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: 9 | ARCHIVED on 20-Oct-2017 | ISR29936 | Implementing Agencies: Government of Croatia, Ministry of Health 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  Moderately Satisfactory  Moderately Unsatisfactory Overall Implementation Progress (IP)  Moderately Satisfactory  Moderately Unsatisfactory Overall Risk Rating  Substantial  Substantial 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, excellent 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 September visit, the Ministry of Health and the Bank have agreed on key actions to accelerate implementation of lagging reforms. The Ministry of Health and Bank have also agreed on the need to restructure the Program. The restructuring scope is yet to be discussed and it might include revisions of the definition and targets for Disbursement Linked Indicators and related Results Framework indicators in the context of continuing support to health sector reform in Croatia to improve the quality and efficiency of health services. 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 46% 10/20/2017 Public Disclosure Copy Page 1 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 -- 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  --  Moderate  Substantial Fiduciary  --  Moderate  Moderate Environment and Social  --  Substantial  Substantial Stakeholders  --  Moderate  Moderate Other  --  --  -- Overall  --  Substantial  Substantial 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 12161.00 Date 31-Dec-2012 22-Jul-2015 03-Mar-2017 Comments Achieved. This DLI, also being a PDO indicator, has been fully achieved, with the final target of 12,800 for the number of acute care beds surpassed ahead of schedule with an actual value of 12,161 (a 23-percent reduction over the baseline value of 15,930 in 2012). The achievement of final DLI target was verified and confirmed by the Bank team in February 2017, and the full allocated DLI amount of EUR 7.5 million has been disbursed. PHDLIPDOTBL  2. Number of “hospital reshaping scheme” projects implemented (Number) Baseline Actual (Previous) Actual (Current) 10/20/2017 Public Disclosure Copy Page 2 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 0.00 0.00 Date 31-Dec-2012 22-Jul-2015 03-Mar-2017 Comments Delayed but achievable. This DLI is on track for achievement by the Program’s current closing date of June 30, 2018. Per information from the MOH, twelve hospitals have been functionally integrated into six units, with legal agreements between the MOH and respective counties signed and necessary changes made to their operations, work flows, staffing, etc. The MOH will share with the Bank technical details regarding the proposed hospital reshaping projects, including copies of legal agreements concluded with the counties, etc. Based on this information, the Bank and MOH will identify an appropriate completion measure for full functionalization of each pilot project. 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 22-Sep-2017 Comments Delayed. The final target of 80 percent cannot be achieved by Program closing date. The MOH will share updated hospital arrears analysis identifying hospitals and spending categories that drive incidence of arrears. More technical discussions on restructuring will be needed should the MOH make decisions on the way forward with a meaningful restructuring. 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 22-Jul-2015 03-Mar-2017 Comments Achieved. The final target of 60% for this DLI was achieved ahead of schedule in January 2016 and confirmed by the Bank team. Over time, HZZO has also increased the list of services performed on an outpatient basis. Going forward, a further expansion in the list of outpatient surgeries and share of surgeries performed on an outpatient basis should be incentivized. 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 22-Jul-2015 03-Mar-2017 Comments Delayed. This DLI has shown some good progress since the previous visit in June 2017, with the final target potentially to be achieved by the 10/20/2017 Public Disclosure Copy Page 3 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Program closing in June 2018. Since June, 2017, the AQAHS has completed pilot audits in 9 hospitals using 4 audit teams. Based on pilots, the AQAHS has prepared a time-bound business plan and updated related audit documents. It plans to conduct audits in 19 remaining hospitals by the end of November 2017 subject to required financial support from the MOH, with subsequent data compilation and analysis to be performed in February-March 2018 for the results to be verified in May 2018. 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 03-Mar-2017 Comments Delayed. Based on updated information from the AQAHS, this DLI will need more time beyond the current closing date to be met even with the adjustments to implementation agreed during the MTR. The AQAHS and Bank team had agreed on considering the use of existing mandatory quality standards (MQS) as a first step towards full-fledged accreditation standards, but external assessment and on-site visits must be taken by AQAHS for this to be a stepping stone towards full accreditation process. 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 03-Mar-2017 Comments Achieved. This DLI was fully achieved in June 2015 as scheduled. The allocated amount of EUR 7.5 million has been fully disbursed. The HZZO continues to monitor over-prescription and discuss corrective actions with doctors on a monthly basis as a part of the performance indicators in hospital contracts. 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 9.00 Date 31-Dec-2012 22-Jul-2015 22-Sep-2017 Comments Delayed. The MOH has indicated that the final target of this DLI as currently defined cannot be achieved by the current Program closing date. Despite the MOH taking several steps to further implement joint/centralized procurement, the share of spending (as distinct from estimated contracts) through joint/centralized procurement remains low. Although the responsibility for tendering and negotiating framework contracts for 12 procurement categories (planned to be further increased to 20) was shifted to the MOH in April 2017, only two tenders had been launched by the time of the visit. 10/20/2017 Public Disclosure Copy Page 4 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 03-Mar-2017 Comments Achieved. DLI was fully achieved in June 2015, ahead of schedule. The allocated amount of EUR 7.5 million has been fully disbursed. 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 64.70 Date 31-Dec-2012 22-Jul-2015 07-Jun-2017 Comments Achieved. This DLI was fully achieved, with confirmation issued in June 2017. 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 15,930.00 12,161.00 12,161.00 12,800.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 31-Dec-2017 10/20/2017 Public Disclosure Copy Page 5 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 03-Mar-2017 22-Sep-2017 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 0.00 0.00 40.00 Date 31-Dec-2012 03-Mar-2017 22-Sep-2017 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 03-Mar-2017 22-Sep-2017 31-Dec-2017 Overall Comments Overall, out of the four PDO indicators, only one PDO indicator, number of acute beds has been fully achieved. The PDO indicator related to hospital arrears will not be achieved by closing date. The PDO indicator related to technical audit appears on track provided no further slippage, but evidence is yet to be received. The PDO indicator related to hospital accreditation will need more time to be achieved since the MOH is yet to submit full proposals on implementation. 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 78/20/1 78/20/1 90 / 19 / 1 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 10/20/2017 Public Disclosure Copy Page 6 of 9 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 03-Mar-2017 03-Mar-2017 29-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 61.10 61.10 60.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-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 03-Mar-2017 03-Mar-2017 29-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 4,000.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 PHINDIRITBL  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 68.80 50.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 10/20/2017 Public Disclosure Copy Page 7 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 66.90 66.90 60.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 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 31-Dec-2012 08-Sep-2016 08-Sep-2016 29-Dec-2017 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 16.00 16.00 60.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 PHINDIRITBL  10. Number of counties implementing specialized services on palliative care. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 10.00 10.00 15.00 Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 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 10/20/2017 Public Disclosure Copy Page 8 of 9 Public Disclosure Copy The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 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 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 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 41.00 64.70 60.00 Date 31-Dec-2012 03-Mar-2017 07-Jun-2017 29-Dec-2017 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 31-Dec-2012 03-Mar-2017 03-Mar-2017 29-Dec-2017 Overall Comments Overall, out of 14 intermediate results indicators, 5 indicators (#3, 6, 7, 8 and 13) have achieved final targets, 3 indicators (# 1, 2 and 10) are likely to achieve final targets but need further updates on data, and 6 indicators (#4, 5, 9, 11, 12 and 14) are unlikely to be achieved based on most recent available data and past trend. 10/20/2017 Public Disclosure Copy Page 9 of 9