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: 5 | ARCHIVED on 24-Oct-2015 | ISR21120 | 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. Operational plans for 2015 and 2016 are currently being finalized with input from hospitals. The Program is making progress on three out of four Disbursement Linked Indicators (DLIs) related to the Project Development Objectives (PDOs). The final targets for DLIs 7 (monitoring of over-prescribers) and 9 (primary care group practices) have been achieved ahead of schedule. The first targets for DLIs 1 (acute care beds contracted), 4 (outpatient surgeries), and 10 (hospital reporting on sentinel events) have been achieved. The final target for DLI 4 is expected to be achieved in the next few months. Although the health sector reform is at a relatively early stage of implementation, the achievement of several critical DLIs suggests that the reforms are beginning to yield results. Systematically measuring the impact the reforms are having on quality, efficiency and costs, and communicating them to the Croatian public and key internal stakeholders could contribute to maintaining momentum on the reforms and make course corections, if needed. 10/24/2015 Public Disclosure Copy Page 1 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 10/24/2015 Public Disclosure Copy Page 2 of 11 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 -- 10/24/2015 Public Disclosure Copy Page 3 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 15930.00 13572.00 Date 31-Dec-2012 -- 22-Jul-2015 Comments HZZO (Croatian Health Insurance Fund) anticipates that the target of 12,800 will be met by the end of 2015. 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 -- 22-Jul-2015 Comments The Master Plan was approved by Parliament in February 2015. As of July, the revised proposal for the network of public hospitals was under review by regional and local governments and professional associations before its approval. 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 0.00 Date 31-Dec-2012 -- 22-Jul-2015 Comments The Ministry of Health is taking a number of steps towards meeting this DLI including improving incentives for quality and efficiency in the purchasing of hospital services, improving hospital oversight and management and reforms to increase the quality and efficiency of the health system as indicated by tracer DLI results achieved. As of September 2015, the MoH's monitoring data showed that hospitals continued to generate new arrears, adding Kuna 121 million in new arrears between January 1 and June 30, 2015. By comparison, hospitals generated Kuna 1.5 billion in new arrears between January and December 2014 after factoring in debt forgiveness 'rehabilitation' transfers to hospitals in 2014. The health sector as a whole realized savings of Kuna 10 million in the first half of 2015. 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) 10/24/2015 Public Disclosure Copy Page 4 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 5.00 15.00 57.00 Date 31-Dec-2012 -- 22-Jul-2015 Comments In February this year, the MoH and HZZO launched a new initiative, ‘Program Plus’, to reduce waiting lists and increase the share of outpatient surgeries on the elective surgeries list. Hospitals are incentivized to perform these elective surgeries on an outpatient basis through higher reimbursement rates. HZZO’s outreach to hospital managers and staff to communicate the quality and efficiency benefits of outpatient surgeries may have also contributed to the higher uptake at hospitals. 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 46.00 0.00 Date 31-Dec-2012 -- 22-Jul-2015 Comments The list of rationalized hospitals assessed as best-performing based on initial indicators had been publicly disclosed previously. Since then, AQAHS has updated key performance indicators for the technical audits, including indicators based on clinical protocols to be extracted through medical record review. The first target for this indicator based on a refined set of indicators is due in 2016 (for this reason, the current value for this indicator has been reset to 0. The revised indicators will be piloted before implementation is scaled up, likely in early 2016. 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 -- 22-Jul-2015 Comments 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 -- 22-Jul-2015 Comments The final target of 90 percent for this DLI has been achieved. 10/24/2015 Public Disclosure Copy Page 5 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 30.00 10.00 Date 31-Dec-2012 -- 22-Jul-2015 Comments The first target for this DLI was due in 2014. The MoH anticipates that the DLI target of 30 percent will be met in 2016 and not 2015 as previously anticipated. On March 20, 2015, the MoH issued a new decision supporting compulsory implementation of joint procurement for drugs, supplies and devices. As of July 2015, the value of joint public procurements in the fiscal year was Kuna 133 million or 10 percent of the total potential value. PHDLIPDOTBL  9. Percentage of primary health care doctors in the Republic of Croatia working in group practices (Percentage) Baseline Actual (Previous) Actual (Current) Value 0.00 65.11 65.11 Date 31-Dec-2012 -- 14-May-2015 Comments The final target of 50 percent for this DLI has been achieved. 