OFMIIAL ((77-4 -1- DOCUMENTS REPUBLIC OF TURKEY 18 MAY 2013 April , 2013 International Bank for Reconstruction and Development 1818 H Street, N.W. Washington, D.C. 20433 United States of America Dear Sir/Madam: Re: Loan No. 7717-TU PROJECT IN SUPPORT OF RESTRUCTURING OF HEALTH SECTOR (previously known as the HEALTH TRANSFORMATION AND SOCIAL SECURITY REFORM PROJECT) Revised Performance Monitoring Indicators We refer to our letter dated June 30, 2009 attaching the Performance Monitoring Indicators for the captioned project. We also refer to our letters dated July 31, 2012 and September 25, 2012, requesting the Bank to amend said Loan Agreement. As part of the restructuring of the Project, please find attached the Performance Monitoring Indicators which supercedes those attached to our letter dated June 30, 2009. The Borrower hereby confirms to the Bank that the revised Indicators set forth in the attachment to this letter shall serve as a basis for the Borrower to monitor and evaluate the progress of the Project and the achievement of the objectives thereof. Very truly yours, REPUBLIC OF TURKEY !. Elvan ONG YN ESEN Acting Deputy Diret' General Attachment Results Framework and Monitoring TURKEY: PROJECT IN SUPPORT OF RESTRUCTURING OF HEALTH SECTOR Original Project Development Objective (PDO): (i) to increase the effectiveness of the Social Security Institution (SSI) and 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 Revised Project Development Objective: To increase the effectiveness of the Ministry of Health (MOH) in formulating and implementing reforms in provider payments and health systems performance Revised PDO level Results Indicators D=Dropped Cumulative Target Values** PDO Level Results C=Continue Frequency Data Source/ Responsibility PD evlReut N= New Unitlofeof for Data Indicators* C;Measure Baselinelog RIRevised 2010 2011 2012 2013 2014 2015 reporting MethodooCollection 1 Per capita annual visits to R Number 2 visits per 2.7 2.8 3.3 4 visits per 4 visits per 4 visits per Family Medicine Public Health Family Medicine physicians capita visits visits visits capita capita capita Information Institution per per per Annual System (FMIS), capita capita capita Methodology number of visits to FM divided by number of people enrolled in FM program in the past year 2. Share of Family N % 35% n/a n/a 37% 38% 39% 40% Annual Family Medicine Public Health Medicine visits in total O Information Institution visits System (FMIS) 3. Client satisfaction with R % 63.4% 63.4% 62% 69% 71% 73% 76% Annual Life satisfaction TURKSTAT health services O survey MOH 4. Ministry of Health N Text MOH is a n/a n/a n/a MOH is MOH is MOH is By 2013 MOH reorganized and provider of restructured restructured restructured focus exclusively on the health services and no and no and no health sector's stewardship l longer a longer a longer a functions provider of provider of provider of health health health services services d services 5 Increase in the D % TBD TBD TBD TBD TBD n/a n/a Annual Family Medicine MOH (DG of percentage of first-time Information Primary visits to specialists that are O Systems (FMIS) Health Care) referrals by family medicine and household practices survey -3- 6. Decrease in SSI C % 40% of 45% 35% 33% 30% n/a n/a Annual SSI Health SSI and TUIK expenditures on expenditures on 50% 45% 42% 40% expenditure data pharmaceuticals and pharmaceuticals and national outpatient health care 50% of Health Accounts treatment costs on outpatient 7. Smoking prevalence C % Tobacco use 0% 0% 5% 10% n/a n/a Annual FMIS MOH (DG of among 18-29 age group in knowledge, change change decrease in Primary pilot provinces decreases attitude and pilot Health Care) more relative to non-pilot 0 practices provinces provinces) (KAP) survey to be implemented in 2009 8. High blood pressure in C % Baseline NCD 0% 5% 10% 15% n/a n/a Annual FMIS MOH (DG of population in pilot assessment to change change change change Primary provinces decreases more as O be carried out Health Care) compared to non-pilot in 2009 provinces) INTERMEDIATE RESULTS Revised Intermediate Results (Component One) D=Dropped Cumulative Target Values** PDO Level Results N= N inue Unit of Data Source/ Responsibility 0 NNeBaeieof for Data Indicators* RReie Measure Baseline o ehdlfrDt R=Revised 2010 2011 2012 2013 2014 2015 reporting Methodology Collection I.Numberof provinces N Number 31 81 81 81 81 81 Annual Administrative Public Health implementing family E data Institution medicine scheme 2. Percentage of family R % 0% 15% 30% 40% 50% 60% 70% Annual Human Public Health medicine phycicians that resource data Institution have completed second O phase of orientation training 3. Establishment of N Text Public Health n/a n/a Public Public Public Public Annual Administrative Public Health Public Health Institution Institution not Health Health Health Health data Institution responsible for health in existence Agency Agency Agency Agency promotion, disease established fully fully fully prevention and family operational operational operational medicine -4- 4. Share of public N % 0% n/a n/a 0% 100% 100% 100% By project Administrative Public hospitals organized in end data Hospitals public hospital unions E Institution with performance contracts for managers and