THE WORLD BANK IBRD IDA I WORLD1BANKGROUP ARUP BANERJI Country Director, Belarus, Moldova, Ukraine Europe and Central Asia December 22, 2021 H.E. Mr. Dumitru Budianschi MinisterMinistry of Finance 7 Constantin Tanase St. MD-2005 Chisinau Republic of Moldova MOLDOVA: Health Transformation Operation Program Credit No. 5469-MD and Project Credit No. 5470-MD Second Amendment of the Financing Agreement Excellency: We refer to the Financing Agreement entered into between the Republic of Moldova (the "Recipient") and the International Development Association (the "Association"), dated July 11, 2014 for the above-captioned Credit (the "Financing Agreement"), amended on November 27, 2018. Please note that capitalized terms used in this letter (the "Amendment Letter") and not defined herein have the meaning ascribed to them in the Financing Agreement. We are pleased to inform you that pursuant to your request to restructure this operation, and consequently amend the Financing Agreement, contained in letter No. 14/1-07/493 dated December 14, 2020, the Association hereby agrees to amend the Financing Agreement as follows: 1. The first paragraph of Schedule 1 to the Financing Agreement on the objective of the Operation, is hereby amended to read in its entirety as follows: "The objective of the Operations is to contribute to reducing key risks for non-communicable and infectious diseases, including COVID-19, and improving efficiency of health services in Moldova." 2. The Table under Section IV.A.2 of Schedule 2 to the Financing Agreement is hereby amended to read as follows: "Category for the Amount of the Program Program (including Disbursement Linked Result (as Financing Disbursement Linked applicable) Allocated Indicator as (expressed in SDR) applicable) (1) DLI #1: DLR#1.1: Starting in 2018, all imported DLR#1.1: 323,500 All imported and locally and locally produced cigarettes in the produced cigarettes in market are in line with the tobacco the market are in line labelling regulation with the tobacco labelling regulation 2 "Category for the Amount of the Program Program (including Disbursement Linked Result (as Financing Disbursement Linked applicable) Allocated Indicator as (expressed in SDR) applicable) (2) DLI #2: DLR#2. 1: Increase in the number of DLR#2.1: 1,294,000 Increase in the number people with CVDs benefitting from of people with CVDs compensated medications for treatment of benefitting from CVDs by 5 percent from the baseline DLR#2.2: 1,617,500 compensated medications for DLR#2.2: Increase in the number of DLI allocation is 29,115 for treatment of CVDs people with CVDs benefitting from every 0.1 percent increase from compensated medications for treatment of the baseline, up to a maximum CVDs by 10 percent from the baseline of 2,911,500. (3) DLI #3 DLR#3.1: 17 in Year I DLR#3.1: 582,000 Decrease in the number of annual acute care DLR#3.2: 16.5 in Year 2 DLR#3.2: 485,500 hospital admissions per 100 persons, from a DLR#3.3: 16 in Year 3 DLR#3.3: 485,500 baseline of 17.6 DLR#3.4: 15.6 in Year 4 DLR#3.4: 388,000 DLI allocation is 97,050 per a reduction of every 0.1 annual admission for acute care per 100 persons compared to the previous year, up to a maximum of 1,941,000. (4) DLI #4 DLR#4.1: 17,000 in Year 1 DLR#4.1: 689,000 Number of acute care hospital beds, from a DLR#4.2: 16,500 in Year 2 DLR#4.2: 588,000 baseline of 17,586 DLR#4.3: 16,000 in Year 3 DLR#4.3: 588,000 DLR#4.4: 15,000 in Year 4 DLR#4.4: 1,176,000 DLI allocation is 1,200 for every reduction of one acute hospital bed compared to the previous year, up to a maximum of 3,041,000. (5) DLI #5 DLR#5.1: Issuance of a joint order of the DLR#5.1: 1,294,000 Adoption of a revised MoH and the CNAM adopting a revised outpatient drug benefit drug benefit package in which the package for anti- average reimbursement rate for generic, hypertensive drugs first line medications in the three main categories of anti-hypertensive is at least 70% 3 "Category for the Amount of the Program Program (including Disbursement Linked Result (as Financing Disbursement Linked applicable) Allocated Indicator as (expressed in SDR) applicable) (6) DLI #6 DLR#6.1: Revision and adoption of the DLR#6.1: 323,500 Revision and revised Performance-Based Incentive implementation of the Scheme in primary care in a manner Performance-Based acceptable to the Association Incentive Scheme in primary care DLR#6.2: All primary care centers DLR#6.2: 323,500 contracted by the CNAM in the Recipient's territory have signed an agreement with the CNAM to implement the revised Performance-Based Incentive Scheme in Year 2 DLR#6.3: Revision of incentive scheme DLR#6.3: 323,500 and performance indicators for family medicine DLR#6.4: Implementation of the revised DLR#6.4: 323,500 contracts with providers of primary care (7) DLI #7 DLR#7.1: Design of incentive scheme for DLR#7.1: 323,500 Design and piloting of hospitals the Performance-Based Incentive Scheme for all DLR#7.2: Revision of the pay-for- DLR#7,2: 485,250 hospitals performance scheme DLR#7.3: Piloting of the revised DLR#7.3: 485,250 methodology in at least 7 hospitals (8) DLI #8 DLR#8.1: DRG prices account for at least DLR#8.1: 323,500 Implementation and 40% of total payment by the CNAM to update of DRG prices public acute care hospitals in Year 1 for public acute care hospital payments DLR#8.2: DRG prices account for at least 50% of total payment by the CNAM to DLR#8.2: 323,500 public acute care hospitals in Year 2 DLR#8.3: DRG process account for at least 60% of total payment by the CNAM to public acute care hospitals in Year 3 DLR# 8.3: 323,500 DLR#8.4: Preparation of updated DRG prices costing report using country data for hospitals payments in Year 4 DLR#8.4: 323,500 4 "Category for the Amount of the Program Program (including Disbursement Linked Result (as Financing Disbursement Linked applicable) Allocated Indicator as (expressed in SDR) applicable) (9) DLI #9 DLR#9. 