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: HEAHN IBRD/IDA | Program-for-Results Financing | FY 2017 | Team Leader(s): Dinesh M. Nair, Shuo Zhang Seq No: 5 | ARCHIVED on 07-Sep-2019 | ISR36855 | Created by: Tao Su on 27-Apr-2019 | Modified by: Dinesh M. Nair on 29-Aug-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 Both Anhui and Fujian have been moving forward with the health reform implementation on the ground. Some key results include  Public Hospital Reform. Building on the momentum, both provinces have continued the reforms to improve performance levels of public hospitals. Anhui issued the ‘Implementation Guidance on Establishing Modern Hospital Management System’ in 2018 and identified 40 provincial level hospitals for the provincial pilot and five for the national pilot. Fujian province has identified 39 hospitals at various levels as the provincial pilots and five as national pilot hospitals. The annual salary-based performance evaluation system for public hospital directors is being scaled up to both Prefecture and County level hospitals in the two provinces. Increasing hospitals’ autonomy has been one of the focus areas in Fujian and the reforms are taking place in 95 pilot hospitals. In addition, both provinces have continued to push forward the clinical pathway and case-based payment approaches as the means to improve service quality and efficiency. The clinical pathway utilization rate has reached 67% in 75 county hospitals in Anhui (far exceeding the 2018 target). A total of 202 hospitals in Fujian have implemented clinical pathway and the clinical pathway utilization rate has reached 42.71% (of which county level hospitals reached 38.07%), also exceeding the 2018 target. In Anhui, clinical pathway and case-based payment have been further scaled up to the tertiary hospitals in the urban areas and to the Urban Employee Basic Medical Insurance scheme. Fujian has implemented case-based payment reform in all public hospitals of the province and strengthened the training on core quality assurance mechanisms for all hospitals (secondary level and above) in the province.  People-centered Integrated Care (PCIC). Building medical alliances to link county, township and village facilities continues to be the core reform in both Anhui and Fujian in building the PCIC system. All counties in Anhui have established medical alliances and piloting of Tightly Integrated Medical Alliance (TIMA)which is being rolled out in 37 of these counties. In the Tongling prefecture, a pilot of urban TIMA is underway, with the intention of rolling out to more cities if successful. The successful Senior Nurse Practitioner deployment program is being scaled up in Anhui. The TIMA has been piloted in 41counties in Fujian province, of which 70% have started to implement capitated global budget payment. Sanming prefecture has established two urban TIMAs, which have unified management, accountability, service provision, and benefit among the member health facilities in the Alliance. Family doctor empanelment in both provinces has made progress (Fujian 40%, Anhui 34%) and attention is being paid to providing personalized, tailor-made services to the residents. To support the TIMA, a Medical Imaging Cloud in Anhui has been developed, which links 1,060 hospitals and enables the sharing of diagnostic images. Lower level health facilities can now get expert diagnostic support from the higher levels in the Alliance. To ensure sustainability, Anhui has developed fee schemes for telemedicine services between the higher levels and lower levels within the Alliance.  Addressing cross cutting dimensions. Both provinces have continued to prioritize investment in health information systems and health human resources. Fujian has achieved universal connectivity linking province level down to the villages. Three essential databases (electronic medical records, electronic health records, and whole population information) have been built allowing different health information to be shared across facilities and locations. A primary health care (PHC) information system has also been established standardizing the procedures of medical services and public health services at the PHC facilities. Anhui has been piloting the use of artificial intelligence and smart medical services to strengthen the quality of care. Anhui issued the “Smart Medical Care” three-year enhancement action plan and “Smart Hospital Construction Standards”. “Smart Physician Assistant System” is being rolled out in 50 9/7/2019 Page 1 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) counties in Anhui. Anhui also developed and launched “Provincial Family Doctor” empanelment information management system” to eliminate paper-based health records by the end of 2019. Both provinces have stepped up the training and availability of General Practitioners (GPs). Anhui trained 1,079 GPs and Fujian (on average) had 2.2 GPs per 10,000 population in 2018--0.46 more than 2017.  Several key activities were supported under the central level Component of the PforR including the results verification process with the Center for Health Statistics and Information (CHSI), health reform conferences across provinces to exchange experiences at national level and planning for the organization of an International Workshop on Building PCIC (including preparing for the public service announcement video). The CPSM has also invited domestic experts to conduct an implementation review on integrated NCD management, case-based payment methods, and clinical pathways; draft reports are under preparation. 