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1 Public Disclosure Authorized EAST ASIA AND PACIFIC China Health, Nutrition & Population Global Practice IBRD/IDA Program-for-Results FY 2017 Seq No: 2 ARCHIVED on 25-Feb-2018 ISR31105 Implementing Agencies: Anhui Provincial Health and Family Planning Commission, Fujian Provincial Health and Family Planning Commission, National Health and Family Planning Commission Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Program Development Objectives Program Development Objective (from Program-for-Results 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 Overall Risk Rating High High Implementation Status and Key Decisions Implementation of health reforms in line with the Healthy China and the 13th Five-year plan is well underway in both Anhui and Fujian, with support from the Central NHFPC. In addition to general implementation support to the program, the World Bank is also leveraging its staff, as well as international experts, to help the government in strengthening the technical underpinnings and the quality of care aspects of the reform initiatives. These technical support efforts are focused on key areas - such as provider payments (to incentivize optimal service delivery in hospitals, as well in primary care settings), integrated healthcare delivery, management of non-communicable diseases (to ensure that the clinical pathways and treatment protocols are consistent with international best practice) - that are relevant to both public hospital reform, as well as to People-Centered Integrated Care (PCIC). In addition, efforts are being made to strengthen the monitoring, and particularly the evaluation, of the health reform initiatives and their outcomes, as well as to encourage learning by doing through the establishment of learning collaboratives. The Bank is also working with the government to ensure a two-way learning process, whereby the two provinces learn from experiences in the rest of China and internationally, while China's health reform experiences are shared globally. In Fujian - Using the Sanming experience, Fujian is well ahead in addressing the hospital reform especially in seeking efficiencies. The two-invoice system for drug procurement has been implemented in all public institutions and the Provincial Medical Security Management Committee Office had set up an online system for drug procurement building transparency. Guidelines on the scale-up of case based payment and for making hospital directors salary performance based had been issued. The Provincial Health Commission has also developed a guideline on public disclosure of hospital performance indicators, and 100 standardized clinical pathways that can be adapted at county level hospitals to streamline care quality. To promote PCIC among the various levels of providers, there is now at least one medical alliance in each prefecture and this integrated medical alliance will be paid through a global budget. Fujian is also promoting the empanelment of family doctor services in both urban and rural areas in the entire province with multidisciplinary teams consisting of a physician, nurse, public health worker and village doctor. In Anhui - Case-based payment has been implemented for over 200 diseases. Anhui has established a drug monitoring list and prefectural health commissions publicly disclose percentage of the drugs procured that are on the list and also conduct prescription audits. Anhui has established a headcount turnover pool to improve the efficient allocation of health workforce, rebalance the staff needs of public hospitals with idle headcounts and insufficient headcounts. Using the Tianchang experience, Anhui was moving rapidly with the scale-up of medical alliances. Medical alliances have been scaled up to 66 counties, covering 90% of all counties and being paid through global budget and case-based payment. A performance assessment system for medical alliances and the member health providers had also been established. Innovations like having senior Nurse Practitioner join the community health centers and act as a key liaison officer linking the lower with the upper level of the health system was underway in the urban areas of 3 prefectures. Anhui has also been promoting family doctor empanelment. However, as in Fujian, the capitation Page 1 of 9

2 payment for family doctor service packages only covers basic public health services and some routine check-up for identified high-risk population. Implementation structure - To provide guidance and oversight to the implementation of the PforR, a central level steering committee has been established during the program design. The Provincial Health Reform Leading Groups provide stewardship to the implementation of the PforR at the provincial level. To coordinate the day-to-day activities, offices have also been established/staffed up at the provincial, prefecture and county levels. In addition, to provide technical guidance to the program, expert panels have been constituted at both the central and provincial level. Learning Agenda: Progress has also been made on the learning agenda, which is an important part of the PforR. Study tours were undertaken to Brazil and Costa Rica by Chinese government officials to learn about health reforms in those countries and share the Chinese experience. Furthermore, plans are in place to have a Chinese delegation from the national and provincial level to visit the World Bank in Washington in April 2018 where they will interact with the HNP GP Leadership team, Bank and international experts in relevant areas of health reform, and visit US organizations with experience in integrated healthcare delivery. Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed Disbursed P IBRD Effective USD % Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P IBRD Effective 09-May Jun Sep Dec 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 High High Institutional Capacity for Implementation and Sustainability High High High Fiduciary Substantial Substantial Substantial Environment and Social Moderate Moderate Moderate Stakeholders Low Low Low Other Overall High High High Disbursement Linked Indicators (DLI) Page 2 of 9

