INTEGRATED SAFEGUARDS DATASHEET
APPRAISAL STAGE
I. Basic Information
Date prepared/updated: 11/13/2007 / Report No.: AC31741. Basic Project Data
Country: Kazakhstan / Project ID: P101928
Project Name: Health Sector Technology Transfer and Institutional Reform
Task Team Leader: Peyvand Khaleghian
Estimated Appraisal Date: October 31, 2007 / Estimated Board Date: January 17, 2008
Managing Unit: ECSHD / Lending Instrument: Specific Investment Loan
Sector: Health (40%);Information technology (35%);Compulsory health finance (10%);Central government administration (10%);Vocational training (5%)
Theme: Health system performance (P);Administrative and civil service reform (P);Education for the knowledge economy (S);Other human development (S);Trade facilitation and market access (S)
IBRD Amount (US$m.): 118.00
IDA Amount (US$m.): 0.00
GEF Amount (US$m.): 0.00
PCF Amount (US$m.): 0.00
Other financing amounts by source:
Borrower 180.00
180.00
Environmental Category: C - Not Required
Simplified Processing / Simple [] / Repeater []
Is this project processed under OP 8.50 (Emergency Recovery) or OP 8.00 (Rapid Response to Crises and Emergencies) / Yes [ ] / No [X]
2. Project Objectives
To introduce international standards and build long-term institutional capacity in MOH and related healthcare institutions in support of key health sector reforms pursued by the Government of Kazakhstan in the context of the State Health Care Reform and Development Program.
1. Improved efficiency and equity of health expenditure and better financial protection for households in oblasts that implement a comprehensive package of healthcare financing and management reforms;
2. Improved quality and efficiency of medical care through the establishment of functioning systems/ institutions for clinical practice guideline development/dissemination and health facility accreditation, and through improved performance in the laboratory and blood transfusion systems;
3. Improved quality of medical graduates and improved ability to carry out medical research through upgrading the medical/pharmacological education and research systems and introducing international standards;
4. Improved efficiency and quality in health facility management through access to reliable, timely health information from a unified health information system;
5. Improved safety, efficacy, quality and affordability of drugs through reforms in pharmaceutical procurement, pricing, prescribing monitoring, information provision, benefit package design and quality control; and
6. Improved food safety and speedier WTO accession through the introduction of international sanitary and phytosanitary norms.
3. Project Description
Component A: Health Financing and Management
Subcomponent A1. Strengthening the Capacity for Health Policy and Strategy Formulation. This subcomponent would improve the quality of policymaking at the Ministry of Health by establishing a twinning arrangement between an internationally-recognized health policy agency and a newly-established Economics and Policy Analysis Unit in MOH to carry out economic and policy analysis (including survey-based exercises) and develop strategic options for policy reform and budget development in the health sector. These capacities are weak in MOH but are essential if the Ministry is to modernize its operations and bring them in line with international practice. The subcomponent would provide equipment for an Economics and Policy Analysis Unit under the Department for Strategic Development and International Cooperation and would finance international TA, training, study tours and a series of special studies/surveys to provide factual input to policy decisions on financing issues. The subcomponent would also finance special studies/surveys including inter alia household health surveys, out-of-pocket payment surveys, patient and provider satisfaction surveys and surveys of human resource surveys.
Subcomponent A2. Strengthening Budgeting, Planning and Management in the Health Sector. This subcomponent would extend the above-mentioned twinning relationship to strengthen planning, budgeting and “purchasing” functions in the health sector by strengthening performance among health sector “principals” such as MOH,the Oblast Health Departments (OHD) , and regulatory agencies/financial departments such as Treasury, the Ministry of Economy and Budget Planning (MOEBP) and oblast finance departments. With a move towards output-based financing, arm’s-length relationships and managerial autonomy in public administration in general and the health system in particular, the importance of specifying roles, responsibilities and performance indicators becomes critical. This subcomponent would finance capacity building activities to strengthen the ability of MOH and OHDs to plan, execute and monitor health spending under three headings: collection, pooling and purchasing. Collection of health sector resources would be strengthened by (a) helping MOH staff (and several oblasts) complete a comprehensive National Health Accounts for Kazakhstan, including study tours and dissemination efforts; and (b) providing technical support, training and special studies on budget planning, the role of health insurance and the role of additional tax sources for the health budget (including training in how to regulate health insurance markets and how to model budgets and alternative revenue sources). Pooling of health sector resources would be strengthened by (a) developing and refining a risk-adjusted geographic allocation formula; (b) moving toward output-based program budgeting and (c) carrying out an advocacy program to help policymakers, oblast leaders and the public understand the rationale and benefits of oblast-level budget consolidation. Purchasing of health care services, i.e. moving away from input-based financing (e.g. financing beds and staff directly) to a more market-oriented model that finances outputs, would be strengthened at national and oblast levels. At the national level, purchasing would be strengthened by (a) reviewing and reforming the health sector control environment to streamline operations and improve the business climate for private providers; (b) continuously refining the Basic Benefits Package and co-payment policy; (c) introducing performance-based payment methods for all MOH programs and implementing the necessary regulatory changes; and (d) reviewing and implement reforms in health sector governance (esp. appointment of health facility managers). At the oblast level, purchasing would be strengthened by providing training for OHD, OFD and others in implementation of these reforms, especially those concerning provider autonomy, performance-based provider payment methods and health facility governance.