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 0.00 204.69 395.31 34% 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 DLI Disbursement Achievement Disbursed amount in Disbursement % DLI ID DLI Type Description Coc DLI Amount Status Coc for DLI Loan: IBRD87440-001 County-level IDS in 50 1.1 Regular USD 15,000,000.00 Fully Achieved 15,000,000.00 1% counties-AH Integra 3 health insurance 1.2 Regular USD 40,000,000.00 Fully Achieved 40,000,000.00 1% scheme-FJ Discharged patients % are Partially 2.1 Regular USD 68,000,000.00 17,000,000.00 4% paid-AH Achieved Discharged patients % are Partially 2.2 Regular USD 68,150,000.00 10,150,000.00 6.7 % paid-FJ Achieved Inpatients % treat thru Partially 3.1 Regular USD 66,240,000.00 44,640,000.00 1.5 % clinical path-AH Achieved Inpatients % treat thru Partially 3.2 Regular USD 66,090,000.00 16,090,000.00 4.1 % clinical path-FJ Achieved Outpatient care services % 4.1 Regular USD 40,000,000.00 Not Achieved 0.00 delivere-AH Outpatient care services % 4.2 Regular USD 40,000,000.00 Not Achieved 0.00 delivered-FJ Partially 5.1 Regular # prefectures use NCD-AH USD 45,047,500.00 15,047,500.00 3% Achieved 9/7/2019 Page 2 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Partially 5.2 Regular # prefectures use NCD-FJ USD 44,972,500.00 14,815,105.00 3% Achieved # County-township-village Partially 6 Regular USD 50,000,000.00 7,500,000.00 6.7 % health IS-AH Achieved # THCs/CHCs estab. Care Partially 7 Regular USD 50,000,000.00 20,200,000.00 2.5 % health IS-FJ Achieved Experience sharing& Partially 8 Regular USD 5,000,000.00 1,500,000.00 3.3 % dissemin-National Achieved 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 Technical Client Due Date 31-Dec-2018 Completed Anhui and Fujian have established the healthcare security administrations (HSAs). The HSAs are responsible for the Completion management of all the medical insurance schemes, medical pricing, as well as procurement of medicine and Measurement equipment. 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 Technical Client Due Date 31-Dec-2018 Completed Completion The new data cleaning and verification module is up running in the online reporting system. 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 Fiduciary Systems Client Due Date 28-Sep-2017 Completed Completion Guidelines were issued. According to the Progress Report, the guidelines were strictly implemented, and no event Measurement has occurred against the suspended list as of now. Comments 9/7/2019 Page 3 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) 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 Fiduciary Systems Client Recurrent Semi-Annually Completed Completion According to the Progress Report, no cases or allegations of fraud or corruption were reported so far. 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 Environmental and Social Client Recurrent Semi-Annually Completed Systems Completion In 2018, Anhui attended or organized three trainings; Fujian conducted 40 rounds of trainings on medical waste and Measurement radiation risk control and conducted ecologic and environmental protection performance M&E. 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 Environmental and Social Client Due Date 29-Dec-2017 Completed Systems Completion Anhui and Fujian have issued the relevant protocols and has conducted multiple inspections or trainings. 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). Source DLI# Responsibility Timing Timing Value Status Environmental and Social Client Recurrent Semi-Annually Completed Systems Completion No land acquisition so far Measurement 9/7/2019 Page 4 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) 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 Environmental and Social Client Recurrent Semi-Annually Completed Systems Completion Public participation and information disclosure activities have taken place in both provinces. 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 Risk ratings remain same rating from previous ISR. Results PDO Indicators by Objectives / Outcomes PDO Indicators 9/7/2019 Page 5 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) IN00696556 ►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 AH:48.4; FJ:21.88 Value AH: 12 FJ: 3 AH: 32 FJ: 50 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696557 ►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:66.6; FJ:33.78 AH:67.5; FJ:38.07 Value AH: 4 FJ:0 AH:50 FJ: 50 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696558 ►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:57.92; FJ: 53.1 AH: 61.8 FJ: 55 Value Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696559 ►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 AH: 2; FJ: 0 (piloted in 0 (AH: protocol issued; AH: 6 FJ: 4 Value 0.00 Xiamen but it is not in FJ: protocol issued) the PforR scope) Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments Intermediate Results Indicators by Results Areas Intermediate Results IN00696560 ►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:9.27%; FJ:13.77% AH:10.1%; FJ:13.3% Value FJ: 8.88% <10% Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 9/7/2019 Page 6 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Both Anhui and Fujian performance on this indicator have been unsatisfactory and is being followed up. Comments IN00696561 ►Average length-of-stay for county level public hospitals (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 8.82 AH: 8 AH: 7.31; FJ:7.18 