Document of The World Bank Report No: ICR2323 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-4153) ON A CREDIT IN THE AMOUNT OF SDR 48.8 MILLION (USD 70.0 MILLION EQUIVALENT) TO THE SOCIALIST REPUBLIC OF VIETNAM FOR A MEKONG REGIONAL HEALTH SUPPORT PROJECT December 27, 2012 Human Development Sector Unit East Asia and Pacific Region Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
Transcript
Document of The World Bank
Report No: ICR2323
IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-4153)
ON A
CREDIT
IN THE AMOUNT OF SDR 48.8 MILLION (USD 70.0 MILLION EQUIVALENT)
ADB Asian Development Bank ISDS Integrated Safeguards Data Sheet AIDS Acquired Immune Deficiency Syndrome LPMU Local Project Management Unit CAS Country Assistance Strategy MDGs Millennium Development Goals CDC US Centers for Disease Control MOH Ministry of Health CPMU Central Project Management Unit MWMP Medical Waste Management Plan CPRGS Country Poverty Reduction and Growth Strategy NCDs Non-communicable Diseases CTUMP Can Tho University of Medicine and Pharmacy NHPs National Health Programs DFID Department for International Development (United Kingdom) NHSP National Health Support Project DO Development Objective NTPs National Target Programs DoHs Department of Health OED Operations Evaluation Department EC European Commission OP Operational Policy EMPF Ethnic Minority Policy Framework PCN Project Concept Note EMDP Ethnic Minority Development Plan PDO Project Development Objective FM Financial Management PH Provincial Hospital FMB Fund Management Board PHB Provincial Health Bureau GDP Gross Domestic Product PHRD Policy and Human Resource
Development GFATM Global Funds to fight AIDS, Tuberculosis and Malaria PIC Public Information Center GSO General Statistics Office PID Project Information Document HCFP Health Care Funds for the Poor PPMCs Provincial Preventive Medical
Centers HCMC Ho Chi Minh City PRSC Poverty Reduction Support Credit HIS Hospital Information System RAC Regional Advisory Committee HIV Human Immunodeficiency Virus CTNGH Can Tho National General Hospital
IAPSO Inter-Agency Procurement Services Office of the United Nations SARS Severe Acute Respiratory Syndrome IBRD International Bank for Reconstruction and Development SIL Specific Investment Loan ICB International Competitive Bidding TB Tuberculosis IDA International Development Association VNHS Vietnam National Health Survey IEC Information, Education and Communication VHWs Volunteer Health Care Workers KfW German Development Cooperation - German Financial Cooperation VLHSS Vietnam Households & Living
Standard Survey IP Implementation Progress VSS Vietnam Social Security
Vice President Pamela Cox
Country Director Victoria Kwakwa Sector Manager Toomas Palu
Project Team Leader Huong Lan Dao ICR Team Leader Sarbani Chakraborty
SOCIALIST REPUBLIC OF VIETNAM
MEKONG REGIONAL HEALTH SUPPORT PROJECT
TABLE OF CONTENTS
A. Basic Information ...................................................................................................................... i B. Key Dates ................................................................................................................................... i C. Ratings Summary ...................................................................................................................... ii D. Sector and Theme Codes ......................................................................................................... iii E. Bank Staff ................................................................................................................................ iii F. Results Framework Analysis .................................................................................................... iv G. Ratings of Project Performance in ISRs .................................................................................. ix H. Restructuring (if any) .............................................................................................................. ix I. Disbursement Profile ..................................................................................................................x
1. Project Context, Development Objectives and Design ............................................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................................. 5 3. Assessment of Outcomes .......................................................................................................... 12 4. Assessment of Risk to Development Outcomes ....................................................................... 19 5. Assessment of Bank and Borrower Performance ..................................................................... 20 6. Lessons Learned........................................................................................................................ 21 7. Comments on Issues Raised by Borrower and Implementing Agencies .................................. 25
Annex 1: Project Costs and Financing ..........................................................................................26 Annex 2: Outputs by (Component) Performance Indicators ........................................................27 Annex 3: Results Framework........................................................................................................31 Annex 4: Economic and Financing Analysis ................................................................................41 Annex 5: Bank Lending and Implementation Support/Supervision Process ................................45 Annex 6: Summary of Borrower’s ICR and/or Comments on Draft ICR ....................................47 Annex 7: List of Supporting Documents ......................................................................................49
MAP
i
A. Basic Information
Country: Vietnam Project Name: Mekong Regional Health
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Moderately Satisfactory Government: Satisfactory
Quality of Supervision: Satisfactory Implementing Agency/Agencies:
Satisfactory
Overall Bank Performance:
Satisfactory Overall Borrower Performance:
Satisfactory
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments (if
any) Rating
Potential Problem Project
at any time (Yes/No): No Quality at Entry (QEA): Moderately Unsatisfactory
Problem Project at any time
(Yes/No): No
Quality of Supervision
(QSA): Moderately Satisfactory
DO rating before
Closing/Inactive status: Satisfactory
iii
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
Central government administration 1 1
Compulsory health finance 3 3
Health 88 88
Non-compulsory health finance 8 8
Theme Code (as % of total Bank financing)
Health system performance 33 33
Malaria 16 16
Other financial and private sector development 17 17
Other social protection and risk management 17 17
Social risk mitigation 17 17
E. Bank Staff
Positions At ICR At Approval
Vice President: Pamela Cox Jeffrey S. Gutman
Country Director: Victoria Kwakwa Klaus Rohland
Sector Manager: Toomas Palu Fadia M. Saadah
Project Team Leader: Huong Lan Dao Samuel S. Lieberman
ICR Team Leader: Sarbani Chakraborty
ICR Primary Author: Sarbani Chakraborty
iv
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document)
The project aims to improve health services in the Mekong region and to enhance access to and coverage of these services, especially for the poor through: (i) strengthening the health financing policy framework and increasing the financial accessibility of health services for the poor and near-poor; (ii) improving the availability and quality of curative care, including responsiveness to changing disease patterns; (iii) increasing the capacity of preventive health activities; and (iv) building the capacity of the health workforce. The project therefore blends support for demand for health care services among the poor and near poor with outlays that address supply-side opportunities and needs while building physical and human resource capacity. Key outcome indicators include: Percentage of poor and others using and expressing satisfaction with the provision of different levels of health services, including hospital care Percentage of poor and near poor to whom health insurance cards have been issued in project provinces Improvement of quality of hospital care in the project hospitals Revised Project Development Objectives (as approved by original approving authority)
The project development objectives were not changed during implementation (a) PDO Indicator(s)
Indicator Baseline
Value
Original
Target
Values
(from
approval
documents)
Formally
Revised
Target
Values
Actual Value Achieved
at Completion or
Target Years
Indicator 1: Hospitalization and consultation rates in public facilities among the poor and near poor during the given calendar year.
Value quantitative or Qualitative)
20 % (P)
0% (NP)
50% ≥ 23% (P)
≥ 10% (NP)
45.9% (P)
38.5% (NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
v
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”. The target had over reached almost twice (for the poor) and four times (for the near poor) as compared to the formally revised target values.
Indicator 2: Percentage of the poor and near poor with health insurance card.
Value quantitative or Qualitative)
29% (P)
7.2% (NP)
70%(P)
20%(NP)
90% (P)
50% (NP)
Administrative data: 95.9% (P), 42.1%(NP)
Survey data: 94.4%(P), 68.4%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
The target had been over reached in the survey data. However, in the administrative data, only the target for the poor had been reached, but the target for the near poor had not been reached.
Indicator 3: Inpatient mortality (case fatality rate) from (a) Respiratory distress of newborn (P22) and (b) trauma brain injuries (S00-S09, T90, T98).
Value quantitative or Qualitative)
36% (a)
8% (b)
32% (a)
6% (b)
3.7%(a)
3.3%(b)
Date achieved 2008 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. While the inpatient mortality rate from trauma brain injuries had been reduced by 4.7%, that rate from respiratory distress of newborn had been significantly reduced by 28% (about 10 times of reduction).
Indicator 4: Patient satisfaction with the overall treatment and the condition of facilities/equipment.
Value quantitative or Qualitative)
52% ≥ 75% 82.7%
Date achieved 2008 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”.
vi
(b) Intermediate Outcome Indicator(s)
Indicator Baseline Value Original
Target
Values
(from
approval
documents)
Formally
Revised
Target
Values
Actual Value Achieved
at Completion or
Target Years
Component 1: Protecting the Poor and Near Poor
Indicator 1: Percent of the poor and near poor who know all the benefits, entitlements and rules for their health insurance coverage.
Value quantitative or Qualitative)
60% 50% 80% 98.7%(P)
97.0%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”. The target had been over achieved with about 17-19% higher compared to the formally revised target values.
Indicator 2: Share of out-of-pocket health expenditure in the total health spending on non-food items.
Value quantitative or Qualitative)
18% (P)
16.1% (NP)
Not increase Not increase 18.3%(P)
15.2%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Share of out-of-pocket household expenditures for health in total household non-food expenditure among the poor and near poor”. The share of out-of-pocket health expenditure among the poor increased slightly by 0.3%, while that of the near poor decreased by 0.9%.
Component 2: Curative Care Quality and Capacity
Indicator 1: Number of new clinical or para-clinical tests that have been applied in provincial hospital since 2008.
Value quantitative or Qualitative)
0 9 32
Date achieved 2008 12/10/2010 12/2011
Comments This is a new indicator which was added in the restructuring document. The
vii
(incl. % achievement)
number of new clinical or para-clinical tests increased significantly (with an increase of 23 new tests as compared to the revised target).
Indicator 2: Number of referrals to HCMC hospitals
Value quantitative or Qualitative)
3.4% (P)
6% (NP)
20% reduction
20% reduction
Administrative data: 1.1%
Survey data: 3.7%(P), 4.9%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of self-referrals to Cho Ray hospital in HCMC”. According to the survey data, there was a slight increase in the number of referrals to HCMC hospitals among the poor, while it was a slight reduction among the near poor (a reduction of 1.1% that equals to 18% reduction). However, if compared with administrative data, there was a significant reduction among the poor (a reduction of 68%) and the near poor (a reduction of 82%).
Component 3: Preventive Health
Indicator 1: Number of standard tests (according to the new National Benchmark issued by the MOH in 2009) that can be performed by preventive health centers.
Value quantitative or Qualitative)
45 70 85
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. There were 15 new test increases compared with the revised target.
Indicator 2: Number of districts preventive health centers receive training on surveillance software and computer hardware to produce surveillance reports.
Value quantitative or Qualitative)
0 60 129
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document.
Component 4: Human Resources Development
Indicator 1: Number of training completed as a result of Project support, by specialty and
viii
province (Grade 1, Grade 2, Master, PhD, on-the-job training (cumulative number).
Value quantitative or Qualitative)
0 490 (Gr1)
206 (Gr2)
10 (MSc)
4 (PhD)
1485 (Gr1)
318 (Gr2)
195 (MSc)
11 (PhD)
789 (on the job)
1592 (Gr1)
361 (Gr2)
230 (MSc)
25 (PhD)
1794 (on the job)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of specialist Grade I, Grade II, Master and PhD as a result of project support, by specialty and province”. All target had been over reached, particularly the number of on-the-job training and the number of PhDs doubledcompared with the revised target.
Indicator 2: Number of health staff who has completed short-term training courses (from 1 month up to 1 year) as a result of Project support.
Value quantitative or Qualitative)
0 1696 1000 8008
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of curative care and preventive health staff who have completed short-term specialization training required for utilization of new equipment”. The number of health staff who completed short-term training courses was 8 times as high as the revised target.
Indicator 3: Percentage of specialty posts filled
Value quantitative or Qualitative)
0 95% 90%
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. The target had been nearly reached.
Indicator 4: Percent of medical professionals returning to their original workplace after long term training supported by the project.
Value quantitative or Qualitative)
0 90% 96.8%
ix
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. The target had been over reached (with an increase of 6.8%).
