Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Health System Quality and Efficiency Improvement (P144871) EUROPE AND CENTRAL ASIA | Croatia | Health, Nutrition & Population Global Practice | IBRD/IDA | Program-for-Results | FY 2014 | Seq No: 6 | ARCHIVED on 19-Apr-2016 | ISR23136 | Implementing Agencies: Program Development Objectives Program Development Objective (from Program-for-Results Appraisal Document) The Program will contribute to (a) improving the health care delivery system in order to provide more equitable quality and sustainable health services to the population; (b) rationalizing the hospital network in order to streamline health care services to the population; (c) strengthening Government's capacity to develop and monitor effective health sector policies in the area of health financing, resource allocation, and provider payments; and (d) promoting effective public health interventions. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO  Satisfactory  Satisfactory Overall Implementation Progress (IP)  Satisfactory  Satisfactory Overall Risk Rating  Moderate  Moderate Implementation Status and Key Decisions The Program was approved by the World Bank (WB) Board of Directors on May 8, 2014 and declared effective on Sep 8, 2014. The hospital Master Plan was approved by Parliament on February 27, 2015. The Ministry of Health plans to start implementing the hospital masterplan in October 2016. The Ministry of Health also plans to prioritize implementation of joint procurement for medical consumables, drugs and devices. The Program is making progress on three out of the four Project Development Objective (PDO) indicators (number of acute care beds, percentage of rationalized hospitals without arrears, percentage of best-performing rationalized hospitals). Several critical disbursement-linked indicators (DLI) have also been achieved. The first target has been achieved and surpassed for DLI 1 (number of acute care beds). The final target has been achieved for DLI 4 (outpatient surgeries), DLI 7 (monitoring of over-prescribers) and DLI 9 (primary care group practices). 4/19/2016 Public Disclosure Copy Page 1 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 4/19/2016 Public Disclosure Copy Page 2 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P144871 IBRD-83650 Effective USD 103.50 103.50 0.00 9.39 93.15 9% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P144871 IBRD-83650 Effective 08-May-2014 10-Jun-2014 08-Sep-2014 30-Jun-2018 -- Disbursement Linked Indicators (DLI) PHDLIPDOTBL  1. Total number of hospital beds in Rationalized Hospitals classified as Acute Care Beds. (Number) Baseline Actual (Previous) Actual (Current) Value 15930.00 13572.00 13572.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments On track. The first target on this DLI has been surpassed, and its achievement confirmed by the Bank team on February 24, 2016. Preliminary updated information on acute care beds contracted by HZZO (Croatian Health Insurance Fund) for 2016 indicates that the full target of 12,800 is likely to have been achieved, pending verification of forthcoming evidence. PHDLIPDOTBL  2. Number of “hospital reshaping scheme” projects implemented (Number) Baseline Actual (Previous) Actual (Current) Value 0.00 0.00 0.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments The MoH informed the Bank team of their plans to begin hospital reshaping in October 2016 once the operational plans are updated. The MoH also informed the Bank team that additional investments would be needed in some hospitals to support this. Per the discussion, the hospital network will be reshaped as follows: 1 national-level hospital, 8 regional hospitals, and remaining local hospitals. Local hospitals will be re- profiled to focus on palliative care and long- term care. This will enable greater concentration of other services such that quality of care can be maintained and improved. Furthermore, functional networks of hospitals will be created with shared administrative, medical and non-medical services and will allow flexible use of human resources within networks. 4/19/2016 Public Disclosure Copy Page 3 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) PHDLIPDOTBL  3. Percentage of rationalized hospitals without arrears incurred during the preceding calendar year. (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 0.00 35.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments According to data from HZZO and Ministry of Finance, the health sector as a whole reduced its stock of arrears in 2015 without receiving any rehabilitation (‘sanation’) transfers. However, some hospitals generated new arrears, and these were mostly tertiary care hospitals. Nevertheless, arrears generated by tertiary care hospitals in 2015 are substantially lower (76 percent) of those generated in 2014. 11 of 31 rationalized hospitals did not generate any new arrears in 2015. Reforms implemented in recent years contributed to these improvements, particularly the changes to resource allocation and contracting of hospitals. The MoH plans to assess what worked (or did not work) under the hospital sanation plans to identify an operational plan to reduce arrears. The Bank team and MoH agreed that the next Bank mission to be held in May 2016 would focus on an analysis of and recommendations to sustainably reduce hospital arrears following the MoH’s own analysis which will be conducted by a working group in April 2016. PHDLIPDOTBL 4. Percentage of all surgeries included in the elective surgeries list performed as outpatient surgeries in the preceding six months. . (Percentage) Baseline Actual (Previous) Actual (Current) Value 5.00 57.00 61.