties for foreign pharmaceutical companies to participate in tender process. According the local legislation (Law #165 dated August 2, 2017 “On pharmaceuticals” of the Kyrgyz Republic) the foreign pharmaceutical companies should be registered in the License Department of the MoH before participation in a tender. In 2017 and 2018, 11621 tenders were conducted by health procurement entities in the country. Only one foreign company registered before tender. This confirmed that there is no attraction for foreign companies to register before awarding the contract. It is necessary to allow for foreign pharmaceutical companies to participate in tender process, while the bidder is starting in parallel the registration with the License Department (14 days). In case such bidder is recommended for contract award, the License Department of the MoH will have to register the bidders firm in 21 days. All above mentioned conditions only applicable for Stringent Regulatory Authorities countries, Regulator Countries and suppliers of pre-qualificator pharmaceuticals according Decree #405 of the Government of the Kyrgyz Republic dated August 28, 2018. For other countries, duration of registration about 90 days. 123 The World Bank Primary Health Care Quality Improvement Program (P167598) 35. Complaints Handling Mechanism: On October 14, 2015 the MoF approved the regulation on the procedures of the ICRC. The ICRC was established six months later in March 2016 with a mandate to ensure fair resolution of any procurement related complaints. Unreliable suppliers can be included for non-fulfilment of their contractual obligations, and for violation of the rules of participation in the PPL by the ICRC. Currently complaints are reviewed by a panel of experts who have completed the mandatory procurement training. When a complaint is received an automated computer program randomly selects one expert from each of the three groups to review and decide on the complaint. The selected member from each group reviews the complaint and any accompanying documentation online and required to submit their response through the e-Portal and the use of e-signatures will be implemented subject to the approval of the PPD’s development plan and appropriate funding. 36. The PPL includes a standstill period between notification to award the contract and contract signature. The standstill period for Simplified Acquisition is two (2) working days and for Single/Two Stage is seven (7) working days. The PPD are looking at options so that when a complaint is received, the e- Portal automatically stops the procurement process and locks the system so that access isn’t given to the procurement process that a complaint has been received until the complaint has been reviewed by the ICRC. While existing complaints review mechanism is sufficient, there is risk of sustainability/quality of complaint review due to the fact that penal of experts is working on voluntary basis. Conducted analysis showed that in the health sector 147 complaints were received by ICRC during the year of 2018. Review period in 54% (80 complaints) was more than 10 days while PPL requires that review is conducted within 7 days (Data Source: e-Portal). 37. Database of the unreliable contractors and suppliers. The PPL has provisions to blacklist poor performing suppliers and contractors. If a blacklisted contractor or supplier feels they have been unfairly blacklisted, they can present their case to the ICRC for independent review. If the ICRC upholds the blacklisting, the contractor or supplier still has the rights to take their case to court. The modules for online filing of complaints and for publication of decisions on the e-Portal have been developed, tested and launched. In accordance with Articles 9 and 49 of the PPL the decisions of the ICRC for review of complaints are posted on the e-Portal. Despite of obvious improvements, sustainability of the complaints review system raises certain concerns because experts are working in this commission on voluntary base. These arrangements do not provide for required professional capacity of the commission. The government should introduce either a small fee for submission of complaints or consider other ways of the experts’ motivation and capacity building. 38. Internal Controls, Contract Management and Internal Audit. The internal control procedures in health sector are regulated by the Budget Code, budget laws, government decrees, ministerial orders and internal instructions of the MoH and the MHIF. The PEFA 2014 founds that the controls over non- salary and salary expenditures still need to be improved. Control over non-salary expenditure is exercised only at the payment/liability stage, and not at the order/commitment stage. Controls over payroll remain weak, with each health facility responsible for its own payroll within aggregate allocations from the MoF and MHIF. 39. The procurement control procedures are defined in the PPL, according to which, if the value of procurement made under one bidding (taking into account the total amount of all lots) exceeds the fivefold ceiling amount, prior to concluding a procurement contract with the bid winner, each procuring 124 The World Bank Primary Health Care Quality Improvement Program (P167598) entity must conduct a procurement audit (to be conducted by Internal Audit department) in order to ascertain the compliance of the procurement with the requirements, established in this Law and other regulations of the Kyrgyz Republic, regulating public procurement. Compliance with the PPL is the responsibility of the PPD and is reviewed by the Chamber of Accounts and Internal Auditors. 40. The Program will largely finance salary payments (including statutory tax and social payments), estimated to be around 75% of the Program expenditures (see Table 4.1 above). Salary and related statutory payments are made via treasury transfers with no use of petty cash. There is overall acceptable level of payroll controls at central, the MoH and MHIF level. Although the sample review of payroll and salary payments at selected eleven PHCs conducted during the assessment did not identify major issues, the level of payroll controls at PCH facility needs to be improved as the internal and external audit reports of on-going Bank-financed projects in health sector identified cases of inaccuracies with payroll calculations (as a result of lack of sufficient knowledge on relevant legislations and regulations), and improper maintenance of timesheets at some health facilities ( Source: External and Internal Audit report). 41. Additionally, the reviews conducted by Internal Audit functions of the MoH, the MHIF and the Chamber of Accounts identified cases of falsified doctors’ qualification certificates (used to obtain additional top-ups to the salary levels), improper application of top-up rates (such as for work experience or improper documentation) and conducting purchase of goods without proper bidding procedures. Some of the above issues are the result of low capacity of the respective staff at PHC facilities, while others indicate a need for enhanced controls. To eliminate such practices, the MoH takes actions such as making online accessible the information regarding the doctors’ qualification issued by training center. Starting the FY2018 end the MHIF implements the result-based incentive payments to PHC’s with the aim to improve the financial situation of PHC facilities and medical staff salary. The MoH has developed specific instructions on the result-based incentive payments, which are overall adequate, however do not include procedures for physical verification of the delivered results (such as contacting patients via phone and verifying the fact of service provision). 42. Another area of concern is improper segregation of duties between procurement and accounting functions at some PHC facilities. As per the MoH monitoring data, as of November 2018, around at 30% of PHC facilities the procurement function is carried out by accounting specialists ( Data Source: MoH monitoring report). The MoH should adopt respective measures to eliminate such a practice by segregating these duties. 43. In general, there are adequate contract management arrangements at the MoH level, with some minimal contract management arrangements in place at PHC facilities, which however need to be improved. PHC facilities have their own systems to monitor the usage of goods and materials. While each PHC facility operates an inventory monitoring system, it is not connected to the general ledger or accounting system. In eleven sample PHC facilities reviewed goods acceptance procedures were not clear and could lead to increased fiduciary risks. 