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 | Requesting Unit: ECCEU | Responsible Unit: GHN03 IBRD/IDA | Program-for-Results | FY 2014 | Team Leader(s): Huihui Wang Seq No: 10 | ARCHIVED on 24-Apr-2018 | ISR31599 | Created by: Huihui Wang on 15-Feb-2018 | Modified by: Baktybek Zhumadil on 19-Apr-2018 Program Development Objectives Program Development Objective (from Program 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 Moderately Unsatisfactory Moderately Unsatisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Unsatisfactory Implementation Status and Key Decisions Overall, the Health Program-for-Results has made good progress to date on many crucial fronts as reflected by the achievement of several key indicators of intermediate and final expected results in the national health sector reforms. More specifically, good progress has been achieved in the reduction of the number of acute care beds, establishing sentinel surveillance schemes in rationalized hospitals with surgery wards, increasing the share of elective surgeries performed on an outpatient basis, monitoring over-prescription of drugs, and incentivizing primary care doctors to work in group practices. Taken together, these achievements are expected to lead to improved quality and efficiency of health services in Croatia. However, there have been delays with the implementation of some key reforms, specifically: with implementing hospital reshaping schemes, reducing hospital arrears, implementing hospital accreditation, and joint / centralized procurement of drugs, medical supplies and devices. Following the February 2018 visit, the Bank and the Government of Croatia have agreed on a formal Program restructuring, which includes a set of actions to be undertaken by both the Government and the Bank, with the restructuring expected to be completed in May 2018. By allowing time for the achievement of several lagging Disbursement Linked Indicators, these actions would facilitate the achievement of the Program Development Objectives within a one-year extension of the Loan Closing Date to June 30, 2019, thus contributing to the overall progress of sector reforms and, ultimately, to the quality and efficiency of health services in Croatia. 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 47.71 46.49 51% Key Dates (by loan) 4/24/2018 Page 1 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date Program Action Plan Action Description Expansion of the centralized procurement system Responsibility Recurrent Frequency Due Date DLI# Status No 8. Percentage of total public spending per fiscal year on medical consumables, drugs, and devices for Ministry of Health 31-Oct-2014 hospital (in and Delayed outpatient) services made through centralized procurement and disclosed Expansion of the centralized procurement has been delayed for political and legislative environment reasons Comments described in the Status and Key Decisions section. This action will be adjusted as part of the proposed Program restructuring. Establishment of a quality control mechanism and define related quality and efficiency control protocol for technical Action Description audit of hospital Responsibility Recurrent Frequency Due Date DLI# Status No 5. Percentage of best- performing rationalized hospitals which are publicly MoH, AQAHS, HZZO 30-Sep-2014 Completed disclosed (including results) based on the technical audit in the preceding 12 months. Completed. The established quality control mechanism and defined protocol for technical audits have been applied in Comments conducting technical audits in all 28 rationalized hospitals, which were completed by December 1, 2017. Action Description Establishment of a sentinel event surveillance system Responsibility Recurrent Frequency Due Date DLI# Status No 10. Percentage of hospitals with surgery wards that have MoH, AQAHS, HZZO 31-Dec-2014 established quality- Completed and safety-related sentinel surveillance schemes thatare 4/24/2018 Page 2 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) reporting the rates of specific events Comments As of June 2017, quality- and safety-related surveillance system is in place in 64.7% of hospitals with surgery wards. Internal financial audit units functioning in tertiary hospitals (increased in coverage by 20% each year over 5 years of Action Description the Program) Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health, Yes Yearly In Progress hospitals Comments On track. Action Description Completion of the hospital rationalization plan Responsibility Recurrent Frequency Due Date DLI# Status No 2. Number of “hospital Ministry of Health 28-Feb-2014 reshaping scheme” Completed projects implemented The hospital rationalization plan developed under the preceding Development of Emergency Medical Services and Comments Investment Planning Project was approved by the Parliament in February 2015. Action Description Feasibility and pre-investment studies for “hospital reshaping schemes” Responsibility Recurrent Frequency Due Date DLI# Status No 2. Number of “hospital Ministry of Health 30-Jun-2018 reshaping scheme” In Progress projects implemented In 2017, the MoH initiated the functional integration of several pairs of general and county general hospitals. An EU- Comments consultant will assess the functionality of hospitals that have been integrated. Action Description Training in preparation of applications for EU funds, including Energy Efficiency proposals Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health Yes CONTINUOUS In Progress Employees of the MoH and health institutions continuously attend training workshops on preparation of applications for Comments EU funds, including on energy efficiency, organized by the Croatian Ministry of Construction and Spatial Planning. Action Description Technical and project documentation and preparation of applications for EU