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments The final target of 60% for this DLI has been achieved and confirmed by the Bank team. Going forward, the Bank recommends that the MoH builds on the remarkable progress achieved by further expanding the list of elective surgeries with interventions that could be performed on an outpatient basis and would result in substantial savings to hospitals and the health system in general. This will likely require further investments. However, given the likely reductions in unit costs of services, these investments will make the health system more efficient and will improve quality. PHDLIPDOTBL 5. Percentage of best-performing rationalized hospitals which are publicly disclosed (including results) based on the technical audit in the preceding 12 months. (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 0.00 0.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments The list of rationalized hospitals assessed as best-performing based on initial indicators had been publicly disclosed previously. The first target for this indicator based on a refined set of indicators is due by the end of 2016; for this reason, the current value for this indicator has been reset to 0. Although with some delays relative to initial plans, the first target of 20 percent for this DLI is on track to be achieved by the end of 2016. With contribution from HZZO, AQAHS is finalizing the list of key performance indicators and a manual for the technical audits. An indicator to measure time from performing triage to patient examination for hospitals’ emergency departments will be added to the current list of 5 outcome and 6 process indicators for technical audits. The technical audits will be implemented by a team that includes AQAHS, HZZO and hospital staff and will begin in September-October 2016. The results will be analyzed and discussed with relevant stakeholders in November- December 2016, with subsequent arrangements to scale-up implementation. 4/19/2016 Public Disclosure Copy Page 4 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) PHDLIPDOTBL  6. Percentage of Rationalized Hospitals accredited by AQAHS through the Acceptable Accreditation Process (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 0.00 0.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments No progress was reported on this DLI during the mission. Progress on accreditation is pending legal endorsement of accreditation standards and will require additional resources including technical assistance, to support implementation. PHDLIPDOTBL  7. Percentage of identified doctors with whom corrective course of action has been discussed on a person-to-person basis in the preceding six months. (Percentage) Baseline Actual (Previous) Actual (Current) Value 20.00 93.10 93.10 Date 31-Dec-2012 -- 01-Apr-2016 Comments The final target of 90% for this DLI has been achieved and verified at an actual value of 93.10. The Bank team, MoH and HZZO discussed that the next stage should be is to build a set of algorithms to help to enforce the use of clinical protocols, including reduction of under-prescription of preventive drugs. PHDLIPDOTBL  8. Percentage of total public spending per fiscal year on medical consumables, drugs, and devices for hospital (in and outpatient) services made through centralized procurement and disclosed (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 10.00 10.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments The first target for this DLI was due in 2014. A software tender to automate management of all framework agreements and signed contracts was signed on July 1, 2015, and the software has been installed and operationalized. Hospitals are now compiling the evidence to confirm DLI achievement, and the MoH anticipates that this should be completed by June 2016. PHDLIPDOTBL  9. Percentage of primary health care doctors in the Republic of Croatia working in group practices (Percentage) Baseline Actual (Previous) Actual (Current) 4/19/2016 Public Disclosure Copy Page 5 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 65.11 65.11 Date 31-Dec-2012 -- 01-Apr-2016 Comments The final target of 50% for this DLI has been achieved and confirmed at an actual value of 65.11. PHDLIPDOTBL  10. Percentage of hospitals with surgery wards that have established quality- and safety-related sentinel surveillance schemes thatare reporting the rates of specific events (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 53.30 41.00 Date 31-Dec-2012 -- 01-Apr-2016 Comments The Bank team has confirmed achievement for the first target for this DLI with an actual value of 41 percent. The next step is for the MoF to submit a Withdrawal Application to the Bank for the associated DLI value of € 5.125 million. The Bank team and AQAHS agreed that the sentinel reporting system needs to be expanded in terms of the range of events covered and the number of hospitals included. Results Results Area Intermediate Results Area Project Development Objective Indicators PHINDPDOTBL  First phase of the hospital master plan achieved: Total number of hospital beds in Rationalized Hospitals classified as acute care beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 15930.00 13572.00 13572.00 12800.