3 The County IDS system has been scaled up to at least 50 counties/districts in Anhui (Text) Final verification reports will be available in March 2018, and the ISR Results Framework will be updated thereafter. The integration of the management of the three health insurance schemes at the provincial level in Fujian is undertaken (Text) NA -- Done Final verification reports will be available in March 2018, and the ISR Results Framework will be updated thereafter. Proportion of hospital discharges paid through case-based payment for all county-level public general hospitals and TCM hospitals (Text) AH: 12 FJ: 3 -- AH: 12; FJ:3 Proportion of inpatients to be treated through standardized clinical pathways at county level public general hospitals (Text) AH:4 FJ:0 -- AH:4; FJ:0 Page 3 of 9

4 Proportion of outpatient care delivered by primary care facilities (Text) AH: 61 FJ: AH:61; FJ:51 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) No minimum -- Data not available yet Number of counties that have established a county-township-village population health information system [Anhui] (Text) No minimum -- Data not available yet Number of THCs / CHCs that have established primary care health information systems [Fujian] (Text) No minimum -- Data not available yet Page 4 of 9

5 Program experience sharing and dissemination (Text) NA -- Data not available yet Data for CY 2017 will be available in March 2018 and the ISR Results Framework will be updated thereafter. Results Results Area Intermediate Results Area Project Development Objective Indicators PHINDPDOTBL Proportion of hospital discharges paid through case-based payment for all county-level public general hospitals and TCM hospitals (Text, Custom) AH: 12 FJ: 3 -- AH: 12; FJ:3 AH: 32 FJ: 50 PHINDPDOTBL Proportion of inpatients to be treated through standardized clinical pathways at county level public general hospitals (Text, Custom) AH: 4 FJ:0 -- AH: 4; FJ:0 AH:50 FJ: 50 Page 5 of 9

6 PHINDPDOTBL Proportion of outpatient care delivered by primary care facilities (Text, Custom) AH: 61 FJ: AH:61; FJ:51 AH: 61.8 FJ: 55 PHINDPDOTBL 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) AH: 6 FJ: 4 Overall Intermediate Results Indicators Growth rate of medical service revenue of public hospitals in the entire province (Text, Custom) AH: 8% FJ: 8.88% -- AH:8%; FJ:8.88% <10% Average length-of-stay for county level public hospitals (Text, Custom) AH: 8.82 FJ: AH:8.82; FJ:7.41 AH: 8 FJ: 7.37 Page 6 of 9

7 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) AH: 55 FJ:10 -- AH:55; FJ:10 AH: 61 FJ: 68 Proportion of labor based service revenue in total service revenue for all public hospitals in the province (Text, Custom) AH: 25 FJ: AH:25; FJ:24.58 AH: 30 FJ: Out-of-pocket payment as portion of the total inpatient services expenditure (Text, Custom) AH: 42 FJ: AH:42; FJ:50.83 AH: 37 FJ: Proportion of patients hospitalized within county (Text, Custom) AH: 69 FJ: AH:69; FJ:63 AH: 73 FJ: 80 Proportion of total Registered Physicians (assistant physician) and Registered Nurses practicing at the primary care facilities (Text, Custom) AH: FJ: AH:26.80; FJ:29.09 increase Page 7 of 9

8 Number of hypertension patients that are under standardized management (Text, Custom) AH: FJ: AH: ; FJ: AH: FJ: Number of counties that have established a county-township-village population health information system [Anhui] (Text, Custom) Number of THCs / CHCs that have established primary care health information systems [Fujian] (Text, Custom) 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) AH: 0 FJ: 2 -- AH:0; FJ:2 AH: 12 FJ: 10 Program experience sharing and dissemination (Text, Custom) Page 8 of 9

9 NA -- NA NA The county IDS system has been scaled up to at least 50 counties/districts in Anhui (Text, Custom) NA NA The integration of the management of the three health insurance schemes at the provincial level in Fujian is undertaken (Text, Custom) NA -- Done NA Overall Page 9 of 9