AH: 7.71; FJ:7.28 Value FJ: 7.41 FJ: 7.37 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696562 ►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:68 AH:61; FJ:68 Value FJ:10 FJ: 68 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696563 ►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:32.9; FJ:29.98 AH:29.7; FJ:29.6 Value FJ: 24.58 FJ: 30.00 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 The performance on this indicator is not as good as that of last ISR. The team will follow up with the Project Comments provinces. IN00696564 ►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:32.5; FJ:46.49 AH:32.1; FJ:46.6 Value FJ: 50.83 FJ: 48.83 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696565 ►Proportion of patients hospitalized within county (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 69 AH: 73 AH:76.51; FJ:66.78 AH:68.06; FJ:66.96 Value FJ: 63 FJ: 80 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 9/7/2019 Page 7 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) The performance of Fujian is on track, however Anhui is faltering. The team will follow up with Anhui. Comments IN00696566 ►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:27.25; FJ: 30.3 Value FJ:29.09 increase Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696567 ►Number of hypertension patients that are under standardized management (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target AH: 4500 000 AH:4862437; AH:5029164; AH: 4700 000 Value FJ: 1250 000 FJ:1671218 FJ:1501200 FJ: 1300 000 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Anhui is doing well on this indicator but Fujian is still struggling to increase hypertensives under Comments standardized management . IN00696568 ►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 9.00 8.00 20.00 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Anhui adjusted the achievement in the latest progress report (changed from 9 to 8) after carrying out Comments an internal check. IN00696569 ►Number of THCs / CHCs that have established primary care health information systems [Fujian] (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 202.00 303.00 500.00 Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696570 ►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 All Prefectures thanks AH: 12 Value FJ: 2 Xiamen) to the integration at the FJ: 9 national level Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696571 9/7/2019 Page 8 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) ►Program experience sharing and dissemination (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target 2018 results has been 2018 results is being Value NA achieved, verified, and NA verified confirmed by the Bank Date 09-May-2017 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696572 ►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 31-Jan-2019 22-Aug-2019 31-Dec-2021 Comments IN00696573 ►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 31-Jan-2019 22-Aug-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 NA NA confirmed Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- Comments ►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 Achieved and Value NA NA NA verified, confirmed Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- 9/7/2019 Page 9 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) 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 Value FJ: 3 AH:42.6; FJ:17.93 AH:48.4; FJ:21.88 -- Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- The verification of 2018 results is in progress. 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:4 Value FJ:0 AH:66.6; FJ: 33.78 AH:67.5; FJ: 38.07 -- Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- The verification of 2018 results is in progress. 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 Value FJ: 51 AH:59.1; FJ:52.5 AH:57.92; FJ:53.1 -- Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- Anhui did not achieve 2018 target whereas Fujian achieved. Comments ►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: 2; FJ: 0 (piloted in AH: protocol issued; FJ: Value No minimum Xiamen but it is not in the -- protocol issued PforR scope) Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- The verification of Anhui result is in progress. Comments ►DLI 7 Number of counties that have established a county-township-village population health information system [Anhui] (Output, 7.50, 0%) 9/7/2019 Page 10 of 11 The World Bank Implementation Status & Results Report China Health Reform Program (P154984) Baseline Actual (Previous) Actual (Current) end Dec 2017 Value No minimum 9.00 8.00 -- Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- The verification of 2018 result is in progress. The government adjusted the achievement in the progress report Comments (changed from 9 to 8) after internal check. ►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 202.00 303.00 -- Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- The verification of 2018 result is in progress. Comments ►DLI 9 Program experience sharing and dissemination (Process, 1.50, 100%) Baseline Actual (Previous) Actual (Current) end Dec 2017 Launched operational Launched operational research on three key research on three key reform areas; and reform areas; and Value NA organized two national organized two national -- workshops on the health workshops on the health reform in China reform in China Date 09-May-2017 31-Jan-2019 22-Aug-2019 -- 2018 result has been achieved, verified and confirmed. Comments 9/7/2019 Page 11 of 11