1. Project Context, Development Objectives and Design
1.1 Context at Appraisal
1. At project appraisal (June 2005), the economic situation in Vietnam was positive. Gross domestic product (GDP) had been on a continuous upward trend and in 2004-05 Vietnam recorded, on average, 7 percent GDP growth. In a decade poverty rates in Vietnam had decreased by almost 20 percent. Health indicators had continued to improve nationally. Despite these improvements, several problems persisted in the health sector. There were disparities in health outcomes and new health challenges such as HIV/AIDS, Sudden Acute Respiratory Syndrome (SARS) and avian influenza. High out-of-pocket payments for health was a major concern, and financial barriers were acute for poor households. The 2004 World Bank Participatory Poverty Assessment identified that health shocks were one of the main reasons for households falling into poverty. Moreover the 2004 Vietnam Living Standards Survey (VLSS) found that 10 percent of households spent more than 16 percent of their consumption on health care. According to the VLSS, an inpatient visit for a household in the lowest quintile would cost more than four times the monthly income of that household and more than half of poor households seeking inpatient care had to borrow the money to cover the costs. Average household expenditures on both inpatient and outpatient care in the Mekong Delta region were the second highest in the country. 2. Some health reforms had already been implemented from 1990-2005. In a context of limited public sector resources, hospitals had been allowed to charge user-fees for services. Health insurance options had been incrementally expanded and provinces had been given greater responsibility for health care management. Nevertheless, these reforms had not adequately addressed the disparities in health outcomes and financial protection between various income quintiles and the Government was interesed in further reforms. 3. In 2002, Decree 10 strengthened the hospital user-fee policy by giving facilities the flexibility and incentives to develop new and better services. There were hospitals that took advantage of these developments and upgraded their facilities and introduced new services against user charges. In the same year, Decree (139) on a Health Care Fund for the poor was announced by the Government. The objective of this Decree was to improve the access of the poor to health care, specially in-patient (hospital) treatment. The Decree created province-level Health Care Funds for Poor (HCFPs) with the objective of financing out-of-pocket costs of eligible individuals using publicly provided health services. Province-level governments were expected to play a major role by either buying health insurance cards for the poor, or paying directly for the out-of-pocket costs of services provided to beneficiaries by public hospitals and other public providers. Implementation of Decree 139 was expected to bring significant benefits for the poor – in terms of increased utilization of health services and financial risk protection thereby mitigating any potential income loss for households from health care use. The other objective of Decree 139 was to incrementally divide responsibilities between financing and service delivery (purchaser/provider) and through the implementation of appropriate health provider incentives create pressures for improving service quality. The project aimed at supporting a regional approach to the implementation of Decree 139. Moreover, recognizing that “near poor” households also needed financial risk protection, the project proposed – on a pilot basis – to test the enrollment of the “near poor” into health insurance. 4. The project was consistent with the Country Assistance Strategy (CAS) for 2003 – 2006 which supported the implementation of Vietnam’s Comprehensive Poverty Reduction and
2
Growth Strategy. A key objective of the CAS was enhancing equitable, inclusive and sustainble development. “Providing basic social services to the poor” was identified among the key sub-themes. The January 2004 CAS Progress Report recognized that the needs of the poor are likely best addressed through complementary supply- and demand-side investments. It also emphasized the importance of narrowing the gap between the rich and poor provinces and encouraging effective decentralization.
1.2 Original Project Development Objectives (PDO) and Key Indicators
5. The project aimed at improving health services in the Mekong region and enhance access to and coverage of these services in the Project Provinces, especially for the poor population through: (i) strengthening the health financing policy framework and increasing the financial accessibility of health services for the poor and the near poor; (ii) improving the availability and quality of curative care, including the responsiveness to changing disease patterns; (iii) increasing the capacity of preventive health activities, and (iv) buillding the capacity of the health workforce. Key outcome indicators included:
1. Percentage of patients and service users, poor and non-poor, and other groupings satisfied with the provision of different levels of health services, including hospital care.
2. Percentage of poor and near poor to whom health insurance cards have been issued in project locations.
3. Percentage of poor patients in selected project areas with increased use of quality health care.
6. In addition to the PDO indicators, there were indicators defined for each of the Components which are in a table format in Annex 1.1.
1.3 Revised Project Development Objectives and Key Indicators:
7. The Project Development Objective (PDO) was not revised during the life of the project. However PDO indicators as well as component indicators were revised. The restructuring paper revising these indicators was approved by the World Bank Management in December 2010. As a result of the revisions, the total number of project indicators (PDO and component indicators) were reduced from 21 to 14, and the revised indicators more precisely formulated and aligned to the project activities.
3
Table 1: Original and Revised PDO Indicators
Original Revised
Percentage of poor and near poor to whom health insurance cards have been issued in project locations.
Percentage of the poor and near poor with health insurance card.
Percentage of poor patients in selected project areas with increased use of quality health care.
Hospitalization and consultation rates in public facilities among the poor and near poor during the given calendar year. Inpatient mortality (case fatality rate) from (a) Respiratory distress of newborn (P22) and (b) trauma brain injuries (S00-S09, T90, T98).
Percentage of patients and service users, poor and non-poor, and other groupings satisfied with the provision of different levels of health services, including hospital care.
Patient satisfaction with the overall treatment and the condition of facilities/equipment.
8. The Component indicators were also revised. These are described in Annex Table 1.2
1.4 Main Beneficiaries
9. The main beneficiaries of the project were the poor and near-poor populations of the 13 provinces of the Mekong Region included under the project (approximately 2 million individuals). The following public sector health facilities were also main beneficiaries: Can Tho Central General Hospital, 2 specialized hospitals, (Can Tho Pediatrics Hospital and An Giang Cardiovacular Hospital), 3 Inter-District Hospitals, Can Tho University of Medicine and Pharmacy, 12 Medical Colleges and 13 Provincial Preventive Care Centers.
Original Components:
10. The project consisted of five components: 11. Component One Protecting the Poor and Near Poor (US$8.0 million): The objective of this component was to support the central and provincial governments in ensuring access to poor and near poor populations through the expansion of the health insurance program. Specifically, the component supported: (i) capacity building for the management of provincial Health Funds for the Poor (HCFPs); (ii) strengthening coordination and collaboration among involved agencies; and (iii) improving the flow of information; and developing an information technology system. It mobilized technical assistance to help MOH and Vietnam Social Security (VSS) identify key issues and constraints for the shift from supply – to demand side financing. To foster the expansion of heath insurance, the component supported coverage of catasthrophic health care costs for the poor and near poor through pilot schemes in the project provinces. Finally, the component supported innovative pilot schemes to improve the effectiveness of the HCFPs, in establishing targeting mechanisms to better reach ethnic minority people, ensure access to services for mobile populations such as migrant laborers, or set up public-private partnerships in health care for the poor. Provincial health departments will prepare work
4
programs with a detailed description of the pilot schemes that they wish to undertake, as well as conduct evaluations of these innovative pilots. 12. Component Two: Curative Care Quality and Capacity (US$38.0 million). This component aimed to improve the quality and capacity of hospital services in the Mekong Region, by investing in equipment for provincial hospitals and the Can Tho Central General Hospital (CTCGH) and in a region-wide hospital information system (HIS) to assist the integration of private providers into the health insurance system as newly manadated by Decree 63. The provincial hospitals received investment in two stages: (i) to ensure that provincial hospitals could provide an essential level of care; and (ii) to allow provincial hospitals to expand selected clinical services in response to demand. The CTCGH was supported through a two-stage investment: (i) providing equipment for core, tertiary-level services; and (ii) allowing for the expansion of servies based on demand. The hospital information system aimed to be designed based on end users’ needs followed by investments in software, hardware and training to improve information about hospital performance and disease patterns across the region. Finally the private sector regulation initiatives helped integrate the private sector in the health insurance system by financing guidelines, tools and information dissemination to assist the government in accrediting and monitoring private providers. Medical waste management is supproted under this component. 13. Component Three: Preventive Health (US$6.5 million). This component built the capacity of the region’s preventive health system to address long-standing and emerging infectious disease threats as well as new health challenges arising from economic growth in the region. This was achieved through through investment in laboratory capacity and supporting the implementation of an improved surveillance system in the Mekong’s 13 Provincial Preventive Medicine Centers (PPMCs). These investments are complementary to the reforms in the Preventive Health system at the national level and to investements in the remaining provinces of Vietnam through the ADB Preventive Health System Support project, in particular, national-level surveillance software developed under the ADB project. Satisfactory completion of software was a condition for Project disbursement for surveillance. 14. Component Four: Human Resources Development (US$8.0 million). This component aimed to improve the capacity of the health workforce to deliver quality health services, especially for the poor and near poor. The component financed training activities for health teams at different levels of the health system, and supported the CTUMP in delivering and organizing priority training activities, and piloting non-training human resources (HR) initiatives. Importantly, this component provided the training inputs to complement investments in Curative Care and Preventive Health components to ensure efficient use of new equipment. Training activities for local health staff would be determined through a bottom-up planning exercise looking at linkages to services for the poor and near poor, skill gaps based on demand and projected population growth and skills needed for project-financed equipment. Support to the CTUMP included training teaching staff to develop new or supplementary teaching capacities crucial for the training needs of local health staff and the provision of essential teaching equipment. Non-training HR initiatives would include an HR planning exercise to help pilot provinces understand the existing HR situation and to make strategic choices in addressing labor market constraints, including schemes to bring in health workers from outside to address staff shortages in poor areas. It would also finance an HR information system for planning, monitoring and evaluation in the region. Each initiative is initially piloted in one or two
5
provinces and findings and lessons learned shared among all 13 provinces at the mid-term review. 15. Component Five: Project Management, Monitoring and Evaluation (M&E) (US$6.5
million). This component supported the establishment and operation of the Central Project Management Unit (CPMU), Local Project Management units (LPMUs), and Regional Advisory Committee (RAC) by funding: (i) consulting services to cover technical issues as well as procurement, financial management, and disbursement; (ii) training of project management staff; (iii) provision of office equipment; and (iv) incremental operating costs. This component also financed data collection through baseline, mid-term, end-of-project surveys, and evaluations.
Revised Components
The project components were not revised or restructured during implementation.
2. Key Factors Affecting Implementation and Outcomes
Project Preparation, Design and Quality at Entry
2.1 Soundness of Background Analysis:
16. The project development objectives were consistent with the prevailing conditions and ongoing policy reforms in the Vietnamese health sector. At the time of project design, the Vietnamese health sector had started introducing health reforms to address various identified problems in the health sector. The Ministry of Health initiated incremental movement away from direct service provision to more standard-setting and regulations. The country implemented fiscal decentralization and provinces were given fiscal responsibility for sectoral allocation. Decree 10 which had granted autonomy to health facilities to raise resources for the sector by implementing innovations and developing new services – paid for against user fees − had also been implemented. These reforms generated some impacts but poor households were being left behind – utilization rates among poor households were significantly lower and households faced high out-of-pocket payments when accessing health services. In response, the Government launched a demand-side financing program for poor households (Decree 139), but there was need for implementing these various reforms within a coherent policy framework. At the same time, the supply- side was not adequately developed, and there was recognition that with the expansion of health insurance there was a need to also improve the supply side. The project design clearly aimed at providing adequate health insurance coverage to poor housheolds while making sure the supply side was ready for increased demand as a result of coverage expansion. 17. The Bank, through policy dialogue and analytical work, undertook a Public Expenditure Review (PER) (Managing Poverty Reduction for Growth and Expenditure, Report No. 30035–VN) which included a chapter on the health sector. The PER noted that while the Vietnam health sector had made good progress on improving indicators at the aggregate level, these indicators were not improving among poor households. It commended the Government policy of expanding health insurance coverage for poor households, while recognizing that implementation of the decree could be a challenge. It noted the need for strengthened monitoring at the hospital level to make sure that hospital funds were not diverted to provide services for the rich. It mentioned the need for establishing accreditation mechanisms for both public and private hospitals. The project design took into account available global evidence on improving health systems performance – namely the need to balance demand and supply side elements.
6
2.2 Assessment of Project Design:
18. In defining project objectives, the project was well aligned to the diagnosis of health problems in Vietnam. Moreover, it took into account the lessons learned from the implementation of health projects in Vietnam as well as other World Bank projects that were supporting health insurance expansion programs for poor and near poor households. The IDA-supported National Health Support Project, which closed in 2006, found that facility-level improvements in Vietnam needed to be underpinned by greater attention to the demand-side to ensure quality and access. The early lessons of implementation were already available to the team at the time of design of this project and were incorporated by the team. 19. The implementation arrangements built upon in-country experience with World Bank health projects. Most of the previous World Bank projects were designed as national projects and implemented in selected districts throughout the country. This approach was found to increase project complexity and reduce impact and therefore there was discussion of moving to a regional approach. A regional approach was conceived as optimal for packaging key inputs (demand- and supply-side) to obtain results. Generating accountability at the local level for project management was also identified as a lesson and incorporated in the design of the Regional Advisory Committee (RAC) which consisted of high level officials from each province. The Mekong project was the first one to try the Regional approach. 20. In a context of decentralization, the project design appropriately focused on Local Project Management Units (LPMUs) for implementation. Moreover, it established a Regional Advisory Committee as a regional coordination mechanism to oversee project implementation at a higher (local) governmental level, as well as sustain the efforts after the project closed. 21. The project did not duplicate the work of other development agencies but rather built upon and collaborated with other initiatives, such as the Asian Development Bank (ADB) Project which supported the implementation of a provincial public health model for Mekong.