funds Responsibility Recurrent Frequency Due Date DLI# Status 4/24/2018 Page 3 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Ministry of Health Yes CONTINUOUS In Progress 62 proposals for EU structural funds developed by the MoH and health institutions have been accepted to date by the Comments relevant authority after being correctly prepared and submitted. HZZO Service for Control Directorate has: (a) conducted regular inspections of hospitals under the Program; and (b) Action Description conducted specialized reviews based on risk assessments or significant complaints regarding health services provided. Responsibility Recurrent Frequency Due Date DLI# Status HZZO Yes CONTINUOUS In Progress All the planned full controls of the operation and execution of contractual obligations in hospital health institutions, and Comments specialized controls in hospitals (25 and 162 in 2018, respectively) have been conducted regularly. Establishment and implementation of Program for improvement of Energy efficiency in the Healthcare sector and Action Description preparation of projects for EU funds absorption Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 Completed The Program for Energy Reconstruction of Buildings in the Public Sector for the period 2016-2020 was adopted by the Comments Government of the Republic of Croatia on March 2, 2017. The progress to date continues to be positive. Action Description Establishment and implementation of the Program for education and training for radiological and radiotherapy safety Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 Delayed This Program Action has been significantly delayed and no official coordination has been established between the Comments MoH and State Office for Radiological and Nuclear Safety. Action Description Public disclosure of the best-performing hospitals based on technical audit in the preceding calendar year Responsibility Recurrent Frequency Due Date DLI# Status Yes 5. Percentage of best- performing rationalized hospitals which are publicly Ministry of Health, AQAHS Yearly In Progress disclosed (including results) based on the technical audit in the preceding 12 months. As of December 1, 2017, technical audits were conducted in all 28 rationalized hospitals. Disclosure of best- Comments performing hospitals on the MoH website is planned for the end of June 2018. 4/24/2018 Page 4 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Action Description Public awareness and communication campaign about the health sector reform Responsibility Recurrent Frequency Due Date DLI# Status Minisry of Health No 31-Dec-2014 Completed The initially planned communications campaign was implemented in November-December 2015. The MoH has Comments continued to use communications to successfully address concerns and create consensus on various reform initiatives. Action Description Rationalization of expenditures for pharmaceuticals Responsibility Recurrent Frequency Due Date DLI# Status HZZO Yes CONTINUOUS In Progress In addition to feedback to physicians on their prescription practices, HZZO regularly carries out annual calculation of Comments prices of medicines and public tenders for determining the prices of medicines for the basic and supplementary list of medicines. Action Description Diagnosis-Related Group (DRG) system. Review of the costing of each group based on some pilot costing system. Responsibility Recurrent Frequency Due Date DLI# Status HZZO No 30-Jun-2015 In Progress HZZO department for analytics and development of health services (DTP and DRG) continuously works on the Comments analysis and improvement of DRG and DTP prices. Current DRG and DTP prices are published in the Official Gazette. Action Description Hospital management training Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 Completed In 2015, hospital managers were trained for professionally interviewing for the media with the purpose of building a Comments better reputation and skillful communication of key messages in the media. TA to AQAHS in foreseen implementation of hospitals’ accreditation (assistance in preparation of accreditation Action Description scheme legislation, accreditation, environmental guidance, trainings, etc.) Responsibility Recurrent Frequency Due Date DLI# Status No 6. Percentage of Rationalized Hospitals accredited by AQAHS AQAHS 31-Mar-2015 Delayed through the Acceptable Accreditation Process 4/24/2018 Page 5 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Actions to accredit hospitals have been delayed. This Program Action will be re-formulated as part of the proposed Comments Program restructuring. TA to AQAHS in establishment of monitoring system of the hospitals’ compliance with adopted mandatory quality Action Description standards Responsibility Recurrent Frequency Due Date DLI# Status No 6. Percentage of Rationalized Hospitals accredited by AQAHS AQAHS 30-Jun-2015 Delayed through the Acceptable Accreditation Process Actions to accredit hospitals have been delayed. This Program Action will be re-formulated as part of the proposed Comments Program restructuring. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Substantial Substantial Macroeconomic -- Substantial Substantial Sector Strategies and Policies -- Substantial Substantial Technical Design of Project or Program -- Moderate Moderate Institutional Capacity for Implementation and Sustainability -- Substantial Substantial Fiduciary -- Moderate Moderate Environment and Social -- Substantial Substantial Stakeholders -- Moderate Moderate Other -- -- -- Overall -- Substantial Substantial RiskComments Comments Risk remains the same until project restructuring is processed as there are no changes. Results PDO Indicators by Objectives / Outcomes 4/24/2018 Page 6 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Improved quality of health care in Croatia ►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 0.00 0.00 40.00 Date 31-Dec-2012 22-Sep-2017 28-Feb-2018 30-Jun-2018 ►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-Sep-2017 30-Jun-2018 30-Jun-2018 Improved efficiency of health services in Croatia ►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 15,930.00 12161.00 12,161.00 12,800.