Subcomponent A3. Management Training and Investment Planning for the Health Sector. This component would improve the quality and efficiency of healthcare facility management and the efficiency and effectiveness of investment decisions in the health sector by (a) strengthening the capacity of health care managers and building capacity for long-term health care management training in Kazakhstan and (b) introducing modern techniques for investment planning in the health sector. Management training would be strengthened by (i) identifying and building capacity in a long-term home for health management training in Kazakhstan, including through the development of faculty and training materials and the establishment of satellite training centers in the six Medical Academies; (ii) providing advanced on-the-job training and overseas training opportunities for managers of large and/or merged facilities, especially in oblast capitals; and (iii) establishing a formal set of health management qualifications, including possibly a Master of Health Care Management program. The modernization of investment planning would be achieved in three steps: (i) upgrading health facility planning standards to international standards and establishing a cogent, comprehensive set of planning standards in the form of a new health planning “atlas”; (ii) training MOHand OHD staff to carry out a detailed review of existing health systems using the new standards to identify gaps, surpluses and opportunities for rationalization; and (iii) carrying out a detailed master-planning exercise in four oblasts through a twinning relationship between international experts and MOH/OHD staff through which detailed opportunities for rationalization and a prioritized list of investments would be identified.
Component B: Health Care Quality Improvement
Subcomponent B1: Accreditation: Modernizing Standards for Health Facilities. This subcomponent would improve the quality of healthcare facilities by establishing an accreditation system and carrying out first-cut accreditation of at least 30 health facilities by 2012. This would involve: (a) contracting an internationally-recognized accreditation body to review Kazakhstan’s accreditation standards and accreditation system regulations (including those of the planned accreditation body) and develop business investment and communication plans for the accreditation agency as well as a training program, curriculum and guide book for assessors; (b) establishing a permanent institutional mechanism for training of surveyors and quality managers; (c) training 500 surveyors and 500 quality managers; (d) printing of standards for all health facilities in Kazakhstan; (e) creating a permanent review and upgrading mechanism for periodically adjusting standards; (f) developing a national and subnational monitoring and evaluation indicator packages for eventual recognition by an international accreditation body. The subcomponent would also finance training, study tours and learning activities for staff involved in the design and implementation of accreditation system reforms.
Subcomponent B2: Upgrading Clinical Practice and Introducing Health Technology Assessment. This subcomponent would improve the quality of clinical/ medical practice by (a) establishing a system for continuous development and review of evidence-based clinical practice guidelines (CPG); (b) supporting the development and widespread dissemination of 50 international-standard CPGs in each of five key clinical specialties; (c) printing and training 65 percent of the workforce in each of these clinical specialties in the updated CPGs; (d) and building the capacity of Kazakhstani specialists to carry out Health Technology Assessment (HTA) and conduct 3-4 HTAs independently by 2012
The subcomponent would support two lines of action: one on institution and capacity building (to build the capacity of Kazakhstani institutions and specialists in economics, epidemiology, clinical epidemiology, medical statistics and evaluation methods and develop a national cadre of leaders in evidence-based medicine) and one on dissemination and implementation (to upgrade clinical practice among the body of practicing physicians in Kazakhstan by disseminating and providing training in 50 core CPGs). The institution and capacity building line would finance a twinning relationship between an internationally-recognized institution and the Health Care Development Institute (plus other key players such as the Expert Council and professional associations) on CPG/HTA development and in developing a business plan, budget (investment and recurrent costs), training plan, communication plan, CPG uptake plan and overall work-plan for HTA and CPG development. The twinning institution would also arrange for training and professional exchange opportunities for Kazakhstani specialists from MOH, clinical centers, universities and professional associations on subjects including health economics, epidemiology, evaluation methods, pharmacoeconomics, evidence-based medicine and HTA. The dissemination line would involve a large-scale effort to disseminate the 50 core CPGs among practicing physicians throughout Kazakhstan using a combination of cascade training, classroom/skills lab education and distance learning using the Internet, modern videoconferencing/IT techniques and self-directed learning through CD-ROMs and DVDs. This would involve printing CPG manuals for the entire targeted medical workforce, building training capacity and establishing distance learning facilities in each oblast.