22. There were some areas where design could have been stronger. At the time the project was designed, overall utilization of health services in the country was already high. Average length of hospital stay was around 12 days, the referral system was inefficient, and there was excessive use of hospitals over primary care services. The project included a preventive health care component – this was mostly on surveillance at the provincial level, not entirely linked to increased use of primary care. Payment systems – strategic purchasing to encourage providers to deliver cost-effective care – was, however, not a focus of the project. As is discussed later, this approach led to some unintended outcomes – namely a large increase in the number of hospitalizations and consultations – including among the poor. It is not clear how much of this increase is due to supplier-induced demand and how much of it is real unmet need in the population. It is perhaps a combination of both, but in a context where the country was moving towards universal coverage, a large number of hospitalizations is a key indicator for future fiscal sustainability and quality of health care in the health sector. 23. A Quality Assurance Review (QAG) of project design assigned a rating of moderately unsatisfactory.1 One of the main comments of QAG was on the weaknesses in the results framework and linkages between the various levels of indicators that would allow the
1 World Bank. Quality at Entry Assessment. September 2006.
7
Government and the team to adequately track and report on results under the project. The QAG also noted that project design perhaps was not streamlined enough to make the connections between demand side expansions through health insurance coverage, and improved access to health services and quality of care at the hospital level.The QAG comments on M&E framework was valid. The project team revised and strengthened the result framework after the QAG review. On the overall design and the relevance of project to the health sector situation in Vietnam, it is considered that the project design was relevant to the country situation and remains relevant throughout the project implementation period (detailed evaluation of the design is
discussed in Paragraph 54). The weaknesses in M&E framework were not sufficient justification for a Moderately Unsatisfactory rating of the Project design.
Adequacy of Government Commitment
24. The Government of Vietnam (GOV), specifically the Ministry of Health was fully committed to the project. The MOH exhibted full ownership from the start since the project supported the implementation of key government policies. It was fully committed to the regional approach as well. The necessary policy and legal frameworks were already in place, which indicated strong commitment of the Government to the implementation of health insurance for poor households.
2.3 Assessment of Risks:
25. The description of project risks is detailed, including assessment of risks by component. Identification of potential policy and program risks based on a technical assessment of design was adequate. For example, the project recognized that better off provinces may move faster than others and identified mitigation strategies. It identified that expansion of health insurance coverage for the poor and near poor may lead to a moral hazard situation where beneficiaries have less incentive to demand low-cost services and providers have less incentive to provide these services. It correctly identified that working with Vietnam Secuity on benefits caps and exclusions and in general strengthening payment mechanisms and purchasing would be needed. This did emerge as a risk during project implementation. Under Component 3, the implementation of which was linked to the implementation of the ADB model, the project identifed that delays may impact the project. Interestingly, the project risks section did not include a risk on project management, including project management capacity. During implementation, this emerged as one of the major risks. Implementation during the early years of the project was considerably slowed down. Moreover, monitoring and evaluation capacity was limited at project conception and this capacity was only very slowly built during project implementation. Adequate identification of risks at project entry is supposed to provide the task team with issues that should be carefully monitored and mitigated during project implementation. In hind sight, identification of project management risks during design could have led to better, early mitigation and improving readiness for implementation.
2.4 Implementation:
26. Overall, in the Vietnam context, project implementation has been impressive. The project has closed on time, fully disbursed and has achieved the PDO and component targets. This is one of the few projects in Vietnam that was not extended beyond the closing date. Initially, implementation was slow as were disbursements due to several reasons. The project management structure blends national and decentralized entities, and capacity at the decentralized level was uneven. The Central Project Management Unit (CPMU) was responsible for supporting the
8
Local Project Management Units (LPMUs), but on a day-to-day basis the LPMUs were in charge of implementation. For start-up of the project, thirteen out of fifteen feasibility reports had to be prepared and approved by the People’s Committee for each of the provinces; two out of the fifteen feasibility reports, (Can Tho Central General Hospital and Can Tho University of Medicine and Pharmacy) had to be approved by the MOH. 27. For Component A, there were policy changes in 2008 – the premium for poor households was increased from VND 80,000 to VND 130,000. The national government decided that the government would finance 50 percent of the premium for near poor households. This meant that each province had to come up with a detailed plan based on the new national policies. For Component B, one fourth of all the medical equipment purchased under the project was for Can Tho Medical University Hospital. Since the procurement for Can Tho was packaged with medical equipment for the provincial hospitals, there were initial delays. In addition, there were delays in finalizing the technical specifications for medical equipment packages. Component C of the project (preventive health) was linked to the implementation of the ADB project and the ADB project had a slow start as well, impacting the implementation of Component C. 28. However, after initial delays, due to proactive involvement of the GOV and World Bank teams, implementation picked up susbtantially as the CPMU and LPMUs built their capacity in procurement of medical equipment and other goods using Bank procurement rules. For example by the time of the August 2009 supervision mission, project disbursements and commitments had increased from 12 percent to 30 percent of total grant proceeds (in approximately 12 months), the prepartion time for bidding documents had been reduced from six months to four months and around 80 percent of actions identified during the previous missions for the health insurance coverage component, which were quite difficult to achieve, had been completed on time. By the time of the September 2011 supervision mission, disbursements had reached 60 percent of total grant proceeds and commitments 85 percent. 29. Despite the highly decentralized nature of project management which could have been problematic and chaotic, implementation of the project went smoothly. The CPMU maintained a close collaboration (almost day-to-day) contact with the LPMUs, made frequent visits and were available to answer any questions. The project management structure which consisted of MOH, DOH staff and consultants worked well. The MOH and DOH staff ensured close connection with policy issues. The World Bank team and CPMU worked together to resolve implementation problems. 30. The GOV and World Bank team conducted a strong mid-term review (MTR) in 2009. The MTR focused on a review of the PDO, key peformance indicators and component indicators as well as disbursement. An independent review of the project was also completed for the MTR. The conclusion of the MTR was that the project would be able to completed by the closing date, and only a few changes were necessary in the outcome indicators, some new activities needed to be implemented and a reallocation of funds was needed. One weakness of the MTR was perhaps that the M&E framework was not evaluated as closely as possible since the following year, based on a QAG review (described below), the team would restructure the project key performance indicators and component indicators. The project underwent a QAG Review for supervision in 2010. The QAG Review rated implementation progress moderately satisfactory. The reasons for this rating were: (i) given that the project is procurement heavy, delays in the procurement of goods and services could cause substantial delays. The QAG team was concerned that given that total commitments and disbursements under the project were only 40 percent, the project would
9
not be able to fully disburse at closing; (ii) although the project included anti-fraud and corruption measures, it was not sure that these were being followed; and (iii) weaknesses in M&E (see following sections on M&E). The QAG panel report was taken seriously by the team and identified issues addressed. For example, the project closed in June 2012 fully disbursed, with all medical equipment purchased under the project installed and operational. Financial management was rated moderately satisfactory since 2010, and there were no noted procurement problems.
2.5 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
31. Overall, the GOV and World Bank team get high marks for paying attention to M&E systems and taking a proactive approach to refining M&E systems to address identified weaknesses. Monitoring and evaluation is typically one of the most difficult areas for project design and implementation and yet critical for measuring on-the-ground project results. Moreover, M&E systems are critical for project tracking and undertaking necessary restructuring to align with an evolving policy context. Good practice in project M&E highlight the following: (i) selection of a limited number of appropriate indicators; (ii) attention to responsibilities and capacity for data collection, reporting, and analysis; and (iii) leveraging project investments to strengthen country Health Information Systems (HIS); and (iv) making sure that baseline data is available before the start of the project. Surveys can be used as independent assessments to validate HIS data, improve the quality of HIS data reporting and providing in-depth evaluation of specific project areas. 2In this ICR these criteria are applied to the evaluation of project M&E. At design: (i) the PDO and components indicators were broad, and there were too many indicators; (ii) several of the indicators were vaguely defined making it difficult to measure during implementation (e.g., coverage, quality); and (iii) there was limited use of already ongoing, well-established health surveys in the country (e.g., Vietnam Living Standards Survey). The VLSS is conducted every two years and has a well developed health module. Positive M&E project design elements include clear designation of responsibilities for data collection, analysis and reporting and the availability of baseline data for most indicators. Monitoring and evaluation functions were assigned to the CPMU. Moreover, funds were allocated under the project for carrying out the M&E function (Component Five: Project Management, Monitoring and Evaluation). 32. During implementation, the CPMU and LPMUs mainly tracked project activities (inputs). The baseline survey was carried out in 2007 − one year after the project was approved and despite the PHRD grant (both preparation and during implementation), CPMU and LPMU systems were not established to track intermediate indicators. While some indicators were clearly dependent on surveys – such as beneficiary satisfaction and out-of-pocket payments − others such as the number of cards distributed and the hospitalization and consultation rates could have been collected by the LPMUs, drawing upon routine data systems including hospital information systems. Although there was a small sub-component (under Component B) on developing hospital information systems, this mostly focused on the provision of hardware and software and less on linking the hospital information system to a functional M&E system for the project that could eventually be institutionalized by MOH and provincial health units. On the positive side, during implementation, M&E received strong scrutiny during Bank supervision mission and the GOV and Bank were proactive in addressing gaps in M&E. In 2008, the Bank team recommended the use of routine information systems for tracking and this was eventually 2 This section draws upon various IEG evaluations of World Bank lending for HNP projects. For details see Johnston and Stout (1999) and Ainsworth et al.
10
integrated into the M&E system. Under these systems large amounts of data are routinely collected and reported by public authorities, but retroactive fit did not work and the data did not necessarily fit the Results Framework for the project and were not necessarily used by project implementation units, and/or hospitals involved in the project to monitor project implementation, focusing on inputs, outputs and intermediate results. 33. The mid-term review also carried out a review of project indicators and suggested minor changes. Finally in response to a 2010 QAG supervision review, the GOV and World Bank restructured project indicators. The restructured results framework was approved by the World Bank Board in 2010. Three surveys were conducted in 2007 (baseline) 2009 (mid-term) and 2012 (end of project survey). The surveys used the same methodology throughout; there was good quality assusrance of the surveys from the CPMU and the World Bank team, and the surveys cross-validated with other sources of data – administrative and the Vietnam Living Standards Survey. As discussed later (assessment of outcomes), the project surveys results vary from the VLSS. This could be due to methodological differences between the two surveys but the results on the comparison are inconslusive. The availability of the surveys meant that there was comparable data on project results by the end of the project.
2.6 Safeguards and Fiduciary Compliance:
34. Safeguards: Approximately 12 percent of the population of the project areas belong to ethnic minorities. The project developed an Ethnic Minorities Policy Framework (EMPF) The project surveys tracked the impact of the project on ethnic groups. The health insurance coverage rate was relatively equal between the Kinh majority ethnic group and the minor ethnic groups (59.7% and 58.0% respectively) in the Mekong region. The surveys indicate that there was substantial improvement in the uptake and use of the health insurance scheme among the minority ethnic groups. The Kinh majority ethnic group tended to use health care services more than the minority ethnic group, particularly the poor and the near poor. Total health care expenditure per one treatment episode of the minority ethnic group who had health insurance was higher than that of the Kinh majority ethnic group. There is no information to indicate why this could be the case, but one possibility could be because of higher health needs among the minority ethnic group. 35. The project allocated US$1,780,000 to health care waste management which is substantially more than it committed at project design and appraisal stages. Part of the funds was used for technical assistance to develop provincial health care waste management plans (HCWMP) and contributed to a stronger hospital waste management program in beneficiary hospitals. By the end of the project, all provinces had operational health care waste management plans. In fact, during the prepartion of the Vietnam Health Care Waste Management Project, the fact that there existed already prepared health care waste management plans for the Mekong Region greatly accelerated project finalization and implementation. 36. Fiduciary: The Mekong health project management unit is considered one of the strongest PMUs among the various World Bank projects implemented in Vietnam, across health and other sectors. Recently, for a fiduciary forum organized for PMUs for other World Bank project, the Mekong fiduciary team was invited to present. This is in recognition of the strong fiduciary capacity of the Mekong PMU. As in the case of overall implementation issues, during the early years of project implementation, financial management capacity in the PMU was weak and the project was at various times rated moderately unsatisfactory for financial management.
