The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Health System Quality and Efficiency Improvement (P144871) EUROPE AND CENTRAL ASIA | Croatia | Health, Nutrition & Population Global Practice | Requesting Unit: ECCEU | Responsible Unit: GHN03 IBRD/IDA | Program-for-Results Financing | FY 2014 | Team Leader(s): Huihui Wang Seq No: 12 | ARCHIVED on 25-Jun-2019 | ISR36232 | Created by: Baktybek Zhumadil on 05-Mar-2019 | Modified by: Maya Razat on 19-Jun-2019 Program Development Objectives Program Development Objective (from Program Appraisal Document) The Program will contribute to (a) improving the health care delivery system in order to provide more equitable quality and sustainable health services to the population; (b) rationalizing the hospital network in order to streamline health care services to the population; (c) strengthening Government's capacity to develop and monitor effective health sector policies in the area of health financing, resource allocation, and provider payments; and (d) promoting effective public health interventions. Overall Ratings Name Previous Rating Current Rating Progress towards achievement of PDO Moderately Satisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Satisfactory Moderately Satisfactory Implementation Status and Key Decisions Some progress in Program activities supporting the government's health reform strategy has been noted by the Bank since its September 2018 visit. More specifically, as part of efforts to improve the quality of health care, the Ministry of Health has completed technical audits of 28 hospitals and published the results, including 40 percent of the best-performing hospitals, on its website on November 6, 2018. After a period of delay related to the incorporation of the former Agency for Quality and Accreditation in Health Care into the Ministry of Health, the activities to verify compliance of 33 acute care hospitals with mandatory quality standards and to adopt the ordinances approving hospital accreditation standards and procedures have been resumed, with plans to complete them during summer 2019. Similarly, there has been some encouraging progress in advancing centralized procurement with the aim to enhance efficiency in the health sector. Specifically, in addition to previously signed framework agreements, the Ministry of Health has finalized the centralized procurement process under 10 tenders and in December 2018 signed the respective framework agreements for 415 categories of drugs on the Croatian Institute for Health Insurance (HZZO) list of drugs that have generic parallels. Another tender for very expensive drugs (the so-called “special drugs”) is currently ongoing, with framework contracts expected to be signed by late June or mid-July 2019. The Ministry is also in the process of conducting a market survey, carrying out public consultations or completing the bidding documents for a few other procurement packages. There is a shared understanding between the Bank and the Ministry that further efforts should include standardizing and streamlining data collection, the work of the multi-member technical expert committees, and technical specifications, bidding and contractual documentation, as well as further enhancing the capacity of the Ministry's Public Procurement Unit. All these are especially important given the expanded role of the Ministry of Health as the central procurement body in the health sector, now responsible for centralized procurement of 25 procurement categories. Based on the Croatian National Reform Program 2017 and the National Plan for functional integration of the hospitals 2018-2020, functional integration needs to result in changes of service delivery, structure of beds and financial improvement of the covered hospitals. With this focus, the Bank and the Ministry are continuing a dialogue to finalize and operationalize meaningful reshaping schemes for two selected pairs of hospitals being functionally integrated. Given the importance of the health sector reform and the Ministry of Health commitment to a successful completion of the Program by October 31, 2019, the Bank and the Ministry will continue to closely monitor, on a monthly basis, the progress of the Program for Results and the sectoral reforms the Program supports. Data on Financial Performance 6/25/2019 Page 1 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Disbursements (by loan) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P144871 IBRD-83650 Effective USD 103.50 88.38 15.12 56.26 21.02 73% Key Dates (by loan) Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date P144871 IBRD-83650 Effective 08-May-2014 10-Jun-2014 08-Sep-2014 30-Jun-2018 31-Oct-2019 Program Action Plan Action Description Expansion of the centralized procurement system Source DLI# Responsibility Timing Timing Value Status Fiduciary Systems DLI 4 Ministry of Health Due Date 31-Oct-2019 In Progress 32.34% of total public spending on