The World Bank Health System Strengthening and Support Project (P152799) 27REPORT NO.: RES32795 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF HEALTH SYSTEM STRENGTHENING AND SUPPORT PROJECT APPROVED ON SEPTEMBER 21, 2015 TO THE REPUBLIC OF TURKEY APRIL 3, 2019 HEALTH, NUTRITION & POPULATION EUROPE AND CENTRAL ASIA Regional Vice President: Cyril E Muller Country Director: Mariam J. Sherman Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Tania Dmytraczenko Task Team Leader: Ahmet Levent Yener The World Bank Health System Strengthening and Support Project (P152799) ABBREVIATIONS AND ACRONYMS AMATEM Treatment Centers for People Suffering from Alcoholism and Substance Addiction ÇEMATEM Treatment Centers for Children and Adolescents Suffering from Substance Addiction GDHI Health Investments General Directorate GDHR Health Research General Directorate GDPHe Public Health General Directorate GDPHo Public Hospitals General Directorate HLC Healthy Living Centers HMIS Health Management Information System HSPA Health System Performance Assessment HTA Health Technology Assessment KETEM Cancer Screening Unit MoH Ministry of Health NCDs Non-communicable diseases PDO Project Development Objective PHC Primary Health Care PMSU Program Management Support Unit PPP Public Private Partnership RF Results Framework SDP Strategy Development Presidency The World Bank Health System Strengthening and Support Project (P152799) BASIC DATA Product Information Project ID Financing Instrument P152799 Investment Project Financing Original EA Category Current EA Category Not Required (C) Not Required (C) Approval Date Current Closing Date 21-Sep-2015 31-May-2020 Organizations Borrower Responsible Agency Ministry of Treasury and Finance Ministry of Health Project Development Objective (PDO) Original PDO The Project Development Objective (PDO) of the HSSSP is to improve primary and secondary prevention of selected NCDs, increase the efficiency of hospital management, and enhance the capacity of the MoH for evidence-based policy making. OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IBRD-85310 21-Sep-2015 30-Sep-2015 26-Nov-2015 31-May-2020 134.30 31.27 103.33 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank Health System Strengthening and Support Project (P152799) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING 1. The Health System Strengthening and Support Project (HSSSP or the Project) was approved on September 21, 2015 in the amount of EUR120 million (US$134.3 million equivalent) and became effective on November 26, 2015. The Project has been rated moderately unsatisfactory since November 2017. The mid-term review of the Project, which took place in April 2018, confirmed a need for this restructuring. The Government’s request for restructuring was received on March 12, 2019. 2. Even though the Project Development Objective (PDO) and Implementation Progress have been rated as moderately unsatisfactory since November 2017 and this restructuring seeks, for the first time, an extension of the Closing Date from May 31, 2020 to June 30, 2021, a waiver to the Bank’s Directive on Investment Project Financing (October 1, 2018) on extension of the Closing Date is not sought since the PDO remains achievable as explained below. 3. The Project Development Objective (PDO) is to improve primary and secondary prevention of selected non- communicable diseases (NCDs), increase the efficiency of hospital management, and enhance the capacity of the Ministry of Health (MoH) for evidence-based policy making. Progress towards achieving the PDO has been rated moderately unsatisfactory since November 2017 because only two out of five PDO indicators have achieved their respective target value expected for the end of 2018. Progress against the PDO indicators is outlined below: - PDO indicator No.1 (education/counselling on risk factors): The actual cumulative values (all: 40.5%, males: 38.1%, females: 42.9%) has surpassed the target values (all: 10.8, males: 7.8%, females: 14.5%) - PDO indicator No.2 (Percent change of target population using services of Healthy Living Centers): This indicator could not be monitored given that the population targets of Healthy Living Centers (HLC) envisaged under the pilot provinces/districts were removed. - PDO indicator No.3 (Early detection rates of cervical and breast cancer): The actual cumulative values (cervical 52.9%, breast cancer 48%) partially meet the cumulative targets (cervical 40%, breast cancer 55%). - PDO indicator No.4 (Increase in average composite productivity index for all public hospitals): The actual cumulative value of 0% is lagging behind the target value of 1%. - PDO indicator No.5 (Percent of policy and decision makers that use HMIS regularly): The actual cumulative value of 3% has surpassed the original target value of 0%. 4. The PDO remains achievable as explained below: a. The commitment of the Government to achieve Project objectives is iterated by the MoH, Ministry of Treasury and Finance, and the Strategy and Budget Unit of the Presidency (former Ministry of Development). The proposed restructuring will align the PDO indicators with the new Strategic Plan of the MoH, and the proposed changes in the indicators would better reflect the perspective of the PDO and would better align the indicator with Project activities. b. PDO indicators No. 1 and 5 have surpassed the original target values for end 2018 and are expected to continue this positive trend. c. The Bank team agrees with MoH to drop PDO indicator No. 2, as the exact target population that HLCs serve can only be defined after the HLCs are expanded nationwide. d. Though the original restructuring request proposes dropping PDO indicator No.3 as it has been lagging so far, given how important early cancer detection is to MoH, the Bank team wants to keep this indicator. In fact, the MoH highlights the importance of early detection of cancer in its new Strategic Plan 2019-2023. The restructuring will ensure that the cumulative target values of this indicator and the detection formula will be aligned with the The World Bank Health System Strengthening and Support Project (P152799) new Strategic Plan targets. The Project will continue improving the screening capacity in HLCs and the Cancer Screening Units (KETEMs) with adequate staffing and procurement of additional equipment (including mammography devices). e. PDO indicator No. 4 will be revised to better reflect improvements in the provision of efficient and specialized healthcare services in public hospitals. 