11
Procurement capacity as mentioned earlier, was weak during the early stages of the project but was substantially improved during the life of the project.
12
Post-Completion Operation/Next Phase
37. The main elements of the Mekong project are expected to be sustained as the Government has put in place a national policy on health insurance for the poor and near poor, financing the poor and providing 70 percent of government subsidies for the near poor. In addition, provincial hospitals are fully equipped and operations and maintainence for facilities is integerated into the hospital’s annual budget. Since hospitals in Vietnam are allowed to charge fees, and the availability of health equipment is one factor that attracts patients to the hospital, operations and maintainence is not a concern. However, there may be a concern vis-à-vis hospital selection of particular patients (paying, non-paying) or giving preference to patients that enjoy better benefits from the VSS. The GOV and the Bank could consider tracking O&M expenditures in the hospitals ensuring that these can be financed from hospital budgets and do not pose additional resources burden on hospitals. The VN-Hospital Waste Management Project includes several of the project sites in the Mekong (5 Provincial Hospitals and 10 District Hospitals). The health team supervising this project plans to continue to follow-up on the environmental impacts of the Mekong health project and to make sure that lessons are shared at the national level. The Government is also continuing with the model of regional health projects.The World Bank is currently designing a new Regional Project for the North East and Red River Delta that would support the Government in strengthening essential service delivery, especially within the district and commune health system. These systems are quite weak, including in the Mekong Region, and increase consumer preference for hospital services. The application of district and commune health strengthening as national policies will contribute to further strengthening of Mekong health services, including those elements developed through this project. 38. It will also provide examples of how commune services can be strengthened to address excessive utilization of hospital services. Therefore, the proposed new Regional Project can be considered a next phase operation for the Vietnam health system, with implications for the Mekong region. Finally, the World Bank has a strong non-lending/analytical and advsiory services (AAA) program in Vietnam to complement its lending program. Under the AAA program, the Bank, along with other development partners, is undertaking a review of the 2009 Health Insurance Law with the objective of supporting the Government to undertake strategic revisions in health insurance implementation as it works towards achieving universal health care (UHC). This review will cover critical areas related to the equity, efficiency and sustainability of health insurance expansion, including for the poor and near poor. Depending on the uptake of the recommendations from the review by the GOV, the policy interventions supported through the project will be further strengthened and sustained.3
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
39. The project development objectives remain of high relevance for Vietnam as it strives to achieve universal health care by 2015 through demand (health insurance) and supply (health
3 World Bank. 2011. Concept Note: Assessment of the implementation of health insurance in Vietnam and options for consideration, World Bank Country Office, Hanoi, Vietnam.
13
service expansions) side interventions. The Mekong Project, which was the first regional project to support the operationalization of Decree 139 (health insurance for the poor), was also innovative in that it included interventions to test the enrollment of the near poor into the health insurance system through a partial subsidy scheme – where the premium is shared between the government and the individual. Based on the Mekong experience, the Government has decided to scale-up the Government cost-sharing program, by covering 70 percent of the total premium for the near poor. Global experience on universal health coverage indicates that enrolling the informal sector and near poor populations through contributory programs is difficult. Several countries that are on the path towards universal health coverage have implemented cost-sharing schemes (partial or full subsidy through the Government). Examples include Colombia, Mexico and Thailand. The results of the pilot and its scale-up by the Government is consistent with global experience. 40. The objective of improving the supply of services to improve demand – mainly through structural inputs such as medical equipment and human resources development remains equally important for other regions of Vietnam as it scales up universal health care. The project has also generated important lessons regarding the design of benefit packages and provider payment systems at the hospital level. Currently, hospital payments are on a fee-for-service basis and based on what we know globally about such payment regimes, it could be argued that the high rates of hospitalization – as experienced under the project – was partly due to the payment mechanism. Finally, the excessive use of hospital services under the project points to the need to strengthen primary care. Therefore, both in terms of its original design and implementation, as well as in the lessons it has generated, the project holds high relevance for the Vietnam health sector. The new Country Partnership Strategy for Vietnam (2012-16) includes health under the “opportunities” pillar and the main CPS indicator is increased health insurance coverage among poor and near poor households.
3.2 Achievement of Project Development Objectives
41. Based on available information, project development objectives were achieved and even surpassed in some cases (Table 2). Data for evaluating the achievement of the PDO indicators is based on the project baseline and final survey.4
4 The survey combined quantitative and qualitative methods. The quantitative survey was conducted in all 13 provinces, and had a sample size of 3,550 households (around 13,935 individuals), and 775 hospital patients. The households were selected using randomized sampling method for population-based study. The hospital patients were also randomly selected using the list of patients who would be discharged from the provincial hospital the next day. The results presented in this section are from the survey results.
14
Table 2: Project Development Objectives: Baseline, Targets and End-of-Project Results
Indicator Baseline Value Original Target
Values (from
approval
documents)
Formally
Revised Target
Values
Actual Value
Achieved at
Completion or
Target Years
Original Indicator # 1: Percentage or poor and others using and expressing satisfaction with the
provision of health services, including hospital care. Revised Indicator # 1: Hospitalization and consultation rates in public facilities among the poor and
near poor during the given calendar year.
Value quantitative or
Qualitative)
20 % (P)
0% (NP)
50% ≥ 23% (P)
≥ 10% (NP)
45.9% (P)
38.5% (NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Original Indicator # 2: Percentage of poor and near poor to whom health insurance cards have
been issued in project locations.
Revised Indicator # 2: Percentage of the poor and near poor with health insurance card.
Value quantitative or
Qualitative)
29% (P)
7.2% (NP)
70%(P)
20%(NP)
90% (P)
50% (NP)
Administrative data: 95.9% (P), 42.1%(NP)
Survey data: 94.4%(P), 68.4%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Indicator 3: Inpatient mortality (case fatality rate) from (a) Respiratory distress of newborn (P22)
and (b) trauma brain injuries (S00-S09, T90, T98).
Value quantitative or
Qualitative)
36% (a)
8% (b)
32% (a)
6% (b)
3.7%(a)
3.3%(b)
Date achieved 2008 12/10/2010 12/2011
Comments (incl. %
achievement)
This is a new indicator which was added in the restructuring document. While the inpatient mortality rate from trauma brain injuries had been reduced by 4.7%, that rate from respiratory distress of newborn had been significantly reduced by 32.3%.
Original Indicator 4: Percentage or poor and others using and expressing satisfaction with the
provision of health services, including hospital care”.
Revised Indicator 4: Patient satisfaction with the overall treatment and the condition of
facilities/equipment.
Value quantitative or
Qualitative)
52% ≥ 75% 82.7%
Date achieved 2008 12/10/2010 12/2011
15
Achievements under Specific Components
42. The component indicators (intermmediate indicators) are described in Annex Table 1. 1. The revised component indicators are in Annex Table 1.2. 43. Component 1: Protecting the Poor and Near Poor: According to the targets set for intermediate indicators, this component was successful at increasing health insurance coverage for the poor and near poor. Results under this indicator were exceeded (project target 90 percent, final results 98 percent for poor and 97 percent for near poor). The policy impact of the enrollment mechanism for the near poor was also substantial since the central government recently announced that it will finance up to 70 percent of the premium for near poor families. The other intermediate indicator was out-of-pocket payments with the target that these would not increase from the baseline of 18 percent of non-food household expenditures; the result was an increase to 23 percent, and the target was not achieved. Measuring out-of-pocket payments for health needs to be carefully done, and and a detailed assessment of the baseline should accompany any such analysis. In other countries (e.g., China), out-of-pocket payments for health increased after health insurance was introduced. Due to financial barriers to accessing care, the baseline for out-of-pocket payments may be low at baseline. As access to health insurance improves, the major financial barriers are removed, and utilization improves. However, households may pay for transportation to access health services, or there may be other costs which are not fully covered by health insurance. The household survey also calculated other household expenditures. This could be the reason why the target was not achieved. 44. Component 2: Curative Care Quality and Capacity: The main objective of this component was to support provincial and regional hospitals to improve structural quality of care through the provision of needed medical equipment. The number of new clinical or para-clinical tests conducted in hopsitals increased significantly from 7 at mid-term to 32 (with a target of 9). The other indicator on reduced referrals to Ho Chi Minh city for poor was not achieved – referrals increased from 3.4% to 3.7%, while the expected 20% decline for non-poor was achieved. Medical equipment purchased under the project are in place, well used and maintained by the hospitals. This component also envisaged support to the Vietnam Social Security for private sector regulatory activies that would allow VSS to develop private facility accreditation guidelines and procedures as well as carry out quality assurance activities. This part of the project did not make much progress and at the end of the project such guidelines have not been developed. 45. Component 3: Preventive Health: The defined indicators for the component achieved and even exceeded target values in the M&E framework (details below). The objective of this component was to invest in laboratory capacity and support the implementation of an improved surveillance system in the Mekong’s 13 Provincial preventive Medicine Centers (PPMCs). The investment in laboratory capacity took place through the provision of equipment for essential services in all provinces and for more advanced services in Can Tho PPMC. The indicator that PPMCs would carry out standard tests as per national benchmarks was exceeded. The target
was 70 and the final number was 85. The other indicator was the number of districts
receiving training and the target was also exceeeded (60 with a final outcome of 129). 46. Component 4: Human Resource Development: As Annex Table 1.3 shows the majority of the component indicators were met, or even exceeded their targets. The objective of the component was to improve the capacity of the health workforce to deliver quality health
16
services, especially for the poor and near poor. This component financed training activities for health teams at different levels of the health system, by supporting the CPMU in delivering and organizing priority training activities.
47. Component 5: Project Management. The objective of this component was to support the central and provincial project management units (PMUs) to carry out project tasks in a timely and efficient manner. There were no specific component indicators defined. As noted in the implementation sections, the Central and provincial PMUs initially had a slow start and difficulties with procurement of the rather complex medical equipment packages. Over time the provincial PMUs built their capacity with strong support from the Central PMU. The PMU organizational structure, i.e., that the head of the PMU is a senior staff from the Ministry of Health, helped in integration of the PMU into the Ministry of Health and ensured that project implementation was not disconnected from policy developments and the lessons from the project integrated into policy making. This is also evidenced by the adoption of the national government of the financing plan for the near poor which was piloted under Component 1 of the project. Finally at the provincial level, regular meetings between the project management units – facilitated by the central PMU – helped in creating a supportive environment where the provincial PMUs could learn from each other. As the results of the project show, lower capacity provinces within the Mekong region did not necessarily perform worse than the higher capacity provinces. 48. Triangulating Project Data with Other Surveys: To better evaluate project achievements and triangulate with other sources of data, data from the survey was compared with data from the Vietnam Household Living Standards Survey (VHLSS, 2010). Comparison with the VLSS 2010 shows differences. Across the board, the rates noted in the project survey are significantly higher than the VLSS. For example for Q1, the VLSS noted a utilization rate of 31% for the Mekong, while the survey rate was 36%. Again, it is not clear why there are differences (Figure 2). One possible reason is that the VLSS was conducted in 2009 and the survey in 2011. The utilization rate for Q1 is the VLSS is slightly higher in Mekong as compared with the national rates. Comparing the VLSS (2004 and 2010) shows that national rates for health consultations (inpatient and outpatient) have increased nationally from 34 percent to 40 percent. In Mekong, the improvements in health consultations are from 42.8 to 50.3 percent (7.5 percent). Among the regions in Vietnam for which 2004 and 2010 data are available, Mekong recorded the second highest increase in health consultation rate (North East had the highest: 10.5%). In other words, the VLSS corroboates that there was an improvement in the utilization rate in Mekong. All the improvements were in outpatient consultants. Inpatient consultations remained the same from 2004 to 2010 (6.7%). In 2004 (before the project), 1.3 percent of inpatient consultations were among the insured (28 percent of total inpatient consultations). In 2010, this had incresed to 3.3 percent (49 percent). 49. For outpatient consultations, the percentage insured using services in 2004 was 25 percent of total consultations and this increased to 36 percent by 2010. These data corroborate the survey results on increased utilization of health services among the insured. Moreover, the percentage of the surveyed population using government hospitals (project beneficiaries) in Mekong increased by 9 percent. 5 For out-of-pocket payments, the rates for Mekong for quintile 1 are slightly lower than the national rates (See Figure 1). However the project survey results indicate significantly higher out-of-pocket expenditures for Q1 as compared to the national and 5 General Statistics Office. 2010. Vietnam Living Standards Survey (VLSS): 2010.