medical consumables, drugs, and devices for hospital services in the preceding Completion fiscal year to be made through centralized procurement/framework contracts and disclosed on the Ministry of Health Measurement website. Comments In progress; current value: 20.93%. Establishment of a quality control mechanism and define related quality and efficiency control protocol for technical Action Description audit of hospital Source DLI# Responsibility Timing Timing Value Status DLI 5 MoH, AQAHS, Technical Due Date 30-Sep-2014 Completed HZZO Completion Protocol and tools available for technical audit. Measurement Completed. The established quality control mechanism and defined protocol for technical audits have been applied Comments conducting technical audits in all 28 rationalized hospitals, which were completed on December 1, 2017. Action Description Establishment of a sentinel event surveillance system Source DLI# Responsibility Timing Timing Value Status DLI 10 MoH, AQAHS, Technical Due Date 31-Dec-2014 Completed HZZO Completion Surveillance system in place and first reporting available. Measurement Comments As of November 2018, quality and safety related surveillance system in place in 82% of hospitals with surgery wards. 6/25/2019 Page 2 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Internal financial audit units functioning in tertiary hospitals (increased in coverage by 20% each year over 5 years of Action Description the Program) Source DLI# Responsibility Timing Timing Value Status Ministry of Health, Fiduciary Systems Recurrent Yearly In Progress hospitals Completion Audit reports. Measurement On track. The health institutions are covered with internal audit function to a high extent (either having their own Comments internal audit department or benefitting from an internal audit department that is joint for a couple of healthcare institutions). Action Description Completion of the hospital rationalization plan Source DLI# Responsibility Timing Timing Value Status Technical DLI 2 Ministry of Health Due Date 28-Feb-2014 Completed Completion Final Report approved by MoH. Measurement The second new National Hospital Development Plan for the period 2018-2020 (based on the National Health Care Comments Strategy for 2012-2020), was formally adopted by the Government on September 20, 2018. Action Description Feasibility and pre-investment studies for “hospital reshaping schemes” Source DLI# Responsibility Timing Timing Value Status Technical DLI 2 Ministry of Health Due Date 31-Oct-2019 In Progress Completion Feasibility and pre-investments studies for two “hospital reshaping schemes” completed. Measurement In 2017, the MoH initiated the functional integration of six pairs of general and county general hospitals. The Comments information collected indicate some progress for the 2 most advanced. However, sustainability remains uncertain. Action Description Training in preparation of applications for EU funds, including Energy Efficiency proposals Source DLI# Responsibility Timing Timing Value Status Technical Ministry of Health Recurrent Continuous In Progress Completion Training report. Measurement Employees of the MoH and health institutions continuously attend training workshops on preparation of applications Comments for EU funds, including on energy efficiency, organized by the Croatian Ministry of Construction and Spatial Planning. 6/25/2019 Page 3 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Action Description Technical and project documentation and preparation of applications for EU funds Source DLI# Responsibility Timing Timing Value Status Technical Ministry of Health Recurrent Continuous In Progress Completion Sub-Project proposals. Measurement 118 proposals for EU structural funds developed by the MoH and health institutions have been accepted to date by Comments the relevant authority after being correctly prepared and submitted. HZZO Service for Control Directorate has: (a) conducted regular inspections of hospitals under the Program; and (b) Action Description conducted specialized reviews based on risk assessments or significant complaints regarding health services provided. Source DLI# Responsibility Timing Timing Value Status Technical HZZO Recurrent Continuous In Progress Completion Inspection and supervision reports. Measurement All the planned full controls of the operation and execution of contractual obligations in hospital health institutions, and Comments specialized controls in hospitals (25 and 162 in 2018, respectively) have been conducted regularly. Establishment and implementation of Program for improvement of Energy efficiency in the Healthcare sector and Action Description preparation of projects for EU funds absorption Source DLI# Responsibility Timing Timing Value Status Environmental and Social Ministry of Health Due Date 30-Jun-2015 Completed Systems Completion Program Report. Measurement The Program for Energy Reconstruction of Buildings in the Public Sector for the period 2016-2020 was adopted by Comments the Government of the Republic of Croatia on March 2, 2017. Progress to date continues to be positive. Action Description Establishment and implementation of the Program for education and training for radiological and radiotherapy safety Source DLI# Responsibility Timing Timing Value Status Environmental and Social Ministry of Health Due Date 30-Jun-2015 In Progress Systems Completion Program Report. Measurement Comments There is evidence of progress, but mostly outside of the Program's influence. 