1: Three public hospitals in DLR#9.1: 517,500 Consolidation of Chisinau are under common management departmental hospitals under the MoHLSP authority (10) DLI #10 DLR#10: Adoption of the revised DLR#10: 678,000 Adoption of the revised National Health System Development National Health System Strategy which shall include hospital Development Strategy, rationalization measures including hospital rationalization measures (11) DLI #11 DLR#1 1.1: Implementation of a survey to DLR#11.1: 1,099,000 Incorporate lessons assess people's knowledge, behaviors and learned in population- attitudes related to slowing the DLR#11.2: 1,099,000 based behavior change transmission of COVID-19, communication DLR#11.3: 1,099,000 campaigns and vaccine DLR#1 1.2: Implementation of a COVID- readiness assessment 19 Vaccine Readiness Assessment. DLR# 11.3: Revision of the National Communication Strategy for COVID-19, based upon the results of the survey and Vaccine Readiness Assessment, and has implemented six (6) activities of the revised National Communication Strategy for COVID-19. (12) Goods and consultant services under Section 1.6 of Not applicable 714,500 Schedule 1 to this (Financed at 100%) Agreement TOTAL AMOUNT W8600000 3. Item (c) under Section IV. B.1 of Schedule 2 to the Financing Agreement is hereby amended to read in its entirety as follows: "l. Notwithstanding the provisions of Part A of this Section, no withdrawal shall be made: (c) under Category (12) referred to in the table in Part A.2 of this Section, until and unless the Recipient has furnished evidence satisfactory to the Association that the Procurement Guidelines and procedures set forth in Section III of Schedule 3 to this Agreement have been complied with." 5 4. The Appendix to the Financing Agreement is hereby amended by removing the following terms and definitions: * "Adult Smoking Prevalence" means the percentage of people aged 15 and above who are current smokers as measured by the STEP methodology. * "Adults With Hypertension Under Control" means the percentage of people aged 18 and above identified as having blood pressure under control as measured by the STEP methodology. * "Baseline Tobacco" means the percentage of people aged 15 and above who are current smokers as measured by the 2013 Moldova STEP survey. * "Baseline Hypertension" means the percentage of hypertensive people aged 18 years old and above identified as having blood pressure under control as measured by the 2013 Moldova STEP survey. * "STEP" means Stepwise Approach to Surveillance of Non-communicable Diseases. 5. The Appendix to the Financing Agreement is amended by adding, and placing in alphabetical order the following terms and definitions (and, as a result, the remaining terms and definitions are renumbered to maintain alphabetical order): * "COVID-19" means the coronavirus disease caused by the 2019 novel coronavirus (SARS- CoV-2). * "COVID-19 Vaccine Readiness Assessment" means the framework developed by the World Bank to help countries assess readiness to deliver COVID-19 vaccines when they become available, identify gaps and prioritize opportunities for enhanced readiness. * "National Communication Strategy for COVID-19" means the national communication strategy for COVID -19 approved by the Recipient on April 6, 2020, pursuant to Ministerial Order No. 1141, dated December 4, 2020, which describes the activities performed to effectively coordinate communications and community engagement activities to prevent the spread of the COVID-19 disease. With reference to the provisions of Section II.A. of Schedule 3 and Section III.A. of Schedule 2 to the Financing Agreement, the indicators set out in the attachment to this letter shall serve as a basis for the Borrower to monitor and evaluate the progress of the Project and the achievement of the objectives thereof. The indicators set out in Annex 1 of this letter replace those established in Supplemental Letter No. 2, July 11, 2014. Please confirm your agreement with the foregoing amendment by signing and dating all the originals of this Amendment Letter in the spaces provided below and return one frilly signed original to us. This Amendment Letter shall become effective upon: (a) receipt by the Association of: (i) one countersigned original; and (ii) evidence that the execution and delivery of the Amendment Letter on behalf of the Recipient has been duly authorized by all necessary governmental action; and (b) dispatch by the Association to the Recipient of the notice of its acceptance of the evidence required herein. 6 Please note that it is the Association's policy to make publicly available this Amendment Letter and any information related thereto, after this Amendment Letter has become fully signed. The approved Restructuring Paper dated December 17, 2020 (Annex 2) will be disclosed on the Association's external website. Very truly yours, INTERNATIONAL DEVELOPMENT ASSOCIATION Country Director, Belar oldova, Ukraine Europe and Central Asia Region AGREED: REPUBLIC OF MOLDOVA By: Authorized Representative Name: Title: tks 2 c Date:.t A 25K ~ s62 Attachments: 1. Indicators 2. Restructuring Paper cc: H.E. 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