The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) Health System Strengthening and Support Project (P152799) EUROPE AND CENTRAL ASIA | Turkey | Health, Nutrition & Population Global Practice | IBRD/IDA | Investment Project Financing | FY 2016 | Seq No: 9 | ARCHIVED on 21-Nov-2019 | ISR39268 | Implementing Agencies: Ministry of Health, Ministry of Treasury and Finance Key Dates Key Project Dates Bank Approval Date: 21-Sep-2015 Effectiveness Date: 26-Nov-2015 Planned Mid Term Review Date: 23-Feb-2018 Actual Mid-Term Review Date: 13-Apr-2018 Original Closing Date: 31-May-2020 Revised Closing Date: 30-Jun-2021 pdoTable Project Development Objectives Project Development Objective (from Project Appraisal Document) 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. Has the Project Development Objective been changed since Board Approval of the Project Objective? No Components Table Name Primary and Secondary Prevention:(Cost $28.52 M) Increasing Efficiency of Hospital Management and Operations:(Cost $32.95 M) Improving the Effectiveness of Overall Health Sector Administration:(Cost $47.63 M) Unallocated:(Cost $25.30 M) Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Unsatisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Unsatisfactory Overall Risk Rating Moderate Moderate Implementation Status and Key Decisions This ISR reflects recent developments since project restructuring in May 2019. Since the recent restructuring there is improvement in achieving the PDO targets and progress towards achieving the PDO has been rated as Moderately Satisfactory as three out of four PDO indicators have achieved their respective target value. However, Implementation Progress rating remains as Moderately Unsatisfactory, as there are delays in key procurement activities (i.e. monitoring and evaluation system for PPP health facilities), and there exists a gap between projected disbursement figures and the actuals. 11 out of 17 11/21/2019 Page 1 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) Intermediate Results Indicators (IRIs) have achieved their respective target values in 2019. The Bank team will continue evaluating the implementation progress until the planned second restructuring by the end of December 2019. Progress on some key activities from the last ISR are as follows:  Healthy Living Centers: The HLC initiative is now being rolled out nationwide. There are currently 195 HLCs in Turkey and MoH continues to increase their capacity both in terms of the equipment and infrastructure, specialized health human resources and quality health care service delivery.  Simulation-based medical education and training centers: MoH will be operating such centers in three provinces instead of two, as indicated in the last ISR. The center in Izmir has become operational and Ankara center is expected to be operational in the last half of 2020. This center will provide a wide range of training activities including clinical engineering, general surgery, CVD, urology, labor and delivery and virtual reality. There are uncertainties for the Istanbul center concerning its location, therefore the Bank team will revisit its status and progress in the next ISR. Risks Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance Substantial Substantial Substantial Macroeconomic Moderate Moderate Moderate Sector Strategies and Policies Low Low Low Technical Design of Project or Program Moderate Moderate Moderate Institutional Capacity for Implementation and Sustainability Substantial Substantial Moderate Fiduciary Substantial Substantial Moderate Environment and Social Low Low Low Stakeholders Low Low Low Other -- -- -- Overall Moderate Moderate Moderate Results PDO Indicators by Objectives / Outcomes Objective 1: to improve primary and secondary prevention of selected non-communicable diseases IN00765379 ►Percent of households that receive from health workers counselling or education related to healthy living (by gender) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 10.00 40.50 40.50 50.00 Date 31-Dec-2012 28-Feb-2019 30-Sep-2019 30-Jun-2021 11/21/2019 Page 2 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) The reporting period for this survey is 2021, the respective survey will be conducted in 2020. 2018 target Comments: was surpassed. IN00765427 Percent of households that receive from health workers counselling or education related to healthy living (males) (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 7.00 38.10 38.10 40.00 Date 31-Dec-2012 28-Feb-2019 30-Sep-2019 30-Jun-2021 IN00765428 Percent of households that receive from health workers counselling or education related to healthy living (females) (Percentage, Custom Breakdown) Baseline Actual (Previous) Actual (Current) End Target Value 13.00 42.90 42.90 60.00 Date 31-Dec-2012 28-Feb-2019 30-Sep-2019 30-Jun-2021 IN00765429 ►Early detection of (a) cervical cancer (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 39.20 52.90 50.30 58.00 Date 31-Dec-2014 28-Feb-2019 30-Sep-2019 30-Jun-2021 The actual detection figures are reflected with a delay of two years under this indicator. While early detection target of breast cancer for 2019 (2017 figures) is met, the actual detection rate of cervical cancer is below the target value. PHGD Cancer Department explains the main reason of under-performance for cervical cancer detection as follows: The actual screening practices take into consideration the invasive cases only, which causes missed cases in screening the pre-invasive lesions. Furthermore, detection of pre-invasive lesions requires a specific set of skills and due to high staff turnover and low number of qualified health personnel for such screenings in highly populated provinces, the pre-invasive cases are missed. In order to assure data quality, MoH has decided to include data form 12 provinces so that the completeness of pre-invasive lesions can be met. This has further prompted revisions in the early Comments: diagnosis rate targets. The cumulative target values of this indicator, and