The World Bankdocuments.worldbank.org/curated/en/...The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 4. A number of health sector challenges remain. Some

The World Bank Kyrgyz Second Health and Social Protection Project (P126278)

REPORT NO.: RES24817

RESTRUCTURING PAPER

ON A

PROPOSED PROJECT RESTRUCTURING

OF

KYRGYZ SECOND HEALTH AND SOCIAL PROTECTION PROJECT

APPROVED ON MAY 3, 2013

TO

KYRGYZ REPUBLIC

MARCH 7, 2017

HEALTH, NUTRITION & POPULATION

EUROPE AND CENTRAL ASIA

Regional Vice President: Cyril E Muller Country Director: Lilia Burunciuc

Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Enis Baris

Task Team Leader: Ha Thi Hong Nguyen, Oleksiy A. Sluchynskyy

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized


ABBREVIATIONS AND ACRONYMS

EmONC Emergency Obstetric and Neonatal Care

FM Financial Management

IUDs Intra‐uterine Devices

IFR Integrated Fiduciary Report

IMCI Integrated Management of Child Illnesses

KFW Kreditanstalt fur Wiederaufbau

KIHS Kyrgyz Integrated Household Survey

MBPF Monthly Benefit for Poor Families with Children

MCH Maternal and Child Health

MHIF Mandatory Health Insurance Fund

MoLSD Ministry of Labor and Social Development

MSB Monthly Social Benefits

MTR Mid‐term Review

NCDs Non‐Communicable disease

PDO Project Development Objectives

PHC Primary Health Care

SGBP State Guaranteed Benefit Package

SDC Swiss Agency for Development and Cooperation

TA Technical Assistance


BASIC DATA

Product Information

Project ID Lending Instrument

P126278 Investment Project Financing

Original EA Category Current EA Category

Partial Assessment (B) Partial Assessment (B)

Approval Date Current Closing Date

03‐May‐2013 31‐Dec‐2018

Organizations

Borrower Responsible Agency

Kyrgyz Republic Ministry of Health

Processing (this section will be automatically removed by the system before the paper is disclosed)

Form Type Based on the proposed changes this Restructuring type is

Full Restructuring Paper Level 1

Decision Authority

Board/AOB Decision

Project Development Objective (PDO)

Original PDO

The proposed PDO is to: (i) improve health outcomes in four health priority areas in support of the “Den Sooluk” National Health Reform Program 2012‐2016; and (ii) enable the Government's efforts to enhance effectiveness and targeting performance of social assistance and services

Note to Task Teams: The following sections are system generated and can only be edited online in the Portal.


Summary Status of Financing

Ln/Cr/Tf Approval Signing Effectiveness Closing Net

Commitment Disbursed Undisbursed

IDA‐52350 03‐May‐2013 16‐Dec‐2013 11‐Jul‐2014 31‐Dec‐2018 9.07 0 7.99

IDA‐H8390 03‐May‐2013 16‐Dec‐2013 11‐Jul‐2014 31‐Dec‐2018 7.43 6.19 .65

TF‐15135 05‐Feb‐2014 28‐May‐2014 11‐Jul‐2014 30‐Jun‐2017 11.96 7.46 4.50

Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)?

No

I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING

1. The Kyrgyz Second Health and Social Protection Project (SWAp-2) was approved by the Board on May 3, 2013, and

became effective on June 11, 2014, with an original closing date of December 31, 2018. The current PDO is to: (i) improve health outcomes in four health priority areas in support of the “Den Sooluk” National Health Reform Program 2012-2016; and (ii) enable the Government's efforts to enhance effectiveness and targeting performance of social assistance and services. The IDA Credit of SDR 5.9 million (US$9.07 million equivalent) and IDA Grant of SDR 4.9 million (US$ 7.43 million equivalent) are co-financed by a US$11.96 million grant from the Swiss Agency for Development and Cooperation (SDC). This Level 1 restructuring applies to the IDA Credit (Cr. 52350-KG) and Grant (H8390-KG), and the SDC Grant (TF15135).

Status of Achievement of PDOs & Key Intermediate outcomes

2. At the country level, several important achievements in terms of health outcomes and intermediate outcomes have

occurred since the start of Den Sooluk in 2012. Kyrgyzstan have achieved the MDG4 goal of reducing child mortality. Maternal mortality continues to go down, however at a reduced rate. There has been a reduction in total mortality of cardiovascular disease and tuberculosis (TB). Ninety five percent of pregnant women were reported having received at least four visits of antenatal care. Treatment coverage of Multi-Drug Resistance TB increased from 58% in 2011 to 95% in 2014.

3. In particular, important steps towards improved health management and access to services have taken place. A

number of the clinical guidelines/clinical protocols on diseases that do not require hospitalization and clear criteria for admission have been introduced. By 2014, outpatient care utilization in rural areas increased across all quintiles leading to a decrease in the urban-rural utilization gap. Further, the Government of Kyrgyzstan (GoK) expenditure on health has been maintained at 13% of total government expenditure; and the government maintained the integrity of Mandatory Health Insurance Fund (MHIF) as a single purchaser of health services.

Note to Task Teams: End of system generated content, document is editable from here.


4. A number of health sector challenges remain. Some key health outcomes and outputs are lagging. Around 80% of adults with raised blood pressure are not currently on medication, despite the focus on primary prevention and reducing the burden of non-communicable diseases (NCDs). The role of primary health care (PHC) in detecting and managing NCDs has not been improved. Family planning services are not receiving the priority they deserve given the relatively high Total Fertility Rate and the contribution family planning can make to reducing maternal and newborn mortality. Significant gaps remain in the competencies required for primary and secondary prevention among front line staff. Quality of clinical care continues to need strengthening. Although significantly reduced during earlier periods, out-of-pocket expenditures have gone up again and have disproportionately affected the poor. The project supported Den Sooluk program, designed to improve health status in four priority areas through improving health system measures, has not been successful in adopting a whole system approach and has over time been managed like silo vertical programs with little systematic investment in the key health system building blocks.

