Uzbekistan - Health I

Report No. PIC2943 Project Name Uzbekistan-Health I (@) Region Europe and Central Asia Sector Other Population Health & Nutrition Project ID UZPE9125 Borrower Republic of Uzbekistan Implementing Agency Ministry of Health, Tashkent Date This PID Prepared June 30, 1997 Projected Appraisal Date November, 1997 Projected Board Date February, 1998 Country and Sector (See 1/) Background 1 Indicate importance of sectoral in overall country strategy and include brief sectoral overview (e.g., sector policy, public expenditure and institutional framework, government sectoral strategy, progress in resolving sectoral issues).Uzbekistan lies at the heart of Central Asia, with the region's largest population. Twenty three million people, over 70 percent ethnic Uzbek, occupy the country's 447,400 km2. Uzbekistan is rich in natural resources, including gold, oil, natural gas, coal, silver, and copper and is the fourth largest producer of cotton and its third largest exporter. However, since its independence in 1991 the Uzbek economy has been affected by ongoing economic problems related to transition from the former Soviet planned economy, resulting in reduced household incomes (especially for the most vulnerable groups) and the disruption of social support infrastructure including funding for health services. The GNP in 1995 was estimated at only US$ 930. 2 Uzbekistan's initial approaches to economic reform have been cautious, subsequently, the deteriorating economic situation and collapse of the ruble in the early 1990s prompted the Government to initiate far reaching reforms, including the acceleration of privatization and enterprise reform. More recent policy measures, including cuts in consumer subsidies, confirm the shift to a reform program. At the same time, the country has not always followed through on initial timelines for economic reform measures, and has been reluctant to move to open trading policies with foreign countries and organizations. 3 The health status of the population is affected by a wide range of risk factors prevalent in Uzbekistan. Of particular relevance are high rates of fertility, inadequate supply of water and sanitation, smoking and alcohol abuse, and poor diet. High fertility rates (4 versus 3.1 for other middle income countries), a high birth rate (29.8/1,000 in 1995) and a low total mortality (6.4/1,000 in 1995) over the past three decades have resulted in a  high population growth rate, with 41% of the population under the age of 15 years. The structure and dynamics of the population in Uzbekistan has a profound impact on the quantity and nature of the burden of disease. Nearly 70 percent of the population live in rural areas, perhaps increasing the infant mortality rate (IMR), the maternal mortality rate (MMR), and the crude birth rate (CBR) in the aggregate as compared with other countries. The IMR (26/1,000) and MMR (32.2/1,000), though declining in recent years, are still high as compared to other countries in the region and with similar incomes. Life expectancy has been high at 70.4 years. Literacy rates, especially for women (more than 80 percent have at least six year's of schooling), show good human development outcomes. However, there is a need for safer motherhood, immunization, and management of the sick child, especially in rural areas. 4 Uzbekistan's health care system mainly reflects the heritage of the Soviet model. It is comprehensive and extensive, and services are provided mainly free of charge. The distribution of health resources (facilities and personnel) by oblast is relatively equitable, on a per capita basis. However in Uzbekistan, as elsewhere in the former Soviet Union, excessive numbers of doctors and hospitals can lead to unnecessary hospitalizations, medical diagnosis and treatment. Compared with many other counties, middle- income or high income, the overall efficiency of the Uzbek system appears to be low. Low quality is a problem at many points throughout the health care system, including outdated clinical information and standards, shortages of essential equipment for diagnosis and treatment, an inadequate supply of drugs, and other requirements for provision of basic primary health services. 5 The health sector is, like the rest of the economy, under unprecedented pressure to change its organization and financing. Local budgets, that finance the bulk of health services, have come under increasing pressure, reflecting more general fiscal constraints and the difficulties created by high inflation. The withdrawal of enterprises and collective farms from the traditional role of financing the construction and recurrent communal services of local health facilities has created further budget pressures. 6 There is a need to reorient the system of care, and focus upon a basic package of services. In 1991, the Minister of Health outlined a health care development concept which was further developed during 1992-1996, outlining the following priority areas for care: women and child health protection; infectious diseases prophylactics and environmental protection; and strengthening primary health care. The MOH also has been developing several laws, several of which have been recently enacted, including a health sector reform strategy. 