The World Bank Implementation Status & Results Report China Health Reform Program (P154984) China Health Reform Program (P154984) EAST ASIA AND PACIFIC | China | Health, Nutrition & Population Global Practice | Requesting Unit: EACCF | Responsible Unit: GHN02 IBRD/IDA | Program-for-Results Financing | FY 2017 | Team Leader(s): Dinesh M. Nair, Shuo Zhang Seq No: 4 | ARCHIVED on 04-Mar-2019 | ISR35712 | Created by: Wei Han on 03-Jan-2019 | Modified by: Dinesh M. Nair on 26-Feb-2019 Program Development Objectives Program Development Objective (from Program Appraisal Document) To improve the quality of healthcare services and the efficiency of the healthcare delivery systems in Anhui and Fujian provinces. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Satisfactory Satisfactory Overall Implementation Progress (IP) Satisfactory Satisfactory Implementation Status and Key Decisions In alignment with the national government’s guidance, both Anhui and Fujian have been moving forward with the health reform implementation on the ground. Some of the key results include  Public Hospital Reform. Both Anhui and Fujian have continued to push forward reforms to improve the efficiency and quality of the hospital services. In Fujian, public hospital management committees have been established at all levels and a performance assessment of hospital directors is being carried out in all provincial, prefectural, and over 70% of county-level public hospitals and the results linked to salaries. In Fujian the share of medicine expenditure out of total expenditure was reduced to 29.37% (a 12.06% reduction compared to that of 2014). Clinical pathways are being implemented (66% and 34% of discharges followed clinical pathways in Anhui and Fujian respectively). Prospective payment methods (case-based payment/diagnostic related grouping-DRG) are being increasingly used for insurance payments in both Provinces (Fujian 18%, Anhui 42%).  People-Centered Integrated Care: Both Provinces have continued to build a tiered delivery system, with primary care at the center, to deliver efficient, high quality and accountable care. Medical alliances have been formed in both Anhui and Fujian and they are an important strategy to improve care coordination and align incentives. In Anhui, over 137 medical alliances have been established in urban and rural areas. Both Provinces have issued the protocols for the integrated management for type II diabetes and identified pilot prefectures. Further, to address the shortage of health workforce at primary levels and improve the efficiency of human resources allocation within the medical alliances, based on the pilots in 3 prefectures, Anhui has been scaling up a Senior Nurse Practitioner Program to more prefectures. Fujian has made progress on the Family Doctor empanelment and nearly 7,000 family doctor groups have been established with the coverage rate of 40%; and 100% for poverty-stricken populations. While these reforms have improved the utilization of primary care services, the impact of these have yet to be seen on the overall share of outpatient visits in primary health care (PHC) institutions to total visits. Going forward a new focus on the quality of clinical care will be required especially improving clinical practice.  Addressing cross cutting dimensions: Following the establishment of the National Healthcare Security Administration similar institutional arrangements have been established in Anhui and Fujian at Provincial and sub-Provincial level. Fujian now has established integrated medical security administration at prefecture level. Comprehensive human resource reforms to strengthen primary care have been introduced, including expanding the numbers of general practitioners, deploying senior nurses to PHC, introducing standardized training for resident doctors, and providing incentives for key positions. Both Provinces have prioritized the building up of health information systems: In Fujian 202 primary care institutions have set up a primary health information system. Anhui has been making tremendous efforts to promote the use of technology in health care delivery, with the establishment of a population health information system, a health service platform, electronic patient cards, cloud for medical imaging, and the Hefei big data center. On the learning agenda, progress is being made on the three-level knowledge generation and learning framework. An international workshop on “Building Value-based Quality Service Delivery System” was held in Fuzhou between November 11-14, 2018. The workshop, targeted at an international and domestic audience, drew 133 participants comprised of senior government and project officials from Vietnam, and Ukraine, health program implementers from 11 reform pilot Provinces in China, as well as domestic and international 3/4/2019 Page 1 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) experts. Aimed at both sharing and learning from People-Centered Integrated Care (PCIC) reforms, the workshop provided a platform for health care practitioners to discuss the practicalities of implementing the PCIC around the four building blocks: governance, service model, quality and payment reforms. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P154984 IBRD-87440 Effective USD 600.00 600.00 0.00 59.25 540.75 9.9% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P154984 IBRD-87440 Effective 09-May-2017 30-Jun-2017 11-Sep-2017 31-Dec-2021 31-Dec-2021 Program Action Plan Technical: Make steady progress on the integration of the three health insurance schemes (such as starting with the Action Description integration of urban and rural resident schemes), so as to ensure unified provider payment policies across the different schemes. Source DLI# Responsibility Timing Timing Value Status Client Due Date 31-Dec-2018 Completed Completion Measurement Comments Technical: Strengthen the National Health and Family Planning Statistics online reporting system with a new data Action Description cleaning and data verification function, so as to improve the quality of M&E system of health reform. Source DLI# Responsibility Timing Timing Value Status Client Due Date 31-Dec-2018 In Progress Completion Measurement Comments Fiduciary: CPSM and two provinces