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 53.30 Date 31-Dec-2012 -- 22-Jul-2015 Comments Hospital reporting on sentinel events has been expanded to include diabetes-related amputations and all the events for this DLI are now included in hospital sentinel events reporting. The first target for this DLI was 30 percent. Results Results Area 10/24/2015 Public Disclosure Copy Page 6 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Intermediate Results Area Project Development Objective Indicators PHINDPDOTBL  First phase of the hospital master plan achieved: Total number of hospital beds in Rationalized Hospitals a classified as acute care beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 15930.00 15930.00 13572.00 12800.00 Date 31-Dec-2012 20-Nov-2014 22-Jul-2015 31-Dec-2017 Comments The current actual value of 13,572, which suggests the first target of 15,000 has been exceeded, is pending verification data. The HIF anticipates that the target of 12,800 will be met by the end of 2015. 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 0.00 80.00 Date 31-Dec-2012 20-Nov-2014 22-Jul-2015 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 53.30 40.00 Date 31-Dec-2012 10-Apr-2015 22-Jul-2015 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 20-Nov-2014 22-Jul-2015 31-Dec-2017 10/24/2015 Public Disclosure Copy Page 7 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Overall Comments 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 20-Nov-2014 22-Jul-2015 30-Dec-2017 Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 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 20-Nov-2014 22-Jul-2015 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 15.00 57.00 60.00 Date 31-Dec-2012 20-Nov-2014 22-Jul-2015 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 20-Nov-2014 22-Jul-2015 24-Dec-2017 Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 10/24/2015 Public Disclosure Copy Page 8 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. PHINDIRITBL  6. Percentage of primary health care doctors working in group practices (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 62.25 65.11 50.00 Date -- 20-Nov-2014 22-Jul-2015 -- 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 Value 0.00 0.00 0.00 60.00 Date -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 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 84.00 93.10 90.00 Date -- 20-Nov-2014 22-Jul-2015 -- 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 10/24/2015 Public Disclosure Copy Page 9 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 30.00 10.00 60.00 Date -- 20-Nov-2014 22-Jul-2015 -- Comments The current value of joint public procurements in this fiscal year stands at HRK 133 million or about 10 percent of the total potential value. This is expected to increase to an estimated 13 percent by the end of 2015. The MoH highlighted capacity gaps as the main constraint. 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 -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 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 -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 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 Date -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. 10/24/2015 Public Disclosure Copy Page 10 of 11 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 31.50 60.00 Date -- 20-Nov-2014 22-Jul-2015 -- Comments Since April 2015, hospital reporting on sentinel events has been expanded to include diabetes-related amputations with the result that all the events for this DLI are now included in hospital sentinel events reporting. Hospitals with surgery wards have been reporting on wrong patient surgery, wrong site surgery and postoperative pulmonary embolism and deep vein thrombosis using a web-based reporting platform since December 2014. Sentinel events reports for 2013 excluding diabetes-related amputations are available on the AQAHS website, and work is in progress to complete data collection on sentinel events for diabetes-related amputations for 2014 to publish these data on the AQAHS website. Hospitals now report within seven days of the sentinel event for events covered through the web-based tool, and every quarter for diabetes-related amputations. For the latter, hospitals report via email. 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 -- 20-Nov-2014 22-Jul-2015 -- Comments Updated Results Framework is awaited from the MoH to enable update of this indicator. Overall Comments 10/24/2015 Public Disclosure Copy Page 11 of 11