17
Mekong rates in the VLSS. This is most likely attributable to the methdology in the survey which calculated cash and non-cash expenditures for health, including income loss of both sick persons and family members that took care of the patients. According the project survey results, out-of-pocket payments are also regressive, i.e., poor households pay more than rich households. The VLSS shows that the differences between poor and rich households is much smaller, indicating a much lower level of regressivity.
Figure 1: Share of out-of-pocket health expenditure in the total health spending on non-food items
Source: VHLSS and MRHSP.
Figure 2: Hospitalization and consultation rates in public facilities by income quintiles derived from
VLHSS and MRHSP endline survey
Source: VHLSS and MRHSP.
12.1% 12.2% 10.6%
9.7% 8.3%
11.9% 11.0%
10.1% 9.5%
8.3%
23.0%
16.4%
9.8% 7.5%
4.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Q1 Q2 Q3 Q4 Q5
National rate in VLHSS 2010 Mekong Regional rate in VLHSS 2010
Mekong Regional in CCRD survey
29.3% 27.4% 27.5% 27.7% 28.7%
31.1% 25.8% 28.5% 28.2% 29.0%
36.6% 37.3% 36.3% 32.2%
38.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Q1 Q2 Q3 Q4 Q5
National rate in VLHSS 2010 Mekong Regional rate in VLHSS 2010Mekong Regional in CCRD survey
18
3.3 Efficiency
50. The project did not undertake a quantitative estimate of the project’s net present value (NPV). It mainly focused on the equity, efficiency and fiscal impacts of the project. The fiscal impacts are covered under the sustainability section of the ICR, and this section mainly focuses on the impact of the project on technical and allocative efficiency in the Mekong health sector. The project expected increased efficiency, both through resource savings (i.e., enabling reductions in the cost of health care without compromising health outcomes) and by improving the Mekong region’s health outcomes. According to the baseline and final survey for the project – based on self-reported data – morbidity in the Mekong region did not improve during the life of the project. In fact, the percentage of people of the surveyed population that had experienced at least one sick episode increased from 25% for the poor and near poor to 36%. The cost of health care at baseline and at project closing does not seem to have been reduced as measured by indicators such as the frequency of hospitalization per patient increased from 1.45 for poor and near poor to 1.90 at end of project, as well as the average number of hospitalization days which increased from 12 to 15 days for the poor and from 12 to 13 days for the near poor. 51. There is no available information on the price of health care services at baseline and at project completion, but upgrades in health technology can result in cost savings or become cost-enhancing depending on use. Based on the data collected, the number of tests per capita in project sites appears to be on the high side. Therefore, it could be argued that the provision of improved medical equipment without the parallel improvements in provider payment systems which is largely fee-for-service in the hospitals, has not contributed to technical efficiency under the project. Based on survey data, it seems that generally, as a result of health insurance, the use of health services both inpatient and outpatient increased among the poor and near poor. However, there is no data available to gauge the effectiveness of treatment encounters, indicating possibly technical and allocative efficiency concerns.
19
Table 3: Average sick episodes, frequency of hospitalization and hospitalization days per capita in
the last 12 months by poverty status
Baseline survey End line survey
Poor & Near-poor
Non-poor Total Poor Near-
poor Non-poor Total
Proportion of people who experiences at least one sick episode.
25.0 %
24.0 %
25.0%
39.4%
34.9%
37.0 %
37.3 %
Average number of sickness episode.
3.57 3.21 3.26 3.99 4.18 3.51 3.63
p=0.06 p<0.0001
Average frequency of hospitalization per inpatient.
1.45 1.43 1.44 1.90 1.65 1.41 1.54 p=0.89 p<0.01
Average hospitalization days. 12.12 12.14 12.14 15.25 13.17 11.06 12.15
p=0.99 p<0.05
Average frequency of outpatient treatment per capita.
n.a. n.a n.a 5.01 4.91 3.93 4.23
p<0.0001
Average number of self-treatment per capita.
n.a n.a n.a 5.72 4.84 4.65 4.83
p<0.0001
Source: Baseline and Final Household Survey. 52. Overall Rating: Based on the analysis presented in the previous section, the overall assessment of project outcomes in Satisfactory. The project was a first generation universal coverage project that aimed at expanding coverage for the poor and near poor population and ensuring that services were available and accessed by the newly insured. These objectives were achieved and even exceeded. The project remains highly relevant for the country as it strives towards universal coverage and expanding access for the poor and near poor. The project had national level policy impact since the enrollment of the near poor became national policy. Nevertheless, there are shortcomings in terms of efficiency – namely the large increase in use of hospital level services and potential concerns with supplier-induced demand in a fee-for-service environment. However, these impacts were already noted during the implementation process, and through additional policy dialogue with the client, the current policy interventions with the Vietnam Social Security now largely focus on provider payment reforms.
4. Assessment of Risk to Development Outcomes
53. The risks to development outcomes is rated moderate. The GOV is continuing the reforms that were implemented in the project – broadly under the rubric of universal health care. The Prime Minister has announced that the Government will pay up to 70% of the premiums for the near poor. In the Mekong Region, as a result of the project, all provincial hospitals and the Regional Hospital in Can Tho have been equipped to provide the level of health services that hospitals at this level in Vietnam are expected to provide. The Project has generated important lessons for the implementation of universal coverage in the country including enrolling the near
20
poor, implementing a catastrophic health care package, and the impacts of improved structural quality of care (inputs) on utilization of health services at the hospital level. This has also triggered concerns with technical quality of care and provider payment mechanisms which the MOH is now beginning to address as part of second generation universal coverage reforms. Ensuring that these issues are addressed as national policies will ensure that provincial level implementation follows. From the financial perspective, Vietnam continues on a strong growth trajectory. The Vietnamese economy is growing at a rate of 6-7% on average and public financing for health needed to sustain enrollment of the poor and near poor is projected to grow.
5. Assessment of Bank and Borrower Performance
54. Bank Performance at Design: Bank performance at design is rated moderately
satisfactory. The project design was relevant to the health sector situation in Vietnam and took into account both demand- and supply-side dimensions which is critical for achieving better results in the health sector. Project design built upon key Government laws and regulations, namely Decree 139 (health insurance) and 10 and 40 (financial autonomy for health facilities) and took into account Government’s preferences for a regional approach. There were a few design elements which could have been stronger with the expansion of health insurance and improvement in structural quality of care (through the provision of medical equipment and training), it was expected that utilization would increase. However, increased hospitalization rates, as well as excessive use of medical devices (compared with either national or international benchmarks) are not necessarily a good development and something that needs to be closely tracked at a policy and project level. Moreover, provider payment systems become very important in this context to make sure that supplier-induced demand is not a problem. The project design, while mentioning that capacity of VSS would be built, did not include any specific mechanism to ensure that these policy developments on provider payments systems would be calibrated with the roll out of health insurance and facility upgrades. The weaknesses in M&E design were already elaborated earlier. 55. Bank Performance during Supervision: Bank performance during supervision is rated satisfactory. Projects operate in a dynamic policy and institutional context and even the best designed project may be poorly implemented and not contribute to results on the ground. The World Bank team took a continuous, proactive approach to supporting project implementation. It was also responsive to various M&E reviews and took corretive action. 56. The project indicators were revised through a formal restructuring of the project (2010). The team began to raise with the Government quality of care issues. For example, the March-April 2010 aide memoire notes that while health insurance coverage was on track in many of the 13 provinces, in those provinces where coverage was reaching almost 100 percent, it was important to shift attention to quality of care issues. Based on these discussions Long An province prepared a quality improvement proposal. It was perhaps because the team had already raised quality of care as an emerging issue, that the findings of the ICR team were of no surprise to the Ministry of Health (MOH) and in fact very well received in terms of next steps for reform. 57. Continuity within the task team has been good and there were three task team leaders (TTLs) since the beginning of the project cycle with a well planned transition from one TTL to the next. The team has brought in technical specialized expertise as needed (e.g., medical equipment specialist). The Bank team worked closely with the Borrower providing implementation support on procurement, financial management and technical issues. The task team, along with the team leader and country sector coordinator (also health specialist) were
21
based in the field and were therefore able to respond promptly to emerging problems. In the early years, although the team leader was based in Washington DC, the TTL had good relations with the client and was able to provide good support from a long distance. There were also frequent missions undertaken. 58. Implementation experience in the expansion of health insurance and quality improvements at the provincial hospital levels indicates the need for national level policy reforms in strategic purchasing by VSS. Therefore, in this type of project design, the Bank team should have continuously integerated the policy dimensions into national level policy dialogue. Based on discussions with counterparts during the ICR mission, the ICR team concluded that the task team had indeed been integrating the lessons from the project into the national policy dialogue. In fact, the lessons learned from the implementation of health insurance for the near poor were integrated into national policy (70% coverage of premium for the near poor). Moreover, there is recognition that payment systems at the hospital level – mainly fee for service − could be encouraging increased volume of services (number of diagnostic test carried out), and there is a need to implement different payment mechanisms and strengthen technical quality of care. Overall Bank performance rating is satisfactory.
59. Borrower Performance during Design: Borrower performance at design is rated satisfactory. The Borrower strongly owned the design of the project which focused on the implementation of key policy and regulatory reforms. This project was originally designed as two projects − a health insurance project and a second project supporting the supply-side. The GOV however did not want two projects. The potential recurrent cost implications of borrowing from the World Bank for health insurance premiums was a concern, and therefore, the Borrower requested only one project. In hindsight, having one project instead of two reduced project complexity and increased the success of the implementation of demand- and supply-side elements that need to be carefully phased for project impact. 60. Borrower Performance during Supervision: Borrower performance during supervision is rated satisfactory. Despite, initial delays, the CPMU and LPMUs significantly improved their performance over time, making sure that the project closed on time, fully disbursed, and results achieved as per project targets. Over time, project management capacity was significantly improved, and the CPMSU and LPMSUs worked in close coordination on the procurement of medical equipment. Capacity to procure technical assistance was, however, more limited. There was strong supervision from the Central PMSU, and continuous support to LPMSUs. This is evidenced by the fact that prior to project closure, close to 90% of planned medical equipment under the project has been purchased and installed, staff trained; andmedical equipment operational in all provincial hospitals and Can Tho Regional Hospital.
Overall borrower performance is rated satisfactory.