7 Strengthening primary health care, through restructuring the rural infrastructure and delivery system, is one of the stated priorities for the next 10 years. The Government in early 1996 announced a major social rural infrastructure initiative, which included the building of new rural outpatient centers, coupled with the rationalization of the old Soviet model of the feldsher -2 -  stations and small outpatient centers and small district hospitals of 30-60 beds. The reform strategy includes training of general and family practitioners, and the introduction of improved management and financial incentives to health care providers. 8. Uzbekistan appears to have chosen many of the appropriate clinical services priorities focused on primary care, (See 2/) including prenatal and delivery care, vaccination, food supplementation, tuberculosis treatment, case management of acute respiratory infections and diarrhea, and treatment of sexually transmitted diseases. However, while the essential clinical interventions may be covered, underfunding, inefficiency, and supply shortages may affect actual delivery. Project Objectives 9. The project objectives are both regional and national in scope. The project would -- in three "pilot" oblasts of Fergana, Navoii and Syrdarya -- seek to improve the quality and cost effectiveness of primary health care services, particularly in the rural areas where the great majority of the population live. It also would seek to strengthen the management and financing of primary health care services, in part by redefining the role of government in both the financing and provision of health care, and by establishing a minimum package of health care services that should be accessible to the whole population. Combined results from these three very different oblasts which represent the diversity of conditions in Uzbekistan, are expected to help guide the Government's effort to strengthen the primary health care services in the country as a whole. Project Description 10. In order to achieve those objectives, the proposed project would have the following four components: (1) Strengthening Primary Health Care Services in Rural Areas; (2) Financial and Management Strengthening; (3) Health Personnel (General Practitioner/Nurse Training); and (4) Project Management. A description follows: (1) Strengthening Primary Health Care Services in Rural Areas: The project would contribute to the establishment of a network of modern, better staffed, and better equipped "rural medical centers" ("SVPs" using the Russian acronym) in the three pilot oblasts. This would involve determining the basic package of services, SVP function and design, construction standards, identifying needed protocols, and distribution and delivery of appropriate drugs. This component would finance some civil works, but mostly medical equipment and drugs. (2) Financial and Management Strengthening: The project would ensure the sustainability of the initiative, and of the Government's rural health care reform program. This component would be implemented in the following two phases: (a) pilot demonstrations in the three oblasts: This -3 -  would involve developing and testing various policies and actions to assure long-run sustainability of the new SVPs and associated reforms, through interventions such as facility rationalization, improved efficiencies in the delivery of services, new incentives at the local level, and greater flexibility and decentralization of authority to the local level. An improved incentive-based system for matching facility workloads and staffing patterns will also be developed. This component would finance a new financing and information management system, and training in specific districts/health care facilities. (b) pilot demonstration evaluation and roll-out: The pilot demonstrations in the three oblasts and the reforms would be evaluated, replicated and disseminated throughout the three oblasts. This component would finance technical assistance and training. (3) Health Personnel (General Practitioner/Nurse Training): Health personnel training is a critical prerequisite for reforming and strengthening primary health care and improving quality and efficiency of SVP services. This component would specify a training strategy for undergraduate and post graduate work related to General Practitioners (GPs), and onsite training programs for trainers and for actual physicians at SVPs. This component would finance short and long term training courses for GPs, nurses and trainers; training equipment and supplies; and study tours. (4) Project Management: This component would finance the costs of overall project management and implementation in the three oblasts. Scope of activities are yet to be determined. Implementation 11. A Project Coordinating Unit (PCU) consisting of a PCU Director and other staff has been established in Tashkent, linked to the Ministries of Finance and Health, and "component coordinators" in the pilot oblasts. The Oblast authorities are to nominate counterpart officials, with the recent