the formula for calculation were revised during the first restructuring, in line with the targets of the draft Strategic Plan. However, MoH informed the Bank team that in the final version of the new MoH Strategic Plan (2019-2023) early detection targets of cervical and breast cancer as well as the formula for detecting early detection rates were revised again. The formula for breast cancer was revised where number of diagnosed cases for the stages 00 and 01 (invasive stages) are taken into consideration in the numerator cancer. The formula for cervical cancer was revised where number of diagnosed cases for the stage 00 are taken into consideration in the numerator. The Bank team expects to receive a formal restructuring request to amend the cumulative targets and the formula. IN00765430 Early detection of (b) breast cancer (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 48.70 47.90 49.50 51.00 Objective 2: to increase the efficiency of hospital management IN00765426 ►Simulation assisted trainings and implementations' coverage ratio of the targeted healthcare professionals (Percentage, Custom) 11/21/2019 Page 3 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 10.00 Date 30-Sep-2019 28-Feb-2019 30-Sep-2019 30-Jun-2021 The Bank team expects the target to be met as the Izmir simulation center is operational. The next Comments: reporting period for this indicator is February 2020. Objective 3: to enhance the capacity of the MoH for evidence-based policy making IN00765380 ►Percent of policy and decision makers that regularly use HMIS regularly (monthly) (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 10.00 22.00 80.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The actual value for 2019 has surpassed the cumulative target value. The next reporting period for this Comments: indicator is January 2020. Intermediate Results Indicators by Components Component 1: Primary and Secondary Prevention IN00765432 ►Percent change in share of the general population who can state two or more negative health impacts of selected risk factors of non-communicable diseases (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 4.00 Date 19-Oct-2018 28-Feb-2019 30-Sep-2019 30-Jun-2021 The reporting period for this survey is 2021, the respective survey will be conducted in 2020. Comments: IN00765434 Percent change in share of general population who can state negative health impacts of substance use (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 4.00 IN00765439 ►Number of Healthy Living Centers established (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 80.00 182.00 195.00 270.00 Date 31-Dec-2017 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target will not be met for 2019, as PHGD plans to have 205 HLCs operational by the end of 2019. Comments: While the cumulative target values of this indicator were revised during the first restructuring, in line with the targets of the draft Strategic Plan, MoH informed the Bank team that in the final version of the new 11/21/2019 Page 4 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) MoH Strategic Plan (2019-2023) HLC numbers were revised again. The Bank team expects to receive a formal restructuring request to amend the cumulative targets of this indicator in line with the Strategic Plan targets. IN00765441 ►Number of individuals in 12 project provinces who visit Substance Use Treatment Centers to receive patient-specific counselling (new and returning visitors) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 90.00 8,117.00 9,738.00 13,887.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 In 2018, 11,122 people visited the treatment centers. In the first half of 2019, there were 9,738 visitors to the treatment centers. The Bank team expects that 2019 targets for this indicator will be met. The next Comments: reporting on this indicator will be in Spring 2020. IN00765442 ►Percent of target population screened for 3 types of cancer: (a) cervical (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 82.70 80.00 80.00 83.50 Date 31-Dec-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The cumulative target values for this indicator are not met. PHGD explains the reasons for underperformance as follows: Cervical cancer screenings are below the target value due to the existence of a resistant population against screenings (2%). Breast cancer screenings slowed down due to the delay in the central analysis of mammography imaging tender. The main reason for not meeting the targets for Comments: colorectal cancer is linked with the test kits getting wasted during fecal occult blood tests. MoH informed the Bank team that the cumulative targets for this indicator will be revised. The Bank team expects to receive a formal restructuring request to amend the cumulative targets. IN00765445 Percent of target population screened for 3 types of cancer: (b) breast (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 33.50 37.00 37.00 55.00 IN00765447 Percent of target population screened for 3 types of cancer: (c) colorectal (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 22.40 24.00 24.00 45.00 IN00765448 ►Number of PHC-level staff who have satisfactorily completed standardized face-to-face training modules required by the staff’s job profile (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1,000.00 1,000.00 4,331.00 5,000.00 Date 19-Oct-2018 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target for this indicator is surpassed. Actual number of trainings for 2018, and 2019 are 2,842, and Comments: 1,486 (first 9 months) respectively. The next reporting period on this indicator will be in January 2020 IN00765449 ►Direct project beneficiaries (number) (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target 11/21/2019 Page 5 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) Value 0.00 11,411,083.00 15,192,243.00 28,000,000.