44. There is overall adequate control at the PHC and MHIF level over medication prescription and payment scheme under state guaranteed drug benefit packages. The prescriptions are issued in prenumbered forms in three copies with different colors, one of which is issued to the patient, who based on the prescription gets the necessary medication at participating drug stores. The PHC facility enters the 125 The World Bank Primary Health Care Quality Improvement Program (P167598) prescription information into the MHIF electronic prescription database. The medication cost is reimbursed to drug stores at predetermined rates directly by MHIF, upon the requests received from drug stores and after reconciliation of the payment request with information the electronic prescription database. In the meantime, the registration and distribution scheme at PHC facility level for medication procured locally and to be used in-house at PHC facility should be improved. The in-house procured medication is registered in warehouse module of 1C accounting software, with details indicating the medication name, quantity, price, expiration day, and other details. The medication is distributed as per the per the doctors’ request accompanied with three copies of medication distribution note (one stays at ware house, the other is sent to accounting division, while the third one stays with the recipient). At this level the register and distribution of medications are automated and reflected in the accounting software. However, further distribution of medication to patients is only manually recorded in patients’ medical cards, and there are no any controls exercised to verify that the medication actually was delivered to patients as recorded in books. A sample physical verification for medication distribution to patients should be exercised at PHC facility level. To reduce the above risks, with the support of KfW, internal instructions for acceptance of medical goods have already been developed, and it is expected that the MoH will approve and disseminate the instructions to PHC facilities for execution. Additionally, the MoH and MHIF internal auditors will conduct a sample physical verification of medication distribution to patients. 45. During the fiduciary systems assessment, cases of delayed payments for goods accepted were observed, which were due to unclear payment terms in contracts, not specifying a specific deadline for payments; instead the contract indicates that the payment will be made upon provision of financing from the budget. The MoH should ensure that the contracts specify specific deadlines for payments, which should not exceed 3 months period after goods acceptance, as indicated in PPL. During the assessment, payments under 55 sample contracts at eleven PHCs were reviewed, and it was observed that in only around 55% of payments were made within 90 days of the receipt of goods/services. The rest of the contracts were paid within a period exceeding 90 days, of which seven contracts were paid during the period exceeding 150 days, with one paid on the 339-th day after the delivery ( Data Source: e-Portal). In general, the payable period for such arrears for goods/services is no more than a year. The imposition of a specific payment deadline in contract would significantly improve the payment practice at PHC facilities. 46. The Internal Audit (IA) function in Kyrgyz Republic is gradually gaining more importance and reliance in the public sector. There is overall adequate IA function at both the MoH and the MHIF, while no IA function exists at PHC facility level. In total 12 staff in the sector is involved with the Internal Audit function (the IA unit of the MHIF consists of eight staff, while the IA unit of the MoH has only four staff), making it the largest in the public sector, constituting over 10% of the IA resources in the public sector (Data Source: MoF annual reports on IA function activities). Most of the IA staff has passed local IA qualification exams and participated in a number of accounting, financial reporting and procurement trainings (Data Source: IA staff CVs). 47. The professional qualities of the staff to conduct audits are overall adequate, and the audits are conducted as per annual audit plans and cover health institutions, including PHC facilities with higher risks determined based on the size of the institution’s budget and issues identified during previous years’ audits. It was observed that due to limited number of the IA staff as well as increasing level of requests from other supervisory bodies (such as Chamber of Accounts, Prosecutor’s Office, and other Law 126 The World Bank Primary Health Care Quality Improvement Program (P167598) Enforcement bodies) to assist in their inspections and to conduct special and ad hoc audits, the annual audit plans are underperformed resulting in some health institution not being audited for long periods. In total in 2017 the health sector’s IA function conducted audits of the health facilities with 1,588 staff/day input, of which 544 staff/days input (or around 34% of total input) was provided for special reviews. The latter represents over 27% of total special reviews/investigations in public sector, indicating greater reliance of the law enforcement bodies on the professional qualities of the health sector IA function. In 2018 the use of the law enforcement bodies of the health sector IA function increased to over 38% of total staff/day input by IA function of the health sector. (Data Source: The MoF annual report on IA function activities, the MoH and MHIF IA reports). It is also worthwhile to indicate that the sector’s IA function is among those few in public sector with highest level of follow up and implementation rate for audit recommendations: 653 recommendations out of 703 issued in 2017 (amounting to 93%) and 617 out of 641 issued in 2018 (amounting 96.3%) were implemented during the audit year (Data Source: The MoF annual report on IA function activities, the MoH and MHIF IA reports). 48. To ensure stricter control at PHC facility level, it has been agreed that within the Program, the IA units of the MoH and the MHIF will combine their resources and will conduct joint audits of the PHC facilities, including test of control systems on achievement of results (such as sample based physical verification of service delivery to patients). The annual plans of the IA units of the MoH and MHIF will also include the review of implementation of the activities under the Program. The annual audit plans of the MoH and the MHIF will ensure that each PHC facility is audited at least once in a three-year period, with more regular audits of health institutions with higher risks. During the IA audit, particular attention should be paid to payroll controls at PHC facility level, sample physical verification of medical services delivered to patients, review of control system over medication and drug prescription registration and distribution. The IA units of the MoH and MHIF will agree with the Bank the annual audit plans, terms of reference and the audit scope. Also, the audit reports and findings will be shared with the Bank. 49. Program Governance and Anticorruption. Kyrgyz Republic ranked 132th out of 180 countries according to Transparency International Corruption Perceptions Index 2018 50 representing a slight change since the last year position of 135th. Although there is a quite intense anti-corruption agenda in the country and the current efforts of the Government and the state bodies on setting anti-corruption measures are encouraging, the current system of distribution and coordination of anti-corruption functions is ineffective as the functions are dispersed among too many authorities, when everyone does everything without proper coordination, making it impossible to ensure the necessary level of independence, allocation of resources and specialization of these authorities in accordance with the international standards.51 50. The Law of the Kyrgyz Republic "On National Security Bodies of the Kyrgyz Republic" specifies that the national security bodies of the Kyrgyz Republic combat corruption and carry out operative and investigative activities, inquiries and preliminary investigations of individuals who have committed offences or are suspected of committing them, including through the use of operational, technical and other means, and keep records of these persons. 50 https://www.transparency.org/cpi2018 51 https://www.oecd.org/corruption/acn/OECD-ACN-Kyrgyzstan-4th-Round-Monitoring-Report-2018-ENG.pdf 127 The World Bank Primary Health Care Quality Improvement Program (P167598) 51. In the framework of the State National Security Committee of the Kyrgyz Republic, the Anti- Corruption Service (ACS) was established by the decree of the President of the Kyrgyz Republic. The ACS’s task is to prevent, suppress, identify, and investigate corruption offences, for cases established by the law, against individuals at top political and administrative positions at state and municipal level, staff of law enforcement, judicial and other state and municipal bodies, heads of institutions, organizations which are financed from the state budget or if the state has its stake in. On the other hand, the investigation of criminal cases in the system of national security bodies is carried out by the Main Investigation Department (MID) and investigative units of the regional departments of the State National Security Committee (SNSC) of the Kyrgyz Republic. Both the ACS and the MID are structural subdivisions of the State National Security Council (SNSC) and report to the senior management of SNSC. 52. Another national level body, which is assigned anti-corruption functions is the State Service for Combating Economic Crimes (also called Financial Police), the specific functions of which are defined by the Regulation "On the State Service for Combating Economic Crimes (SSCEC) under the Government of the Kyrgyz Republic," approved by Government Resolution in 2012. Among several tasks of the Financial Police are carrying out investigation and operational search activities, registering, examining applications, reports, incoming materials from state bodies and individuals on crimes committed, being committed or prepared, and also taking timely measures to prevent, disclose, detain persons who committed them. Also, it determines tactics and methods of operative and investigative activities, develops methods to counter economic and official offences, conducting professional training. 53. The Office of the Government coordinates the state bodies’ work to develop and implement state anti-corruption plans, as well as controls the implementation and analyzes the anti-corruption situation in the country and develops improvement measures . The Prosecutor General is responsible for coordination of activities on fighting corruption of law enforcement, fiscal and other state bodies, state administration and local self-government bodies, analyses information on the state of corruption in the country, assesses the effectiveness of the measures taken. 