6. Lessons Learned
61. More than 30 low and middle income countries globally are currently pursuing universal health care (UHC) policies. In many of these countries, an explicit focus is on expanding health insurance programs for poor and near poor households. In that context, the VN Mekong Health Support Project which was one of the early Bank projects to adopt the combined demand- and supply-side approach is instructive for Vietnam as well as for other countries in the Region and
22
elsewhere. In the lessons learned section, the ICR team focused on two aspects of lessons learned: (i) the technical lessons learned of relevance for the World Bank and other countries work on universal health care; and (ii) the particular project design and implementation issues which have implications for the design of such projects. Technical Lessons Learned
62. One of the main objectives of universal health care is to improve access to quality health services. In the Mekong project, this objective was pursued through expanding health insurance coverage for the poor and near poor, and at the same time improving the structural quality of care in provincial hospitals to serve the needs of the insured population. In many countries where the Bank works, similar reforms are being undertaken. As the results from the project show for the Mekong Region, the number of insured population increased significantly during the life of the project. Providing medical equipment and training to hospitals helped upgrade the structural quality of care in the hospitals and allowed the hospitals to better serve the needs of the population. However, there are some key lessons learned. 63. Bringing Poor and Near Poor Households into Health Insurance: One of the key challenges facing Vietnam, and other countries in the East Asia and Pacific Region is how to bring poor and near poor families into health insurance. Enrollment of near poor families is a particular challenge since there is typically no coherent approach and countries adopt different approaches based on country-specific conditions and fiscal space considerations. However, countries in the region such as Thailand that have been able to achieve universal coverage, did so by covering the near poor from general budget revenues. The Mekong Health project which provided coverage for near poor households up to 80% (50% through the province, 30% through the project and 20% through member participation) demonstrated that such a cost-sharing arrangement could attract the near poor to enroll into health insurance. Although the project stopped paying its share in 2011, enrollment of near poor has not dropped. The province as well as the national government are picking up a large share of the premium. However, in 2011, the national government subsidy was not in place and individuals were willing to pay their share (50 percent). This possibly indicates that the near poor see the benefit of enrollment in health insurance through access to health care services, especially hospital services. 64. Phased Implementation of Demand- and Supply-Side Interventions: In many countries implementing universal health care, there are large supply-side gaps in delivering services. The Mekong Project shows the importance of phased sequencing of demand- and supply-side interventions. It also indicates that some level of hospital autonomy is needed so that hospital managers and staff are able to effectively use inputs to generate results. The key gap – in the case of Vietnam – is in benefits package definition and provider payment reforms, in the absence of which, the goals of universal health care for the poor will not be achieved. It seems that due to weaknesses in district level financing and management of the insured population, utilization of provincial hospitals is quite high. Since hospitals are allowed to charge over and above what is paid by the VSS – albeit in a regulated manner, this has implications for uneven access to care for the poor and near poor. 65. High utilization rate at the provincial hospital level for given burden of disease in
the population. The data on leading causes of morbidity in the Mekong Region in 2010 and the leading causes of morbidity reported by provincial hospitals in the Mekong River (Vietnam Living Standards Survey or VLSS and the household survey for the project) indicate acute
23
tonsilitis and pharyngitis, post-viral fatigue syndrome, acute bronchitis. Only 2 percent were catasthrophic (heart disease, heart failure). The majority of hospital admissions are for similar reasons. For example, an estimated 20 percent of admissions were for viral fever. Many of these conditions can be treated at the primary care centers and district hospital levels. 66. The project dealt with provinical and tertiary level hospitals and aimed at reducing the number of referrals to Ho Chi Hinh City. However, it did not tackle referrals between district to provincial levels. Therefore, it is hard to understand why there is a preference for provincial hospitals. It could be that care at the district level is inadequate and the population feels they will get better care at the hospital level. It could also be a reflection of the provider payment systems at different levels of the system. At the district level, capitation (fund holder model) is in place, while provincial and tertiary level hospital payments are largely fee-for-service. Looking ahead, as Vietnam moves towards universal coverage, the inter-relationship between the district and provincial health systems will require more attention. Primary care systems could perhaps also be strengthened. At the national policy level, there is discussion of introduction of diagnostic related groups or DRGs. This payment mechanism would help control high use of medical devices and encourage hospital to carry out more efficient care. 67. General technical quality of care issues. The project did not collect information on use rates for medical equipment provided through the project (Computer Tomography scans, Magnetic Resonance Imaging or MRIs, X rays). Nor was data available for use rate among poor, near poor and non-poor populations, although this data is available in the Vietnam Social Security (VSS) and could be analyzed. During the field visit to Ca Mau provincial hospital, hospital administrators indicated that the hospital carries out 30 to 40 CT scans a day, which means 1200 CT scans per month in a population of 1 million. Approximately 300-400 x-rays are carried out each day. We know from OECD countries that high rates of usage of diagnostic testing do not necessarily perform the best on health outcomes. As Vietnam gets into the next stage of universal health care reforms, perhaps addressing technical quality of care will emerge as a concern. There is already policy discussions at the national level on the implementation of clinical pathways or other mechanisms to address technical quality of care. Project Specific Lessons Learned
68. Success of the Regional Project Design: The Mekong Health Project was the first attempt at a regional approach. The objective of the regional approach is to make the necessary investments at the regional level combined with pilot testing of interventions which then impact national policies. In this case, the Mekong region was selected since it was one of the regions in Vietnam with poor health outcomes. The project piloted interventions for enrolling the poor and the near poor into health insurance which have subsequently been adopted as national policies. In 2009, the GOV announced the integration of the health insurance for the poor scheme into the national health insurance system. In 2012, the GOV announced that the national government would cover 70 percent of the premium for near poor households. This turned out to be good approach focusing project inputs within a region and getting impacts at the regional level, as well as lessons learned. The project at design identified the risks of a regional approach and effectively managed these risks during project implementation. As a result of the success of the regional approach under Mekong, this approach will now be continued under the proposed Red River Delta project.
24
69. Strong Project Management and Capacity: The project implementation design of a central PMSU and local PMSU worked well, as did the Regional Advisory Committee (RAC) which provided a mechanism for provincial leaders to share experience and hold provinces accountable for results under the project. While at the beginning of the project, capacity in the PMSU and LPMSU was weak which impacted the pace of project implementation, capacity was built over time. Project management unit has built up considerable capacity and it would be good to keep this capacity in the health sector since several other regional projects are currently under design. 70. Strong Project Implementation Support and Good Integration of Policy Dialogue
into Implementation Support: The World Bank team worked continuously and in a proactive, problem-solving manner with the GOV to provide implementation support. The team carried out a strong mid-term review (MTR) using the MTR to reiterate GOV commitment to strong project implementation. Small adjustments were also made during the MTR to enhance chances of the project closing on time, and fully disbursed. The implementation of regional projects, such as Mekong Health, requires strong and continuous policy engagement at the national level. The health team in Vietnam managed to keep a good balance between project implementation support and national-level policy dialogue. This is evidenced by the fact that the implementation experience from the project on enrolling the near poor has been announced as national policy by the Prime Minister with the national government paying 70 percent of the premium for the near poor. The lessons from the Mekong Project which integerated demand- and supply-side issues have also contributed to the Bank’s ongoing policy dialogue on provider payment reforms in Vietnam. The Bank has been strongly engaged as well on hospital reforms and jointly produced policy notes on this topic with the Ministry of Health, Vietnam. The lessons from the Mekong project are being incorporated into the the design of the Health Task Force under the Central North Regional Health Support Project. This support was developed taking experience from the Mekong project to bring up project issues to national level policy. 71. Limited Focus on Building Country Systems for Monitoring and Evaluation: Every World Bank financed project is an opportunity to strengthen country data systems in monitoring and evaluation While the project supported software and hardware for hospital management information system, these investments were not linked to the to the broader M&E framework that would allow outputs from this component to be used for M&E. The project had an interesting design wherein a technical assistance component financed through a Japan grant (PHRD) were utilized for capacity building. However, few of the PHRD funds were used for supporting country systems in M&E. The strong M&E element of the the project were the baseline, mid-term and final survey, which were completed on time for the mid-term review and project closing and provided comparable data on project impacts. This is often not the case in most Bank projects and provides key information to gauge the impact of the project. In the future design of HNP projects in Vietnam, the GOV and World Bank teams could perhaps focus more on building country systems for M&E in the health sector.
25
7. Comments on Issues Raised by Borrower and Implementing Agencies
72. Borrower comments on the ICR have been incorporated. The Borrower has two comments under the Implementation Section:
(a) The Borrower corrected the approval process for the feasibility reports; and (b) The Borrower mentioned that project implementation in Can Tho Hospital was not
delayed due to construction.
26
Annex 1: Project Costs and Financing
(a) Project Cost by Component in SDR (USD Million equivalent)
Component Cost at Appraisal
(USD millions)
Actual Costs
(USD millions)
Percentage of
Appraisal
1. Protecting the Poor and Near Poor
5,577,143 (8.0)
6,300,515 (10.0)
113
2. Curative Care Quality and Capacity
26,491,429 (38.0)
28,219,644 (44.8)
106.5
3. Preventive Health 4,531,429 (6.5)
4,956,254 (7.8)
109.3
4. Human Resources Development
5,577,143 (8.0)
7,073,904 (11.2)
126.8
5. Project Management, Monitoring and Evaluation
4,531,429 (6.5)
2,235,132 (4.2)
49.3
6. Unallocated 2,091,429 (3.0)
- -
TOTAL 48,800,000 (70.0)
48,785,449 (77.4)
99.97
(b) Financing
Source of Funds Type of Co-
financing
Appraisal
Estimate (million
USD millions)
Actual/Latest
Estimate (USD
millions)
Percentage of
Appraisal
The Japan PHRD Grant 5.00 4.89 97.8 International Development Association (IDA)
48,800,000 (70.00)
48,785,449 (77.4)
99.97
27
Annex 2: Outputs by (Component) Performance Indicators
Annex Table 2.1: Original Intermediate Results Indicators for Each Project Component
Component Indicators
Component 1: Protecting the Poor and Near Poor – Improve access to health care services for the poor and near poor.
Percentage of poor and other target beneficiaries using and expressing satisfaction with the provision of different levels of health services, including hospital Care.
Percentage of poor and near poor to whom health insurance cards have been issued, by province.
Percentage of poor and near poor who are covered by the catastrophic support scheme.
Awareness among beneficiaries (poor and others), health providers and local authorities of Government’s policies and project’s supported schemes in providing health care support to the poor and others.
Share of out-of-pocket household expenditures for health in total household non-food expenditure among poor and near poor.
Number of proposals supporting the poor and near poor submitted, approved and implemented in project provinces.
Component 2: Curative Care Quality and Capacity: Improve quality and availability of hospital services in demand by the public, especially the poor.
Percentage of patients (poor & others) using and reporting satisfaction with hospital care.
Improvement of quality of hospital care in the project Hospitals.
Utilization of health care services, especially hospital services, by the poor, near poor and others.
Percentage of high-tech medical services available at the project provincial hospitals (against the MOH’s official list).
Utilization rates of new equipment.
Number of self-referrals.
Number of self-referrals to Cho Ray hospital in HCMC.
Number o f provincial hospitals that have installed and are using the improved HIS.
Number of private sector practitioners and or hospitals applying for registration with Vietnam Social Secuirty (VSS)
28
and being accredited.
Component 3: Preventive Health. Improve capacity of preventive health services to control priority infectious diseases, food poisoning, occupational and environmental diseases, and school health problems.
Utilization rate of new equipment.
Availability of key laboratory services at provincial level.
Number of provinces that have installed and are using improved surveillance software.
Component Four: Human Resources Development. Improve capacity of health workforce to deliver better quality health services, especially to the Poor.
Percentage of patients/service users (poor and others) satisfied with performance of health staff at the supported health facilities.
Number of Specialist Grade 1, Grade 2, Master and PhD as a result of project support, by specialty and province.
Number of curative care and preventive health staff who have completed short-term specialization training required for utilization of new equipment by province.
Number of project-supported health facilities which introduce new HR management tools to improve staff retention, performance, and skills.
Table 2.2: Original and Revised Intermediate Component Indicators
Original Revised
Component 1:
Percentage of poor and other target beneficiaries using and expressing satisfaction with the provision of different levels of health services, including hospital care.
Percentage of poor and near poor to whom health insurance cards have been issued, by province.
Percentage of poor and near poor who are covered by the
Percent of the poor and near poor who know all the benefits, entitlements and rules for their health insurance coverage.
Share of out-of-pocket health expenditure in the total health spending on non-food items.
29
catastrophic support scheme.
Awareness among beneficiaries (poor and others), health providers and local authorities of Government’s policies and project’s supported schemes in providing health care support to the poor and others.
Share of out-of-pocket household expenditures for health in total household non-food expenditure among poor and near poor.
Number of proposals supporting the poor and near poor submitted, approved and implemented in project provinces.
Component 2:
Percentage of patients (poor and others) using and reporting satisfaction with hospital care.
Improvement of quality of hospital care in the project hospitals.
Utilization of health care services, especially hospital services, by the poor, near poor and others.
Percentage o f high-tech medical services available at the project provincial hospitals (against the MOH’s official list).
Utilization rates of new equipment.
Number of self-referrals.
Number of self-referrals to Cho Ray hospital in HCMC.
Number of new clinical or para-clinical tests that have been applied in provincial hospital since 2008.
Number of referrals to HCMC hospitals.
30
Number of provincial hospitals that have installed and are using the improved HIS.
Number of private sector practitioners and or hospitals applying for registration with VSS and being accredited.
Component 3:
Utilization rate of new equipment.
Availability o f key laboratory services at provincial level.
Number of provinces that have installed and are using improved surveillance software.
Number of standard tests (according to the new National Benchmark issued by the MOH in 2009) that can be performed by preventive health centers.
Number of districts preventive health centers receive training on surveillance software and computer hardware to produce surveillance reports.
Component 4:
Percentage of patients/service users (poor and others) satisfied with performance of health staff at the supported health facilities.
Number of Specialist Grade 1, Grade 2, Master and PhD as a result of project support, by specialty and province.
Number of curative care and preventive health staff who have completed short-term specialization training required for utilization of new equipment by province.
Number of project-supported health facilities which introduce new HR management tools to improve staff retention, performance, and skills.
Number of training completed as a result of Project support, by specialty and province (Grade 1, Grade 2, Master, PhD, on-the-job training (cumulative number).
Number of health staff who has completed short-term training courses (from 1 month up to 1 year) as a result of Project support.