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 There were 15,192,243 direct Project beneficiaries between January and September 2019. The share of Comments: female beneficiaries is 81.7%. The Bank team expects that the target for 2019 will be met. IN00765450 Direct project beneficiaries of which female (percentage) (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 66.00 81.70 66.00 IN00765451 ►Health personnel receiving training (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 3,450.00 18,775.00 42,500.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 Target is surpassed. The next reporting period for this indicator is December 2020. Comments: IN00765452 ►Health facilities constructed, renovated, and/or equipped (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 83.00 98.00 285.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The Bank team does not expect the cumulative target for 2019 will be met. PMSU informed the Bank team Comments: that an amendment request will be sent to the Bank. IN00765453 ►Percent of users of Healthy Living Centers satisfied with ease of access to Healthy Living Centers and/or responsiveness of services to users’ individual needs (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 80.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The satisfaction survey will be conducted by the end of 2019. The Bank team will report the progress for Comments: this indicator in January 2020. Component 2: Increasing Efficiency of Hospital Management and Operations IN00765435 ►Number of simulation-based medical education centers established (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 1.00 2.00 Date 19-Oct-2018 28-Feb-2019 30-Sep-2019 30-Jun-2021 11/21/2019 Page 6 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) The MoH has started establishing simulation centers in Ankara, Izmir and Istanbul. The first simulation Comments: center is operational in Izmir as of October 2019. The next reporting on this indicator is in February 2020. IN00765438 ►Establishment of a PPP M&E system (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 28-Feb-2019 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target for this indicator is not met as the M&E system is not operational and able to provide Comments: comparative analysis to users due to delays in procurement. Component 3: Improving the Effectiveness of Overall Health Sector Administration IN00765431 ►National-level Health System Assessment conducted annually and published (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value Yes No No Yes Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The Bank team expects that the HSPA report will be published by December 27, 2019. In line with the agreement with HSGD officials to discontinue remaining activities linked with this indicator, the Bank team Comments: expects to receive a formal restructuring request to amend the target for 2021. IN00765433 ►Key information technology standards developed and integrated into updated draft regulations (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 12.00 20.00 20.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target has been met before the end of 2019. The technology standards on: Health Coding Reference Dictionary & HL7 Standards and National Health Data Dictionary have been developed. The next Comments: reporting period for this indicator is in January 2021, presenting actual values for 2020. IN00765436 ►Percent of health facilities that share data to HMS (a) public hospitals (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.50 80.00 91.00 100.00 Date 20-Apr-2015 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target has been surpassed before the end of 2019. The next reporting period for this indicator is Comments: January 2021, presenting actual values for 2020. IN00765437 Percent of health facilities that share data to HMS (b) family medicine centers (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 80.00 91.00 100.00 IN00765440 11/21/2019 Page 7 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) Percent of health facilities that share data to HMS (c) private hospitals (Percentage, Custom Supplement) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 50.00 54.00 60.00 IN00765443 ►Percent of health indicators within MoH databases meeting international standards (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 51.00 51.00 59.50 75.00 Date 19-Oct-2018 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target has been surpassed before the end of 2019. Several meetings have been conducted within a variety of divisions to emphasize international standard meanings and its involvement in electronic data Comments: systems. The next reporting period for this indicator is January 2021, presenting actual values for 2020. IN00765444 ►At least 12 Health Technology Assessments on prioritized topics prepared in line with new HTA strategy and published (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 6.00 5.00 12.00 Date 20-Apr-2015 19-Oct-2018 30-Sep-2019 30-Jun-2021 The target was partly met. New HTA strategy is in place, but the number of HTA reports are below the Comments: target. IN00765446 ►Process mapping of all MoH units (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Process mapping Value No process mapping No process mapping No process mapping completed Date 19-Oct-2018 28-Feb-2019 30-Sep-2019 30-Jun-2021 The target was met. Updating of process flow charts is completed in 11 MoH central units out of 12 (92%) Comments: and 47 provincial offices out of 81 (58%). Data on Financial Performance Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P152799 IBRD-85310 Effective USD 134.30 134.30 0.00 37.69 96.87 28% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date 11/21/2019 Page 8 of 9 The World Bank Implementation Status & Results Report Health System Strengthening and Support Project (P152799) P152799 IBRD-85310 Effective 21-Sep-2015 30-Sep-2015 26-Nov-2015 31-May-2020 30-Jun-2021 Cumulative Disbursements Restructuring History Level 2 Approved on 23-Apr-2019 Related Project(s) There are no related projects. 11/21/2019 Page 9 of 9