global budgets 5. MOH annual R Yes/No 0 0 Yes Yes Yes Yes Yes Annual Administrative MOH performance program data (Strategy prepared and submitted E Development to the National Presidency) Assembly 6 Adoption of National N Number 4 (action plans n/a n/a 0 4 (action 5 (action 6 (action Annual Administrative Public Health Action Plans for (i) for obesity, plans for plans for plans for data Institution Health Promotion, (ii) CVD, CRD and healthy healthy healthy Healthy Aging, (iii) diabetes) aging and aging and aging and Diabetes, (iv) Obesity, [O health health health (v) Cardiovascular promotion) promotion) promotion) Diseases (CVD), (vi) Chronic Respiratory Diseases (CRD)' 7. Development ofthe N Text No clinical n/a n/a Guideline Guideline Guideline Guideline Administrative MOH (GD of Clinical Guideline O guideline prepared and prepared and prepared and prepared and data Health Preparation Manual preparation disseminated disseminated disseminated disseminated Services) manual exists N Text No Law passed Agency Agency Agency Annual MOH Pharmaceuticals Established Established Established and Medical and and and 8. Establishment of the Devices responsible responsible responsible Pharmaceuticals and Agency of for licensing for licensing for licensing Medical Devices Agency Turkey in and and and of Turkey existence regulation of regulation of regulation of drugs and drugs and drugs and medical medical medical devices device device 9. Number of N Number 0 n/a n/a 0 2 2 2 Annual Administrative MOH international conferences data (External to share Turkey's health Relations reform experience Department) 10. Percentage of acute D % Baseline data TBD TBD TBD TBD n/a n/a Annual Hospital MOH care public hospitals collection will Information (Strategy using revised clinical be done in 2009 Systems Development guidelines for secondary Department) care as requirement of performance payment system -5- D Number Not available I bi- 2 bi- 2 bi-annual I bi-annual n/a n/a 11 Dissemination of bi- annual annual reports report Annual M&E Unit MOH (M&E annual HTP Tracking report reports Databases Unit) reports by M&E for first Directorate of MOH part of 2010 12. Percentage of family D % Not available Baseline 10% 15% n/a n/a Annual Physician MOH physicians using rational KAP increase increase KAP survey drug prescription Study guidelines 13. Percentage of MOH D % 0 60% 70% 80% 85% n/a n/a Annual PMSU- MOH, PMSU Implementing Agencies Projects for HTSSRP completing Monitoring project management El Systems training and connected to PMSU-Net for project monitoring Revised Intermediate Results (Component Two) D-Dropped Cumulative Target Values** Intermediate Results C=Continue Unit of Frequency of Data Source/ Responsibility for 0 N=New Bsln Indicators* R=Revised Measure Baseline 2010 2011 2012 2013 reporting Methodology Data Collection 2 Percentage of cases in pilot C % No data Baseline data 20% 90% 100% Annual FMIS-Non- Public Health provinces diagnosed and under collection communicable Institution follow-up by family group disease data practices for the following base NCDs: hypertension, diabetes, obesity/overweight 3 Higher increase in appropriate C % To be 10% 32% 35% 72% Annual FMIS-Non- Public Health knowledge and attitudes determined on communicable Institution regarding global risk factors for the basis of disease data NCDs in pilot provinces as E baseline KAP base compared with non-pilot survey in pilot provinces provinces and selected non- pilot provinces 4. 100 percent compliance with C % System will be 20% 40% 80% 100% Annual FMIS-Non- Public Health reporting on implementation of set up by the compliance compliance compliance compliance communicable Institution screening activities as well as El end of 2009 disease data patient records (through family base medicine information system) -6- Revised Intermediate Results (Component Three) 2. Actuarial analysis of UHI C Text 2nd actuarial 3rd actuarial updated for 2010 and 2012 based OI" actuarial analysis of UHI analysis of Every two Reports from SSI (Actuary on updated macro and micro El analysis done by WB UHI done by year/M&E Actuary Department) data) completed and SSI WB and SSI Report Department 3. Costly interventions under C Text Review of Review of cost- Changes in Decrease in Decrease in Annual MEDULA SSI (DG of UHI) Benefits Package for UHI Benefits effectiveness Benefits spending on spending on revised using cost-effectiveness Package and criteria for Package the the criteria and guidelines developed identification identified implemented interventions interventions by SSI l of interventions & as compared as compared interventions development of to baseline to baseline and baseline guidelines for expenditures Reimbursement Commission 4 Prospective payment systems C Text Stock-taking Relevant Relevant Relevant Relevant Annual MEDULA SSI (DG of UHI) based on international evidence and prospective prospective prospective prospective (capitation, global budgets, development payment payment payment payment DRGs) for outpatient and acute Of action plan systems systems systems systems care adopted for University, l for implemented implemented implemented implemented private and MOH hospitals implementation of prospective payment __________________________systems