Turkmenistan - Proposed Health Project

Report No. PIC4610 Project Name Turkmenistan-Proposed Health Project Region Europe and Central Asia Sector Health Project ID TMPA43330 Borrower Republic of Turkmenistan Implementing Agency Ministry of Health and Medical Industries 95, Magtymguly Ashgabat, 744000 Turkmenistan Tel: 7-363-2-25-10-63 Fax: 7-363-2-25-32-50 Date PID Prepared December 16, 1996 Projected Appraisal September 15, 1997 Projected Board Date December 18, 1997 Country and Sector Background 1. Turkmenistan became independent from the Soviet Union in 1991. The country has abundant energy resources, primarily natural gas and oil, and is rich in other mineral resources. The Government is gradually moving the economy from a command to a market economy. Per capita GDP was estimated at US$920 in 1995. With an area of 488,000 km2 it is the fourth largest country of the Former Soviet Union republics (FSU). However in terms of population, it is relatively small, only ninth largest of the FSU, with a total population of 4.5 million, 45 percent of which live in urban areas. 2. For a country of its income level, health indicators are not good, even compared to other countries of the Former Soviet Union (FSU). Life expectancy is the lowest. The infant mortality rate (officially at 46/1,000) is the highest. Maternal mortality is the fifth highest. Fertility rates are relatively high, and rates of cardiovascular diseases are extremely high and increasing. Respiratory, digestive and infectious and parasitic diseases are also among the highest. An analysis of the burden of disease shows that the most important disease problems are those related primarily to infant mortality (respiratory infections, perinatal conditions and diarrheal disease), and ischemic heart disease. 3. The system of health services in Turkmenistan exhibits most of the features of the inherited Soviet structure. It is very expensive and service accessibility is relatively easy due to the large number of facilities. However, the system is inefficient and has insufficient impact on the country's health problems. The system is characterized by excessive numbers of inappropriately trained staff; very high reliance on hospital rather than primary care services; medical care is overly disease oriented and of generally poor quality; and an emphasis on specialist care with multiple tiers of referral and poor case  management. Objectives 4. The Government, the World Health Organization (WHO-Euro), and the Bank are cooperating in the implementation of a reform strategy, the main objectives of which are to: (i) improve the health status of the population; and (ii) increase the sustainability of the health system. The proposed Health project objectives would be to: (i) achieve improvements in the quality of care and in the efficiency of health care delivery in a pilot district, sufficient to make decisions about national adoption of tested reforms. Such reforms would include rationalization of health services, incentive systems, and new clinical protocols and organizational schemes focusing on the integrated provision of cost-effective care aimed at reducing the burden of disease (infant and maternal mortality and morbidity, and mortality and morbidity caused by communicable diseases such as tuberculosis (TB) and sexually-transmitted diseases (STDs); and (ii) build sufficient capacity in the Ministry of Health and Medical Industries (MOHMI) to prepare, evaluate and replicate tested reforms throughout the country. Description 5. The proposed project comprises two components: (i) a pilot health program; and (ii) institutional strengthening of the MOHMI. The components include: (1) Pilot Health Program (about US$ 6 million): this component would focus on improving the provision of integrated cost-effective care (e.g., immunization, management of the sick child, safe motherhood, tuberculosis and sexually-transmitted diseases programs) aimed at reducing the burden of disease in the pilot district. The component would: (i) rationalize and rehabilitate selected health services in the pilot district. This would involve upgrading and reforming selected primary and secondary health care facilities, and closing down unnecessary services, such as TB and STDs dispensaries; (ii) strengthen links between primary and secondary health care, by updating protocols of care and providing communication equipment and transportation for referrals; (iii) develop family practice and train family physicians and nurses, and some specialists (e.g., pediatricians, obstetricians). This sub- component would also test in-service training, focusing on the above mentioned programs, including obstetric and neonatal care, and would test updated protocols of care; and (iv) test provider payment methods aimed at increasing efficiency. The component would cover civil works, and provide essential medical equipment, supplies and pharmaceuticals, local and foreign consultant services, training of trainers and in-service training of family doctors and nurses, and specialists. (2) Institutional strengthening of the MOHMI (about US$ 4 million): this component would build the institutional capacity of the MOHMI to prepare, evaluate and replicate in the country the new approaches tested in the pilot program. This would be achieved by: - 2 -  (i) Quality of Care (about US$ 2.5 million): this sub- component would contribute to improve the quality of care by (a) updating protocols of care aimed at reducing the highest burden of