Modernization and Improvement of Rehabilitation Services Project

active

Prospective

The Moldovan health system is centralized, with the National Health Insurance Company (Compania Nationala de Asigurari in Medicina, CNAM) serving as the single purchaser of publicly financed health services since 2004. CNAM covers 86 percent of the population with a package of emergency, primary, and inpatient services without payment at the point of access. In 2021, primary health care (PHC) accounted for approximately 25 percent of CNAM’s overall expenditure, reflecting a hospital-centric system. Strengthening PHC has been a priority since 1998 and there has been some progress in recent years. The number of publicly financed PHC providers has grown steadily from 67 in 2008 to 293 in 2021. Nevertheless, the unfinished agenda remains significant across financial protection and service delivery. Weaknesses in service delivery for people with NCDs, particularly cardiovascular diseases, are apparent across three areas: primary care services for those at risk; post-acute services immediately following an acute event, such as a stroke or heart attack; and primary care services for post-acute follow-up and prevention of recurrent events. The Ministry of Health estimates that the unmet need for rehabilitation services is 70 percent. Lack of service provision is driven by a previous lack of prioritization in recent decades, and as a result quality of care is significantly compromised. Adult rehabilitation services are challenged by poor infrastructure and the lack of appropriate facilities and equipment, defined clinical protocols and pathways, and an adequately trained workforce. The limited and low-quality rehabilitation services provided through the public sector have given rise to private sector rehabilitation services. This project is responding with the objective to improve the quality and accessibility of rehabilitation services and strengthen primary care services for addressing non-communicable diseases (NCDs) under the following components: Component 1: Integrated care at the hospital level for NCD patients (US$ 30 million). This component will focus on patients facing catastrophic health events, primarily strokes and heart attacks. This component will: (1) strengthen emergency response capabilities following catastrophic health events, with a focus on strokes and myocardial infarction; and (2) develop and upgrade health facilities and equipment. It will support improvements in the quality, efficiency, and accessibility of rehabilitation services, with a focus on patients following an acute episode requiring intensive rehabilitation services. The component will finance equipment, infrastructure improvements, and transportation, with an initial focus on three facilities: the Clinical Hospital of the Ministry of Health in Chisinau, the Clinical Hospital in Balti, and the Comrat District Hospital. The renovations including modifications of rooms and facilities, such as the introduction of railings and non-slip flooring, are to provide appropriate facilities and the conducive environment to support patients, including those with disabilities, in need of restorative rehabilitation. This component will also finance equipment and service improvements for other selected service lines, where doing so would constitute a cost-effective investment alongside stroke and cardiac care rehabilitation improvements. Additionally, the component will finance the development and uptake of protocols to triage, assess, and manage the care of patients immediately following a substantial trauma, such as a stroke or heart attack; training to support health care workers in rapidly identifying strokes and heart attacks; diagnostic equipment; and emergency transport for patients in need of complex care—to safely transfer them in a timely manner to the appropriate level of the health system. Component 2: Integrated prevention and rehabilitation services at the primary care and population-level (US$ 22.5 million). This component will support services to prevent NCDs through primary care and population-level interventions. The purpose of these interventions at the individual level is to limit the likelihood of an initial acute episode, and at the system level, to limit the use of costly tertiary services. It will focus on patients at risk of strokes and heart attacks and, recognizing the presence of comorbidities, will also include programming for other NCDs. The component will also strengthen preventive and supportive rehabilitation services to support patients following a stroke or heart attack. The purpose of this investment is to address a gap in service provision and better preserve the human capital of patients who have experienced an acute episode. In addition, preventive and supportive rehabilitation are two areas where integration within and across sectors stands to improve the service quality. Subcomponent 2.1. Primary care and population-level interventions for NCD prevention and management (US$ 3.5 million). This subcomponent will finance prevention and disease management programs for NCDs including screening and treatment; training for healthcare workers to better manage chronic disease conditions and to detect the early signs of strokes and cardiac episodes; public awareness campaigns to address the major risk factors for stroke and heart attacks, including hypertension, salt consumption, physical inactivity and diet; and scale up existing telemedicine and digital health programs to improve access to counselling to address risk factors for vulnerable populations. Subcomponent 2.2. Preventive and supportive rehabilitation services (US$ 3.5 million). This subcomponent will finance the development of materials and training to support utilization of protocols for integration of multidisciplinary care for cardiac and stroke patients; strengthening of digital infrastructure between facilities to support the integration of rehabilitation services; discharge planning and protocols from secondary to primary care; rehabilitation support materials; and the development of home-based care models to minimize unnecessary and prolonged hospital-based treatment. Furthermore, it will support the development of policies and financing mechanisms to improve service delivery and the integration of care for rehabilitation services across and within the health and social care sectors. It will also support enhancements to primary care facilities to improve their accessibility, including the provision of ramps, rails, and other modifications for patients with disabilities. Component 3: Project management (US$ 3 million). This component will provide support for the execution of project management, coordination, and monitoring and evaluation activities, including third party monitoring. It will finance the Project Implementation Unit (PIU), consulting services, office equipment, training, audits, filing systems, and operating costs.Component 4: Contingent Emergency Response (US$0). The objective of this component is to improve Moldova’s capacity to respond to disasters. Following an eligible crisis or emergency, the Recipient may request the Bank to reallocate project funds to support emergency response and reconstruction. This component would draw from the uncommitted grant resources under the Project from other project components to cover emergency response. An emergency eligible for financing is an event that has caused or is likely imminently to cause a major adverse economic and/or social impact on the Recipient, associated with a disaster. The Project Operations Manual (POM) will include a specific annex for the Contingent Emergency Response Component, which lays out the provisions for activating and implementing the component. Relationship to Country Partnership Framework (CPF): The Project seeks to address the binding constraints identified in the 2021 Systematic Country Diagnostic (SCD) Update and is aligned with the upcoming Country Partnership Framework (CPF) for FY23–27. The P

FY17 - Health

World Bank

Project

Residential, Hospital, Commercial, Government