5. In terms of achievement towards the project development objectives, two out of seven PDO indicators have

performed satisfactorily, one is partially achieved, one is not on track to be achieved, and three have either not been measured or have wrong baseline value. Two PDO indicators have been achieved with one of them surpassing its end of project target as follows: (i) Percentage of Government consolidated health expenditures over total consolidated Government expenditures (13.2% actual compared to 13% end of project target); and (ii) Number of disease management programs created (5 programs actual compared to 2 end of project target). One PDO indicator has partially been achieved: Share of Social Assistance spending on poverty-targeted program(s) (baseline 15.5%, actual 23.8% compared to 35% end of project target). The indicator that is not on track for achievement is the exclusion error of the Monthly Benefit for Poor Families with Children (MBPF) program (baseline 71%, latest value based on 2013 survey 79%, target 60%). Furthermore, its measurement has not been taken in the past two years, and its choice is less than optimal to track achievement of the declared objective. The two indicators for which baseline values are questionable are: (i) Financial protection of population measured by level of out-of-pocket payments in the two poorest quintiles as a proportion of total household consumption (original baseline: 30% for poorest quintiles and 22% for 2nd poorest quintiles; yet the 2009 Kyrgyz Integrated Household Survey (KIHS) established a baseline value of 4.4% for poorest and 2.9% for 2nd poorest quintile); and (ii) Access of the patients to preventive care measured by % of detected cases of hypertension (HT) at the primary health care level (original baseline value 27%, target 50%; but later on the Ministry of Health has reported that the baseline should be 4.1%). One sub-indicator remained unmeasured and with no baseline or end of project target: Coverage of the population enrolled in disease management programs. Overall, there is a challenge to assess project’s progress toward the PDO because: (1) some PDO indicators do not lend themselves to a valid measure of the PDO (for example, number of disease programs created does not directly influence health status); and (2) some indicators are either not tracked or have wrong baseline values.

6. In terms of intermediate outcome (IO) indicators, four out of fifteen IO indicators have been achieved with mixed

performance related to the remaining eleven. The following indicators have been achieved: (i) Inter-sectoral determinants of health by conducting at least two comprehensive campaigns (8 campaigns were conducted compared to 2 end of project target); (ii) Submission of Integrated Fiduciary Reports (IFRs) satisfactory to IDA within due dates according to Financing Agreement (all IFRs have been submitted as expected by the end of the project target); (iii) Share of social assistance (MBPF, Monthly Social Benefits (MSB) and Cash compensations) beneficiaries with records in the SA Beneficiary Registry (100% actual compared to 100% end of project target); Turnaround time for processing MBPF applications (3 days compared to 5 days end of project target, while baseline was 8 days). Many of the IO indicators did not have end of project targets and others had no baseline. A few IO have been partially achieved.

Implementation Status

7. Project Ratings. Progress toward achievement of the original PDO has been rated unsatisfactory for the last two ISRs (or since January 2016). Rating for Implementation Progress (IP) was upgraded from moderately unsatisfactory to moderately satisfactory in the last ISR (November 2016) supported by the actions undertaken by the government over


the past months, including substantial progress in procurement and financial management. The combined Fiduciary risk including FM risk remains rated High due to country and sector circumstances. Appropriate capacity building activities are being implemented under SWAp-2 as well as by KfW to strengthen FM arrangements of the Health sector.

8. Country dialogue has been strengthened. Thematic Meetings on Health Financing and Senior Policy Forum have

taken place as recently as September 2016. Key issues discussed cover: (i) improving fiscal space for health; (ii) ensuring access and financial protection through the State Guaranteed Benefit Package (SGBP) and explicit poverty targeting; and (iii) achieving efficiency through strategic purchasing. Dialogue between Mandatory Health Insurance Fund (MHIF) and the Ministry of Labor and Social Development (MoLSD) is taking place to discuss potential room for improved collaboration in data exchange between the two institutions with a view to unify beneficiary category definitions between the two institutions.

9. The Den Sooluk National Health Reform program is being extended to the end of 2018 and initial discussion

started on developing the next, post-Den Sooluk health strategy. As the result of the Mid-term Review (MTR) of Den Sooluk in June 2016, the program has slightly been revised while the overall structure of Den Sooluk remains the same. An initial discussion was held on the process of developing the next, post-Den Sooluk, health sector reform strategy. While the focus of the content remains to be discussed, the formulation of the new health strategy is expected to take place in 2017.

10. Financial Management, Procurement, Audit Status. Procurement performance has improved substantially and its

rating was recently upgraded to moderately satisfactory. The MoH is proceeding with all procurement included in the approved 2016 procurement plan. Financial management (FM) and project management have progressed over the last few months with senior vacant FM positions having been filled, quality and timeliness of Internal Unaudited Financial Reports improved, and reasonable progress with implementation of the FM action plan achieved. The current key issues affecting the FM of the sector remains low pay in the sector, and weaknesses in internal control system in a number of individual health facilities. The Health sector FM capacity building under KfW Accompanying Measures (in the areas of fiduciary capacity building plan development, procurement and internal audit strengthening) has been finally commenced following extensive delays on the KfW side. Financial management and project management continue to perform at moderately satisfactorily level. The last audit report was unmodified and was timely submitted.

11. Monitoring and Evaluation is rated moderately satisfactory given that the MoH continues to provide timely

monitoring reports and updates on the Den Sooluk results framework.

12. Project Disbursements. Project funds have been substantially disbursed. As of December 2016, disbursements have reached US$ 12.65 million of a total of US$ 28.46 million (or 44.4% of total IDA grant and credit). Disbursements against the Grant co-financed by the Swiss Development Cooperation have reached US$6.46 million equivalent or 54% of the total Grant. Project support of the Den Sooluk National Health Reform program is implemented using a Sector-Wide Approach (SWAp). Disbursement projections are agreed yearly among SWAp Joint Financiers and closely monitored. This is a key factor explaining substantial disbursements despite that progress toward PDO and IO indicators has not been satisfactory over the last ISR cycles.

C. Rationale for Restructuring

13. Complexity of the design and ambitiousness of the project objectives compared to the funds allocated for project implementation and client capacity require a simpler design. There is a need to have a simpler project design, with a more realistic objective, and with relevant and measurable results. The current PDO is ambitious, complex, and broad. The project funding, including the pooled basket fund, only accounts for some 5% of the total spending from public and external sources, which in turn comprises about 56% of total health expenditure. This is a modest funding


to contribute to the achievement of the PDO as stated as the project stretches out too thinly and hence is not able to achieve concrete results. For the Social Protection (SP) component, while the project achieved considerable progress in establishing and rolling out an electronic social registry of beneficiaries, it has become clear that out of the two sub-components, only implementation of some parts of each could be expected by the end of the project. On the other hand, the project results matrix includes seven PDO indicators with poor relevance to the stated development objectives making it difficult to measure the progress towards achievement of the PDO.

14. Given the persistently high maternal mortality, a shift is required from focus on increasing utilization to improving

quality. The June 2016 MTR recognized the critical situation of maternal health reflected in persistently high maternal mortality ratio, the highest among ECA countries. This occurs when maternal health service coverage indicators, such as Delivery Attended by Skilled Medical Personnel, Delivery in Health Facility, and Antenatal and Postnatal Care rates, are at their highest level reaching more than 90%. This indicates the need to shift from supporting increases in maternal health utilization rates to a focus on improving the delivery of quality of maternal health care services.

15. Given the inadequate attention to strengthening the key building blocks of the health system and the need to

increase efficiency, a shift is required from supporting vertical programs to integrating their delivery into the health system, especially at primary care level. Another area recognized by the June 2016 MTR was that it is unlikely that budget allocations for the health sector would increase within the next few years given that they have already reached 13% of the total government expenditures. This requires more proactive measures to create efficiencies within the health system. One way of doing this is to support the integration of the delivery of the ongoing relatively expensive health services within the delivery of the health system starting with primary health care.