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 0.00 80.00 Date 31-Dec-2012 22-Sep-2017 28-Feb-2018 30-Jun-2018 Intermediate Results Indicators by Results Areas Quality of health care ►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 4/24/2018 Page 7 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 4,000.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 30-Jun-2018 ►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 Value 0.00 66.90 99.17 60.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►10. Number of counties implementing specialized services on palliative care. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 10.00 12.00 15.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 0.00 100.00 30.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 64.70 64.70 60.00 Date 31-Dec-2012 07-Jun-2017 07-Jun-2017 30-Jun-2018 ►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 38.60 75.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 29-Dec-2017 4/24/2018 Page 8 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Efficiency of health services ►1. Ratio between primary health care/secondary outpatient care/ and hospital inpatient care services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 58 / 18 / 1 78/20/1 78 / 20 / 1 90 / 19 / 1 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 61.10 61.10 60.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 31-Dec-2017 ►6. Percentage of primary health care doctors working in group practices (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 68.80 69.06 50.00 Date 31-Dec-2012 03-Mar-2017 31-Dec-2017 31-Dec-2016 ►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 31-Dec-2012 08-Sep-2016 08-Sep-2016 29-Dec-2017 ►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 16.00 8.00 60.00 4/24/2018 Page 9 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 ►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 62.00 8.00 Date 31-Dec-2012 03-Mar-2017 28-Feb-2018 30-Jun-2018 Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1. Total number of hospital beds in Rationalized Hospitals classified as Acute Care Beds. (Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 15,930.00 13572.00 12,161.00 12800.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments Final target achieved and full disbursement made. ►DLI 2. Number of “hospital reshaping scheme” projects implemented (Intermediate Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 0.00 0.00 2.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments Not achieved yet; additional time required. ►DLI 3. Percentage of rationalized hospitals without arrears incurred during the preceding calendar year. (Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 0.00 0.00 80.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- This PDO-level DLI will be cancelled as part of the proposed Program restructuring since its achievement is Comments not likely even within the proposed Closing Date extension. The full allocation in the amount of EUR 7,500,000 will be cancelled from the Loan amount. 4/24/2018 Page 10 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) ►DLI 4. Percentage of all surgeries included in the elective surgeries list performed as outpatient surgeries in the preceding six months. (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 5.80 57.00 61.10 60.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments Final target achieved and full disbursement made. ►DLI 5. Percentage of best-performing rationalized hospitals which are publicly disclosed (including results) based on the technical audit in the preceding 12 months. (Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 0.00 0.00 40.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments On track to be fully achieved by end-June 2018. ►DLI 6. Percentage of Rationalized Hospitals accredited by AQAHS through the Acceptable Accreditation Process (Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 0.00 0.00 50.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Actions to accredit hospitals have been delayed. The DLI will be reformulated as part of the proposed Program Comments restructuring to incentivize progress towards hospital accreditation. ►DLI 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. (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 20.00 93.10 93.10 90.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments Final target achieved and full disbursement made. ►DLI 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 (Intermediate Outcome, 7,500,000.00, 0%) 4/24/2018 Page 11 of 12 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 10.00 8.00 60.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Not achieved yet for political and legislative reasons described in the Status and Key Decisions section. Target Comments will be revised downwards as part of the proposed Program restructuring. ►DLI 9. Percentage of primary health care doctors in the Republic of Croatia working in group practices (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 65.11 69.06 50.00 Date 31-Dec-2012 14-May-2015 28-Feb-2018 -- Comments Final target achieved and full disbursement made. ►DLI 10. Percentage of hospitals with surgery wards that have established quality- and safety-related sentinel surveillance schemes thatare reporting the rates of specific events (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2018 Value 0.00 53.30 64.70 60.00 Date 31-Dec-2012 22-Jul-2015 28-Feb-2018 -- Comments Final target achieved and full disbursement made. 4/24/2018 Page 12 of 12