5. The Project has three components: (a) Primary and Secondary Prevention; (b) Increasing Efficiency of Public Hospital Management; and (c) Improving the Effectiveness of Overall Health Sector Administration. Implementation progress has been rated moderately unsatisfactory since November 2017 due to the reasons explained below: a.Significant delays caused by frequent changes in the upper and middle management of the MoH. The Project has seen four Ministers of Health, and two Project Directors. The General Directors of the MoH implementing units, and the Head of Departments in these implementing units were also changed more than once. These changes caused considerable delays in the pace of implementation as responsible units could obtain neither timely nor sufficient managerial support. In addition, the unsuccessful attempted coup of July 15, 2016 and the declaration of a state of emergency afterwards, made it very difficult for the implementing units to recruit the required consultants due to extended security clearance processes, which would take more than six months. From July 2018, under the new Presidential system, the upper management of the MoH was reinstated. b.The preparation of the new MoH Strategic Plan was delayed twice. This slowed down implementation of the Project as the implementing units were asked to align the targets of individual activities with the Strategic Plan objectives. The Strategic Plan 2019 – 2023 is completed and will be published by mid-2019. c. The organic law and the organizational structure of the MoH was changed on August 25, 2017. Two main semi- autonomous implementing bodies, the Public Health Institution and the Public Hospitals Institution, were restructured as central MoH General Directorates. This triggered a reshuffling of technical staff of relevant implementing units. Main procurement activities were also delayed as the disbursement responsibility was transferred several times. The new upper management of the MoH linked Project objectives with the Strategic Plan and started monitoring Project implementation closely. d.Due to some amendments in the organic law (from Decree Law 663 to Decree Law 694), responsibility for some Project activities needed to be reshuffled among implementing units. Additionally, the handover of implementation responsibilities for individual activities created delays. Most of the MoH departments were physically moved to the new headquarters in Bilkent, Ankara in 2018. The re-location of the physical and information infrastructure, which caused delays in implementation, are now resolved. 6. The following section includes a summary of the current implementation status of the Project. With the proposed changes, the IP rating is also expected to improve. Component 1. Primary and Secondary Prevention: Sub-component 1.1: Increase national awareness and behavior change with regard to the risk factors of chronic disease and addiction.  Piloting Healthy Living Centers (HLCs). Some of the main achievements supported by this component include the establishment of HLCs to promote healthy lifestyles. Services in these centers concentrate on awareness raising on NCDs and healthy lifestyles, physical exercise, and personal counseling on a healthy life. Progress under this The World Bank Health System Strengthening and Support Project (P152799) sub-component has been slow as the broader design of the HLC implementation has changed. The MoH is currently piloting the new system with 182 HLCs and, if the implementation is successful, the number of HLCs will be increased to over 250 HLCs nationwide. The MoH is now using Project funds for the refurbishment of HLCs, including procurement of physical exercise equipment and digital X-rays, staff recruitment, staff training and HLC launch events.  Development and application of public outreach materials; methodologies and training materials for health workers and citizens; and targeting to raise popular awareness about healthy living through campaigns, public events, training programs, and health care visits at HLCs: Awareness raising and public information activities about HLCs are held in pilot provinces. Brochures and leaflets are distributed to local population through family medicine staff, and media campaigns are carried out. The Project is also supporting several surveys and studies that will help collect reliable, nationally representative, and internationally comparable data on obesity, diabetes mellitus, nutritional and healthy eating habits to inform policy and develop/adopt campaign messages as well to monitor results (i.e., the Childhood Obesity Survey (COSI) 2016, 2019; and the Turkey Nutrition and Health Survey 2017.  Supporting training, awareness raising, and counseling activities on substance abuse and strengthening the Treatment Centers for People Suffering from Alcoholism and Substance Addiction (AMATEMs) and the Treatment Centers for Children and Adolescents Suffering from Substance Addiction (ÇEMATEM): The MoH has financed refurbishment of some treatment centers, consultancy services, training and workshops under this sub- component, and is currently developing a long-term care model for substance abuse and drafting the regulations on integrated treatment and long-term care models. Sub-component 1.2: Ensure effective screening for the early detection of cancer through improving access to quality primary care services and monitoring efforts at all levels.  Operate and improve capacity in post-screening diagnosis centers (second-level diagnostics). Progress under this sub-component has been slow. The provision of consultancy services did not take place due to procurement problems. The scale of training activities has been reduced since there have been significant staff reductions. However, the MoH has the intention to speed up implementation under this sub component. MoH will procure mammography devices to be placed in KETEMs to improve the screening coverage. The bidding documents are being prepared, and the procurement will be initiated after the budget reallocations.  Introduce the national cancer registry software by improving physical and technical infrastructure and training health workers in its use, as well as develop guidelines, standards, and training modules for palliative care. Due to the changes in organizational responsibilities, responsibility for implementation of the cancer registry software and palliative care activities were transferred in 2018 to the Health Information Systems General Directorate, and to the Public Hospitals General Directorate (GDPHo) respectively. Training activities are continuing without any delay. Sub-component 1.3: Strengthen the capacity of primary health care workers to consolidate the results achieved under the Health Transformation Program and introduce better services related to NCDs.  Support to strengthen the Family Physician Training Program. Progress under this sub-component is also below expectations. One reason for family medicine training performance to be lower than envisaged is the change in the training modality: interns who conduct their one-month internship in family medicine are now being given an official document stating they are exempt from the family medicine orientation training, which reduces the The World Bank Health System Strengthening and Support Project (P152799) number of participants in the family medicine training programs. To address this, the MoH is including the fourth round of first stage orientation training into the procurement plans. The activities will primarily target family physicians who have not received distant training to date, and new recruits (around 2000 graduates).  