16. Fostering synergy between health and social protection. The Project comprises two major components spanning two

different sectors, health and SP. Both components are over-ambitious, are operating in a high risk institutional and political environment, and managed separately although the original intention was to link the two to create synergy. There is a need to establish links between the two components to serve a common purpose that relates to the achievement of the proposed project development objective, especially those that would lead to improved access of the poor and the vulnerable to quality maternal and child health services.

17. In summary, the proposed restructuring is intended to place a greater focus on improving the delivery of quality

maternal and child health care services, while strengthening the health systems ensuring the integration of the delivery of services provided under selected vertical programs (Cardiovascular Diseases, Tuberculosis, and HIV/AIDs) within the services delivered at the primary health care level. A defined set of results measuring the progress towards the achievement of the proposed PDO is introduced taking from the broader government owned Den Sooluk Program. The restructuring also intends to refocus activities managed by the MoLSD that were planned under this project, so they also contribute to achieving results under Den Sooluk Program, and in doing so, the restructured project would explicitly bring together the health sector and social protection sector activities towards a common purpose.

II. DESCRIPTION OF PROPOSED CHANGES

This Level 1 restructuring applies to the IDA Credit (Cr. 52350-KG) and Grant (H8390-KG), and the SDC Grant (TF15135) and seeks to: 18. Modify the Project Development Objectives (PDO): For the IDA Credit and Grant, from “(i) improve health

outcomes in four health priority areas in support of the Den Sooluk National Health Reform Program 2012-2016; and (ii) enable the Government’s efforts to enhance effectiveness and targeting performance of social assistance and


services” to “to contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program”. For the SDC Grant, from “to improve health outcomes in four health priority areas in support of the “Den Sooluk” National Health Reform Program 2012-2016” to “to contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program.” The proposed PDO reflects the change in narrowing down the project scope and its simplified design to focus on improvements in the delivery of quality maternal and child health services still within the national health program Den Sooluk that could be achieved by the closing date of December 31, 2018.

19. Revise project components:

a. For the IDA Credit and Grant to reflect the new proposed activities to be supported by the project until

closing in order to achieve the revised proposed PDO. Component 3 related to Contingent Emergency Response is maintained to allow for a swift response in case an emergency occurs. The proposed changes to components 1 and 2 are as follows:

i. Component 1 is renamed to: “Strengthening the delivery of quality MCH care services within the “Den Sooluk” National Health Reform Program”. This component would be revised to provide support to help the country maintain the high coverage of maternal health services, such as antenatal care, postnatal care, and institutional delivery; and to gain additional improvements in the delivery of child health services. The component would also support activities that would strengthen the delivery of Emergency Obstetric and Neonatal Care (EmONC) services. Support agreed is largely in the form of procurement of medical, laboratory, and infection control equipment, drugs, and supplies including those required for EmNOC and child health services; developing clinical protocols and guidelines; and competency training of health workforce on EmNOC, primary health care according to protocols and guidelines including Integrated Management of Child Illnesses (IMCI) and maternal health care. Support will also be extended to the procurement of family planning methods especially intra-uterine devices (IUDs) and training providers in the use of IUDs;

ii. Component 2 would be renamed to: “Strengthening health system within the “Den Sooluk” National Health Reform Program”. This component would be revised to support activities that contribute to (i) further integrating CVDs, TB and HIV services into PHC; (ii) delivering the SGBP and performing other selected health system strengthening activities; and (iii) Improving the registry of SGBP beneficiaries, as follows: Sub-component 2.1 - Integration of TB, HIV, and CVDs services within the delivery of primary

care services: support would include development of clinical protocols and guidelines and training of health workers on CVDs and TB. Support would also be provided to test pregnant women for HIV/AIDs, counseling and treating those infected as well as their infected newborns, and securing the procurement of contraceptives to prevent further transmission of infection. To further strengthen the delivery of PHC services, this sub-component would finance the procurement of equipment for primary health care labs, development of lab certification standards and training of lab workers, TA to develop a PHC strategy on human resources for health, strengthening nursing functions including task sharing, and assessing the service delivery network to set the stage for future work on optimization.

Sub-component 2.2 - Improvement of the SGBP delivery and other health system strengthening activities: support would include the development of by-laws to be adopted for legislation on pharmaceuticals, a drug database for hospitals, TA for centralized procurement of medicines, and stewardship function of the central MoH and oblast level management and coordination.

Sub-component 2.3 – Improvement of the registry of SGBP beneficiaries: support to activities that would strengthen mechanisms of data exchange between the MoLSD and MHIF for effective provision of the SGBP. Support would be through enhanced enrollment and registration of beneficiaries of the main social assistance programs, Monthly Benefit for Poor Families with


Children, as well as certification of the disabled population who benefit from copayment exemption under the SGBP. Continued efforts to improve poverty targeting mechanism would be considered.

b. For the SDC Grant, to also reflect the new proposed activities to be supported by the project until closing in

order to achieve the revised proposed PDO. Component 2 related to Contingent Emergency Response is maintained to allow for a swift response in case an emergency occurs. The proposed changes to Component 1 would be as follows:

i. Component 1 is renamed to: “Strengthening the delivery of quality MCH care services and health system within the “Den Sooluk” National Health Reform Program” and would be revised to

Sub-component 1.1 “Strengthening the delivery of quality MCH care services” to provide support to help the country maintain the high coverage of maternal health services, such as antenatal care, postnatal care, and institutional delivery; and to gain additional improvements in the delivery of child health services. The component would also support activities that would strengthen the delivery of Emergency Obstetric and Neonatal Care (EmONC) services. Support agreed is largely in the form of procurement of medical, laboratory, and infection control equipment, drugs, and supplies including those required for EmNOC and child health services; developing clinical protocols and guidelines; and competency training of health workforce on EmNOC, primary health care according to protocols and guidelines including Integrated Management of Child Illnesses (IMCI) and maternal health care. Support will also be extended to the procurement of family planning methods especially intra-uterine devices (IUDs) and training providers in the use of IUDs; and

Sub-component 1.2 “Strengthening health system” to support activities that contribute to further integrating CVDs, TB and HIV services into PHC and improving the delivery of the SGBP and other health system functions, including:

ii. Integration of TB, HIV, and CVDs services within the delivery of primary care services: support would include development of clinical protocols and guidelines and training of health workers on CVDs and TB. Support would also be provided to test pregnant women for HIV/AIDs, counseling and treating those infected as well as their infected newborns, and securing the procurement of contraceptives to prevent further transmission of infection. To further strengthen the delivery of PHC services, this sub-component would finance the procurement of equipment for primary health care labs, development of lab certification standards and training of lab workers, TA to develop a PHC strategy on human resources for health, strengthening nursing functions including task sharing, and assessing the service delivery network to set the stage for future work on optimization.

iii. Improvement of the SGBP delivery and other health system strengthening activities: support would include the development of by-laws to be adopted for legislation on pharmaceuticals, a drug database for hospitals, TA for centralized procurement of medicines, and stewardship function of the central MoH and oblast level management and coordination.