54. At the national level regular coordination meetings are held under the chairmanship of the Prosecutor General with the participation of the Secretary of the Security Council , the Prime Minister/Vice Prime Minister, deputies of the Supreme Council, representatives of the Office of the President, the heads of the Supreme Court, the Chamber of Accounts, ministries and departments. Similar meetings are held by at regional level. 55. An institution of the Commissioner for Preventing Corruption in the State Bodies has also been established. In connection with the introduction of this office there were introduced full-time offices of the Commissioner for Preventing Corruption for 43 state bodies in the Register of the State and Municipal Offices of the Kyrgyz Republic (Decree of the President of the Kyrgyz Republic as of January 31, 2017 No. 17). In some ministries and departments there operate anti-corruption departments (units) with a staffing of 3-4 full-time offices. At the MoH the anti-corruption Commissioner’s unit is functioning relatively recently and is at its premature stage. It has only one staff assigned to this function who is working at this position since October 2018. The main responsibilities of the Commissioner include coordination the MoH activities in combating corruption and developing anti-corruption action plan for fraud and corruption prevention as well as monitoring of implementation of anti-corruption measures. The anti-corruption action plan for such units is approved by the Government, and the reports are approved by SNSC. The 128 The World Bank Primary Health Care Quality Improvement Program (P167598) Commissioner is also responsible for assessing corruption risks in the sector, identifying factors that may create potential for conflict of interest, conducts analysis of the MoH Public Reception Center’s work on registering and addressing complaints received from citizens, as well as monitoring of mass media information on fraud and corruption. The anti-corruption Commissioner represents the main chain linking the MoH and SNSC on fraud and corruption agenda. 56. The MoH Public Reception Center is responsible for registration of and follow up with written and oral appeals of citizens. The Center is guided by the Law of the Kyrgyz Republic No. 8 “Procedure for considering proposals, applications and complaints of citizens” dated July 05, 1995 and other regulatory and legal acts. The main task of the Center is the timely response to complaints of citizens of the Kyrgyz Republic on health issues. The Center employs three specialists, who are responsible for transferring the application for consideration to relevant authorities and taking respective actions or rejecting a complaint (if unjustified) with respective clarification provided. The complains are registered in two books of records (one for personal visits to the Center and the other for complains received via “hot-line” phone at the MoH). Citizens are promptly notified on the results of their complaint. Once a year, the Prosecutor’s Office of the Kyrgyz Republic conducts routine inspection of the registration of complaints and respective measures taken. 57. During 2017, 1871 appeals (1,294 via phone calls and 577 in person appeals) were registered, and during 2018 1766 appeals (1,417 via phone calls and 349 in person appeals). Complaints mostly relate to poor treatment, poor quality of services (such as rudeness and negligence), issues relating to co- payment, poor ambulance work, extortion of money, etc. At year end all complaints have been resolved (or justifications provided for rejected complains), with no pending issues. 58. To address the possible cases of fraud and corruption associated with the Program implementation, the Program will rely on the respective country systems, and the MoH anti-corruption Commissioner will be the responsible staff for the implementation of the Program anti-corruption measures. The Program implementation will be aligned to the Anti-Corruption Guidelines (ACG) applicable to PforR operations, and will include the below measures: 59. Sharing of debarment list of firms and individuals. The Recipient will use the World Bank’s List of Debarred and Cross-Debarred firms and individuals to ensure that persons or entities debarred or suspended by the Bank are not awarded contracts under the Program during the period of such debarment or suspension. The list can be accessed on the World Bank’s website (www.worldbank.org/debarr). The compliance with this requirement would be checked by the Program’s procurement auditor. 60. Sharing of information on fraud and corruption allegations. The Recipient will share with the World Bank information on all complaints and actions taken or being taken on complaints and grievances received on fraud and corruption under the Program. The World Bank will be also informed about the actions and decisions taken by the relevant institutions to address the matter raised in the complaint. The Commissioner for Preventing Corruption located in the MoH will be responsible for collecting this information and sharing with the Bank. 61. Investigation of fraud and corruption allegations. The implementing agencies will provide full support to the country’s anti-corruption agencies and the World Bank when carrying out investigations 129 The World Bank Primary Health Care Quality Improvement Program (P167598) related to fraud and corruption allegations made during the Program implementation. The World Bank will be informed on all credible and material allegations or other indications together with the investigative and other actions that the Recipient proposed to take with respect thereto. The World Bank will retain a right to investigate allegations, and the Recipient will provide the World Bank the necessary access to needed persons and information applicable to the Program. 62. Other pillars of the Program Anti-Corruption system include use of independent auditors/verifiers for the audit/verification of the Program. The auditors will be appointed from the list of auditors acceptable to the Bank. In addition, as it was agreed during the Program assessment, the IA units of the MoH and the MHIF will combine their resources and will conduct joint audits of the PHC facilities. The annual plans of the IA units of the MoH and MHIF will also include the review of implementation of the activities under the Program. 63. Program Auditing. All public-sector entities are subject to oversight by the country’s Supreme Audit Institution (SAI) – the Chamber of Accounts of Kyrgyz Republic. The Chamber of Accounts is responsible for the audit of Government, including Republican and Local Self-Governments (LSG’s) accounts, the MHIF52 and the Social Fund budgets. The Chamber of Accounts annually submits to the Parliament and the President a report of the result of audit of Government revenue and expenditure. Financial, performance and compliance audits are carried out by the Chamber of Accounts who use a defined methodology for auditing accounts, which includes a section on procurement compliance. In 2014, a guidance was developed on Auditing of Public Procurements, which must be used during audits. Audit reports are made public by the Chamber of Accounts on its website (www.esep.kg). 64. During the last several years, with the Bank support, some reforms were initiated to enhance the Chamber of Accounts, particularly in the areas of annual audit planning, compliance and financial audit methodology development, audit workflow automation as well as legislative changes were introduced. However, a progress in the consistent quality of performance and financial audit is yet to be achieved. No audit opinion is issued on the budget execution reports as a whole nor for individual ministries, departments and agencies. In practice, Chamber of Accounts does not consistently follow international auditing standards, despite they have financial and compliance audit methodology developed based on international standards and good practices. Considering the above, the Bank does not rely on the Chamber of Accounts for conducting audits of the Bank-financed projects’ financial statements, and all the financial audits of the projects in the World Bank portfolio in the country are conducted by private auditors acceptable to the Bank. 65. PEFA 2014 assessed PI-26 (i) Scope and nature of audit performed dimension to be scored at “C”, while PI-26 (iii) Evidence of follow-up on audit recommendations is scored at “A”. The latter indicates strong follow up arrangements for implementation of the Chamber of Accounts recommendation. PI-28 (ii) Extent of hearings on key findings undertaken by the legislature and PI-28 (iii) Issuance of recommended actions by the legislature and implementation by the executive dimensions are both rated “B” meaning that there is overall adequate attention paid by parliamentarians to the audit findings, and the Parliament endorses the Chamber of Accounts’ recommendations/prescriptions in a Resolution sent to the Government at the end of its consideration of each annual budget execution report. 52 The latest published audit is for FY2017 is available at http://www.esep.kg/images/docs/2018/09/Otchet_foms2017_ru.pdf 130 The World Bank Primary Health Care Quality Improvement Program (P167598) The implementation of recommendations issued by the Chamber of Accounts is mandatory for the country’s government bodies. 