Conduct a thorough workload analysis and standardize work procedures to allow for the development of more effective service delivery and quality of care by family physicians. Upper management of the MoH has decided not to conduct a workload analysis until a new performance-based payment model is developed. Component 2. Increasing Efficiency of Public Hospital Management: Sub-component 2.1: Strengthening public hospital management and clinical operations.  Developing and applying models and standards for efficient health facility management: The GDPHo hired consultants, conducted training programs, and established a portal to strengthen public hospital efficiency (on rational drug use, classification of medical and biomedical materials, and clinical area architectural and infrastructure design). A pilot implementation was successfully completed in Umraniye district of Istanbul. In line with changing priorities of the upper management of the MoH, the remaining budget allocations for this sub- component will be used for simulation-based medical education and training activities to enhance provision of specialized healthcare service in public hospitals. The models developed under the Project will be expanded to other public hospitals under the national budget. Sub-component 2.2: Introducing architectural and technical standards for health facilities.  As the MoH will rely on the experiences achieved under the implementation of the broader Public Private Partnership (PPP) program to improve the architectural and technical standards of health facilities, activities under this sub-component are discontinued in order not to duplicate efforts. Sub-component 2.3: Providing technical support to the PPP program implementation unit.  Planned activities under this sub-component were delayed due to the frequent changes in administrative positions. Still, Health Investments General Directorate (GDHI) could recruit qualified consultants (financial management, legal, etc.) to strengthen their institutional capacity for PPP transactions management. The MoH’s upper management decided to use the remaining budget allocation for this sub-component for efficient monitoring and control. Component 3. Improving the Effectiveness of Overall Health Sector Administration: Sub-component 3.1: A well-functioning Health Management Information System (HMIS).  The progress under institutionalizing Health System Performance Assessment (HSPA) and harmonizing health sector data in line with international standards has been somehow slow due to the MoH’s organizational restructuring and the uncertainty about the organizational alignment/position of the Health Research General Directorate (GDHR). With the Decree Law 694, dated August 15, 2017, GDHR was abolished and the Project- related departments of GDHR were moved under the General Directorate of Health Services which created an additional slowdown in implementation. Still, the HSPA of 2017 has been developed and will be published in 2019.  Efforts to improve Turkey’s ability to meet international health data requirements are ongoing. The future targets on meeting those requirements will be revised since there have been changes in the HMIS structure of the MoH, the international data requirements list and indicator definitions of international institutions.  The MoH has conducted a Household Health Survey to identify the ratio of the general population who can state two or more negative health impacts of selected risk factors of non-communicable diseases and substance use The World Bank Health System Strengthening and Support Project (P152799) relative to the general population. Survey provides data for the PDO indicator # 1 and Intermediate Results Indicator # 1. The baseline survey was completed in 2017, and a follow-up survey will be conducted in 2019.  Developing and adopting national e-health standards and legislation to improve the quality of health data and ensure the interoperability of health information systems nationwide and internationally. Progress under this sub- component is on track. Sixteen standards have been adopted in 2017 and 2018. The MoH has also implemented activities to develop and adopt national e-health standards and legislation to improve the quality of health data and ensure the interoperability of health information systems nationwide and internationally.  Enhancing the technical audit capacity and widening the use of evidence-based medical practice (at the primary and secondary levels) to improve the quality of health service provision; and establishing an Evidence-Based Medical Practices Decision Support System. The amendment of the organic law has affected the nature and scope of the activities related to the auditing mechanisms at the provincial level. The MoH has now aligned the Project activities with the new organizational structure and has started strengthening the audit capacity of the Provincial Health Directorates. Sub-component 3.2: Sharing Turkey’s Experience.  The targets on providing training to other countries’ health workers are exceeded. In May 2017, a presentation on the Turkish Health System was delivered at the 70th World Health Assembly, Geneva, at the “Partnership for Health System Transformation: Valuing the Experiencers” event. Sub-component 3.3: Building Capacity in Health Technology Assessment (HTA).  The development of the HTA strategy has been completed with a delay of over one year. The MoH is expected to publish the strategy document by mid-2019, after upper management approval is obtained. For the next phase of the Project, the MoH will develop HTAs on prioritized topics prepared in line with the new HTA strategy. Sub-component 3.4: Project Management.  PMSU has launched a series of policy labs in 2017. Dedicated teams composed of upper management officials, international experts, staff of the MoH implementation units, and field observers have participated in these labs. The outputs were used to develop the new Strategic Plan for 2019-2023.  SDP is coordinating the development of the MoH’s Strategic Plan. SDP is establishing an effective monitoring and evaluation system to properly communicate planned actions to relevant stakeholders to ensure their engagement to monitor activities in the field and to take the necessary course of action based on the feedback coming from the field. This mechanism will help to properly and regularly report to the top management progress on the Strategic Plan and Project activities, challenges encountered, solutions and recommendations.  PMSU’s web-based Program Management System (PMS) introduced World Bank procurement procedures and principles to the users in MoH implementing units a stepwise approach (as a process flow) to accelerate the preparatory works and minimize possible mistakes which may cause delays in implementation. 