20. Revise the Results Framework to include new and revised PDO level indicators and intermediate results indicators to

reflect the significant change in the PDO, the implementation progress of the revised project components, and to improve the measurability of specific indicators, and the consistency of data sources. The revised results framework is presented in Annex 1. Specifically, the following changes are proposed:

New PDO Level Indicators:

Proportion of normal deliveries in district (rayon) hospitals that received services following clinical protocols (Percentage)


Proportion of complicated deliveries in district (rayon) hospitals that received services following clinical protocols (Percentage)

Births attended by skilled health personnel (Number) (cumulative) (Core) Diarrhea treatment with oral rehydration therapy among children under five (Percentage)

Dropped PDO Level Indicators

Number of disease management programs created Coverage of the population enrolled in disease management programs Access of the patients to preventive care measured by % of detected cases of hypertension at the primary health

care level Financial protection of population measured by level of out-of-pocket payments in the two poorest quintiles as a

proportion of total household consumption Share targeting of MBPF transfers by reducing exclusion errors Share of Social Assistance spending on poverty-targeted program(s)

New IO Level Indicators:

Number of facilities adequately equipped to provide emergency obstetric and neonatal care (cumulative) Number of pregnant women receiving any antenatal care (cumulative) Number of providers trained in IUD insertion and removal (cumulative) Number of children treated with ORS for diarrhea or with antibiotic for pneumonia (cumulative) Proportion of HIV infected pregnant women that received antiretroviral drugs to reduce risk of mother-to-child

transmission (percentage) Number of family doctors, feldshers, TB doctors, and nurses trained on TB clinical protocols and guidelines

(cumulative) Number of family doctors, feldshers, and nurses trained on CVD (percentage) Proportion of families with children receiving social assistance (MBPF) who are electronically registered

(percentage) Number of districts where the Social Registry Information System has been fully rolled out (cumulative)

Dropped IO Level Indicators:

Inter-sectoral determinants of health by conducting at least two comprehensive campaigns Indicators in JAF have baseline and are up to date Indicators in JAF are disaggregated by gender and location where applicable Health personnel receiving training (number) Share of social assistance (MBPF, Monthly Social Benefits (MSB) and Cash compensations) beneficiaries with

records in the SA Beneficiary Registry Turnaround time for processing MBPF applications Number of beneficiaries of targeted social assistance programs (Number of beneficiaries of the) Monthly Benefit for Poor Families with Children (MBPF) (Number of beneficiaries of the) Monthly Social Benefits (MSB)

Amended IO Level Indicator:

Change “Children immunized – under 5 years against Polio” to “Children immunized – under 12 months against Polio” to be in line with international practice and country’s HMIS.

Change “Roadmap to reform disability certification service developed and endorsed by the Ministry” to “Roadmap to reform disability service developed.”


21. Change to a legal covenant is necessary to allow the Recipient adequate time to conduct the Procurement Post Review and issue its report given the lengthy process in procuring the services of an international consulting firm and the fact that the review covers the entire health sector and not only the procurement packages funded from the Joint Financiers’ basket of fund. The change is as follows:

Original Covenant: Procurement Post-review | Description: The Recipient shall have its procurement at health facilities reviewed by an independent consultant as terms of reference agreed with the Association. Each Procurement Post Review Report shall cover the period of one fiscal year of the Recipient. The Procurement Post Review Report for each such period shall be furnished to the Association not later than six months after the end of such period. Revised Covenant Procurement Post-review | Description: The Recipient shall have its procurement at health facilities reviewed by an independent consultant as terms of reference agreed with the Association. Each Procurement Post Review Report shall cover the period of one fiscal year of the Recipient. The Procurement Post Review Report for each such period shall be furnished to the Association not later than twelve months after the end of such period. 22. Update the Appraisal Summary, including the Technical Analysis (Annex 2) and Economic Analysis (Annex 3) to

justify the revised focus of the project.

23. Implementation arrangements. The SWAp will continue to be managed by the MoH while the non-SWAp component (now sub-component 2.3) will continue to be managed by the MoLSD. Specifically, Component 1, Sub-components 2.1, and 2.2 will be managed under a SWAp mechanism to support the Den Sooluk national health reform program while sub-component 2.3 (non-SWAp component) will be managed by the MoLSD through the Project Implementation Unit already in place. Therefore, there is no substantial change to the implementation arrangements.

24. Further, no change in IDA fund allocation and SDC Grant allocation is anticipated. The IDA allocation remains at US$13.5 million equivalent for Component 1 (specific to the health sector), and US$3 million equivalent for Component 2, specifically Sub-component 2.3 (specific to the Social Protection sector in support of the Health Sector). However, the descriptions of the existing Categories no. 1 and 2 would require an adjustment in order to correct the references to the relevant components and sub-components that would be financed from them. Additionally, same adjustments would need to be made to the currently applicable Disbursement Letter. The SDC Grant (TF15135) will co-finance all activities under the SWAp (new Component 1, Sub-components 2.1, and 2.2) to support the “Den Sooluk” National Health Reform Program.

25. Extend the Closing Date of the SDC Grant (TF015135). The Closing Date of the SDC Grant is planned to be

extended by 18 months from June 30, 2017 to December 31, 2018 to align with the current Closing Dates of the “Den Sooluk” National Health Sector Program and of the IDA Credit and Grant. The related Administration Agreement (AA) between the SDC and the International Bank for Reconstruction and Development and the International Development Association concerning the Kyrgyz Republic Swiss TF for the project Single-Donor Trust Fund (TF072031) is being amended separately to extend the End Disbursement Date to June 30, 2019, following which the SDC Grant’s Closing Date would be extended until the said date of December 31, 2018. Due to time needed to amend the AA, SDC Grant’s extension would be handled via a separate notification to the recipient, based on this Restructuring Paper.