6/25/2019 Page 4 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Action Description Public disclosure of the best-performing hospitals based on technical audit in the preceding calendar year Source DLI# Responsibility Timing Timing Value Status DLI 5 Ministry of Health, Technical Recurrent Yearly Completed AQAHS Completion Disclosed reports. Measurement Results of the technical audits were presented on September 27, 2018 and best-performing hospitals (including their Comments results) were disclosed on the MoH website on November 6, 2018. Action Description Public awareness and communication campaign about the health sector reform Source DLI# Responsibility Timing Timing Value Status Technical Ministry of Health Due Date 31-Dec-2014 Completed Completion Communication campaign evaluation report. Measurement The initially planned communication campaign was implemented in November-December 2015. The MoH has Comments continued to use communications to successfully address concerns and create consensus on various reform initiatives. Action Description Rationalization of expenditures for pharmaceuticals Source DLI# Responsibility Timing Timing Value Status Technical HZZO Recurrent Yearly In Progress Completion Study report. Measurement In addition to feedback to physicians on their prescription practices, HZZO regularly carries out annual calculation of Comments prices of medicines and public tenders for determining the prices of medicines for the basic and supplementary list of medicines. Action Description Diagnosis-Related Group (DRG) system. Review of the costing of each group based on some pilot costing system. Source DLI# Responsibility Timing Timing Value Status Technical HZZO Due Date 30-Jun-2015 In Progress Completion Review report. Measurement 6/25/2019 Page 5 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) HZZO department for analytics and development of health services (DTP and DRG) continuously works on the Comments analysis and improvement of DRG and DTP prices. Current DRG and DTP prices are published in the Official Gazette. Action Description Hospital management training Source DLI# Responsibility Timing Timing Value Status Technical Ministry of Health Due Date 30-Jun-2015 In Progress Completion Training Report. Measurement MoH and hospitals’ managerial and other staff are regularly trained in different subject areas (from postgraduate Comments education in health management to trainings related to the absorption of EU funds, etc.). Implement mandatory environmental quality standards. Prepare environmental standards proposal (containing full Action Description sets of environmental indicators envisaged by the ESSA) through AQAHS to be subsequently included in a comprehensive accreditation system. Source DLI# Responsibility Timing Timing Value Status Environmental and Social DLI 6 MoH (reorganized Due Date 31-Oct-2019 In Progress Systems AQAHS) Completion Environmental standards. Report on implementation of mandatory environmental quality standards. Measurement Restructured and on track: hospitals’ compliance with environmental quality standards will be assessed along with Comments mandatory quality standards. The environmental standards proposal is integrated in the accreditation standards and procedure proposal. Conduct a self-assessment and external results verification of mandatory standards, propose / outline Action Description (recommendations for) monitoring system for the hospitals’ compliance with full accreditation (including comprehensive environmental indicators). Source DLI# Responsibility Timing Timing Value Status Environmental and Social DLI 6 MoH (reorganized Due Date 30-Jun-2015 In Progress Systems AQAHS) Completion Report on self-assessment and external results verification of mandatory standards. Recommendations for monitoring Measurement system for the hospitals’ compliance with full accreditation. Restructured and on track: hospitals’ external audits to be completed in July 2019, and expert panel conclusions by Comments September 2019. Monitoring system proposal integrated in accreditation standards & procedure proposal. Risks 6/25/2019 Page 6 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Systematic Operations Risk-rating Tool Risk Category Rating at Approval Previous Rating Current Rating Political and Governance -- Substantial Substantial Macroeconomic -- Substantial Substantial Sector Strategies and Policies -- Substantial Substantial Technical Design of Project or Program -- Moderate Moderate Institutional Capacity for Implementation and Sustainability -- Substantial Substantial Fiduciary -- Moderate Moderate Environment and Social -- Substantial Substantial Stakeholders -- Moderate Moderate Other -- -- Substantial Overall -- Substantial Substantial RiskComments Comments Out of the three DLIs remaining to be achieved (DLIs 2, 6, and 8), DLI 2 (hospital reshaping schemes) is at risk of non-achievement by the Program closing date. Results PDO Indicators by Objectives / Outcomes Improved quality of health care in Croatia IN00677390 ►Quality control procedures in place: Percentage of best-performing rationalized hospitals which are publicly disclosed (including results) based on the technical audit in the preceding 12 months (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 40.00 40.00 40.00 Date 31-Dec-2012 06-Nov-2018 30-Apr-2019 31-Oct-2019 Achieved. Percentage of best-performing rationalized hospitals (including results) was publicly disclosed on Comments MoH’s website on November 6, 2018. IN00677507 ►Quality control procedures in place: Percentage of acute hospitals meeting mandatory quality standards, as defined in the ordinance of Quality Standards and their Implementation from 2011. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 80.00 Date 30-Jun-2018 02-Nov-2018 30-Apr-2019 31-Oct-2019 On track. The first three (“pilot”) audits are scheduled for May 29th 2019 (CH Dubrava), June 04th (CHC Comments Zagreb) and June 06th (CH Merkur). It was agreed that the MoH team would try to complete all on-site assessments by the end of July 2019 to give the audit teams and hospitals time to implement remedial 6/25/2019 Page 7 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) activities in hospitals where the target (compliance with at least 80% of mandatory quality standards) may not be met. Improved efficiency of health services in Croatia IN00677506 ►First phase of the hospital master plan achieved: Total number of hospital beds in Rationalized Hospitals classified as acute care beds (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 15,930.00 12,161.00 12,161.00 12,800.00 Date 31-Dec-2012 30-Jun-2018 30-Apr-2019 31-Oct-2019 Achieved. Comments Intermediate Results Indicators by Results Areas Quality of health care IN00677508 ►5. Percentage of Primary Health Care group practices achieving performance indicators and accessing to payment incentives. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 99.17 99.24 60.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 Surpassed. The reported value is dated December 31, 2018. Comments IN00677510 ►8. Number of counties implementing specialized services on palliative care. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 1.00 17.00 19.00 15.00 Date 31-Dec-2012 02-Nov-2018 31-May-2019 31-Oct-2019 Surpassed. Data reported is dated January 31, 2019. 1. Varaždin County 2. Požega Slavonija County 3. Osijek-Baranja County 4. Međimurje County 5. Istria County 6. Karlovac County 7. Vukovar-Srijem County 8. Dubrovnik-Neretva County Comments 9. Zadar County 10. Šibenik-Knin County 11. City of Zagreb 12. Sisak-Moslavina County 13. Primorje-Gorski Kotar County 14. Krapina-Zagorje County 15. Virovitica-Podravina County 16. Brod-Posavina County 17. Zagreb County 18. Vukovar-Srijem County 6/25/2019 Page 8 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 19. Koprivnica-Križevci County IN00677512 ►10. Percentage of Nosocomial Infections Surveillance system in place in tertiary hospitals and secondary hospitals. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 100.00 100.00 30.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 Surpassed. Data for 2018. Comments IN00677514 ►11. Percentage of hospitals with surgery wards that have established quality-and safety-related sentinel surveillance schemes that are reporting the rates of specific events. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 82.00 82.00 60.00 Date 31-Dec-2012 02-Nov-2017 30-Apr-2018 31-Oct-2019 Surpassed. Data for 2017. Analysis for 2018 is ongoing and will be finalized by June 2019. Comments IN00677516 ►12. Percentage of patients’ satisfaction by a perception of increased responsiveness. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 38.00 38.60 38.60 75.