7. Financial Management of the Project has been rated satisfactory. There are no outstanding audit reports for the Project. The Project audit report for the year ended December 31, 2017 was received. The auditors have issued an unmodified (clean) audit opinion on the Project financial statements. The audit report is acceptable to the Bank. 8. Procurement rating of the Project is moderately satisfactory. The last procurement post review of the Project was conducted in July 2018 and no issues were raised. The World Bank Health System Strengthening and Support Project (P152799) 9. Disbursement. The Project implementation delays are reflected in a considerable slowdown of disbursement since July 2016, with only 22 percent of the loan amount disbursed to date. The level of commitments (contracts signed not yet disbursed) represents 23 percent of the loan. Since Project approval, the euro has appreciated against the Turkish lira (appreciation is currently at 40 percent), lowering the estimated cost of contracts in the procurement plan. Rationale for Restructuring 10. This first phase restructuring includes (a) a revision of some of the Project activities planned under each of the component; (b) a revision of the Results Framework (RF) (including formulation, definition, baseline, target values); (c) revision of the budget by Project components; and (d) an extension of the loan Closing Date from May 31, 2020 to June 30, 2021. Once the Government resolves internal legal issues that will impact Project institutional arrangements, a second restructuring will (a) change the PDO; (b) include a new component on research and development; and (c) reallocate the Eur 22.5 million unallocated savings to a new category. a. As explained in detail under the current implementation status section, there are changes in some Project activities. As all Project activities will be linked with the Strategic Plan, the restructuring will realign the Project to the Government’s and the MoH’s strategic objectives for the health sector. b. The proposed restructuring aims to establish a plausible association between outputs and outcomes. The RF is reformulated to establish a clear link with the activities and achievements so that the Key Performance Indicators fully captures achievement of objectives. c. As mentioned above, the euro appreciation against the Turkish lira has provided enough savings to potentially expand the scope of the Project. The MoH implementing units reevaluated their budget needs for Project activities accordingly. Instead of cancelling the savings, the Government has indicated interest in using these savings to support research and development in the health sector. This proposition is satisfactory to the Bank, as it has already been defined as a potential area of engagement in line with the priorities of the Government in the health sector. However, as the legal arrangements related to supporting research and development through the Turkish Health Institutes (TUSEB) are to be finalized in a couple of months, the current Government’s request for restructuring is being processed immediately as a first phase restructuring, pending the issuance of a second request to add this area of potential support. d. While there has been considerable time and effort spent by the MoH and the Bank to refocus the Project in the context of a rapidly evolving health sector reform in Turkey, the delays encountered create urgency in financing activities with an end-date beyond the current Closing Date of May 31, 2020. There is increased ownership now that the upper management of the MoH has been reinstated and units are currently implementing their activities smoothly. However, because of the delays in initiation of important activities, additional time is required for their successful completion. The World Bank Health System Strengthening and Support Project (P152799) A. DESCRIPTION OF PROPOSED CHANGES 11. Specifically, the first phase restructuring entails the following: 12. Revision of Project components and costs. In addition to the changes to some Project activities under each of the component, as presented below, it is proposed to reallocate the Eur 22.5 million unallocated savings to a new category. As part of the second phase restructuring to be processed upon Government’s decision to strengthen the research & development (R&D) capacity in the health sector, particularly in supporting innovation in biopharmaceutical products and medical devices, the funds under the unallocated category will be further reallocated to finance the new proposed component. This new category will mainly finance prototype development grants, and industrial design grants. If no decision is taken in that regard by the Government of Turkey by September 30, 2019, the Bank will recommend to the Government that unallocated savings be cancelled. 13. Below are the revisions by component. They include activities added or dropped, and budget adjustments: Component 1 - Primary and Secondary Prevention (original US$44.09 million; revised US$28.52 million) 14. Develop guidelines, standards, and training modules for palliative care: The responsibility for palliative care activities has been transferred to the Public Hospitals General Directorate. Consequently, these activities will now be financed under the national budget and are, therefore, dropped under the Project. 15. Improve service delivery and quality of care by family physicians through the analysis of current workload practices and procedures: the MoH has decided not to conduct a workload analysis until the development of performance-based payment models for family physicians is finalized. This activity is therefore dropped under this component. Component 2 - Increasing Efficiency of Public Hospital Management (original US$46.61 million; revised US$32.95 million) 16. Develop architectural and technical standards for health facilities of various profiles: the MoH will build on the experiences gained from the implementation of the broader PPP program to improve the architectural and technical standards of health facilities. Therefore, these activities are dropped under the Project. 17. Simulation assisted trainings and implementations: under this component, establishment of simulation assisted training centers is replacing the investments for training centers on clinical engineering to increase the specialized health workforce supply, as well as to enhance the provision of specialized healthcare services in public hospitals. 18. Establishment of a PPP monitoring and evaluation system: the MoH will procure consultancy services for a new monitoring and evaluation system that would facilitate the tracking of PPP processes and contracts from planning to tendering, investment and management. This activity is therefore added to component 2 of the Project. Component 3 – Improving the Effectiveness of Overall Health Sector Administration (original US$43.60 million; revised US$47.63 million) 19. Process mapping of all MoH units: As the MoH has been subject to major organizational restructurings, SPD has initiated a new activity to prepare process flow diagrams of the MoH implementing units. This activity is added to component 3 to institutionalize a better system of collecting, processing, validating, and using information for policy decisions. 