The World Bank Report No: ISR15295 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: 9 Status: ARCHIVED Archive Date: 28-Jun-2014 (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 04-Dec-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 Satisfactory Overall Risk Rating Substantial Moderate Implementation Status Overview The Project has disbursed 71% of loan proceeds. This amount will increase to 73% after the canceled amount is deducted from the total loan amount as a result of the first level restructuring (as of May 2014). Page 1 of 7 The World Bank Report No: ISR15295 Some of Government's main achievements supported under the Project include increased access to family medicine providers, which resulted in an increase of primary care services utilization from 2 to 3.1 outpatient visits per capita between 2009 and 2012. The share of family medicine visits in total visits was also increased from 35% to 38% from 2009 to 2012. Since the implementation of the two-phased support to the Health Transformation Program, patient satisfaction with overall health services increased from 63.4 percent in 2009 to 74.8 percent in 2012. Public Disclosure Copy After the approval of the Decree Law No. 663 on the Organization and Duties of the Ministry of Health (MOH) and Its Affiliates on November 3, 2011, the MOH completed its restructuring till November 2012, which 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 MOH’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. Undersecretariat of Treasury countersigned the amendment letter for the first level restructuring on May 21, 2015. After the completion of two-stage restructuring, 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. The reorganization process of the MOH was completed and the overall implementation capacity - including human resources management and fiduciary issues - of the MOH Project Management Support Unit (PMSU) has been improved significantly. In line with the considerable recovery in the implementation capacity and increased disbursement rate, the Implementation Progress rating of the Project is increased to Moderately Satisfactory. 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 3.10 4.00 physicians Date 31-May-2009 12-Jun-2014 31-May-2015 Comments Per capita visits for all primary 4 visits per capita health facilities (including Public Disclosure Copy family medicine physicians) in 2012 was realized as 3.1. Share of family medicine visits in total visits Percentage Value 35.00 38.00 40.00 Date 31-Dec-2011 12-Jun-2014 31-May-2015 Comments Share of visits to family medicine physicians increase to 38% as of December 31, 2012. 3. Client satisfaction with health services Text Value 63.4 74.8 76 Page 2 of 7 The World Bank Report No: ISR15295 Date 31-May-2009 12-Jun-2014 31-May-2015 Comments percent Client satisfaction with health percent services increased to 74.8% Public Disclosure Copy as of December 31, 2012. Ministry of Health reorganized and focus Text Value MOH is a provider of health Target met. MOH is MOH is restructured and no exclusively on the health sector stewardship services restructured and no longer a longer a provider of health function provider of health services. services Date 31-Dec-2010 12-Jun-2014 31-May-2015 Comments Target met after passage of decree law no 663 in November 2011, and the completion of the overall restructuring in November 2012. 4. Smoking prevalence among 18-29 age Percentage Value 31.20 27.10 group in pilot provinces relative to non-pilot Date 08-Jul-2009 12-Jun-2014 31-Jul-2013 provinces. Comments Global Adult Smoking Component B is canceled and Prevalence Research of MoH MOH decided to go with a dated 2008 nation wide implementation instead of piloting the OBF intervention. Overall prevalence decreased from 31.2% (2008) to 27.1 (2012). 5. High blood pressure in population in pilot Percentage Value provinces decreases more as compared to Date 08-Jul-2009 12-Jun-2014 31-Jul-2013 non-pilot provinces Comments Baseline NCD assessment to Component B is canceled and be carried out in 2011 MOH decided to go with a nation wide implementation instead of piloting the OBF intervention. MoH will provide data and explanation on this Public Disclosure Copy indicator. 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 12-Jun-2014 31-May-2015 Comments Target is met. FM scheme is being implemented nationwide. Page 3 of 7 The World Bank Report No: ISR15295 Component A: 1. Percentage of family Percentage Value 0.00 70.00 medicine physicians who have completed Date 31-May-2009 12-Jun-2014 31-May-2015 second phase of orientation training Comments 0 MoH changed the structure of Public Disclosure Copy orientation training. Continuous Occupational Development Training program for 70% of the FM physicians will be completed at the end of 2014. 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 12-Jun-2014 31-May-2015 Comments The objective is met. Share of public hospitals organized in public Percentage Value 0.00 100.00 hospital unions with performance contracts for Date 31-May-2009 12-Jun-2014 31-May-2015 managers and global budgets Comments MoH will provide further data and explanation on this indicator. 