Percentage of specialty posts filled.
Percent of medical professionals returning to their original workplace after long-term training supported by the project.
31
Annex 3: Results Framework
Annex Table 3.1 : PDO Indicator
Indicator Baseline
Value
Original
Target
Values
(from
approval
documents)
Formally
Revised
Target
Values
Actual Value Achieved
at Completion or
Target Years
Indicator 1: Hospitalization and consultation rates in public facilities among the poor and near poor during the given calendar year.
Value quantitative or Qualitative)
20 % (P)
0% (NP)
50% ≥ 23% (P)
≥ 10% (NP)
45.9% (P)
38.5% (NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”. The target had over reached almost twice (for the poor) and four times (for the near poor) as compared to the formally revised target values.
Indicator 2: Percentage of the poor and near poor with health insurance card.
Value quantitative or Qualitative)
29% (P)
7.2% (NP)
70%(P)
20%(NP)
90% (P)
50% (NP)
Administrative data: 95.9% (P), 42.1%(NP)
Survey data: 94.4%(P), 68.4%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
The target had been over reached in the survey data. However, in the administrative data, only the target for the poor had been reached, but the target for the near poor had not been reached.
Indicator 3: Inpatient mortality (case fatality rate) from (a) Respiratory distress of newborn (P22) and (b) trauma brain injuries (S00-S09, T90, T98).
Value quantitative or Qualitative)
36% (a)
8% (b)
32% (a)
6% (b)
3.7%(a)
3.3%(b)
Date achieved 2008 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. While the inpatient mortality rate from trauma brain injuries had been reduced by 4.7%, that rate from respiratory distress of newborn had been significantly reduced by 28% (about 10 times
32
of reduction).
Indicator 4: Patient satisfaction with the overall treatment and the condition of facilities/equipment.
Value quantitative or Qualitative)
52% ≥ 75% 82.7%
Date achieved 2008 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”.
Indicator: Improvement of quality of hospital care in the project hospitals.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Annex 3.2: Intermediate Outcome Indicator(s)
Indicator Baseline Value Original
Target
Values
(from
approval
documents)
Formally
Revised
Target
Values
Actual Value Achieved
at Completion or
Target Years
Component 1: Protecting the Poor and Near Poor
Indicator 1: Percent of the poor and near poor who know all the benefits, entitlements and rules for their health insurance coverage.
Value quantitative or Qualitative)
60% 50% 80% 98.7%(P)
97.0%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Percentage or poor and others using and expressing satisfaction with the provision of health services, including hospital care”. The target had been over achieved with about 17-19% higher compared to the formally revised target values.
Indicator 2: Share of out-of-pocket health expenditure in the total health spending on non-food
33
items.
Value quantitative or Qualitative)
18% (P)
16.1% (NP)
Not increase Not increase 18.3%(P)
15.2%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Share of out-of-pocket household expenditures for health in total household non-food expenditure among the poor and near poor”. The share of out-of-pocket health expenditure among the poor increased slightly by 0.3%, while that of the near poor decreased by 0.9%.
Indicator: Percentage of poor and near poor who are covered by the catastrophic support scheme.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Indicator: Number of proposals to support the poor and near poor in health care: Submitted; Approved and implemented.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Component 2: Curative Care Quality and Capacity
Indicator 1: Number of new clinical or para-clinical tests that have been applied in provincial hospital since 2008.
Value quantitative or Qualitative)
0 9 32
Date achieved 2008 12/10/2010 12/2011
Comments This is a new indicator which was added in the restructuring document. The
34
(incl. % achievement)
number of new clinical or para-clinical tests increased significantly (with an increase of 23 new tests as compared to the revised target).
Indicator 2: Number of referrals to HCMC hospitals
Value quantitative or Qualitative)
3.4% (P)
6% (NP)
20% reduction
20% reduction
Administrative data: 1.1%
Survey data: 3.7%(P), 4.9%(NP)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of self-referrals to Cho Ray hospital in HCMC”. According to the survey data, there was a slight increase in the number of referrals to HCMC hospitals among the poor, while it was a slight reduction among the near poor (a reduction of 1.1% that equals to 18% reduction). However, if compared with administrative data, there was a significant reduction among the poor (a reduction of 68%) and the near poor (a reduction of 82%).
Indicator: Percentage of high tech medical services available at the project provincial hospitals (against MOH’s official list).
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Indicator: Utilization rate of new equipment, (compared to optimal functional rates of the equipment).
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Indicator: Number of provincial hospitals that have installed and are using the improved HIS.
Value quantitative or Qualitative)
35
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Indicator: Number of private sector practitioners and/or hospitals applying for registration with VSS and being accredited.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
This indicator was dropped/restructured.
Component 3: Preventive Health
Indicator 1: Number of standard tests (according to the new National Benchmark issued by the MOH in 2009) that can be performed by preventive health centers.
Value quantitative or Qualitative)
45 70 85
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. There were 15 new test increases compared with the revised target.
Indicator 2: Number of districts preventive health centers receive training on surveillance software and computer hardware to produce surveillance reports.
Value quantitative or Qualitative)
0 60 129
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document.
Indicator: Utilization rate of new equipment.
Value quantitative or Qualitative)
36
Date achieved
Comments (incl. % achievement)
Dropped/restructured.
Indicator: Availability of key laboratory services at provincial level.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
Dropped/restructured.
Indicator: Number of provinces that have installed and are using improved surveillance software and computer hardware to produce surveillance reports.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
Dropped/restructured.
Component 4: Human Resources Development
Indicator 1: Number of training completed as a result of Project support, by specialty and province (Grade 1, Grade 2, Master, PhD, on-the-job training (cumulative number).
Value quantitative or Qualitative)
0 490 (Gr1)
206 (Gr2)
10 (MSc)
4 (PhD)
1485 (Gr1)
318 (Gr2)
195 (MSc)
11 (PhD)
789 (on the job)
1592 (Gr1)
361 (Gr2)
230 (MSc)
25 (PhD)
1794 (on the job)
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of specialist Grade I, Grade II, Master and PhD as a result of project support, by specialty and province”. All target had been over reached, particularly the number of on-the-
37
job training and the number of PhDs doubledcompared with the revised target.
Indicator 2: Number of health staff who has completed short-term training courses (from 1 month up to 1 year) as a result of Project support.
Value quantitative or Qualitative)
0 1696 1000 8008
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This indicator was revised from the indicator “Number of curative care and preventive health staff who have completed short-term specialization training required for utilization of new equipment”. The number of health staff who completed short-term training courses was 8 times as high as the revised target.
Indicator 3: Percentage of specialty posts filled
Value quantitative or Qualitative)
0 95% 90%
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. The target had been nearly reached.
Indicator 4: Percent of medical professionals returning to their original workplace after long term training supported by the project.
Value quantitative or Qualitative)
0 90% 96.8%
Date achieved 2008 02/09/2012 12/10/2010 12/2011
Comments (incl. % achievement)
This is a new indicator which was added in the restructuring document. The target had been over reached (with an increase of 6.8%).
Indicator: Percentage of patient/service users (poor and others) satisfied with performance of health staff at the supported health facilities (as above).
Value quantitative or Qualitative)
Date achieved
Comments (incl. %
Dropped/restructured.
38
achievement)
Indicator: Number of project-supported health facilities which introduce new HR management tools to improve staff retention, performance, and skills development.
Value quantitative or Qualitative)
Date achieved
Comments (incl. % achievement)
Dropped/restructured.
*) P= the poor; NP= the near poor.
Annex 3.3: Outputs by (Component) Performance Indicators
Component/Subcomponent Expected Outputs
(from
PAD/original
Implementation
Plan)
Actually
Delivered
Outputs
(until 31 Dec
2011)
Remarks
Component 1: Protecting the Poor and Near Poor
Percent of the poor and near poor who know all the benefits, entitlements and rules for their health insurance coverage.
80% 98.7%(P) 97.0%(NP)
Revised to be more measurable
Share of out-of-pocket health expenditure in the total health spending on non-food items.
Not increase 18.3%(P) 15.2%(NP)
Revised to be clearer
Percentage of poor and near poor who are covered by the catastrophic support scheme.
Dropped/restructured
Number of proposals to support the poor and near poor in health care: Submitted; Approved and implemented.
Dropped/restructured
Component 2: Curative Care Quality and Capacity
Number of new clinical or para-clinical tests that have been applied in provincial hospital since 2008.
Percentage of high tech medical services available at the project provincial hospitals (against MOH’s official list).
Dropped/restructured
Utilization rate of new equipment, (compared to optimal functional rates of the equipment).
Dropped/restructured
Number of provincial hospitals that have installed and are using the improved HIS.
Dropped/restructured
Number of private sector practitioners and/or hospitals applying for registration with VSS and being accredited.
Dropped/restructured
Component 3: Preventive Health
Number of standard tests (according to the new National Benchmark issued by the MOH in 2009) that can be performed by preventive health centers.
70 85
New indicator
Number of districts preventive health centers receive training on surveillance software and computer hardware to produce surveillance reports.
60 129 New indicator
Utilization rate of new equipment.
Dropped
Availability of key laboratory services at provincial level.
Dropped
Number of provinces that have installed and are using improved surveillance software and computer hardware to produce surveillance reports.
Dropped
Component 4: Human Resources Development
Number of training completed as a result of Project support, by specialty and province (Grade 1, Grade 2, Master, PhD, on-the-job training (cumulative number).
1485 (Gr1) 318 (Gr2) 195 (MSc) 11 (PhD) 789 (on the job)
1592 (Gr1) 361 (Gr2) 230 (MSc) 25 (PhD) 1794 (on the job)
Revised to be clearer
Number of health staff who 1000 8008 Revised to be clearer
40
has completed short-term training courses (from 1 month up to 1 year) as a result of Project support. Percentage of specialty posts filled.
95% 90% New indicator
Percent of medical professionals returning to their original workplace after long term training supported by the project.
90% 96.8% New indicator
Percentage of patient/service users (poor and others) satisfied with performance of health staff at the supported health facilities (as above).
Dropped/restructured
Number of project-supported health facilities which introduce new HR management tools to improve staff retention, performance, and skills development.
Dropped/restructured
41
Annex 4: Economic and Financing Analysis
1. The project did not include a quantitative analysis of project benefits, for example in terms of net present benefits. It focused on the potential economic impacts of the project in terms of improved equity and efficiency. It also looked at financial sustainability of investments through the project. 2. The project expected increased efficiency, both through resource savings (i.e., enabling reductions in the cost of health care without compromising health outcomes), and by improving the Mekong region’s health outcomes. According to the baseline and final survey for the project – based on self-reported data – morbidity in the Mekong region did not improve during the life of the project. In fact, the percentage of people of the surveyed population that had experienced at least one sick episode increased from 25% for the poor and near poor to 36%. The cost of health care at baseline and at project closing does not seem to have been reduced as measured by indicators such as the frequency of hospitalization per patient − increased from 1.45 for poor and near poor to 1.90 at end of project, as well as the average number of hospitalization days which increased from 12 to 15 days for the poor and from 12 to 13 days for the near poor. 3. There is no available information on the price of health care services at baseline and at project completion, but upgrades in health technology can result in cost savings or become cost-enhancing depending on use. Based on the data collected, the number of tests per capita in project sites appears to be on the high side. Therefore, it could be argued that the provision of improved medical equipment without the parallel improvements in provider payment systems – which is largely fee-for-service in the hospitals, has not contributed to technical efficiency under the project. Based on survey data, it seems that generally, as a result of health insurance, the use of health services – both inpatient and outpatient increased among the poor and near poor. However, there is no data available to gauge the effectiveness of treatment encounters, indicating possibly technical and allocative efficiency concerns.
42
Annex Table 4.1: Average sick episodes, frequency of hospitalization and hospitalization
days per capita inthe last 12 months by poverty status
Baseline survey Endline survey
Poor & Near-poor
Non-poor
Total Poor Near-poor
Non-poor
Total
Proportion of people who experiences at least one sick episode.
25.0
%
24.0
%
25.0%
39.4%
34.9%
37.0
%
37.3
%
Average number of sickness episode.
3.57 3.21 3.26 3.99 4.18 3.51 3.63
p=0.06 p<0.0001
Average frequency of hospitalization per inpatient.
1.45 1.43 1.44 1.90 1.65 1.41 1.54
p=0.89 p<0.01
Average hospitalization days. 12.12 12.14 12.14 15.25 13.17 11.06 12.15
p=0.99 p<0.05
Average frequency of outpatient treatment per capita.
n.a. n.a n.a 5.01 4.91 3.93 4.23
p<0.0001
Average number of self-treatment per capita.
n.a n.a n.a 5.72 4.84 4.65 4.83
p<0.0001
Source: Baseline and Final Household Survey.