selection of participating oblasts, to specifically define the implementation arrangements for the project at the local level. Project Sustainability 12. The proposed project aims to create replicable models for health care delivery of critical services, financing and cost recovery mechanisms, and effective management and information systems. The oblast level interventions will be pilot programs, with built-in monitoring to measure impact and potential replicability. Operating costs of care in the new rural medical centers will increase, and these costs will need to be offset with a multi-dimensional strategy including i) diversity of funding sources; ii) facility rationalization, and iii) improved efficiency - 4 -  in the organization and provision of care. The project will lay the ground for these and other, wider reforms in the health sector across the republic. Lessons Learnt from Past Bank Projects 13. The Government has recently enacted a new law on health sector reform which envisages a series of changes over the next 10 years. Nevertheless, the start-up of Bank activities in Uzbekistan has been somewhat later than in the other FSU countries. Bank assistance to date has focused on policy dialogue, grant support in the design of a reform program, and institution building. It also has engaged in a long-standing dialogue on the prudence and relative cost-effectiveness of public investments related to pharmaceutical and vaccine production. This would be the Bank's first lending operation to the health sector in Uzbekistan. 14. Experience with other health projects in transition countries undergoing transition (such as Hungary and Poland), and health project preparation elsewhere in the FSU, suggest that project design should be kept as simple as possible with a small number of components. Project preparation in other sectors in Uzbekistan also indicates the need for straightforward project design and implementation mechanisms, given limited institutional capacity and weak financial systems. Achieving simplicity is difficult, however, given the necessity of oblast level interventions in order to implement change in the health sector, and the array of largely interlinked issues that are involved in efforts to improve health sector performance, wherein financing and management reforms are central. Poverty Impact 15. The proportion of the poor among project beneficiaries will be significantly higher than in the overall population because of the emphasis of investments on critical basic services. The project will help to ensure access to health services for vulnerable groups during a period of increasing fiscal stress on the system. Environmental Aspects 16. The project is not expected to have any significant adverse environmental impacts; it is therefore classed as a category "C" project. Program Objective Categories 17. The proposed project would make a direct contribution to better public administration by improving the capacity of the Ministry of Health at the central level and the capacity of local health agencies in the pilot areas, and improving critical basic health services in selected areas. Benefits 18. The main benefit, for up to one million residents in the - 5 -  oblasts that would participate in the project, would be: first, improvements in the delivery of critical basic services; and second, improved decisions of providers about health care through the creation of strengthened information and management structures and integrated with appropriate incentives. The project should lead to fiscal savings flowing from more efficient and targeted use of resources for health care and pharmaceuticals. Indirect benefits for efficiency would follow improved management and information systems, and the better supply of pharmaceuticals as a result of continued sector reform. Risks 19. The main risk to project success is the lack of administrative and institutional capacity in the Government and in the Ministry of Health generally and, in particular, with respect to a project of the nature envisaged. For example, there may be inadequate capacity to set up the information systems required for effective and timely implementation. Lack of experience with World Bank procedures and processes could be a serious problem. There is also a risk of delay in project preparation, given that the resources and responsibility for this process has been largely allocated to the borrower. This risk will be alleviated through PHRD technical assistance during project preparation, and through intensive collaboration with key counterparts on the part of the project team based in Tashkent (which includes the WHO-financed Public Health Adviser to the Minister of Health) and nominated staff of the Regional Mission. 1/ See Uzbekistan: Adjusting Social Protection (World Bank gray cover report, # 13023-UZ), Chapter 8. 2/ See the guidelines for a basic health package from the World Development Report of 1993. Contact Point: Jack Langenbrunner, Task Manager The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 473-3270 Fax No.: (202) 477-3387/477-0711 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending July 18, 1997. - 6 -