The World Bank Report No: ISR10343 Implementation Status & Results Turkey Project in Support of Restructuring of Health Sector (P102172) Public Disclosure Copy Operation Name: Project in Support of Restructuring of Health Sector Project Stage: Implementation Seq.No: 8 Status: ARCHIVED Archive Date: 04-Dec-2013 (P102172) Country: Turkey Approval FY: 2009 Product Line: IBRD/IDA Region: EUROPE AND CENTRAL ASIA Lending Instrument: Adaptable Program Loan Implementing Agency(ies): Key Dates Board Approval Date 11-Jun-2009 Original Closing Date 31-Jul-2013 Planned Mid Term Review Date Last Archived ISR Date 31-Mar-2013 Effectiveness Date 29-Sep-2009 Revised Closing Date 31-May-2015 Actual Mid Term Review Date 24-Oct-2011 Project Development Objectives Project Development Objective (from Project Appraisal Document) The specific objectives of the Project are: (i) increasing the effectiveness of the Social Security Institute (SSI) and the Ministry of Health (MOH) in formulating and implementing reforms in provider payments and health systems performance; and (ii) piloting output-based financing for non-communicable diseases (NCD) prevention and control. Has the Project Development Objective been changed since Board Approval of the Project? Yes No Component(s) Component Name Component Cost Support for MOH's Strategic Plan 46.17 Output Based Financing for Preventive Health Services 6.84 Capacity Building for Social Security Institution 3.09 Public Disclosure Copy Overall Ratings Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Unsatisfactory Overall Risk Rating Substantial Substantial Implementation Status Overview The Project has disbursed 61% of loan proceeds. Some of the Government’s main achievements supported under the Project include increased access to family medicine providers, which resulted in an increase of primary care Page 1 of 6 The World Bank Report No: ISR10343 services utilization from 2 to 3.3 outpatient visits per capita between 2009 and 2011. Since the implementation of the two-phased support to the Health Transformation Program, patient satisfaction with primary care services in provinces where family medicine was introduced increased from 69 percent in 2004 to 89.8 percent in 2012. Patient satisfaction with health services in public hospitals increased from 41 percent in 2003 to 76 percent in 2011. Public Disclosure Copy The approval of the Decree Law No. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates on November 3, 2011 has further helped establish the legal basis for the reforms being supported by the Project by defining the stewardship role of the MOH, increasing hospital autonomy, expanding family medicine services and further strengthening performance management and pay for performance initiatives. The recent completion of the Ministry’s medium-term strategic plan, covering the period from 2013 to 2017, confirms its commitment towards implementation of the reform program, and strengthens the basis for continued support under the Project. Notwithstanding these significant achievements, the Project has suffered from implementation delays, reflected in a Moderately Unsatisfactory rating of Implementation Progress in the last ISR. This reflects a considerable slow-down in disbursements as the MOH and SSI reconsidered the focus of the project, resulting eventually in the request to cancel the output-based financing and SSI-related activities under the project, the incorporation of new activities (including a new sub-component on international knowledge sharing) and the extension of the project implementation period. A considerable turnover of staff in the project implementation unit and the resulting need to rebuild procurement capacity, as well as change in Minister while discussions on a project restructuring and extension were ongoing contributed to the delay in project implementation and the finalization of the restructuring. A forthcoming restructuring (Board submission foreseen second quarter of FY14) of the project is expected to continue the recent acceleration in activities and efforts to consolidate the reform results. The revised PDO is achievable. The project is being streamlined with the cancellation of components, disbursement has picked up and a new implementation plan is being finalized. The updated procurement plan with all activities has been cleared. Locations No Location data has been entered Results Project Development Objective Indicators Indicator Name Core Unit of Measure Baseline Current End Target 1. Pre-capita annual visits to family medecine Number Value 2.00 3.30 4.00 physicians Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Target on track. 3.3 Visits per 4 visits per capita capita in 2011 Public Disclosure Copy Share of family medicine visits in total visits Percentage Value 35.00 37.00 40.00 Date 31-Dec-2011 06-Sep-2013 31-May-2015 Comments 3. Client satisfaction with health services Text Value 63.4 73 76 Date 31-May-2009 06-Sep-2013 31-May-2015 Comments percent percent Page 2 of 6 The World Bank Report No: ISR10343 Ministry of Health reorganized and focus Text Value MOH is a provider of health MOH is restructured and no exclusively on the health sector stewardship services longer a provider of health function services Public Disclosure Copy Date 31-Dec-2010 06-Sep-2013 31-May-2015 Comments Target met after passage of decree law no 663 in November 2011. 4. Smoking prevalence among 18-29 age Percentage Value group in pilot provinces relative to non-pilot Date 08-Jul-2009 06-Sep-2013 31-Jul-2013 provinces. Comments NCD survey to be Component B will be implemented in 2011. cancelled as the MOH decided to go national instead of piloting the intervention first. 