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 PHINDPDOTBL  First phase of the hospital master plan achieved: Percentage of rationalized hospitals without arrears incurred during the preceding calendar year (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 35.00 80.00 4/19/2016 Public Disclosure Copy Page 6 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 PHINDPDOTBL  Quality control procedures in place: Percentage of best-performing rationalized hospitals which are publicly disclosed (including results) based on the technical audit in the preceding 12 months (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 53.30 0.00 40.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 PHINDPDOTBL  Quality control procedures in place: Percentage of Rationalized Hospitals accredited by AQAHS through the Acceptable Accreditation Process (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 50.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 Overall Comments Both PDO and Implementation progress for the Program are rated ‘Satisfactory’. The Program is making progress on three out of the four PDO indicators. The first target has been achieved and surpassed for Disbursement Linked Indicator (DLI) 1 (number of acute care beds), and DLI 10 (sentinel events reporting by hospitals). The final target has been achieved for DLI 4 (outpatient surgeries), DLI 7 (monitoring of over-prescribers) and DLI 9 (primary care group practices). Further progress with the reform will require investments in modernizing and reshaping the service delivery network, and implementation and enforcement of clinical guidelines and pathways. Intermediate Results Indicators PHINDIRITBL  1. Ratio between primary health care/secondary outpatient care/ and hospital inpatient care services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value Ratio 58 / 18 / 1 58/18/1 58/18/1 90 / 19 / 1 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 30-Dec-2017 4/19/2016 Public Disclosure Copy Page 7 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) PHINDIRITBL  2. Number of “hospital reshaping scheme” projects implemented (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 2.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 PHINDIRITBL 3. Percentage of all surgeries included in the elective surgeries list performed as outpatient surgeries in the preceding six months. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 57.00 61.00 60.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 31-Dec-2017 PHINDIRITBL  4. Number of clinical guidelines with specific protocols for most prevalent NCDs (including care pathways). (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 20.00 Date 31-Dec-2012 22-Jul-2015 01-Apr-2016 24-Dec-2017 PHINDIRITBL  5. Number of Primary Health Care doctors re-trained in updated clinical protocols (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 4000.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  6. Percentage of primary health care doctors working in group practices (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 65.11 65.11 50.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  7. Percentage of Primary Health Care group practices achieving performance indicators and accessing to payment incentives. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target 4/19/2016 Public Disclosure Copy Page 8 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 0.00 0.00 60.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  8. Percentage of identified doctors a with whom corrective course of action has been discussed on a person-to-person basis in the preceding six months. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 93.10 93.10 90.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL 9. Percentage of total public spending per fiscal year on medical consumables, drugs, and devices for hospital (inpatient and outpatient) services made through centralized procurement/ framework contr (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 10.00 10.00 60.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  10. Number of counties implementing specialized services on palliative care. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 1.00 1.00 15.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL 11. Number of proposals for EU structural funds accepted by the relevant authority after being correctly submitted. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 8.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  12. Percentage of Nosocomial Infections Surveillance system in place in tertiary hospitals and secondary hospitals. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 30.00 4/19/2016 Public Disclosure Copy Page 9 of 10 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  13. Percentage of hospitals with surgery wards that have established quality-and safety-related sentinel surveillance schemes that are reporting the rates of specific events. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 31.50 41.00 60.00 Date -- 22-Jul-2015 01-Apr-2016 -- PHINDIRITBL  14. Percentage of patients’ satisfaction by a perception of increased responsiveness. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 38.00 0.00 0.00 75.00 Date -- 22-Jul-2015 01-Apr-2016 -- Overall Comments 4/19/2016 Public Disclosure Copy Page 10 of 10