66. While for monitoring purposes the Bank will use the information reflected in the Chamber of Accounts audit reports on the sector, the Program audit arrangements will rely on the existing independent auditing arrangements under the Bank-financed on-going projects implemented by the MoH. By the time of the assessment there were no due audits under those projects, thought delays in the submission were observed for FY2017 audits. 67. The audit of the Program annual financial statements will be conducted (i) by independent private auditors, acceptable to the Bank, on the Terms of Reference acceptable to the Bank and procured by the MoH, and (ii) according to the International Standards on Auditing (ISA) issued by the International Auditing and Assurance Standards Board of the International Federation of Accountants (IFAC). The audited financial statements of the Program will be presented to the Bank within 9 months53 after the end of each reporting period, and at the end of the Program. The Recipient has agreed to disclose the audit reports for the Program within one month of their receipt from the auditors and acceptance by the Bank, by posting the reports on the MoH web sites. Following the Bank's formal receipt of these reports from the Recipient, the Bank will make them publicly available according to World Bank Policy on Access to Information. 68. The audit of the Program procurement will be conducted by independent private firm , including a thorough review of the procedures and processes followed by the procuring entities and the contracts selected for verification. The review of contracts will include (i) an overview of the documentation available in the files of the procuring agencies, (ii) visits to facilities for quality inspection and the number of goods, works and services delivered. Where required, compare prices with similar contracts in the country and region and international market prices for the items of interest. The audit report also will include information about average length of procurement, time for bid evaluation, percent of contracts (by value) awarded on a sole source basis and bidders participation and timeliness of payments. The Program procurement audit will be procured by the MoH, on the terms of reference agreed with the Bank, and the report will be presented to the Bank within 9 months after the end of each reporting period, and at the end of the Program. 69. Procurement and Financial Management Capacity. Within the context of reviewing the performance of institutions responsible for implementing and management of the Program expenditures, the assessment included a sample of eleven PHC facilities to review their fiduciary management capacity. The review found that in some cases the functions of procurement specialists are assigned to PHCs accountants. It is necessary to avoid possible conflict of interests by separating functions of accountants and procurement specialists. Also, there is a lack of procurement capacity as more than half of the procurement specialists from PHC facilities do not have mandatory procurement certificate 53The nine-month submission period for the audited financial statements of the Program is proposed considering the lengthy process of preparation of statutory financial statements, based on which the Program financial statements will be produced, as well as the fact that as per the public procurement regulations, the audit firm selection process can be commenced only after the reporting year is completed and the process itself takes quite long. 131 The World Bank Primary Health Care Quality Improvement Program (P167598) required by PPL. They shall be trained in the Training Center of the MoF or through on-line courses and then shall be certified. 70. Financial management capacity of the whole health sector is also weak. The IT and accounting skills of FM staff of PHC facilities vary from quite developed to very week. As a result, 1C accounting software is not fully used in all PHC facilities. There is significant turnover of FM staff both in the MoH and in PCH facilities. The main reason is low salary level resulting is qualified staff to move to private sector. The health sector FM information system should continue to rely on qualified consultants who provide critical support to the sector’s FM system. The health sector’s external auditor’s reports consistently indicate that the fiduciary staff turnover in the sector is high for last several years (2014 through 2017 being above 10%). Increasing trend was persistent in 2018: as per the MoH monitoring, the accounting staff turnover as of September 1, 2018 was around 18% (Data Source: The MoH). 71. Many of the fiduciary weaknesses discussed in this assessment are common capacity constraints of the country’s Public Finance Management (PFM) system including public procurement. The Program action plan aims at maintaining at least minimum required level of fiduciary capacity of the health sector. In parallel with maintaining at least minimum required level of fiduciary capacity in the sector, the MoH should develop and implement the health sector fiduciary capacity building plan, including measures to reduce the fiduciary staff turnover rate as well as to increase the fiduciary staff professional capacity both at the MoH and the PHC level. The action plan, agreed with the Bank, to be developed and approved by the MoH no later than 6 months after the Program effectiveness. 72. Program Systems and Capacity Improvements. The key institutions, the MoH and the MHIF as well as the PHCs facilities have overall acceptable procurement and financial management systems to plan budgets, execute and record transactions and produce the Program’s annual financial reports subject to the actions to be implemented as per the Action Plan (Annex 6). The assessment findings conclude that the fiduciary framework for the Program is overall acceptable to support its implementation and to achieve its desired results. Overall the fiduciary risk for the operation is assessed as High given weaknesses identified FM arrangements, including internal controls, accounting, financial reporting, and procurement risks. 73. Detailed Fiduciary Implementation Support plan is provided in Annex 7. 132 The World Bank Primary Health Care Quality Improvement Program (P167598) ANNEX 5. ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT SUMMARY Primary Health Care Quality Improvement Program 1. The Environmental and Social Systems Assessment (ESSA) was prepared to assess the environmental and social effects of the Program. The ESSA is a project document prepared by the Bank and is based on the data and information provided/collected from the MoH, MHIF, and other stakeholders. 2. Environmental and social screening carried out at Concept stage informed that occupational health and safety (OHS) of the workers and patients at PHC facilities and health care waste management (HCWM) are the key issues. It was identified that potential adverse environmental effects of the Program might be indirectly generated by primary health care services and cross-cutting areas connected with public health, hospital service and ambulance service, and are related to the system of overall infection control. Therefore, the ESSA assesses the government’s system, capacity and performance through the review of national and sectoral laws, regulations, protocols on health care waste management with analysis of the adequacy of institutional arrangements and practices for handling health care waste and OHS. The ESSA also evaluates strengths and challenges in the current primary health care system in relation to the handling, transportation and ultimate disposal of health care waste, and infection and pollution control. 3. Thematic areas identified under the Program (sustainable quality improvement mechanisms in service delivery, health financing, and governance for quality improvement – Program boundary) focusing on PHC will largely bring positive environmental and social effects to the health sector with improved quality of care. The three priority areas identified under the Program and corresponding Disbursement Link Indicators (DLIs) do not recommend activities/actions that will cause significant harm to the environment and/or resulting in adverse environmental and social impacts that are sensitive, diverse or unprecedented or irreversible. 4. Among six core principles that guide the ESSA analysis (OP/BP 9.00), the following three were considered relevant for the KG Health PforR: 5. Core Principle 1: Environmental and Social Management procedures and processes aim to (i) promote environmental and social sustainability in Program design; (ii) avoid, minimize, or mitigate adverse impacts; and (iii) promote informed decision-making related to the Program's environmental and social impacts. 6. Core Principle 3: Public and Worker Safety. Environmental and social procedures and processes aim to protect public and worker safety against the potential risks associated with exposure to toxic chemicals, hazardous wastes, and other dangerous materials under the Program. 133 The World Bank Primary Health Care Quality Improvement Program (P167598) 7. Core Principle 5: Due consideration to be given to the needs or concerns of vulnerable groups. This gives attention to vulnerable and disadvantage groups, including, as relevant, the poor, the disabled, women and children, the elderly, or marginalized ethnic groups. If necessary, special measures are taken to promote equitable access to the Program benefits. 8. The Program does not intend to support land acquisition, nor impact on natural or physical cultural resources. 