I. SUMMARY OF CHANGES

Changed Not Changed

Change in Project's Development Objectives ✔

Change in Results Framework ✔

Change in Components and Cost ✔

Change in Legal Covenants ✔

Change in Economic and Financial Analysis ✔

Change in Technical Analysis ✔

Change in Implementing Agency ✔ Change in DDO Status ✔ Change in Loan Closing Date(s) ✔ Cancellations Proposed ✔ Change in Financing Plan ✔ Reallocation between Disbursement Categories ✔ Change in Disbursements Arrangements ✔ Change in Disbursement Estimates ✔ Change in Overall Risk Rating ✔ Change in Safeguard Policies Triggered ✔ Change of EA category ✔ Change in Institutional Arrangements ✔ Change in Financial Management ✔ Change in Procurement ✔ Change in Implementation Schedule ✔ Other Change(s) ✔ Change in Social Analysis ✔ Change in Environmental Analysis ✔


IV. DETAILED CHANGE(S)

OPS_DETAILEDCHANGES_PDO_TABLE

PROJECT DEVELOPMENT OBJECTIVE Current PDO The proposed PDO is to: (i) improve health outcomes in four health priority areas in support of the “Den Sooluk” National Health Reform Program 2012‐2016; and (ii) enable the Government's efforts to enhance effectiveness and targeting performance of social assistance and services Proposed New PDO

The proposed new PDO is to contribute to improving delivery of quality maternal and child health care services within the “Den Sooluk” National Health Reform Program.

OPS_DETAILEDCHANGES_RESULTS_TABLE RESULTS FRAMEWORK Project Development Objective Indicators

PDO_IND_TABLE

Proportion of normal deliveries in district (rayon) hospitals that received services following clinical protocols Unit of Measure: Percentage Indicator Type: Custom

Baseline Actual (Current) End Target Action

Value 5.70 51.90 58.00 New

Date 01‐Jul‐2014 15‐Apr‐2016 31‐Oct‐2018 Proportion of complicated deliveries in district (rayon) hospitals that received services following clinical protocols Unit of Measure: Percentage Indicator Type: Custom


Value 2.50 39.10 43.00 New

Date 01‐Jul‐2014 15‐Apr‐2016 31‐Oct‐2018 Births (deliveries) attended by skilled health personnel (number) Unit of Measure: Number Indicator Type: Core


Value 150000.00 616000.00 916000.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Diarrhea treatment with oral rehydration therapy Unit of Measure: Percentage


Indicator Type: Custom


Value 77.00 78.00 80.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 (a) Percentage of Government consolidated health expenditures over total consolidated Government expenditures Unit of Measure: Number Indicator Type: Custom


Value 12.90 13.20 13.00 No Change

Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 (b) Number of disease management programs created Unit of Measure: Number Indicator Type: Custom


Value 0.00 5.00 2.00 Marked for Deletion

Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Coverage of the population enrolled in disease management programs Unit of Measure: Text Indicator Type: Custom Supplement


Value TBD n/a TBD Marked for Deletion

(c) Access of the patients to preventive care measured by % of detected cases of hypertension (HT) at the primary health care level Unit of Measure: Percentage Indicator Type: Custom



Date 31‐Dec‐2012 31‐Dec‐2015 31‐Dec‐2018 (d) Financial protection of population measured by level of out‐of‐pocket payments in the two poorest quintiles as a proportion of total household consumption


Unit of Measure: Text Indicator Type: Custom


Value Poorest quintiles: 30% 2nd poorest quintiles: 22

Poorest quintiles: 8.0%; 2nd poorest quintiles: 6.5%

Poorest quintiles: 25% 2nd poorest quintiles: 18

Marked for Deletion

Date 31‐Dec‐2012 31‐Dec‐2015 31‐Dec‐2018 (e) Share targeting of MBPF transfers by reducing exclusion errors Unit of Measure: Percentage Indicator Type: Custom



Date 10‐Dec‐2012 31‐Dec‐2015 31‐Dec‐2018 (f) Share of Social Assistance spending on poverty‐targeted program(s) Unit of Measure: Percentage Indicator Type: Custom



Date 10‐Dec‐2012 30‐Dec‐2015 31‐Dec‐2018

Intermediate Indicators

IO_IND_TABLE Number of facilities adequately equipped to provide emergency obstetric and neonatal care (cumulative) Unit of Measure: Number Indicator Type: Custom


Value 0.00 0.00 10.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Pregnant women receiving antenatal care during a visit to a health provider (number) Unit of Measure: Number Indicator Type: Core



Value 148000.00 609000.00 909000.00 New

Date 31‐Dec‐2013 15‐Apr‐2016 31‐Oct‐2018 Submission of IFRs satisfactory to IDA within due dates according to Financing Agreement Unit of Measure: Yes/No Indicator Type: Custom


Value No Yes Yes No Change

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Number of providers trained in IUD insertion and removal Unit of Measure: Number Indicator Type: Custom


Value 0.00 0.00 200.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Children immunized (number) Unit of Measure: Number Indicator Type: Core


Value 0.00 0.00 0.00 No Change

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Children immunized ‐ under 12 months against DTP3 (number) Unit of Measure: Number Indicator Type: Core Breakdown


Value 114000.00 142122.00 149813.00 No Change

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Children immunized ‐ under 5 years against Polio (number) Unit of Measure: Number Indicator Type: Core Breakdown




Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Children Immunized ‐ Under 12 months against Polio Unit of Measure: Number Indicator Type: Custom Breakdown


Value 135000.00 557000.00 837000.00 New

Date 30‐Apr‐2013 15‐Apr‐2016 31‐Dec‐2018 Number of children treated with ORS for diarrhea or with antibiotic for pneumonia Unit of Measure: Number Indicator Type: Custom


Value 53000.00 127000.00 177000.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Proportion of HIV infected pregnant women that received antiretroviral drugs to reduce risk of mother‐to‐child transmission Unit of Measure: Percentage Indicator Type: Custom


Value 96.10 95.00 95.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Number of family doctors, feldshers, TB doctors and nurses trained on TB clinical protocols and guidelines Unit of Measure: Number Indicator Type: Custom


Value 0.00 1300.00 3300.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Number of family doctors, feldshers and nurses trained on CVD Unit of Measure: Number Indicator Type: Custom



Value 0.00 1300.00 4500.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Percentage of negative deviations of the executed health budget from the initially approved budget and quarterly allocations and execution of the health budget Unit of Measure: Text Indicator Type: Custom


Value < 5% not yet available < 5% No Change

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Proportion of electronically registered families with children receiving social assistance (MBPF) who are electronically registered Unit of Measure: Percentage Indicator Type: Custom


Value 0.00 100.00 100.00 New

Date 31‐Dec‐2013 29‐Jul‐2016 31‐Oct‐2018 Number of districts where the Social Registry Information System has been fully rolled out Unit of Measure: Number Indicator Type: Custom


Value 20.00 40.00 57.00 New

Date 31‐Dec‐2013 30‐Dec‐2016 31‐Oct‐2018 Inter‐sectoral determinants of health by conducting at least two comprehensive campaigns Unit of Measure: Number Indicator Type: Custom



Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Indicators in JAF have baseline and are up to date Unit of Measure: Percentage Indicator Type: Custom




Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Indicators in JAF are disaggregated by gender and location where applicable Unit of Measure: Text Indicator Type: Custom


Value TBD Partially TBD Marked for Deletion

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Health personnel receiving training (number) Unit of Measure: Number Indicator Type: Core



Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Share of social assistance (MBPF, Monthly Social Benefits (MSB) and Cash compensations) beneficiaries with records in the SA Beneficiary Registry Unit of Measure: Text Indicator Type: Custom


Value 0% 100% 100% Marked for Deletion

Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Turnaround time for processing MBPF applications Unit of Measure: Text Indicator Type: Custom


Value 8 days 3 days 5 days Marked for Deletion

Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Roadmap to reform disability certification service developed and endorsed by the Ministry Unit of Measure: Text Indicator Type: Custom



Value No some progress reported New model implemented

Marked for Deletion

Date 10‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Number of beneficiaries of targeted social assistance programs Unit of Measure: Number Indicator Type: Custom



Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Monthly Benefit for Poor Families with Children (MBPF) Unit of Measure: Number Indicator Type: Custom Breakdown



Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018

Monthly Social Benefits (MSB) Unit of Measure: Number Indicator Type: Custom Breakdown



Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018 Roadmap to reform disability service developed Unit of Measure: Yes/No Indicator Type: Custom


Value No No Yes New

Date 31‐Dec‐2012 07‐Oct‐2016 31‐Dec‐2018


OPS_DETAILEDCHANGES_COMPONENTS_TABLE

COMPONENTS

Current Component Name

Current Cost

(US$M) Action

Proposed Component Name

Proposed Cost (US$M)

Component 1 – Support for implementation of Den Sooluk program of reforms

13.50 Revised

Component 1 – Strengthening the delivery of quality MCH care services within eh "Den Sooluk" National Health Reform Program

13.50

Component 2 – Strengthening the Policy and Administrative Capacity of the MSD

3.00 Revised

Component 2 – Strenghtening Health System within teh "Den Sooluk" National Health Reform Program

3.00

Component 3: Contingency Emergency Response (no funds allocated)

0.00 No Change Component 3: Contingency Emergency Response (no funds allocated)

0.00

TOTAL 16.50 16.50

OPS_DETAILEDCHANGES_LEGCOV_TABLE

LEGAL COVENANTS

Loan/Credit/TF Description Status Action

IDA‐H8390

Finance Agreement :Annual Program of Works (APW) and Procurement Plan | Description :The Recipient shall not later than November 15 of each year during implementation, or such later date as may be agreed by the Association, submit to the Association an APW and associated Procurement Plan, satisfactory to the Association, prepared in accordance with the format included in the POM and which shall include agreed amounts of transfers for APWs for the following fiscal year. | Frequency :Yearly

Complied with No Change

IDA‐H8390

Finance Agreement :Health Policy Council | Description :The Recipient, through MoH, shall maintain the Health Policy Council, consisting of the state secretary, deputy ministers and headsof departments that will be



responsible for coordination of Project activities, until completion of the Project. | Frequency :Yearly

IDA‐H8390

Finance Agreement :Inter‐Ministerial Coordination Committee | Description :The Recipient, through MoH, shall maintain the Inter‐Ministerial Coordination Committee, consisting of representatives of MoH, MoF and MSD, responsible for:‐ 1) coordination of project activities, including harmonization activities; and ii) review of the functioning of a complain mechanism for considering complaints re misuse of funds and ensuring follow‐up, until completion of the Project. | Frequency :Yearly


IDA‐H8390

Finance Agreement :Procurement Post‐review | Description :The Recipient shall have its procurement at health facilities reviewed by an independent consultant as terms of reference agreed with the Association. Each Procurement Post Review Report shall cover the period of one fiscal year of the Recipient. The ProcurementPost Review Report for each such period shall be furnished to the Association not later than six months after the end of such period. | Frequency :Yearly

Partially complied with

Revised

Proposed

The Recipient shall have its procurement at health facilities reviewed by an independent consultant as terms of reference agreed with the Association. Each Procurement Post Review Report shall cover the period of one fiscal year of the Recipient. The Procurement Post Review Report for each such period shall be furnished to the Association not later than twelve months after the end of such period.

CP

IDA‐H8390

Finance Agreement :Evaluation Studies | Description :The Recipient, through MoH, shall ensure that evaluation studies are conducted at least twice during Project implementation separately for each of the four priority areas of the Program. | Frequency :Yearly


IDA‐H8390 Finance Agreement :Progress Reports | Description :The Recipient shall not later than September 15 of each year during the implementation of the Project or such later



date as may be agreed by the Association, provide to the Association for its review, a report on the progress achieved in the carrying out of the Project during the period preceding the date of the report. | Frequency :Yearly

IDA‐H8390

Finance Agreement :Joint Annual Review (JAR) | Description :The Recipient shall on an annual basis jointly undertake with the Association and other donors to Den Sooluk, review of the Projectactivities. | Frequency :Yearly


IDA‐H8390

Finance Agreement :Technical Meetings | Description :The Recipient shall on an annual basis, participate in technical meetings with the Association and other donors to Den Sooluk. | Frequency :Yearly


IDA‐H8390

Finance Agreement :Multi‐Year Strategy for Procurement System | Description :By no later than six months after the Effective Date, the Recipient, through MoH, shall prepare a multi‐year strategy for the improvement of the public procurement system for the health sector, including a capacity building needs analysis. | Due Date :16‐Dec‐2014

Expected soon No Change

IDA‐H8390

Finance Agreement :Fiduciary Capacity Building Plan | Description :By no later than one year after the Effective Date, the Recipient, through MoH, shall procure technical assistance to develop and implement a comprehensive fiduciary capacity building plan for the health sector, with a focus on all health facilities, with terms of reference satisfactory to the Association. | Due Date :16‐Jun‐2015

Partially complied with

No Change

IDA‐H8390

Finance Agreement :Internal Audit Function | Description :By no later than August 15, 2015, the Recipient, through MoH, shall procure technical assistance to strengthen the internal audit function within MoH and MHIF, including automation of the

Expected soon No Change


audit workflow, with terms of reference satisfactory to the Association. | Due Date :15‐Aug‐2015


Annex 1: Economic Analysis

1. The economic analysis focuses on the revised project design involving narrowing the scope from the original four priority areas in support of the "Den Sooluk" National Health Reform to target the support to improving delivery and quality maternal and child health care (MCH) services, and the integration of services provided under selected vertical programs (CVD, Tuberculosis, and HIV/AIDs) into a primary health care setting. As previously noted the original project focus was highly complex and broad, making it difficult to achieve concrete results as project support represented a relatively small portion of the total health sector spending (2%). Thus, the proposed restructuring will allow for a better allocation of project funds and clear focus on results which in turn will trigger cost-savings and efficiency gains. 2. The analysis considers a number of direct and indirect benefits associated with Project support, particularly those associated with Den Sooluk MCH interventions: (i) a reduction of maternal and infant mortality; (ii) cost-savings of improving MCH quality of care, in particular, providing quality EmONC; and (iii) savings resulting from supporting the integration of CVDs, HIV and TB into primary health care.