issue clear instructions to the implementing agencies in charge of procurement at Action Description all levels with regard to the compliance with the PforR anticorruption guidelines. Source DLI# Responsibility Timing Timing Value Status 3/4/2019 Page 2 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Client Due Date 28-Sep-2017 Completed Completion Measurement Comments Fiduciary: Report in the progress report on any allegation of fraud or corruption, which has confirmed to be a major Action Description issue after a due investigation. Source DLI# Responsibility Timing Timing Value Status Client Recurrent Semi-Annually Completed Completion Measurement Comments Environment & Social Development: Design and provide periodic training for hospital management, health workers Action Description and the hospital Infectious Disease Control Unit to ensure adequate awareness and skills across all levels healthcare facilities. Source DLI# Responsibility Timing Timing Value Status Client Recurrent Semi-Annually Completed Completion Measurement Comments Environment & Social Development: Strengthen the supervision & enforcement capacity of responsible agencies to Action Description ensure adequate supervision of the chain of custody that covers whole medical wastes classification, storage, collection, transport. Source DLI# Responsibility Timing Timing Value Status Client Due Date 29-Dec-2017 Completed Completion Measurement Comments Environment & Social Development: Report in the progress report any land acquisition under this PforR including Action Description relevant evidence (land use certificates, compensation agreements, land price payments, and land lease agreements with affected parties). 3/4/2019 Page 3 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Source DLI# Responsibility Timing Timing Value Status Client Recurrent Semi-Annually Completed Completion Measurement Comments Environment & Social Development: Develop a public participation plan to increase the awareness of and the support Action Description on the health reform based on successful experience of pilot cities, which include more proactive public participation. Source DLI# Responsibility Timing Timing Value Status Client Recurrent Semi-Annually Completed Completion Measurement Comments Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Moderate Moderate Moderate Macroeconomic Moderate Moderate Moderate Sector Strategies and Policies Moderate Moderate Moderate Technical Design of Project or Program High Substantial Substantial Institutional Capacity for Implementation and Sustainability High Substantial Substantial Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Low Low Low Other -- -- -- Overall High Substantial Substantial RiskComments Comments Remain same rating as previous ISR. 3/4/2019 Page 4 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Results PDO Indicators by Objectives / Outcomes PDO Indicators IN00660234 ►Proportion of hospital discharges paid through case-based payment for all county-level public general hospitals and TCM hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH:42.6; FJ:17.93 Value AH: 12 FJ: 3 AH:48.5; FJ:9.8 AH: 32 FJ: 50 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660235 ►Proportion of inpatients to be treated through standardized clinical pathways at county level public general hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH:56.6 : FJ:0(developed 125 standardized clinical pathways that can be AH:66.6; FJ:33.78 Value AH: 4 FJ:0 AH:50 FJ: 50 adapted at county level hospitals) Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660266 ►Proportion of outpatient care delivered by primary care facilities (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 61 FJ: 51 AH:59.1; FJ: 52.5 AH:59.1; FJ: 52.5 AH: 61.8 FJ: 55 Value Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660267 ►Number of prefectures that manage Type II diabetes patients using the integrated NCD service package (Threshold value for a prefecture to qualify as using the integrated service package is 25% of tota (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 0 (AH: protocol drafted and under the 0 (AH: protocol issued; AH: 6 FJ: 4 Value 0.00 consultation FJ: protocol FJ: protocol issued) issued) Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments Intermediate Results Indicators by Results Areas 3/4/2019 Page 5 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Intermediate Results IN00660268 ►Growth rate of medical service revenue of public hospitals in the entire province (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 8% AH:12.8% FJ:6.01% AH:9.27%; FJ:13.77% Value FJ: 8.88% <10% Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Fujian performance on this indicator has been unsatisfactory and is being followed up Comments IN00660269 ►Average length-of-stay for county level public hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 8.82 AH: 8 AH: 7.56 FJ:7.3 AH: 7.31; FJ:7.18 Value FJ: 7.41 FJ: 7.37 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660270 ►Number of counties that have public disclosure of quality report (e.g. ALOS, drug revenue as a proportion of hospital revenue, expenditure per visit for outpatient, expenditure per admission for inpat (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 55 AH: 61 AH:61 FJ:35 AH:61; FJ:68 Value FJ:10 FJ: 68 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660271 ►Proportion of labor based service revenue in total service revenue for all public hospitals in the province (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 25 AH: 30 AH:26.9; FJ:31.58 AH:32.9; FJ:29.98 Value FJ: 24.58 FJ: 30.00 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660272 ►Out-of-pocket payment as portion of the total inpatient services expenditure (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 42 AH: 37 AH:33.3; FJ:49.21 AH:32.5; FJ:46.49 Value FJ: 50.83 FJ: 48.83 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 3/4/2019 Page 6 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Comments IN00660273 ►Proportion of patients hospitalized within county (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 69 AH: 73 AH:76.51; FJ:67.13 AH:76.51; FJ:66.78 Value FJ: 63 FJ: 80 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660274 ►Proportion of total Registered Physicians (assistant physician) and Registered Nurses practicing at the primary care facilities (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 26.80 AH:27.24; FJ: 29.6 AH:27.24; FJ: 29.6 Value FJ:29.09 increase Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660275 ►Number of hypertension patients that are under standardized management (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 4500 000 AH:4593 992; FJ:1817 AH:4862437; AH: 4700 000 Value FJ: 1250 000 000 FJ:1671218 FJ: 1300 000 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Fujian uses the updated protocol resulting in lower numbers and hence not comparable with previous year. Comments IN00660276 ►Number of counties that have established a county-township-village population health information system [Anhui] (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3.00 9.00 20.00 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660277 ►Number of THCs / CHCs that have established primary care health information systems [Fujian] (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 138.00 202.00 500.00 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660278 3/4/2019 Page 7 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) ►Number of prefectures achieving integration (at least of the management) of the health insurance schemes, thereby allowing unified payment arrangement for all providers (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 0 AH:3;FJ:9( excluding AH:3;FJ:9 (excluding AH: 12 Value FJ: 2 Xiamen) Xiamen) FJ: 9 Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660279 ►Program experience sharing and dissemination (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 2018 results is being Value NA Achieved and verified NA verified Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660280 ►The county IDS system has been scaled up to at least 50 counties/districts in Anhui (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Achieved, verified, Achieved, verified, Value NA NA confirmed confirmed Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments IN00660281 ►The integration of the management of the three health insurance schemes at the provincial level in Fujian is undertaken (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Achieved and verified, Achieved and verified, Value NA NA confirmed confirmed Date 09-May-2017 10-Aug-2018 31-Jan-2019 31-Dec-2021 Comments Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 The County IDS system has been scaled up to at least 50 counties/districts in Anhui (Output, 15.00, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 Acieved and verfied, Value NA 66.00 NA confirmed Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- IDS system has been scaled up Comments 3/4/2019 Page 8 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) ►DLI 2 The integration of the management of the three health insurance schemes at the provincial level in Fujian is undertaken (Process, 40.00, 100%) Baseline Actual (Previous) Actual (Current) end Dec 2017 integration of the management of the three Achieved and Value NA health insurance NA verified, confirmed schemes at the provincial level completed Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- Comments ►DLI 3 Proportion of hospital discharges paid through case-based payment for all county-level public general hospitals and TCM hospitals (Intermediate Outcome, 27.15, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 AH: 12 AH: 48.5; FJ: 9.8 Value FJ: 3 AH:42.6; FJ:17.93 -- Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- 2017 results achieved, verified and confirmed Comments ►DLI 4 Proportion of inpatients to be treated through standardized clinical pathways at county level public general hospitals (Intermediate Outcome, 60.73, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 AH: 56.6; FJ: developed 125 standardized clinical AH:4 pathways that can be Value FJ:0 AH:66.6; FJ: 33.78 -- adapted at county level hospitals Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- 2017 results achieved, verified and confirmed Comments ►DLI 5 Proportion of outpatient care delivered by primary care facilities (Intermediate Outcome, 20.00, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 AH: 61 AH:59.1; FJ:52.5 Value FJ: 51 AH:59.1; FJ:52.5 -- Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- Both provinces did not achieve 2017 targets. Comments 3/4/2019 Page 9 of 10 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) ►DLI 6 Number of prefectures that manage Type II diabetes patients using the integrated NCD service package (Threshold value for a prefecture to qualify as using the integrated service package is 25% of tota (Intermediate Outcome, 30.02, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 (AH: protocol drafted and AH: protocol issued; FJ: Value No minimum under the consultation -- protocol issued FJ: protocol issued) Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- FJ result achieved, verified and confirmed; AH's result is under the verification Comments ►DLI 7 Number of counties that have established a county-township-village population health information system [Anhui] (Output, 7.50, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 Value No minimum 3.00 9.00 -- Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- 2017 result achieved, verified, and confirmed Comments ►DLI 8 Number of THCs / CHCs that have established primary care health information systems [Fujian] (Output, 20.00, 0%) Baseline Actual (Previous) Actual (Current) end Dec 2017 Value No minimum 138.00 202.00 -- Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- 2017 result achieved, verified, and confirmed Comments ►DLI 9 Program experience sharing and dissemination (Process, 1.50, 100%) Baseline Actual (Previous) Actual (Current) end Dec 2017 Three learning groups Launched operational are established for three research on three key key reform areas (e.g., reform areas; and Value NA on clinical pathways, organized two national -- case-based payment, workshops on the health and integrated NCD reform in China service management) Date 09-May-2017 10-Aug-2018 31-Jan-2019 -- 2018 result is being verified Comments 3/4/2019 Page 10 of 10