9. A total analysis of HCWM cycle from PHC facilities and waste collecting points (such as hospitals and other health care centers) and ultimate HCW disposal was carried out. Further, review of policies, legal framework and program documents, institutional analysis, interviews with potential stakeholders, and visit of the primary health care and sanitary control organizations led to identify the following environmental risks in the primary health care waste management system: - Risks of infection for medical and sanitary personnel when providing medical care to patients either at home or at health care facilities (outpatient reception of hospitals, primary health care facilities (FAPs (village based first-aid and obstetrician service station), Groups of Family Doctors, Health Care Centers, Health Care Organization, laboratories, emergency medical services, medical posts in educational institutions, etc.); - Risks of patients’ infection at health care facilities with poor/inadequate infectious and epidemiological control (infection transmitted through air, water and/or the use of poorly sterilized medical instruments; - Risks of air and water contamination due to inadequate HCWM and handling; 10. It should be noted that minimal risks were noticed from disposal of Radiological isotopes. Cancer treatment facility is available in the country at the only Oncology Center in Bishkek and waste is adequately buried at Sokuluk polygon designated specifically for radioactive waste disposal. 11. The environmental regulatory framework in the health sector is well developed and has multilevel legislation and regulations. In addition to national laws, there is a complex system of sub-laws, sectoral decrees, guidelines and regulations. The country has also developed and adopted National Plan for Public Health Emergency Preparedness. Many laws and regulations have also been developed to support international agreements. The system of infection, epidemiological and environmental control in the country is multifaceted, consistently developed and improved. Since the start of health reform program in 2005, there have been significant changes in public health services, including the improvement in the infection control system. Public health care system is aimed at identifying the causes that affect the health of the population such as nutrition, environmental factors and lifestyle. 12. The country has adequate institutional hierarchy to support health care system, including HCWM. The Public Health Service is headed by the Chief State Sanitary Doctor - the Deputy Minister of Health. A well-functioning Department of State Sanitary and Epidemiological surveillance has offices at 134 The World Bank Primary Health Care Quality Improvement Program (P167598) regional, city, and district level. The sanitary-epidemiological councils are established in all districts to collegiate consideration and resolve issues of development, management, and improvement of the sanitary-epidemiological service, acting in accordance with the regulation approved by the Chief State Sanitary doctor. 13. Despite significant progress in multilateral epidemiological, environmental and infection control systems, systemic gaps exist in the organization of public health. Therefore, environmental, sanitary, and occupational health and safety risks remain during diagnostics and disease treatment. Data on public health incidence registration is non-existing or remains incomplete. Diagnostic laboratories are weakly equipped in HCWM, and data on HCW is not recorded at the primary care level in rural areas and also in many towns and cities. Data about quality of water sources are confidential and inaccessible to the population. 14. There is a critical shortage of specialists at the PHC facilities on ensuring safety against infection. Existing professional staff, especially in the rural areas, have inadequate skills in conducting analysis, assessment and prediction of the sanitary and epidemiological situation. The existing information is weakly analyzed and is of little used to improve the system and assess risks at the primary care level. Training personnel in risk assessment methods does not consider using modern international approaches and requirements. Accounting, collection and analysis of information is largely manual with little use of information technology, computers and internet. Use of modern technology, if at all, to reduce the infectious and epidemiological hazards, especially at PHC level, is new and has only recently been introduced. Gap analysis has led to the identification of the following key issues: 15. Hardware: lack of adequate HCW handling (collection and transportation) equipment and disposal infrastructures especially at the PHC level (waste containers, color plastic bags, transportation means adequately equipped, disposal facilities, etc.), inadequate processing and recycling of some medical plastic disposable devices (except syringes), inefficient handling and storage of medical devices and products. In addition, the expensive waste transportation system, the lack of proper storage systems for HCW, and the lack of incinerators increases the burden at the PHC facilities. 16. Systemic: existing HCWM model is overloaded, which revolves around secondary health care level (mainly hospitals). HCW processing is established at hospitals, which also receive HCW from PHC facilities. Hospitals can refuse taking waste from these facilities. Further, harmonization of some of the existing laws and standards could result in better coordination amongst the responsible agencies and fix the responsibilities. Many private PHC facilities do not follow state regulations in HCWM due to gaps in the legislation. 135 The World Bank Primary Health Care Quality Improvement Program (P167598) 17. Staff Training: There is no systematic approach to the training of medical and nursing personnel for the HCWM. This is resulting in occupational health and safety risks for medical staff and to the public and environment. Existing system of capacity building and training for the specialists from remote areas is poor. Independent experts also note the lack of personnel, knowledge, experience, skills, and capability in all areas of infection control and HCWM. The overall conclusion is that current practices in place for HCWM at PHC facilities in the country are still far from appropriate and require major overhaul of the system to become compatible with the international standards for HCWM. Recommended Actions 18. Reviewing and updating legislation, sector standards and policies. The Government will update legislation, sector policies and standards to enable integrated infection and pollution control at the PHC level as well as processing, utilization, and final disposal of HCW generated by PHC organizations. 19. Developing and strengthening the information management framework. The Government will strengthen the information management framework for preventing infectious diseases and environmental pollution at PHC level, including indicators of infection prevention and control, health care waste management, and water quality. Include selected key indicators in the system of national/sectoral statistics. 20. Developing and piloting a capacity building system. Develop systems for capacity building on infection prevention and control and health care waste management for PHC-level personnel. 21. Piloting HCWM models. The Government will pilot and implement health care waste management models in selected districts and PHC facilities, with adequate budget allocated, and a committee designated to provide adequate oversight of the full HCWM cycle. 22. Implementation arrangements for recommended actions: At national level, focal point set up by MoH will be responsible for the implementation of recommended actions in the ESSA. A detailed action plan for each of four key actions will be drawn up at the program start, based on the recommendations made by the ESSA. At Regional level, MHIF will help in the implementation of PAP. In consultation with MoH and MHIF, a coordination and implementation committee on HCWM will be set up adopting members from SAEPF and SIET to formulate PAP recommendations into actions. The Bank team will help setting up annual capacity development program by involving project partners like KfW, Swiss Agency and WHO (with previous experience to help GoK on HCWM) to train relevant staff at select PHCIs and FAPs in infection control, OHS and waste management. The coordination committee will monitor the progress on the implementation of recommended action in the PAP. The Bank team will continue providing implementation support on the ESSA recommended actions for PAP during the program implementation. 136 The World Bank Primary Health Care Quality Improvement Program (P167598) ESSA DISCLOSURE AND PUBLIC CONSULTATIONS 23. The ESSA was prepared in consultation with major stakeholders , reports on HCWM produced by bilateral and donors, and data received from the relevant governmental departments. Key stakeholders have been consulted on the draft ESSA and its findings. For this purpose, a hard copy of the ESSA was disseminated among key stakeholders and electronic version was disclosed at the MoH web-site. On February 15, 2019, a large public consultation was organized in Bishkek, which was attended by major stakeholders including representatives from government, civil society, donor agencies, state and private HCO, scientific community, and the public. Major feedback received from the public consultation was included in the final ESSA, which was published on Word Bank website on April 9, 2019. 