Reduction of maternal and infant deaths

3. The revised component 1 considers prevention and curative activities during the pre- and postnatal stages of pregnancy aiming to maintain current coverage and health gains and reduce the number of maternal and infant deaths. These include training of community health workers, strengthen supervision and management, and provision of EmONC services through better infrastructure, equipment, drugs and supplies. As the original economic analysis indicated, the large majority of the proposed project interventions for improving maternal and child health are highly cost-effective and the cost per DALY adverted is below the GDP per capita in Kyrgyz Republic (US$1,103) WDI, 2015). For instance, individual and population maternal health interventions CEA (US$/DALY) range between 86-152. 4. Improving mothers and children health reap important social benefits in terms of unquantifiable savings of saved lives of mothers and children, savings on medical costs, and economic benefits. In a cost-benefit analysis, saved lives will produce economic benefits that can be added to the entire range of benefits, roughly quantified through assumptions made on the individual’s future participation in the labor force. In Kyrgyzstan, reducing exclusively maternal mortality and disability has the potential to avert a minimum of US$5 million loss of income over 30 years due to premature death of mothers1. To this amount, it is necessary to add savings associated with reduced infant mortality and lost welfare, health systems savings resulting from better quality of care and use of resources, long-term benefits of improved community and facility-level capacity, and better perinatal health outcomes.

Cost-savings of providing quality MCH care service

5. The project restructuring focuses on improving the quality of maternal and child care services, in particular emergency obstetric and Newborn care (EmONC), which is a highly cost-effective intervention, and addresses one or more of the delays in receiving quality maternal health care with the final outcome of reducing maternal and child mortality. It is

1 Estimated based on a MMR (76 per 100,00), about 120 maternal deaths, and a GDP per capita of US$1103.2 (WDI, 2015). Lost income was estimated using 30 years of YLL due to premature death, income discounted at 3% and a 90% burden reduction associated with quality EmONC.


estimated that 15 percent of all pregnant women experience a potentially life-threatening condition and will need emergency care. According to the Disease Control Priority third revision (DCP3) (2016), providing safe cesarean and EmOC, plus providing ambulance and trained lay first responders are extremely cost-effective. For instance, with cesarean delivery for obstructive labor the cost per DALY ranges from US$251 to US$3,462, with a median of US$400. Similarly, improved standards of special neonatal care at hospitals is associated with US$990 per death averted (Mangham-Jefferies, L., et al. (2014). Providing transport for obstetric emergencies is essential, cost per death averted of treating a community of 1 million with rural ambulances in Europe and Central Asia ranged from US$3,600 to US$5,248. Whereas cost per death averted of training emergency first responders is US$130. 6. In the Kyrgyz Republic, it is estimated that ensuring access to a quality EmONC package which requires various resources such as updated infrastructure, sufficient supplies and adequately trained personnel might reduce up to 90% of maternal deaths from post-partum hemorrhage, sepsis and obstructive labor producing substantial cost-savings. In addition to these cost-savings, the project will enhance the EmONC intervention by supporting the provision of effective long-acting family planning methods (such as Intra-Uterine Device), which is considered among the top ten global development priorities due to its high rate of return.

Benefits resulting from improving the integration of CVDs, HIV and TB programs into primary health care 7. The integration of vertical programs into primary health care will reduce inefficiencies in service provision such as duplication of services and infrastructure, overly expensive inputs, and lack of continuum care. Furthermore, by integrating financial and monitoring platforms, economies of scale can be achieved and timely budget planning and execution facilitated. These benefits, however, are not automatic and to be accrued will require to strengthen overall primary health service provision. Project activities will strengthen primary health care services by supporting training of health workers, enhancing infrastructure and equipment, and improving local management, and supervision local capacity.


Annex 2: Technical Analysis

1. The technical analysis conducted as part of the restructuring process confirms the need for adjusting the Project Development Objective (PDO) and consolidating activities to enable the prioritization of resources to achieve concrete results. The analysis also highlights evidence in support of the decision to focus on the quality of maternal and child health (MCH) care services, while enhancing selected areas of health system strengthening taking into account other programs and the need to improve efficiency, as well as synergy between health and social protection.

The need for adjusting PDO and consolidating project’s activities

2. SWAp-2 project was designed to support the implementation of Den Sooluk health reform program 2012-2016. The Den Sooluk strategy selected four priority areas - cardiovascular diseases (CVD), MCH, tuberculosis (TB) and HIV/AIDS - which are essential to achieve better overall health outcomes. The current phase of the Den Sooluk itself, reaching its original end year of 2016, showed mixed results. Maternal mortality remains high compared to other countries of the same income level and are among the highest in the ECA region. Achievements in child health are fragile as demonstrated by the recent measles outbreak. According to the Multiple Indicator Cluster Survey (MICS) 2014, only 80% of children were fully vaccinated by the age of two according to the national immunization calendar; contraceptive prevalence rate is as low as 42% and unmet need for family planning remains high at 19%. Progress in prevention of CVD remains modest, only 4% of hypertension cases were diagnosed at the primary care level, below Den Sooluk’s target. TB and HIV/AIDS have been largely managed as vertical programs. More attention has been paid under Den Sooluk to the four priority health areas than strengthening the building blocks of the health system, which are critical for the ultimate success of any health program. These shortcomings were duly noted by the Independent Review team. The team also acknowledged the ambitiousness of Den Sooluk objectives given the weakened capacity of the key health sector stakeholders compared to when the strategy was designed. 3. The project’s original PDOs were to: (i) improve health outcomes in four health priority areas in support of the "Den Sooluk" National Health Reform Program 2012-2016; and (ii) enable the Government's efforts to enhance effectiveness and targeting performance of social assistance and services. At the time of the MTR, the PDOs were assessed taking into account the current status of client capacity and was found to be overly ambitious in both health and social protection areas. Specifically in health, “improving health outcomes” is a long process and is beyond the reach of the project which has a relatively short timeframe and contributes only a small portion of the total health sector spending (~3% in 2015). As a whole sector support, the ambition to cover all four health areas in Den Sooluk and various health system components stretched out resources devoted by the Bank and government thinly. As the consequence, hardly any concrete results could be achieved or shown, and attention was diluted away from the most critical areas in need of support. Similarly, the PDO relating to social protection has proven to be unrealistic given the strong resistance to a comprehensive targeting reform in the country. At the critical, midterm, juncture, there is a need for the project to scale down its ambition and simplify its activities to allow for a focused approach and generate concrete results over the remaining two years.

Focusing on quality of MCH care services

4. Taking into account disease burden, service coverage, feasibility of success, and synergy with other existing interventions, the technical analysis identified quality of MCH care services as the key focus for the project at restructuring.