4. Poverty Reduction/Welfare Impacts for Poor Households: It was expected that as a result of project intervention, poor and near poor household welfare would be improved, i.e., these households would have access to formal health care at times of need without having to pay out-of-pocket or facing financial burden. The data from the VLSS and the project survey were compared earlier and this showed that survey data on utilization is higher than for the national and Mekong rates under the VLSS. However, this data is not disaggregated by income quintile and urban/rural (where rural is also a proxy for the poor and near poor). In the Table below, disaggregated utilization rates are provided. The data indicates that having health insurance increases health service utilization. Utilization in rural areas have also increased slightly over time (from 38 percent in 2004 to 40 percent in 2010). Moreover, while utilization rates among quintiles 1 and 2 (poor and near poor) have improved between 2004 and 2010, for quintile 5 the rates are the same. This is potentially a sign of progressiveness, and it appears that based on the project results and comparing with national data across income quintiles, the situation is slightly better for poor and near poor households. Access to health insurance seems to be a key factor. Despite these improvements, inequalities persist. Since poor and near poor households would likely have greater health needs, these ineuqalities in utilization across quintiles need to be tracked.
43
Annex Table 4.2: Inequalities in annual health service utilization rates (inpatient and
5. In terms of financial protection, comparing data from the surveys indicates that out-of-pocket payments did not decrease. Moreover, poor and near poor households in the VLSS and survey paid more out-of-pocket payments as compared to other (better-off quintiles). This indicates that out-of-pocket payments are regressive, and despite access to health insurance, this aspect of universal health care has not improved as yet. This could be related to the scope of the benefits package for poor and near poor households and is an issue that needs to be closely tracked by the GOV and the World Bank. Based on these findings, it is not clear that the objective of reduced poverty and welfare gains for Mekong happened as predicted in the economic analysis. It should be noted that as per international definitions, catasthrophic payments which can drive households into poverty is defined as a threshold of 40 percent spending on health as a percentage of total household spending. The rates in the VLSS for poor and near poor households are much lower than this threshold. However, if the survey data is used, a rate of 23 percent is high and could indicate potentially impoverishing effects.
6 Somanathan, Dao and Tien. 2012. Vietnam Case Study for Universal Coverage Challenge Program (UNICO), The World Bank, Washington DC. This table analyzes data from the Vietnam Living Standards Survey (VLSS). The number indicates both inpatient and outpatient consultation rates.
44
Figure 4.1: Share of out-of-pocket health expenditure in the total health spending on non-
food items
Source: VHLSS and MRHSP.
6. Health Expenditures and Implications for Sustainability of Project Investments: Overall health expenditures are increasing in Vietnam. Therefore, most likley fiscal sustainability of investments is not a concern. Total health expenditures accounted for 6.9 per cent of GDP in 2010 or US$85 per capita. In 2002 when the economic analysis was completed, health expenditures on health as a percent of GDP was only 1.6 percent. This is quite a sharp growth in health expenditures over a period of 8 years. Public financing for health is critical for poverty reduction and for sustaining the benefits for poor and near poor households under the project. Total government spending on health as a percentage of total government spending in 2002 was around 6.4 percent. This increased to 8.4 percent in 2005, and currently is estimated at 24.3 per cent in 2009. While these numbers may include external financing as well, 23 percent of total government expenditures is on the high side. The average for East Asia and Pacific countries is much lower (9 percent of total government expenditures). This indicates strong commitment of the government to health. However, the fiscal sustainability of such high investments need to be considered. Moreover, whether these investments are generating value for money need to be evaluated as well. The main sources of government financing are central government, provincial governments and external development partners. Social Health Insurance share of expenditures was 17.9 per cent in 2009, up from 8.8 per cent in 2005. Households continued to account for the largest share of total health expenditures – 50.5 per cent in 2009 – although this has declined from 67.1 per cent in 2005. Therefore, at the overall level, given the strong commitment of the GOV to health, sustainability of investments supported through the project is not a concern. Further attention will have to be paid, though, to efficiency of investments in the future.
12.1% 12.2% 10.6%
9.7% 8.3%
11.9% 11.0%
10.1% 9.5%
8.3%
23.0%
16.4%
9.8% 7.5%
4.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Q1 Q2 Q3 Q4 Q5
National rate in VLHSS 2010 Mekong Regional rate in VLHSS 2010
Mekong Regional in CCRD survey
45
Annex 5: Bank Lending and Implementation Support/Supervision Process
(a) Task Team members
Names Title Unit Responsibility/Specialty
Lending Phillip Brylski Social and Environment Coordinator ESDVP Mariam Claeson Lead Public Health Specialist SASHD David Evans Senior Economist LCSHE Eva Jarawan Lead Health Specialist EASHH Peyvand Khaleghian Public Health Specialist
Samuel Lieberman Lead Health Specialist EASHH Task Team Leader (2003-2009)
Nga Quynh Nguyen Program Assistant HDNHE Lan Thi Thu Nguyen Natural Resource Economist EASVS Mai Thi Nguyen Senior Operation Officer Thu Thi Minh Nguyen Operations Officer Hoa Thi Mong Pham Senior Social Development Specialist EASVS Maryam Salim Social Sector Specialist Minna Hahn Operations Officer
Lingzhi Xu Senior Operations Officer Task Team Leader (2009-March 2011)
Supervision/ICR
Samuel Lieberman Lead Health Specialist EASHH Task Team Leader (2003-2009)
Lingzhi Xu Senior Operations Officer Task Team Leader (2009-March 2011)
Nga Quynh Nguyen Program Assistant HDNHE Sarbani Chakraborty Senior Health Specialist Lead ICR Report Author Kari L. Hurt Sr. Operations Officer
Huong Lan Dao Health Specialist EASHH Team Leader (2011-current)
Anh Thuy Nguyen Operations Officer Toomas Palu Lead Health Specialist Bukhuti Shengelia Sr. Health Specialist Lan Thi Thu Nguyen Natural Resource Economist EASVS Mai Thi Nguyen Senior Operation Officer Nga Nguyet Nguyen Senior Economist EACVF Hiet Hong Thi Tran Senior Procurement Specialist
Mai Thi Phuong Tran Financial Management Specialist EASFM Quynh Thi Xuan Phan Financial Officer GEFOB Rosario Aristorenas Senior Program Assistant AFTEE
Anh Tuan Le Social Development Specialist EASVS
Safeguard Specialist, Social
Minh Thi Hoang Trinh Team Assistant EACVF
46
(b) Staff Time and Cost
Stage of Project Cycle No. of staff weeks USD thousands (Including travel
Annex 6: Summary of Borrower’s ICR and/or Comments on Draft ICR
1. The ICR was sent to the Ministry of Health and the Project Management Unit. Borrower comments on the ICR have been incorporated. The Borrower has two comments under the Implementation Section.
(a) The Borrower corrected the approval process for the feasibility reports; and (b) The Borrower mentioned that project implementation in Can Tho Hospital was not
delayed due to construction.
Below is the summary of the Ministry of Health’s project evaluation report.
2. Project design is relevant. Project Development Objective, components, activities are designed in compliance with
the conditions of Mekong provinces and the needs of the health sector. Supply and demand side intervention: medical equipment - training – capacity building –
support to the poor, near poor. For 6 years of implementation, there have been no major amendment. Some project activities are one step ahead of the government policy, then the MOH
proposes government policy at national level: HI for the near poor; support to heart – surgery and catastrophic cases.
During implementation, minor adjustment have been made in time.
3. Good governance and leadership, coordination among stakeholders. Special attention and guidance from MOH leaders (Minister and Deputy Minister) and
PPC leaders. 13 Mekong PPC Deputy Chairman are the member of the Regional Advisory Committee,
directly support the Project. The project get the timely support for project bottle-necks. The appraisal, approval,
allocation of government counterpart fund is in time, contributing to project completion as committed, reaching the set target and indicators.
Strong support from MOH departments: Planning and Finance; and Medical Equipment.
4. Regional Advisory Committee took the effective role in management. For project with regional design like Mekong Regional Health Support Project, the RAC
is crucial. For regular meeting of RAC, the MOH takes the key role. CPMU and LPMU report regularly to the leaders. 13 PPC leaders directly support the project activities, the coordination among local
departments is under the guidance of the PPC leaders; new proposals that is in line with local needs and the allocated fund from project are approved, reallocation is made under the authority in time.
5. CPMU and LPMU have enough capacity to carry out project activities.
Capacity of CPMU and LPMUs is key factor to project successful completion. CPMU has a good team comprising of experienced and devoted specialists: Coordinator
responsible for Planning; Procurement Specialists knowledgeable of WB procurement
48
guidelines, especially ICB procedure for goods; Training Specialist; Financial Management Specialists.
TOR for each position is clear. For the initial stage, the LPMU capacity is moderate as the LPMU team lack of
experience with WB project. With hands- on training and capacity building, LPMUs are able to carry out project activities.
LPMU have good teams comprising of Coordinator, Procurement Specialist, Chief Accountant.
6. WB provided timely support and guidance
Task Team Leader and WB team (especially WB Procurement Specialist and FM Specialist) are of great assistance and make great contribution to project success.
Timely assistance and guidance from the WB team. Bottlenecks are settled with WB support through direct discussion. TTL and the WB team joined the WB supervision mission, attended project meetings and
provided necessary support.
7. Decentralization and the role of the localities
PPC, DOH, LPMU play the key role in project implementation. The localities identify the needs for investment, carry out project activities, manage and utilize medical equipment, maintain health workers.
Decentralization to localities to carry out activities: support the poor, near poor, training, procurement under IC, NS, NCB and ICB.
CPMU take the key role in providing guidance to LPMUs to ensure the activities are in the right directions. CPMU developed manual, organized training workshop, provided hands- on training, conducted supervision mission at LPMUs.
CPMU conducted missions every 3 months to provide necessary support and adjustment have been made when necessary.
However, the decentralization is at acceptable level, depending on the capacity of LPMU. For tough activities like procurement of medical under ICB procedures, CPMU should provide hands-on training. For the delayed ICB that the capacity of the LPMU is limited, CPMU do the ICB on their behalf (DSA package).
8. Good communications among stakeholders
Smooth flow of information among: Beneficiaries – LPMU – CPMU – WB. Other communications: official documents, exchanges of email, telephone, fax. Exchange through email is an effective way and fast communication means to push up
project progress.
49
Annex 7: List of Supporting Documents
1. World Bank. 2011. Country Partnership Strategy for the Republic of Vietnam, IBRD, IDA, Report No. 62500-VN.
2. World Bank .Mekong Regional Health Support Project. Project Appraisal Document. February, 9 2006.
3. Ministry of Health . Annual Health Statistics Year Book, 2006 – 2010.
5. Ministry of Health. Base line survey. Mekong Regional Health Support Project . Central Project Management Unit. June, 2008.
6. Ministry of Health . Mid-term evaluation report. Mekong Regional Health Support Project. Central Project Management Unit. September 2010.
7. Ministry of Health . End-project evaluation report. Mekong Regional Health Support Project. Central Project Management Unit. June, 2012.
8. Ministry of Health. Master Plan on Universal Health Insurance Coverage, draft. June, 2012.
9. Ministry of Health. Master Plan on Easing Hospital Overcrowded, draft. July 2012.
10. The World Bank. Health Financing and Delivery on Vietnam – Looking forward. Health, Nutrition and Population Series.
Lai ChâuDiên Biên Lào Cai Hà Giang Cao Bang Son La Yên Bái Tuyên Quang Bac Can Lang Son Phú Tho Vinh PhúcThái NguyênBac Giang Quang Ninh Hà NoiBac NinhHà Tây Hung YênHai DuongHai PhòngHòa BìnhHà NamThái BìnhNinh BìnhNam DinhThanh Hóa Nghe An Hà TinhQuang Bình Quang Tri
PROVINCES:
_
˘
˘
`
`
`
`
`
`
˘˘ ˘
'
'
˘
˘
˘
˘
' '
'
'
'
˜
˜
˜
˜
˜
_
_
_
_
_
_
__
VIETNAM
0
0 50 100 Miles
50 100 150 Kilometers
The boundaries, colors, denominations and any other informationshown on this map do not imply, on the part of The World BankGroup, any judgment on the legal status of any territory, or anyendorsement or acceptance of such boundaries.