137 The World Bank Primary Health Care Quality Improvement Program (P167598) . ANNEX 6. PROGRAM ACTION PLAN Action Description Source DLI# Responsibility Timing Completion Measurement The Program’s IDA Fiduciary MoF Other Throughout The approved and published and MDTF funds Systems Program republican budget will will be reflected in implementa separately indicate the Program the republican tion funds. budget under separate functional classification for the MoH and MHIF. During the Fiduciary MoF Other During the As per the MoH and MHIF formation of the Systems formation of requests the Program funds will subsequent year’s the be reflected in the income and republican budget, republican expenditure parts of the reflect the budget (as approved budget. expected amount per the cash flow under the budget Program in the calendar) income and expenditure parts of the republican budget. Ensure timely Fiduciary MoF Other Within The MoH and MHIF will confirm transfer of the IDA Systems reasonable the receipt of relevant funds and MDTF funds to time after after each transfer. the MoH and the the IDA and MHIF in MDTF funds corresponding are received amounts. to the MoF treasury account The MoH and MHIF Fiduciary MoH, MHIF Other Throughout The MoH and MHIF will present will present the Systems Program quarterly financial reports to quarterly financial implementa the MoF. reports to the MoF tion on utilization of the Program funds considering also the effectiveness of achieved indicators. Ensure adequate Fiduciary MoH Other Throughout Roster of existing staff and fiduciary capacity at Systems Program consultants to be reported the central and implementa semi-annually as part of 138 The World Bank Primary Health Care Quality Improvement Program (P167598) regional levels with tion Program implementation at least Head of progress reports and prior to Procurement Unit World Bank implementation and three support visits. specialists (full-time staff) and two Procurement Specialists and one Contract Manager (consultants) in Procurement Unit/MoH. Ensure adequate Fiduciary MoH Other Throughout Roster of existing staff and fiduciary capacity Systems Program consultants to be reported with at least 2 implementa semi-annually as part of consultants at the tion Program implementation MoH for progress reports and prior to FM/Disbursement World Bank implementation function, 2 support visits. consultants (accounting and IT support) at the central level who will support MHIF regional depts in providing services to PHC accounting system Develop and Fiduciary MoH Other No later The health sector fiduciary implement a health Systems than 6 capacity building plan specifying sector fiduciary months concrete activities, resources capacity building after the and deadlines is developed, plan, including Program agreed with the Bank and measures to reduce effectivenes approved by the MoH. The Bank the fiduciary staff s will monitor the turnover and to implementation of the action increase the plan activities. fiduciary staff professional capacity both at the MoH and the PHC level. Ensure that each Fiduciary MoH, MHIF Other Throughout Annual internal audit plans, PHC facility is Systems Program with terms of reference and audited at least implementa audit scope, will be agreed with once in a three- tion the Bank. Annual audit reports year period, with of MoH and MHIF Internal Audit more frequent units will be shared with the audits of PHC Bank. facilities with higher fiduciary 139 The World Bank Primary Health Care Quality Improvement Program (P167598) risks as assessed by MoH and MHIF Internal Audit units. Approve internal Fiduciary MoH, PHCs Other No later Approved instructions to be instructions for Systems than 6 shared with the Bank upon acceptance of months dissemination to PHC facilities medical goods by after PHC facilities and Program disseminate to all effectivenes PHC facilities for s execution. Ensure that PHC Fiduciary MoH, PHCs Other Throughout Contract execution report that facilities pay Systems Program is included in the annual Contractors/Supplie implementa procurement audit, with the rs/Consultants tion target of at least 80% of the according to exact PHC facilities having paid dates indicated in Contractors/Suppliers/Consulta their contracts but nts within four months during no later than four the audited year. months after fulfilment by Contractors/Supplie rs/Consultants of their contractual obligations. Adopt measures to Fiduciary MoH, PHCs Other No later A MoH order prohibiting the eliminate the Systems than 6 practice of dual fiduciary practice of dual months function. MoH to report semi- fiduciary function after annually as part of Program (procurement and Program implementation progress accounting/financia effectivenes reports and prior to World Bank l management s implementation support visits. functions assumed 100% of segregation shall be by the same achieved within 2 yrs individuals) at PHC facilities by segregating these duties. Ensure that the Fiduciary MoF (PPD) Other Throughout MoF (PPD) to report annually ICRC functions Systems Program that ICRC experts are motivated sustainably and implementa using relevant incentives to includes sufficient tion perform quality reviews of number of experts procurement complaints in the with capacity and health sector in a timely qualifications to manner within the period perform their outlined in the PPL. duties in appropriate manner. 140 The World Bank Primary Health Care Quality Improvement Program (P167598) Revise Standard Fiduciary MoF (PPD)/MoH Other No later Revised SBD that includes the Bidding Document Systems than 12 provision that submission of the (SBD) for months License and certification shall pharmaceuticals to after be a condition for contract allow companies Program signature on pharmaceuticals from countries with effectivenes are adopted. Stringent s Regulatory Authorities to participate in tender processes and submit required registration requests to the License Department. Ensure that all PHC Fiduciary MoH Other Throughout MoH to ensure 100% procurement Systems Program compliance within one year specialists are implementa after Program effectiveness and trained in the MoF tion to report semi-annually as part Training Center and of Program implementation certified.All progress reports and prior to individuals carrying World Bank implementation out procurement support visits functions for PHCs shall be trained and certified as per requirements of PPL as soon as as possible. Complete the e- Fiduciary MoF (PPD) Other No later MoF with input from PPD to Government Systems than 6 report that E-GP Module for Procurement months consultancy is completed and Module for after functional selection of Program consultants. effectivenes s Complete Fiduciary MoF (PPD) Other No later MoH with input from MoF PPD adjustment of e- Systems than 6 to report that e-GP module for Government months pharmaceuticals is completed Procurement portal after and functional. to include standard Program bidding documents effectivenes for s pharmaceuticals. Update legislation, Environmental MoH in coordination Other No later Related legislation, sector sector policies and and Social with MHIF & SAEPF, than 12 policies, and standard standards to enable months operations procedures formally 141 The World Bank Primary Health Care Quality Improvement Program (P167598) integrated infection Systems after the adopted. and pollution Program control at the PHC effectivenes level as well as s processing, utilization, and final disposal of HCW generated by PHC organizations. Strengthen the Environmental MoH in coordination Other No later Indicators of infectious safety information and Social with MHIF than 12 and HCWM included and management Systems months regularly collected in the system framework for after the of state and/or sectoral preventing Program statistics. infectious diseases effectivenes and environmental s pollution at PHC level, including indicators of infection prevention and control, health care waste management, and water quality. Develop systems Environmental MoH, MoE, SAP Other No later Number of trained personnel for capacity and Social “Preventive Medicine” than 6 from PHC-level facilities and building on Systems months relevant organizations (in line infection after with capacity building plans for prevention and Program online CPD learning under DLI 2) control and health effectivenes care waste s management for PHC-level personnel. Pilot and Environmental MoH in coordination Other Pilot to start MoH to report semi-annually as implement health and Social with other relevant 6 months part of Program care waste Systems after implementation progress management Program reports and prior to World Bank models in selected effectivenes implementation support visits districts and PHC s indicating number of pilots that facilities, with have started and their adequate budget implementation status. allocated, and a committee designated to provide adequate oversight of the full HCWM cycle. . 