20. Revised Budget by Components. A reallocation of the loan proceeds (in euro) and the creation of a new unallocated category are proposed to reflect the above changes. At the time of restructuring the EUR/USD exchange rate is 0.8935. The World Bank Health System Strengthening and Support Project (P152799) Original Objectives Components/sub-components Revised Budget Allocation i. Increase national (i) Piloting Healthy Living Centers € 3,520,000 € 8,648,308 awareness and behavior (ii) Developing public outreach materials, dissemination change with regards to methodologies, and targeting mechanisms to raise risk factors of chronic € 9,000,000 € 5,711,698 popular awareness through campaigns, public events, and disease and addiction: health care visits, and at Healthy Living Centers unhealthy dietary habits and excessive salt consumption; physical (iii) Supporting training, awareness raising, and counseling inactivity; passive activities on substance abuse and strengthening € 12,800,000 € 5.217.241 smoking, and substance AMATEMs and ÇEMATEMs addiction Sub-component 1.1 € 25,320,000 € 19.577.247 (i) Operate and improve capacity in post-screening ii. Ensure effective € 1,480,000 € 3,076,455 diagnosis centers (second-level diagnostics) screening for early (ii) Introduce the national cancer registry software by detection of cancer improving physical and technical infrastructure and € 870,000 € 341,197 through improving access training health workers in its use to quality primary care (iii) Develop guidelines, standards, and training modules services and monitoring € 1,410,000 € 49,335 for palliative care efforts at all levels Sub-component 1.2 € 3,760,000 € 3,466,987 (i) Support to strengthen the Family Physician Training € 8,400,000 € 2,420,007 iii. Continue support to Program strengthen the Family (ii) Conduct a thorough workload analysis and standardize Physician Training work procedures to allow for the development of more € 1,910,000 €0 Program effective service delivery and quality of care by family physicians Sub-component 1.3 € 10,310,000 € 2,420,007 Component 1 € 39,390,000 € 25.464.241 (i) Developing and applying models and standards for i. Reform of the health efficient health facility management facility management € 25,500,000 € 16,143,215 New: Establishing simulation-based medical education and systems training centers ii. Developing (ii) Developing architectural and technical standards for architectural and health facilities of various profiles (public hospitals, oral € 2,590,000 €0 technical standards for and dental health centers, family health centers, etc.) health facilities (iii) Strengthening the capacity of the GDHI in managing PPP contracts and administrating PPP projects and iii. Technical support to developing in-house capacity in legal, financial, the PPP program operational, and structural aspects of contract € 13,560,000 € 13,280,640 implementation unit management under MOH New: Establishment of a PPP Monitoring and Evaluation system Component 2 € 41,650,000 € 29,423,854 The World Bank Health System Strengthening and Support Project (P152799) Original Objectives Components/sub-components Revised Budget Allocation (i) Institutionalizing HSPA and harmonizing health sector € 10,300,000 € 4.279.714 data in line with international standards (ii) Developing and adopting national e-health standards and legislation to improve the quality of health data and € 2,670,000 € 864,000 ensure the interoperability of health information systems i. Enhancing the nationwide and internationally monitoring and (iii) Developing and implementing a computerized decision evaluation capabilities of support system (health management information system MoH to improve policy [HMIS]) for decision makers on various levels, based on € 6,110,000 € 6.306.632 and decision making the integration of reliable and consolidated data from based on evidence existing systems (iv) Enhancing the technical audit capacity and widening the use of evidence-based medical practice (at the primary and secondary levels) to improve the quality of € 8,180,000 € 1.160.624 health service provision; establishing an Evidence-Based Medical Practices Decision Support System Sub-component 3.1 € 27,260,000 € 12.610.892 ii. Developing a model for sharing of Turkey’s experiences in health sector (including country Sub-component 3.2 € 2,850,000 € 1,900,161 specific analysis, training, and disseminating HTP products) iii. Building capacity in Health Technology Sub-component 3.3 € 3,520,000 € 998.327 Assessment (HTA) iv. Supporting Project Management related Sub-component 3.4 € 5,330,000 € 27,015,953 activities and Strategic Management Component 3 € 38,960,000 € 42.525.334 Unallocated €0 € 22.586.571 TOTAL € 120,000,000 € 120,000,000 21. Revision of the Results Framework. The RF is revised to adjust the PDO indicators and intermediate results indicators to better measure progress in relation to the Project components and to reflect the proposed extension of the Closing Date from May 31, 2020 to June 30, 2021. The World Bank Health System Strengthening and Support Project (P152799) (a) PDO Indicators: Original Indicators Proposed Revision Rationale for changes Objective 1: to improve primary and secondary prevention of selected non-communicable diseases Percent of households that Revised: The reference documents and baseline data were limited at receive from health workers the time of preparation. Consequently, the findings of the counselling or education No change in the indicator Chronic Diseases and Risk Factors Study (2011) were used as related to healthy living (by name. Cumulative target a guide to estimate the baseline value for this indicator on gender). values revised. prevention of risk factors. The Bank, in consultation with the MoH, has revised the target values for 2018, 2019, 2020, and 2021. The MoH envisages a yearly increase of 5 percent in the target values of 2018 and 2019 for the overall population. Concerning NCD counseling, control and treatment, the MoH intends to reach 50 percent of the population by 2025. The MoH’s commitment will therefore contribute to reaching the new targets. The introduction of HLCs will provide additional means for people to receive healthy lifestyle advice from professionals other than health care workers; this will have a positive effect in reaching the targets. Percent change of target Marked for deletion The HLC pilots, which were originally set at eight, were population using services of expanded to over 100 by the time of the mid-term review Healthy Living Centers (by and have now been revised upwards to over 250. In the province, age, gender, original design, HLCs were envisaged to serve a population education, health status, and of 75 thousand people in each pilot district. Due to the by type of services provided) increase in the number of HLC pilots and removal of the population limits, it is not possible for the MoH to identify the target population of each HLC until the HLCs are expanded nationwide. As PDO indicator #1 measures the coverage of these services on a broader scale, the Bank team agreed with the MoH to drop this indicator. Early detection rate of (a) Revised: The Bank agrees with the MoH to revise the cumulative cervical; and (b) breast cancer target indicators in line with the targets of the MoH (by province and age) Disaggregation levels are Strategic Plan. removed. This indicator is defined as (a) number of cases detected at stages 0 and I divided by number of cases detected at