5. High blood pressure in population in pilot Percentage Value provinces decreases more as compared to Date 08-Jul-2009 06-Sep-2013 31-Jul-2013 non-pilot provinces Comments Baseline NCD assessment to Component B will be be carried out in 2011 cancelled as the MOH decided to go national instead of piloting the intervention first. Intermediate Results Indicators Indicator Name Core Unit of Measure Baseline Current End Target Number of provinces implementing family Number Value 31.00 81.00 81.00 medicine scheme Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Component A: 1. Percentage of family Percentage Value 0.00 21.00 70.00 medicine physicians who have completed Date 31-May-2009 06-Sep-2013 31-May-2015 second phase of orientation training Public Disclosure Copy Comments 0 Establishment of Public Health Institution Text Value Public Health Institution not in Public Health Institution fully Public Health Institution fully responsible for health promotion, disease existence operational operational prevention and family medicine Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Share of public hospitals organized in public Percentage Value 0.00 100.00 100.00 hospital unions with performance contracts for Date 31-May-2009 06-Sep-2013 31-May-2015 managers and global budgets Comments Page 3 of 6 The World Bank Report No: ISR10343 2. MOH Annual performance program Text Value 0 Yes Yes prepared and submitted to the National Date 08-Jul-2009 06-Sep-2013 31-May-2015 Assembly Comments Done. Public Disclosure Copy Adoption of National Action Plans for (i) Health Number Value 4.00 4.00 6.00 Promotion, (ii) Healthy Aging, (iii) Diabetes, (iv) Date 31-May-2009 06-Sep-2013 31-May-2015 Obesity, (v) Cardiovascular Diseases (CVD), Comments Action plans for obesity, CVD, Action plans for healthy aging (vi) Chronic Respiratory Diseases (CRD) CRD and diabetes. and health promotion completed. Development of the Clinical Guideline Text Value No Clinical Guideline Guideline prepared and Guideline prepared and Preparation Manual Preparation Manual exists disseminated disseminated Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Establishment of the Pharmaceuticals and Text Value No Pharmaceuticals and Agency Established and Agency Established and Medical Devices Agency of Turkey Medical Devices Agency of responsible for licensing and responsible for licensing and Turkey in existence regulation of drugs and regulation of drugs and medical devices medical devices Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Number of international conferences to share Number Value 0.00 0.00 2.00 Turkey’s health reform experience Date 31-May-2009 06-Sep-2013 31-May-2015 Comments Component B: 1. Percentage of population of Percentage Value 0.00 0.00 pilot provinces screened for NCD risk factors Date 08-Jul-2009 06-Sep-2013 Comments 0 percent Component B will be cancelled as the MOH decided to go national instead of piloting the intervention first. 2. Higher increase in appropriate knowledge Percentage Value 0.00 0.00 Public Disclosure Copy and attitudes regarding global risk factors for Date 08-Jul-2009 06-Sep-2013 NCDs in pilot provinces as compared with non- Comments To be determined on the Component B will be pilot provinces basis of baseline KAP survey cancelled as the MOH in pilot provinces and selected decided to go national instead non-pilot provinces of piloting the intervention first. Page 4 of 6 The World Bank Report No: ISR10343 3. Percentage of cases in pilot provinces Percentage Value 0.00 diagnosed and under follow-up by family group Date 06-Sep-2013 practices for the following NCDs: hypertension, Comments Component B will be diabetes, obesity/overweight Public Disclosure Copy cancelled as the MOH decided to go national instead of piloting the intervention first. 4. 100 percent compliance with reporting on Percentage Value 0.00 0.00 implementation of screening activities as well Date 08-Jul-2009 06-Sep-2013 as patient records (through family medicine Comments System will be set up by the Component B will be information system) end of 2009 cancelled as the MOH decided to go national instead of piloting the intervention first. Component C: 1. Actuarial analysis of UHI Text Value 1st actuarial analysis Component C will be updated for 2010 and 2012 based on updated completed dropped, The ICR will macro and micro data address the progress achieved to date. Date 08-Jul-2009 06-Sep-2013 Comments 2. Costly interventions under Benefits Package Text Value Review of Benefits Package Component C will be for UHI revised using cost-effectiveness criteria and identification of dropped, The ICR will and guidelines developed by SSI; interventions and baseline address the progress expe nditures achieved to date. Date 08-Jul-2009 06-Sep-2013 Comments Component C will be dropped. The ICR will address the progress achieved to date. 3. Prospective payment systems based on Text Value Stock-taking and Component C will be international evidence (capitation, global development of action plan for dropped, The ICR will Public Disclosure Copy budgets, DRGs) or outpatient and acute care implementation of prospective address the progress adopted for University, private and MOH payment systems achieved to date. hospitals Date 31-Jul-2009 06-Sep-2013 Comments Data on Financial Performance (as of 12-Nov-2013) Financial Agreement(s) Key Dates Project Ln/Cr/Tf Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date Page 5 of 6 The World Bank Report No: ISR10343 Project Ln/Cr/Tf Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P102172 IBRD-77170 Effective 11-Jun-2009 30-Jun-2009 29-Sep-2009 31-Jul-2013 31-May-2015 Disbursements (in Millions) Public Disclosure Copy Project Ln/Cr/Tf Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P102172 IBRD-77170 Effective USD 75.13 75.13 0.00 46.66 28.66 62.00 Disbursement Graph Key Decisions Regarding Implementation The preparation for the first-level restructuring has progressed and the restructuring paper is expected to be finalized in November, 2013 for submission to Board during the World Bank second quarter fiscal year FY14. After the restructuring, the DPO and IP ratings are expected to be upgraded to satisfactory. Public Disclosure Copy Restructuring History CD Decision on 26-Mar-2013 Related Projects P120948-Health Systems Performance Assessment Page 6 of 6