142 The World Bank Primary Health Care Quality Improvement Program (P167598) . ANNEX 7. IMPLEMENTATION SUPPORT PLAN Primary Health Care Quality Improvement Program 1. The Implementation Support Plan is in line with the Bank’s PforR operational guidelines. The Borrower is in charge of the implementation of all Program activities in support of achievement of the agreed DLIs, as well as of elimination of inefficiencies/bottlenecks identified in the social, environment and fiduciary assessments. The Bank will tailor implementation support in technical, fiduciary, environmental and social aspects to: (a) Provide technical advice to the implementation of PAP, the achievement of DLIs and elimination of other social, fiduciary or governance- related bottlenecks relevant to the Program; (b) Review program implementation progress, verify achievement of DLIs, review program progress reports and such other relevant information; (c) Monitor health system performance with a particular emphasis on the Program result areas and monitoring compliance with legal agreements, keep records of risks and propose remedy actions to improve program performance, if and as needed; (d) Provide support in resolving any operational issues pertaining to the Program, including review of grievance redress mechanisms; (e) Monitor the performance of fiduciary systems, potential changes in fiduciary risks of the Program, and the MoF compliance with agreed funds flow arrangements for the Program to ensure timely availability to the MoH and MHIF; (f) Monitor the Program financial statement preparation process and assist the Recipient as necessary; (g) Review the Program annual financial and procurement audit reports and management letters, discuss with the Recipient and monitor the implementation of the auditor’s recommendation; (h) Based on the information provided by these audit reports assess, and analyze changes in identified procurement performance indicators and propose actions, as needed; (i) Review the MoH and MHIF internal audit annual plans, terms of reference and the scope of the audit at PHC facilities. Review the annual internal audit reports and discuss with the Recipient the auditors’ finding and recommendations as well as the necessary actions to address the observations and implement the recommendations; (j) Monitor and help the Recipient as needed with institutional fiduciary capacity building. In particular: (i) monitor the compliance with PPL in terms of mandatory certification for procurement specialists in the sector; (ii)conduct semi-annual review the MoH fiduciary staff and consultants’ roster to ensure that MoH maintains adequate level of fiduciary support to the Program; (iii) during the implementation support missions, review the level and scope of consultants’ support provided to the sector’s accounting and IT systems, (iv) periodically review 143 The World Bank Primary Health Care Quality Improvement Program (P167598) the lists of the PHC facilities’ staff carrying out procurement and accounting functions to ensure that there is proper segregation of duties between those functions, and (v) review the implementation of the health sector fiduciary capacity building action plan, with particular attention to implementing specific actions within the specified deadlines as indicated in the action plan. 2. As part of Program preparation, a tentative implementation schedule has been agreed with the two key implementing agencies MoH and MHIF (Table A7.3). The implementation schedule serves as a basis for detailing implementation support provided by the Bank. In particular, the following major categories of support are envisioned: (a) Implementation support, capacity building, and training relating to the result areas and DLIs: some DLIs have initial milestones that require intensive upfront support from Bank staff and consultants. Examples of required expertise and experience include developing technical specifications for several online platforms, content development for online training material, areas relating to the revisions of the benefit package and the drug list (such as evidence-based medicine, health technology assessment, and budget impact analysis), development of procedure classification for PHC, review and design mixed provider payment, and developing reporting templates for quality of care online dashboard; (b) Implementation support in fiduciary area: given the fiduciary weaknesses in the Program system, the fiduciary support will be more extensive than in a regular Bank project. During implementation, activities supporting capacity building on fiduciary at the PHC level could be developed and supported by the Bank; (c) Analytics, just-in-time technical assistance, policy dialogue, and assessments to inform Mid- Term Review, potential restructuring, and successor project: in supporting the government program SPHD2030, the Bank team will stay actively engaged in the policy dialogue on UHC, continuing its leading role on behalf of the development partners in the Joint Annual Review and thematic events of the SPHD2030; and (d) Dissemination and South-South learning: the Bank team will support dissemination efforts both in country and internationally to sensitize population of the reform actions in PHC and to share experience of the Kyrgyz Republic with other countries. The Bank team will facilitate South-South learning activities, such as membership in the Joint Learning Network for Universal Health Coverage, as well as other experience exchange events with countries conducting similar reforms. 144 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A7.1. Main focus of implementation support Time Focus Skills needed Resource estimate* Partner role First 12 Program Operation Manual Operation, planning, M&E Three missions of the Partners participate months (POM) MHIS/e-Health/IT core team to: (1) in mission, provide Tec specs for quality data NCD and MCH Develop the POM and inputs in their areas platform and CPD platform Strategic purchasing train on PforR of expertise and Health information system Health economics implementation; (2) coordinate Revision of benefit package and Costing of services Launch the PforR and activities. drug list Pharmaceuticals start TA on technical Provider payment Quality assurance areas; (3) Supervise and Drug price control measures governance provide Set up QI unit Fiduciary implementation Fiduciary/budget planning Environmental safeguards supports. Environmental safeguards Social safeguards Social safeguards Citizen engagement Missions by consultants Patient experience perspective expertise as needed 12-60 Program operation Operation, planning, M&E Regular implementation Partners participate months Process monitoring and MHIS/e-Health/IT support missions in mission, provide evaluation Expert in content inputs in their areas Content development for online development (focused on Missions for TA support of expertise and CME NCD and MCH) as needed by specialty coordinate Data reporting, QOC measuring Strategic purchasing areas activities. Clinical guideline/protocol Health economics revision Costing of services Missions to participate Procedure classification for PHC Expertise in evidence-based in joint annual reviews Risk adjusted provider payment medicine and thematic meetings Fiduciary/budget planning Pharmaceuticals Environmental safeguards Quality assurance Social safeguards governance Patient experience perspective Fiduciary Environmental safeguards Social safeguards Citizen engagement expertise Mid term Assessment of Program Operation, M&E Conduct mid-term Partners provide review assessment at midterm Program evaluation assessment inputs in the mid- Potential inclusion of Analytical term review hospitals/restructuring Hospital expertise workshop Fiduciary, environmental and social safeguard expertise *Total amount for 5 years estimated to be US$2.5 million 3. The World Bank core task team will include the task team leader(s) (health specialist and/or economist), operations officer, technical specialist (economist and/or health specialist), procurement, financial management, environmental and social safeguard specialists. Some team members are based in the country or region to provide prompt support and follow up on implementation of the Program. Expertise from the Health, Nutrition, and Population Global Practice, as well as from other practices will be drawn upon as needed. 145 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A7.2. Task team skills mix requirements for implementation support (per year) Skills needed Number of Number of Comments staff weeks trips Senior economist (Task Team Leader) 16 3-4 HQ based Senior health specialist 22 Country based Senior operation officer 10 3 HQ based Quality of care and service delivery HQ based 12 3-4 expert Health economist/strategic purchasing 12 3-4 HQ based HMIS expert 4 1 HQ based Technical consultants As required As required International and in country Procurement specialist 5 Country based FM specialist 5 2 Based in the region FM consultant 4 2 Based in the region Environment specialist 2 2 HQ based Social specialist 2 2 HQ based 146 The World Bank Primary Health Care Quality Improvement Program (P167598) Table A7.3. Tentative implementation schedule (based on estimated effectiveness of December 2019-March 2020) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) Result area 1 DLI 1: A Tech-specs for The online Data from at least Automatically Automatically national e- the online quality of care 90% of PHC HFs are generated quality of generated quality of platform for quality of care and CIF based in the quality of care care reports on care reports on collecting and and CIF based primary care platform quality of care are quality of care are reporting primary care data collection distributed through distributed through quality of care data collection platforms Automatically the quality of care the quality of care indicators platforms developed generated quality of platform to at least platform to at least from PHC developed and and fully care reports on 90% of PHC 95% of PHC facilities is approved functioning quality of care are established distributed through Modifications to the Modifications to the and Data exchange the quality of care platforms are made platforms are made functioning standards platform to at least as needed as needed approved 90% of PHC Mechanism for Mechanism for Before Modifications to the collecting and collecting and effectiveness - platforms are made reporting patient reporting patient CIF revised to as needed level data from FAPs level data from FAPs include piloted implemented information on Mechanism for routinely collecting and collected quality reporting patient indicators level data from FAPs developed and approved 147 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 2: A TOR developed Online CPD At least 5 approved At least 8 approved At least 10 approved national in- for the online platform online learning online learning online learning service CPD platform (including a materials on