Subcomponent B3: Reform of Laboratories. This subcomponent would help improve quality in the laboratory network in two ways: by supporting organizational reform, network restructuring and the establishment of a quality control function for state and private laboratories (including specifications and profiles for equipment, staffing, reference laboratories and a preventive maintenance program) by upgrading skills and knowledge through training and study tours for laboratory staff, managers and policymakers. These would be carried out in the context of a twinning relationship between Kazakhstani specialists and an internationally-recognized agency/firm. No equipment financing is envisaged.
Subcomponent B4: Reform of Blood Transfusion System. Following the HIV contamination of more than 70 children in South Kazakhstan, MOH carried out a major review of the Blood Transfusion Service (BTS) and decided to reform of the whole system of sourcing, processing, handling and utilization of blood and blood products. The Ministry’s program includes a structural overhaul of the agencies and configuration of BTS sites; progressive implementation of WHO guidelines, benchmarking with established BTS in other countries; a major upgrade of equipment, facilities and processes including a preventive maintenance program; social marketing to increase the number of voluntary donors; training for physicians in international guidelines on the use of blood products; and a comprehensive system for monitoring and evaluation and continuous quality improvement in the BTS. This subcomponent would support implementation of the Ministry’s program in two ways:by supporting organizational reform, network restructuring and the establishment of a quality control function for the BTS (including specifications and profiles for equipment, staffing, a reference laboratories and preventive maintenance) and by upgrading skills and knowledge through training and study tours for laboratory staff, managers and policymakers. These would be carried out in the context of a twinning relationship between the Republican Blood Transfusion Service and an internationally-recognized peer agency.
Component C: Reform of Medical Education and Medical Science
Subcomponent C1. Reform of Undergraduate and Continuing Medical Education. This subcomponent would improve the quality of undergraduate and continuing medical education in Kazakhstan by (a) upgrading admission criteria, curricula, teaching methods, teaching materials, examination procedures, faculty skills and the overall structure of Kazakhstan’s six medical universities; (b) supporting effortsto obtain international accreditation for at least one of these medical universities; (c) helping modernize Kazakhstan’s licensing/attestation procedures for medical graduates; and (d) upgrading and institutionalize Continuing Medical Education in Kazakhstan. These would be carried out in three blocks: one to carry out an in-depth review of the current system and develop a change management plan; one to support MOH in implementing this plan; and one to finance study tours, professional exchanges, training, conferences and workshops for Kazakhstani specialists involved in the reform effort. These would be carried out in the context of a twinning relationship between the Ministry of Health and an internationally-recognized peer agency/university, including provisions for professional change management services (to help sequence and manage the transition) and for maintaining a dedicated medical education reform team in MOH.
Subcomponent C2. Reform of Medical Science. This subcomponent would improve the quality, efficiency and relevance of medical science research in Kazakhstan by helping implement MOH’s Concept of Medical Science Reform to 2010 (see PAD Annex 4 for details). This would be achieved by (a) designing, communicating and introducing a contemporary competitive system for priority-setting, reviewing and financing medical research (including detailed specification of operational arrangements and procedures for the new system); (b) designing and introducing a system for patient protection in medical research, including detailed specifications of governance arrangements and operational procedures for a national medical ethical/research committee and corresponding institute-/university-level committees; and (c) introducing and providing training for researchers and research managers in internationally-recognized research management tools. These would be carried out in the context of a twinning relationship between the Ministry of Health and an internationally-recognized peer agency/university. Additional support would be provided to maintain a dedicated medical science reform, including provisions for professional change management services (to help sequence and manage the transition) and for maintaining a dedicated medical science reform team in MOH.