all stages (0-IV), (b) number of cases detected at stages 0, I, and II divided by number of cases detected at all stages (0- IV) and will be calculated by including in-situ cancer data. As the actual detection figures are reflected with a delay of two years, cumulative target values for 2016 and 2017 will not be reported. The Bankand the MoH have agreed that disaggregated data by provinces will not be reported under this indicator. The World Bank Health System Strengthening and Support Project (P152799) Objective 2: to increase the efficiency of hospital management Increase in average composite Marked for deletion In line with the changing priorities of the MoH’s upper productivity index for all public management, the Project will not finance all activities to the hospitals. average composite productivity index. Therefore, the Bank has agreed with the MoH to track the coverage of the simulation assisted trainings and implementations as an indicator of strengthened public hospital efficiency. New PDO indicator: The simulation assisted trainings and implementation will Simulation assisted trainings enhance the provision of specialized healthcare services in and implementation coverage public hospitals. This indicator will measure training of the targeted healthcare coverage of the targeted healthcare professionals in the professionals fields of hospital pharmacy, and specialized healthcare services (e.g., cardiovascular surgery, microsurgery, laparoscopy). Objective 3: to enhance the capacity of the MoH for evidence-based policy making Percent of policy and decision Revised This PDO indicator is revised as a new cumulative target makers that use HMIS regularly value is added to reflect the proposed extension of the (on a monthly basis) Closing Date. (b) Intermediate Results Indicators: Original Indicators Proposed Revision Rationale for changes Component 1: Primary and Secondary Prevention Percent of general population Revised: The indicator is reformulated to reflect the change in the who can state two or more share of the population that can state two or more negative negative health impacts of Percent change in share of the health impacts of selected risk factors of NCDs. Stratified selected risk factors of non- general population who can data will not be reported under this indicator, and the communicable diseases and state two or more negative negative impact of selected risk factors of NCDs will be substance use (by province, health impacts of selected risk tracked separately. age, and gender). factors of non-communicable diseases. Percent of target population in Marked for deletion Every HLC was originally planned to serve a population of 8 provinces covered by newly 75,000 in its catchment area. This target value was established Healthy Living calculated in accordance with the number of districts in a Centers (by province). province and the location of each HLC. However, the increasing interest and demand of people living in other districts currently make it difficult for the MoH to identify the exact target population (with NCD related problems) that each new HLC serves. As the Project is financing the establishment (staffing, equipping) of HLCs, the Bank has agreed with the MoH to keep track of the number of new HLCs, instead of the target population. New indicator: As the Project is financing the establishment (staffing, Number of Healthy Living equipping) of HLCs, the Bank has agreed with the MoH to Centers established. keep track of the number of new HLCs. The World Bank Health System Strengthening and Support Project (P152799) Original Indicators Proposed Revision Rationale for changes Number of individuals in 5 Revised The number of centers will be increased from 5 to 12 in line Project provinces who visit with the MoH’s plans. The cumulative target values will be Substance Use Treatment Number of individuals in 12 revised accordingly. Centers to receive patient- Project provinces who visit specific counselling (new and Substance Use Treatment returning visitors). Centers to receive patient- specific counselling (new and returning visitors). Percent of target population Revised The Bank has agreed with the MoH to align the cumulative screened for 3 types of cancer target values with the Strategic Plan targets. Stratified data (by province, age, gender [for will not be reported under this indicator. colorectal]), and cancer type. Percent of Primary Health Care Revised The cumulative target values will be revised as the MoH (PHC)-level staff who have could not provide the ratio of PHC-level staff who have satisfactorily completed Number of new PHC-level staff satisfactorily completed standardized training modules due standardized training modules who have satisfactorily to frequent turnover. As the MoH will provide training required by the staff’s job completed standardized activities to 80 percent of the new recruits, the Bank has profile: (a) distance learning; training modules required by agreed that the MoH will report on the number of new and (b) face-to-face is revised the staff’s job profile recruits who completed training activities. by the number of PHC-level staff who have satisfactorily completed standardized training modules required by the staff’s job profile. Direct project beneficiaries Revised The cumulative target values are revised due to the changes (number), of which female in the scope of related activities. (percentage) Health personnel receiving Revised The cumulative target values are revised due to the changes training in the scope of related activities. Health facilities constructed, Revised The cumulative target values are revised as the scope of the renovated, and/or equipped HLC pilot has expanded. Percent of users of Healthy Revised The cumulative target values are revised due to the changes Living Centers satisfied with in the scope of related activities. ease of access to Healthy Living Centers and/or responsiveness of services to users’ individual needs Component 2: Increasing Efficiency of Hospital Management and Operations Number of Public Hospital Marked for deletion The MoH has implemented a pilot in Istanbul Umraniye Unions where newly developed district to develop models and standards for efficient health hospital management models facility management. This model will be expanded to other are implemented. hospitals under the national budget. The World Bank Health System Strengthening and Support Project (P152799) Original Indicators Proposed Revision Rationale for changes New indicator: This new indicator is expected to better reflect the changing Number of simulation-based priorities of the MoH, as the it intends to give more medical education centers emphasis to high value-added capacity building efforts, established. including simulation-based medical education in the remaining period. The MoH will establish two simulation- based medical education centers and the new indicator will keep track of progress in establishing these centers. Standard guidelines and Marked for deletion GDHI has recruited qualified consultants to strengthen its templates for PPP transactions institutional capacity for PPP transactions management. The