priority materials on priority materials on priority training e- mobile conditions (including conditions (including conditions (including platform is At least one application) MCH, CVD, diabetes) MCH, CVD, diabetes) MCH, CVD, diabetes) established room developed uploaded for use uploaded for use uploaded for use and designated for and fully into the CPD into the CPD into the CPD functioning CPD learning is functional platform platform platform set up in each FMCs (equipped HRH and CPD 10% PHC physicians 20% PHC physicians 30% PHC physicians with computers registries/ meet CPD credit meet CPD credit meet CPD credit connected to databases are hour requirements hour requirements hour requirements internet) integrated for online learning for online learning for online learning into the CPD platform Modifications to the Modifications to the Modifications to the platform are made platform are made platform are made Revisions to as needed as needed as needed CPD regulations introduced to require online credit hours (at least 20%); MoH Order At least 2 approved online learning materials on priority conditions (including MCH, CVD, diabetes) uploaded for use into the CPD platform 148 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 3: Number Monitor data Monitor data Monitor data Monitor data Monitor data of pregnant through the e- through the e- through the quality through the quality through the quality women who Health Center Health Center of care platform and of care platform and of care platform and received and quality of take quality take quality take quality hemoglobin care platform improvement improvement improvement test and urine actions as needed actions as needed actions as needed analysis for QI Unit bacteriuria prepares an during the first analytic report trimester in a on this quality public PHC indicators facility outlining quality gaps and recommended actions 149 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 4: Number (Reach an of diabetic agreement that Procure Procure reagent, Procure reagent, Procure reagent, patients (type HbA1C test will reagent, and and train PHC in and train PHC in and train PHC in I and II) who be centrally train PHC in performing HbA1C. performing HbA1C. performing HbA1C. received procured by the performing HbA1C test at MoH using the HbA1C. Monitor the supply Monitor the supply Monitor the supply least once a same chain and adjust as chain and adjust as chain and adjust as year in a mechanism that Monitor the needed. needed. needed. public PHC is currently used supply chain facility for procuring and adjust as Revise and fine-tune Revise and fine-tune Revise and fine-tune diabetic drugs needed. new HbA1C HbA1C payment HbA1C payment under the SGBP) payment model as model as needed model as needed Incorporate needed Procure FFS for HbA1C Monitor data Monitor data equipment (if test as part of Monitor data through the quality through the quality needed), the payment through the quality of care platform and of care platform and reagent, and model of care platform and take quality take quality train PHC in take quality improvement improvement performing Monitor data improvement actions as needed actions as needed HbA1C. through the actions as needed quality of care platform and take quality improvement actions as needed QI Unit prepares an analytic report on this quality indicator outlining quality gaps and recommended actions Result area 2 150 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 5: The Establish a WG Submit the Approve the revised Apply the revised Apply the revised benefit to draft draft SGBP SGBP SGBP package regulation on regulation (SGBP) is SGBP revision document for Monitor and adjust Monitor and adjust revised to and its action approval Inform providers as needed as needed improve plan for Obtain the and contractual effective implementation approval of arrangement coverage for the regulation between MHIF and priority The WG starts on revision of PHC HFs conditions at working on the SGBP the primary content of the Finalize the care level revised SGBP: draft revised collect data, SGBP literature, secure TA Transfer the task of coordinating SGBP revision to the QI unit which will be established in the MoH by then 151 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 6: The Analyze the Implement Revise and fine-tune Implement risk Revise and fine-tune provider current provider new payment new payment adjusted capitation new payment payment payment model, mechanism mechanisms as that incorporates mechanisms as mechanism for capacity for that includes needed risk adjustment needed PHC is revised implementation P4P and FFS to improve of the roll out for selected Develop risk Monitor for possible quality and BSC, review the priority adjustment formula adjustment of the effective BSC tool, review and/or and revise existing P4P and FFS coverage for facility preventive facility coefficients payments for priority performance. services selected priority services and/or preventive Review CIF revised to services international include ICPC2 practice in PHC codes for payment and selected procedure procedures classification Develop data Draft and reporting approve new mechanism payment for mechanism that procedures as includes P4P the part of the and FFS for CIF online selected priority platform. and/or preventive Collect and services analyze data on population Develop and health risk in approve PHC each provider procedure patient group classification and manual for procedure coding Train providers on the revised payment method Conduct study on costing of PHC services 152 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 7: The Develop action Approve the Incorporate funding Incorporate funding Incorporate funding Additional plan for the revised ADP increase in budget increase in budget increase in budget Drug Package development adopting the planning and planning and planning and (ADP) for and approved execution execution execution insured implementation methodology population is of the regulation Monitor actual Monitor actual Monitor actual revised and its on ADP revision Incorporate spending for spending for spending for budget is methodology funding bottleneck in budget bottleneck in budget bottleneck in budget increased to increase in execution execution execution improve Approve the budget effective regulation on planning and Monitor ADP and Monitor ADP and Monitor ADP and coverage for ADP revision execution revise as needed. revise as needed. revise as needed. priority methodology conditions at Monitor the primary Execute actual care level increased spending for budget for ADP– bottleneck in the budget budget planning at the execution end of 2019 should have incorporated such increase for 2020. Result area 3 153 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 8: Price Develop and Regulation Implement revised Implement revised Implement revised regulation finalize action approved contract between contract between contract between mechanisms plan for the MHIF and MHIF and MHIF and for the development Prepare pharmacies pharmacies pharmacies Additional and ground work: Drug Package implementation sensitize HFs Monitor pharmacies Monitor pharmacies Monitor pharmacies for insured of the regulation and compliance and compliance and compliance and population are on ADP drug pharmacies adjust contracts as adjust contracts as adjust contracts as developed and pricing and needed. needed. needed. implemented reimbursement Conduct 2 public campaigns on Conduct 2 public Conduct 2 public Conduct 2 public new drug campaigns on new campaigns on new campaigns on new pricing and drug pricing and drug pricing and drug pricing and reimbursemen reimbursement reimbursement reimbursement t policy policy policy policy. MHIF contract with pharmacies will be revised to enforce new pricing, prescribing and reimbursemen t model, with penalty clause for violation; Prescription slips will specify the price patients should pay; Price list will be published in contracting pharmacies in visible place in format prescribed by MHIF; Public campaigns on new drug pricing, prescribing and reimbursemen t policy will be conducted; 154 The World Bank Primary Health Care Quality Improvement Program (P167598) Result area Year 1 (CY 2020) Year 2 (CY Year 3 (CY 2022) Year 4 (CY 2023) Year 5 (CY 2024) and DLI 2021) DLI 9: A unit An QI Unit Coordinate Coordinate Coordinate fully establishment established development/revisio development/revisio development/revisio designated to of the QI unit and n and endorsement n and endorsement n and endorsement quality officially functioning of at least 10 clinical of at least 10 clinical of at least 10 clinical improvement endorsed/appro guidelines/protocols guidelines/protocols guidelines/protocols (QI unit) is ved by a legal Develop and on priority on priority on priority established document endorse QI conditions conditions conditions within the (Government action plan MoH and Decree, or and roadmap Prepare and publish Prepare and publish Prepare and publish functioning Ministerial detailed report on quality report on a quality report on a Order, etc.) Coordination quality using facility quarterly basis quarterly basis committee reported data on 9 Develop and formed and priority conditions Share the quarterly Share the quarterly endorse TOR for functioning report with the MoH report with the MoH QI unit and Train QI staff and leadership and all leadership and all Coordination BSC is revised PHC Quality providers providers Committee to inform pay- Committee per- members Train QI staff and Train QI staff and Train QI staff performance PHC Quality PHC Quality and PHC Quality scheme and Committee Committee Committee endorsed by members members members MoH and MHIF Train QI staff and PHC Quality Committee members 155