disease. The protocols would be tested in the pilot district, before being adopted by other health services; and (b) developing curricula of family practice (physicians and nurses), including: (i) in-service training, which would be tested in the pilot district; and (ii) preparatory work for a residency program in family practice. This sub-component would provide teaching/learning and office equipment and supplies, including computers, software and a CD-ROM library, local and foreign consultant services and local and foreign training of trainers, and would cover the dissemination of protocols countrywide. (ii) Health Financing Reform (about US$ 1 million): this sub- component would support ongoing health financing reforms aimed at improving the equity and efficiency of the health system. It would support additional policy analysis and implementation of agreed recommendations in the areas of sources of financing, resource allocation and provider-payment systems. The provider-payment system would be tested in the pilot district before being implemented in other regions. This sub- component would finance equipment, including computers and software, consultant services and local and foreign training. (iii) Health Program Evaluation (about US$ 0.5 million): this sub-component would conduct operational research to evaluate the pilot health program. The sub-component would evaluate the pilot program, disseminate recommendations, and prepare the replication of the program by the MOHMI. The sub- component would provide local and foreign technical assistance, and training, and would cover the dissemination of the recommendations. Financing 6. Total project costs are estimated at US$ 11.5 million to be financed by a Bank loan and Government contributions. Implementation 7. The proposed project is expected to be implemented in two to three years, and the implementing agency is the Ministry of Health and Medical Industries (MOHMI). A Project Preparation Coordination Unit (PPCU) has been set up within the MOHMI to: (i) assist in the implementation of the Turkmenistan Presidential Health Care Program; (ii) coordinate the activities of different donors in order to increase the efficient use of resources; and (iii) prepare and coordinate the implementation of specific projects funded by international organizations, such as the WHO Lukman Health Program and the proposed Health project. Sustainability 8. By focusing on the provision of the most cost-effective care, the - 3 -  project will improve the efficiency of the health system and may not increase recurrent costs. It will downsize health facilities, and the resulting savings will be channeled to improving quality of care. New provider payment mechanisms may create ceilings, preventing cost- escalation and improving efficiency. The Project will start addressing cost-recovery for non essential health interventions, such as mandatory annual medical check-ups. The Project will not increase coverage, benefits, create new structures or lead to the contracting of new staff. Lessons learned from past operations in the country/sector 9. The Bank has limited lending experience in Turkmenistan. Lessons learned during the implementation of the Institutional Development/Technical Assistance Project, and the preparation of the Urban Transport and Water Supply and Sanitation projects include the importance of (i) associating Bank-funded projects with sector policy reforms; (ii) a counterpart team with authority to move the project forward, and (iii) coordination of interested parties. Lessons learned from other health projects in Central and Eastern European countries include: (i) clear national ownership and leadership is key; (ii) it is necessary to strengthen national capacities; (iii) projects should be kept as simple as possible; and (iv) the PCU should be established early. The Government of Turkmenistan has been providing indications of strong commitment to the preparation of the proposed Health project. The project design is simple, focussing on one district and on programs and reforms that were already initiated, such as family practice and provider payment methods. Finally, the project would focus on strengthening MOHMI capacities in specific areas, namely quality of care and health financing. Poverty Category 10. The project falls in category (b) of the Program of Targeted Interventions. The direct beneficiary of the project would be the population of the pilot district Tejen, which is over 100,000. However, the whole country is expected to benefit from the adoption of new standards of care and from improving the efficiency of the overall health system. Environmental Aspects 11. The proposed project is classified as Category C. There are no identifiable environmental impacts from this project. Program Objective Categories 12. The project fits into the categories of Economic Management (50%) and Poverty Reduction and Human Resource Development (50%). It would make a contribution to economic management by improving the quality of care and the efficiency of the health care system in the pilot area. The institutional strengthening component would contribute to human resource development through training, adoption of updated protocols of care, and by creating appropriate incentives. -4-  Contact Point: Joana Godinho, Task Manger The World Bank 1818 H Street N.W. Washington D.C. 20433 Telephone: (202) 458-1988 Fax: (202) 477- 0954 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 January 10, 1997. - 5 -