2. MOH Annual performance program Text Value 0 Annual performance program Yes prepared and submitted to the National for 2013 was not submitted to Assembly the National assembly. Date 08-Jul-2009 12-Jun-2014 31-May-2015 Comments 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 12-Jun-2014 31-May-2015 Obesity, (v) Cardiovascular Diseases (CVD), Comments Action plans for obesity, CVD, Action plans for CVD, and Action plans for healthy aging (vi) Chronic Respiratory Diseases (CRD) CRD and diabetes. CRD were updated. Action and health promotion plans for healthy aging and completed. nephropathy are prepared and will be published. Public Disclosure Copy 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 12-Jun-2014 31-May-2015 Comments Action plan and implementation guideline for healthy aging is prepared. Page 4 of 7 The World Bank Report No: ISR15295 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 Public Disclosure Copy Date 31-May-2009 12-Jun-2014 31-May-2015 Comments Objective is met. Number of international conferences to share Number Value 0.00 2.00 2.00 Turkey’s health reform experience Date 31-May-2009 12-Jun-2014 31-May-2015 Comments MoH organized on event in Turkey and participated in another one in Japan to share Turkey's health reform experience in 2013. Component B: 1. Percentage of population of Percentage Value 0.00 0.00 pilot provinces screened for NCD risk factors Date 08-Jul-2009 12-Jun-2014 Comments 0 percent Component B is canceled as a result of restructuring. MoH decided to go a nation wide implementation instead of piloting the OBF scheme. 2. Higher increase in appropriate knowledge Percentage Value 0.00 0.00 and attitudes regarding global risk factors for Date 08-Jul-2009 12-Jun-2014 NCDs in pilot provinces as compared with non- Comments To be determined on the Component B is canceled as pilot provinces basis of baseline KAP survey a result of restructuring. MoH in pilot provinces and selected decided to go a nation wide non-pilot provinces implementation instead of piloting the OBF scheme. 3. Percentage of cases in pilot provinces Percentage Value 0.00 diagnosed and under follow-up by family group Date 12-Jun-2014 practices for the following NCDs: hypertension, Comments Component B is canceled as diabetes, obesity/overweight Public Disclosure Copy a result of restructuring. MoH decided to go a nation wide implementation instead of piloting the OBF scheme. 4. 100 percent compliance with reporting on Percentage Value 0.00 0.00 implementation of screening activities as well Date 08-Jul-2009 12-Jun-2014 as patient records (through family medicine Comments System will be set up by the Component B is canceled as information system) end of 2009 a result of restructuring. MoH decided to go a nation wide Page 5 of 7 The World Bank Report No: ISR15295 implementation instead of piloting the OBF scheme. Component C: 1. Actuarial analysis of UHI Text Value 1st actuarial analysis updated for 2010 and 2012 based on updated completed Public Disclosure Copy macro and micro data Date 08-Jul-2009 12-Jun-2014 Comments Remaining funds under component C were canceled as a result of restructuring. The ICR will address the progress achieved to date. 2. Costly interventions under Benefits Package Text Value Review of Benefits Package for UHI revised using cost-effectiveness criteria and identification of and guidelines developed by SSI; interventions and baseline expe nditures Date 08-Jul-2009 12-Jun-2014 Comments Remaining funds under component C were canceled as a result of restructuring. The ICR will address the progress achieved to date. 3. Prospective payment systems based on Text Value Stock-taking and international evidence (capitation, global development of action plan for budgets, DRGs) or outpatient and acute care implementation of prospective adopted for University, private and MOH payment systems hospitals Date 31-Jul-2009 12-Jun-2014 Comments Remaining funds under component C were canceled as a result of restructuring. The ICR will address the progress achieved to date. Public Disclosure Copy Data on Financial Performance (as of 10-Jun-2014) Financial Agreement(s) Key Dates 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) Project Ln/Cr/Tf Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P102172 IBRD-77170 Effective USD 75.13 75.13 0.00 53.63 21.88 71.00 Page 6 of 7 The World Bank Report No: ISR15295 Disbursement Graph Public Disclosure Copy Key Decisions Regarding Implementation The preparation restructuring of the project is completed with Treasury's countersigning of the amendment letter on May 21, 2015. A comprehensive assessment of the project development achievements of the project is scheduled to start in the coming months in preparation of the implementation completion report. Restructuring History Level 2 CD Decision on 26-Mar-2013 Related Projects P120948-Health Systems Performance Assessment Public Disclosure Copy Page 7 of 7