2014年-世界发展银行全球_Croatia_Health_System_Quality_and_Efficiency_Improvement___Fiduciary_System_Assessment_57页_1mb

Summary of the Fiduciary System Assessment for the Health System Quality and Efficiency Improvement Program for Results (P144871)

A. Core Content Overview

This document presents the Fiduciary System Assessment (FSA) for the Health System Quality and Efficiency Improvement Program for Results (P144871) in Croatia. The assessment was conducted in accordance with OP/BP 9.0 and aimed to evaluate the fiduciary systems related to the Program, including procurement, financial management, and governance. It also outlines key fiduciary risks, mitigation actions, and performance indicators to monitor and improve the Program's implementation.

B. Main Program Activities and Objectives

Program Development Objective (PDO)

• Improve the quality of health care and efficiency of health services in Croatia.

Program Activities

The Program focuses on five out of eight strategic priorities identified in the National Health Care Strategy 2012–2020:

1. Strengthening management capacity in health care

   • Includes hospital reforms, governance changes, and strategic planning.

2. Reorganizing the structure and activities of health care institutions

   • Focuses on rationalizing the hospital network, promoting group practices for GPs, and improving continuity of care.

3. Fostering quality in health care

   • Involves hospital accreditation, HTA implementation, clinical guidelines, and quality control mechanisms.

4. Strengthening preventive activities

   • Aims to improve the management and funding of preventive care and early warning systems.

5. Preserving financial stability of health care

   • Includes central procurement, performance-based payments, and reducing corruption.

C. Key Fiduciary Performance Indicators (DLIs)

The following Disbursement-Linked Indicators (DLIs) are used to monitor and evaluate the Program's implementation:

1. DLI 1: Reduction of acute care beds from 15,930 to 12,800 through conversion to social, long-term, or palliative care beds.
2. DLI 2: Implementation of at least two substantial subprojects under the hospital reshaping scheme.
3. DLI 3: Percentage of hospitals financially consolidated (zero debt) within the redefined institutional architecture.
4. DLI 4: Percentage of surgeries in predefined lists performed as ambulatory surgeries in the last six months.
5. DLI 5: Percentage of rationalized hospitals publicly disclosed as best-performing based on KPIs and quality indicators.
6. DLI 6: Percentage of HZZO-contracted hospitals accredited through an independent process.
7. DLI 7: Percentage of doctors with non-satisfactory prescription patterns and corrective discussions.
8. DLI 8: Percentage of public spending on medical consumables, drugs, and devices through centralized procurement, disclosed in a simplified format on the Ministry of Health website.
9. DLI 9: Percentage of general practitioners working in group practices.
10. DLI 10: Percentage of hospitals with surgery wards implementing sentinel surveillance schemes for specific quality events.

D. Institutional Framework and Legal Basis

Legal and Regulatory Environment

• Croatia became an EU member on July 1, 2013, aligning its public procurement system with the acquis communautaire, particularly Chapter 32.
• The Croatian Public Procurement Act (PPA), effective January 1, 2012, is the main legal instrument governing public procurement and is aligned with several EU Directives, including:
  • Directive 2004/17/EC
  • Directive 2004/18/EC
  • Directive 2005/75/EC
  • Directive 2007/66/EC
  • Directive 2009/81/EC

Key Institutions and Bodies

• Ministry of Economy: Oversees the development and coordination of the public procurement system.
• Central Procurement Office: Conducts central procurement for 17 categories and acts as a contracting authority.
• Ministry of Finance: Responsible for concessions contracts and operations.
• Public Private Partnership Agency: Handles public-private partnership contracts.
• State Commission for the Supervision of Public Procurement Procedures: Reviews appeals and oversees procurement procedures.
• Ministry of Health (MOH): Primary beneficiary and responsible for managing all hospitals (except one) and supervising HZZO activities.
• Croatian Health Insurance Institute (HZZO): Main stakeholder in implementing reforms, acting as a single payer and managing contracting and quality control.
• Agency for Quality and Accreditation in Health Care and Social Welfare (AQAHS): Supports HZZO in ensuring quality of contracted providers and implementing accreditation.

E. Financial Management and Procurement Systems

• The Program’s financial management and procurement systems are considered adequate and efficient, providing reasonable assurance on the proper use of funds and safeguarding of assets.
• Procurement is conducted under the Croatian PPA, with officials having formal certification.
• DLI 8 is a key indicator to ensure transparency and cost savings from centralized procurement.

F. Program Implementation and Monitoring

• The Program Implementation Period is from 2013 to 2017.
• The Program Results Framework includes:
  • Three PDO-level Results Indicators
  • Ten DLI-level Intermediate Results Indicators, grouped into three subsets corresponding to the three main implementation areas:
    • Rationalization of the health facility network
    • Quality improvement in health care services
    • Financial sustainability of the health sector
• The HZZO collects and verifies most of the data for the Intermediate Results Indicators (7 out of 10), with reporting to the MOH on a semiannual or annual basis.
• Hospitals report financial plans and performance data directly to the HZZO.
• Technical Assistance is provided through the DEMSIPP project and a $10 million allocation to the MOH budget for strengthening health sector regulations and planning.

G. Governance and Anti-Corruption

• Governance and anti-corruption issues are addressed across all national systems and institutions.
• The State Commission for the Supervision of Public Procurement Procedures plays a central role in reviewing procurement procedures and appeals.
• The Program's governance framework is considered adequate, with institutions in place to ensure transparency, accountability, and compliance with EU standards.

H. Key Findings

• The fiduciary and governance framework is adequate to support the Program.
• The financial management systems are satisfactory and provide reasonable assurance.
• The procurement system is well-structured and aligned with EU requirements.
• The Program’s implementation is supported by technical assistance activities, including the DEMSIPP project and $10 million funding.
• DLIs are designed to be achievable and challenging, ensuring both ambition and feasibility in monitoring Program performance.