5. Among the four priority areas of Den Sooluk, maternal health stands out as the most critical. For the past decade, the MMR has virtually never dropped below 50 per 100,000 live births, much higher than the MDG target of 15.7 by 2015. As shown in figure 1 below, Kyrgyzstan compares favorably with Armenia, Russia, and Kazakhstan in NCDs. However, with the MMR of 71/100,000 lives births, Kyrgyzstan ranks way lower than Tajikistan as well as many other countries in the region. Given that service coverage is almost universal (antenatal care 97%, institutional delivery 99% - DHS 2012), this points to quality of care issues, especially emergency obstetric and neonatal care (EmONC). Early neonatal mortality cases, which are more closely associated with pregnancy-related factors and maternal health, constitute a major share of neonatal mortality in Kyrgyzstan.2

Figure 1. Probability of dying between ages 30-70 from any of the four NCDs, %, 2012 (left panel), and Maternal Mortality per 100,000 live births, 2015 (right panel)

Source: WHO 2016 World Health Statistics

6. The new focus on quality of clinical services relating to MCH will enhance synergy with the ongoing Results-Based Financing (RBF) Project and in will turn assure better achievement of outcomes. The WB-financed RBF project has been applying performance-based incentives and peer monitoring to targeting quality of obstetric and neonatal care at district hospitals. A PHC PBF pilot was also launched recently to incentivize a bundle of key PHC services and quality of care at the level of primary care. Thus SWAp will close the loop in the continuum of care by focusing on the EMONC services provided at the tertiary level, which handles some 80% of complicated deliveries. It will fill in the big gaps identified in facilities readiness to provide quality EMONC services, including most importantly adequacy of equipment and competency of health workers. It will also continue to support the development of clinical guidelines and training of health workers for all levels of care. 7. Project support in child health will take into account areas most in need and have not been supported by other donors, in particular GAVI’s recently approved Health System Strengthening (HSS) grant. With the key priority of the GAVI’s HSS being defined as immunization outcomes, SWAp will focus on integrated management of childhood illnesses (IMCI) and improving capacity to provide emergency child health services.

2 http://apps.who.int/maternal_child_adolescent/epidemiology/profiles/neonatal_child/kgz.pdf

24.0

24.124.5

26.2

26.5

28.2

28.528.8

29.7

29.9

31.0

33.9

40.8

Hungary

Latvia

Serbia

Belarus

Republic of Moldova

UkraineKyrgyz Republic

Tajikistan

Armenia

Russian Federation

UzbekistanKazakhstan

Turkmenistan

18

2324

25

25

25

2931

32

36

36

42

76

Latvia

Republic of Moldova

Ukraine

Armenia

Azerbaijan

Russian FederationAlbania

Romania

Tajikistan

Georgia

UzbekistanTurkmenistan

Kyrgyz Republic


Maintaining targeted HSS efforts with focus on service integration and health-social protection linkage

8. While focusing strongly on one priority area of Den Sooluk is a major change in the project direction, as a sector support, there is a mandate to continue engaging in HSS and committing politically to other health areas. The technical analysis identifies three major groups of activities, the successfully implementation of which will contribute directly or indirectly to the achievement of PDO and help improving efficiency in the health sector (which is one of the major weaknesses as shown in a recent fiscal space assessment).3 The three groups of activities are:

(i) Further integrating CVDs, TB and HIV services into PHC

9. TB and HIV programs in the Kyrgyz Republic have relied for the most part on parallel financiers, most notably Global Fund and USAID. While some achievements have been made, the unit cost is high given the vertical nature of these programs. Further, those indicators that require compliance would improve if delivered within the context of a routine delivery of services at the primary health care level. Integrating these services into the PHC system will help assuring sustainability of the services, especially now as Kyrgyzstan will soon graduate from the Global Fund support. For CVDs, the most cost effective interventions will be on public health measures and primary prevention. Support for integrating the three diseases into the PHC will help further strengthening the PHC system which is also another priority of Den Sooluk. The focus for the project will be on public health programs, training of health workforce on prevention and case management, development of clinical protocols and guidelines, and upgrading primary lab system, among other activities.

(ii) Improving the purchasing of SGBP and other health system functions

10. Supporting SGBP was included in the original design of the project and will remain after restructuring. In addition, a strong emphasis will be placed on the capacity of the MHIF is strategic purchasing of the SGBP, the area that will benefit from synergy with a parallel Bank executed ASA on universal health coverage funded by the Japanese Trust Fund PHRD. In this regard, the project will provide TA support for drafting bylaws for the Budget Code governing MHIF budget, framework procurement of medicines, and potentially studies for rationalization of the service delivery network. Focused support to other health system functions will continue in the area of pharmaceutical policy, human resources for health, information system, and stewardship. It is expected that the supported activities will contribute to improving efficiency and freeing resources for important purposes, including but are not limited to MCH programs.

(iii) Improving the registry of SGBP beneficiaries in collaboration with the Ministry of Labor and Social Development

(MOLSD)

11. The project was designed with a dual PDOs to generate synergy between health and social protection and with a recognition that an effective targeting system is crucial for the health sector. Given the challenge in achieving the ambitious PDO on social protection, the focus of the SP activities will be shifted to supporting the health sector in strengthening systems of enrollment, registration, and monitoring of the socially vulnerable groups which include also population eligible for SGBP copayment exemption. Activities conducted by the MoLSD will aim to strengthen mechanisms of data exchange between the MoLSD and MHIF for effective provision of the SGBP. Modernizing the enrollment mechanisms will contribute to better access to health services for the most underprivileged and improved efficiency in the purchasing of the SGBP. Efforts will also be made to explore the potential expansion of the beneficiary registry to explicitly include mothers and children.

3 Assessing Fiscal Space for the Health Sector in the Kyrgyz Republic. Presentation by the World Bank in the Thematic Meeting on Health Financing, September 2016, Bishkek.


The restructured result chain

12. A clear result chain establishes the pathway of effects from the PDO to intermediate outcomes and activities to focus on in the next two years. The results framework has been revised, in which the PDO indicators focus on maintaining the high coverage level of institutional delivery, measuring management of cases according to clinical protocols in cases of normal and complicated deliveries in all 63 district-level hospitals across the country, adherence to evidence-based protocols at the primary care level for treatment of diarrhea and maintaining the allocation of resources to the health sector. 13. The intermediate results indicators will measure progress made in activities chosen to support the achievement of the PDO: maintaining high coverage of antenatal care, equipping hospitals with required basic equipment and supplies to provide emergency obstetric and neonatal care, prevention of mother-to-child transmission of HIV, coverage of key vaccines, treatment of childhood illnesses according to IMCI protocols, training of providers on family planning, CVD, TB and other key health conditions, health budget execution, and better targeting and coverage of the Social Registry Information System.

Documents

The World Bankdocuments.worldbank.org/curated/en/...The World Bank Kyrgyz Second Health and Social Protection Project (P126278) 4. A number of health sector challenges remain. Some