developed. MoH upper management decided to use the remining budget allocation for this sub-component for efficient monitoring and control of PPP transactions. New indicator: The new monitoring and evaluation system will facilitate the Establishment of a PPP tracking of PPP processes from planning to tendering, Monitoring and Evaluation investment and management. The system will also help system. standardize the PPP processes. The new indicator will keep track of progress in establishing this system. Component 3: Improving the Effectiveness of Overall Health Sector Administration National-level Health System Revised This indicator is revised to add a new cumulative target Assessment conducted value to reflect the proposed extension of the Closing Date. annually and published Key information technology Revised This indicator is revised to add a new cumulative target standards developed and value to reflect the proposed extension of the Closing Date. integrated into updated draft regulations Percent of health indicators on Revised The scope of the MoH electronic databases has expanded Health.Net that meet since the design. The formula for this indicator will be international standards Percent of health indicators revised as follows: within MoH databases meeting Percent of indicators within the MoH databases meeting international standards international standards = [(A/B) x 100], where A is the number of indicators within the MoH electronic databases that are fully or partially met for a particular year under international definitions (these are not all of the indicators requested from Turkey by international databases, but are the ones required to be taken only from the MoH electronic databases); and B is the number of all indicators within the MoH electronic databases that are required to be met for a particular year. At least 12 Health Technology Revised This indicator is revised to add a new cumulative target Assessments on prioritized value to reflect the proposed extension of the Closing Date. topics prepared in line with new HTA strategy and published The World Bank Health System Strengthening and Support Project (P152799) Original Indicators Proposed Revision Rationale for changes New indicator: A new indicator is added to track the activities implemented Process mapping of all MoH by the Strategy Development Presidency under Component units 3. As the MoH has been subject to major organizational restructurings, the Strategy Development Presidency will be implementing a new activity to prepare process flow diagrams of the MoH implementing units. These activities will ensure the establishment of a better system of collecting, processing, validating, and using information for policy decisions. 22. Extension of the Closing Date. An extension of the Closing Date is proposed from May 31, 2020 to June 30, 2021. This is the first extension of the Closing Date. This extension will provide adequate time for Project activities to be implemented and achieve the PDO. Changes to the implementation schedule and disbursement estimates are made accordingly. 23. Disbursement estimates. The disbursement schedule is adjusted to reflect the proposed extension of the Closing Date and the reallocation to a new unallocated category. 24. Change to the overall risk rating. There is no change in the overall risk rating, which is moderate. 25. Proposed second phase restructuring. Pending approval of internal legal changes that would allow TUSEB to borrow and receipt of a restructuring request from Government, the second phase restructuring is expected to be completed in the first quarter of fiscal year 2020. It will include (a) a change in the PDO; (b) the addition of a new research and development component; and (c) a reallocation of the loan proceeds to the new component from the unallocated category introduced in this first phase restructuring. 26. Specifically, it is planned that the original PDO is revised to “improve primary and secondary prevention of selected NCDs, increase the efficiency of hospital management, enhance the capacity of the Ministry of Health for evidence- based policy making and build the capacity of the Ministry of Health for research and development in selected health areas. The proposed research and development component will pilot a program to strengthen TUSEB’s capacity to implement a pilot-to-market innovation ecosystem for biopharmaceuticals and medical equipment and accelerate the pilot-to-market process for specific products. The funds under the unallocated category will be transferred to a new category to finance this component. I. SUMMARY OF CHANGES Changed Not Changed Results Framework ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Disbursement Estimates ✔ Overall Risk Rating ✔ The World Bank Health System Strengthening and Support Project (P152799) Implementation Schedule ✔ Implementing Agency ✔ DDO Status ✔ Project's Development Objectives ✔ Cancellations Proposed ✔ Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Institutional Arrangements ✔ Financial Management ✔ Procurement ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_COMPONENTS_TABLE COMPONENTS Current Current Proposed Proposed Cost Action Component Name Component Name Cost (US$M) (US$M) Primary and Secondary Primary and Secondary 44.03 Revised 28.52 Prevention Prevention Increasing Efficiency of Increasing Efficiency of Hospital 47.65 Revised Hospital Management and 32.95 Management and Operations Operations Improving the Effectiveness of Improving the Effectiveness of Overall Health Sector 44.30 Revised Overall Health Sector 47.63 Administration Administration The World Bank Health System Strengthening and Support Project (P152799) 0.00 New Unallocated 25.30 TOTAL 135.98 134.40 OPS_DETAILEDCHANGES_LOANCLOSING_TABLE LOAN CLOSING DATE(S) Original Revised Proposed Proposed Deadline Ln/Cr/Tf Status Closing Closing(s) Closing for Withdrawal Applications IBRD-85310 Effective 31-May-2020 30-Jun-2021 30-Oct-2021 OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2016 28,760,000.00 2,215,450.00 2017 37,480,000.00 10,310,928.42 2018 34,920,000.00 9,224,237.91 2019 25,400,000.00 13,028,006.24 2020 7,740,000.00 46,017,357.57 2021 0.00 53,604,010.86 OPS_DETAILEDCHANGES_SORT_TABLE SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating at Approval Current Rating Political and Governance  Substantial  Substantial Macroeconomic  Moderate  Moderate Sector Strategies and Policies  Low  Low Technical Design of Project or Program  Moderate  Moderate Institutional Capacity for Implementation and  Substantial  Substantial Sustainability Fiduciary  Substantial  Substantial The World Bank Health System Strengthening and Support Project (P152799) Environment and Social  Low  Low Stakeholders  Low  Low Other Overall  Moderate  Moderate . The World Bank Health System Strengthening and Support Project (P152799) . Results framework COUNTRY: Turkey Health System Strengthening and Support Project Project Development Objectives(s) The Project Development Objective (PDO) of the HSSSP is to improve primary and secondary prevention of selected NCDs, increase the efficiency of hospital management, and enhance the capacity of the MoH for evidence-based policy making. Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Objective 1: to improve primary and secondary prevention of selected non-communicable diseases Percent of households that receive from health workers counselling or education 10.00 50.00 related to healthy living (by gender) (Percentage) Action: This indicator has been Revised Percent of households that receive from health workers counselling or 7.00 40.00 education related to healthy living (males) (Percentage) Action: This indicator is New Percent of households that receive from health workers counselling or 13.00 60.00 education related to healthy living (females) (Percentage) The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Action: This indicator is New Percent change of target population using services of Healthy Living Centers (by province, age, gender, education, 0.00 50.00 health status, and by type of services provided) (Percentage) Action: This indicator has been Marked for Deletion Early detection of (a) cervical cancer 39.20 54.00 56.00 58.00 (Percentage) Action: This indicator has been Revised Early detection of (b) breast cancer 48.70 49.00 50.00 51.00 (Percentage) Action: This indicator has been Revised Objective 2: to increase the efficiency of hospital management Increase in average composite productivity index for all public hospitals 0.00 10.00 (Percentage) Action: This indicator has been Marked for Deletion Simulation assisted trainings and implementations' coverage ratio of the 0.00 4.00 6.00 10.00 targeted healthcare professionals (Percentage) Action: This indicator is New The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 Objective 3: to enhance the capacity of the MoH for evidence-based policy making (Action: This Objective has been Revised) Percent of policy and decision makers that regularly use HMIS regularly 0.00 15.00 50.00 80.00 (monthly) (Percentage) Action: This indicator has been Revised PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Component 1: Primary and Secondary Prevention Percent change in share of the general population who can state two or more negative 0.00 4.00 health impacts of selected risk factors of non-communicable diseases (Percentage) Action: This indicator has been Revised Percent change in share of general population who can state negative health 0.00 4.00 impacts of substance use (Percentage) The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator is New Percent of target population in 8 provinces covered by newly established Healthy Living 0.00 90.00 Centers (by province) (Percentage) Action: This indicator has been Marked for Deletion Number of Healthy Living 80.00 182.00 210.00 230.00 270.00 Centers established (Number) Action: This indicator is New Number of individuals in 12 project provinces who visit Substance Use Treatment 90.00 1,000.00 2,400.00 10,500.00 12,075.00 13,887.00 Centers to receive patient- specific counselling (new and returning visitors) (Number) Action: This indicator has been Revised Percent of target population screened for 3 types of cancer: 82.70 83.70 81.30 82.00 83.00 83.50 (a) cervical (Percentage) Rationale: Action: This indicator has been Revised The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Percent of target population screened for 3 types of 33.50 33.60 35.70 45.00 50.00 55.00 cancer: (b) breast (Percentage) Action: This indicator has been Revised Percent of target population screened for 3 types of 22.40 24.10 25.70 38.00 40.00 45.00 cancer: (c) colorectal (Percentage) Action: This indicator has been Revised Number of PHC-level staff who have satisfactorily completed standardized face-to-face 1,000.00 3,000.00 4,000.00 5,000.00 training modules required by the staff’s job profile (Number) Action: This indicator has been Revised Percent of PHC-level staff who have satisfactorily completed standardized 0.00 30.00 training modules required by the staff's job profile: (b)face-to-face (Percentage) The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Marked for Deletion Direct project beneficiaries 0.00 4,434,773.00 9,214,807.00 20,000,000.00 26,000,000.00 28,000,000.00 (number) (Number) Action: This indicator has been Revised Direct project beneficiaries of which female 0.00 72.00 65.00 66.00 66.00 (percentage) (Percentage) Action: This indicator is New Health personnel receiving 0.00 35,000.00 40,000.00 42,500.00 training (Number) Action: This indicator has been Revised Health facilities constructed, renovated, and/or equipped 0.00 220.00 250.00 285.00 (Number) Action: This indicator has been Revised Percent of users of Healthy Living Centers satisfied with ease of access to Healthy Living 0.00 50.00 55.00 65.00 70.00 80.00 Centers and/or responsiveness of services to users’ individual needs (Percentage) The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Revised Component 2: Increasing Efficiency of Hospital Management and Operations Number of Public Hospital Unions where newly developed 0.00 89.00 hospital management models implemented (Number) Action: This indicator has been Marked for Deletion Number of simulation-based medical education centers 0.00 1.00 2.00 2.00 established (Number) Action: This indicator is New Standard guidelines and Standard guidelines and No standard templates for PPP transactions templates for PPP documentation developed (Text) transactions in place Action: This indicator has been Marked for Deletion Establishment of a PPP M&E No No Yes Yes system (Yes/No) Action: This indicator is New Component 3: Improving the Effectiveness of Overall Health Sector Administration National-level Health System Assessment conducted Yes Yes No Yes annually and published (Yes/No) The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 Action: This indicator has been Revised Key information technology standards developed and 0.00 5.00 10.00 20.00 20.00 20.00 integrated into updated draft regulations (Number) Action: This indicator has been Revised Percent of health facilities that share data to HMS (a) public 1.50 20.00 50.00 80.00 100.00 100.00 hospitals (Percentage) Action: This indicator has been Revised Percent of health facilities that share data to HMS (b) 0.00 20.00 50.00 80.00 100.00 100.00 family medicine centers (Percentage) Action: This indicator has been Revised Percent of health facilities that share data to HMS (c) 0.00 10.00 30.00 50.00 60.00 60.00 private hospitals (Percentage) Action: This indicator has been Revised Percent of health indicators on 51.00 59.00 68.00 75.00 Health.Net that meet The World Bank Health System Strengthening and Support Project (P152799) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 international standards (Percentage) Action: This indicator has been Revised At least 12 Health Technology Assessments on prioritized topics prepared in line with 0.00 9.00 12.00 12.00 new HTA strategy and published (Number) Action: This indicator has been Revised Process mapping of all MoH Process flow charts Process flow charts Process mapping No process mapping units (Text) updated updated completed Action: This indicator is New IO Table SPACE The World Bank Health System Strengthening and Support Project (P152799)