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 This indicator is behind target values. Data for 2017. There was no survey in 2018; one is planned to be conducted in 2019, but the results are not Comments likely to be available before the Program closing date. IN00677518 ►13. Ordinance approving accreditation standards and procedure issued. (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No No No Yes Date 30-Jun-2018 02-Nov-2018 30-Apr-2019 31-Oct-2019 On track. Ordinance is expected to be signed by the end of June 2019 (within the prescribed 6 months from Comments the enactment of the Act on Health Care Quality as of January 1, 2019). Efficiency of health services IN00677509 ►1. Ratio between primary health care/secondary outpatient care/ and hospital inpatient care services (Text, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 58 / 18 / 1 84 / 20 / 1 84 / 20 / 1 90 / 19 / 1 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 6/25/2019 Page 9 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) On track. CHIF (HZZO) data as of June 30, 2018. Comments IN00677511 ►2. Number of “hospital reshaping scheme” projects implemented (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 0.00 0.00 2.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 Expected by October 31, 2019 but at risk of non-achievement. Comments IN00677513 ►3. Percentage of all surgeries included in the elective surgeries list performed as outpatient surgeries in the preceding six months. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 5.00 61.10 63.34 60.00 Date 31-Dec-2012 02-Nov-2017 30-Apr-2018 31-Oct-2019 Surpassed. Data updated as of June 30, 2018. Comments IN00677515 ►4. Percentage of primary care doctors working in group practices. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 69.06 69.80 50.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 Surpassed. Updated data dated December 31, 2018. Comments IN00677517 ►6. Percentage of identified doctors with whom a corrective course of action has been discussed on a person-to-person basis in preceding six months. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 20.00 93.10 93.10 90.00 Date 31-Dec-2012 02-Nov-2017 30-Apr-2018 31-Oct-2019 Achieved. Comments IN00677519 ►7. Percentage of total public spending per fiscal year on medical consumables, drugs, and devices for hospital (inpatient and outpatient) services made through centralized procurement/ framework cntrc (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 9.00 20.93 32.34 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 On track. Comments IN00677520 ►9. Number of proposals for EU structural funds accepted by the relevant authority after being correctly submitted. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target 6/25/2019 Page 10 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 118.00 118.00 8.00 Date 31-Dec-2012 02-Nov-2018 30-Apr-2019 31-Oct-2019 Surpassed. Comments Disbursement Linked Indicators DLI_IND_TABLE ►DLI 1 1. Total number of hospital beds in Rationalized Hospitals classified as Acute Care Beds. (Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 15,930.00 12,161.00 12,161.00 12,800.00 Date -- 02-Nov-2018 30-Apr-2019 -- Comments Final target achieved and full disbursement made. ►DLI 2 2. Number of “hospital reshaping scheme” projects implemented (Intermediate Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 0.00 0.00 2.00 Date -- 02-Nov-2018 31-May-2019 -- Progress in implementaion but still at risk of non-achievement by the closing date of October 31, 2019. Comments ►DLI 3 3. Percentage of rationalized hospitals without arrears incurred during preceding calendar year. (Outcome, 0.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 0.00 0.00 80.00 Date -- 02-Nov-2018 30-Apr-2019 -- This PDO-level DLI was dropped as part of the Restructuring completed in June 2018 and associated Loan Comments amount of EUR 7.5 million was cancelled. ►DLI 4 4. Percentage of all surgeries included in the elective surgeries list performed as outpatient surgeries in the preceding six months. (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 5.80 63.34 63.34 60.00 Date -- 02-Nov-2018 30-Apr-2019 -- Comments Final target achieved and full disbursement made. 6/25/2019 Page 11 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Further improvement recorded at 63.34% based on CHIF (HZZO) data as of June 30, 2018. ►DLI 5 5. Percentage of best-performing rationalized hospitals which are publicly disclosed (including results) based on the technical audit in the preceding 12 months. (Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 40.00 40.00 40.00 Date -- 06-Nov-2018 30-Apr-2019 -- This DLI has been achieved: 40 percent of top-ranking hospitals were determined based on technical audit results. The achievement notification letter was received from the MoH on October 18, 2018, and the results of Comments technical audits were disclosed on MoH website on November 6, 2018. The full disbursement of DLI allocation (EUR 7.5 million) was made on December 10, 2018. ►DLI 6 6. Foundations are in place for accelerated implementation of hospital accreditation (Outcome, 7,500,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value No No No Yes Date -- 02-Nov-2018 31-May-2019 -- Original DLI "Percentage of Rationalized Hospitals accredited by AQAHS through the Acceptable Accreditation Process" was revised with this one as part of Restructuring completed in June 2018. Comments This DLI (6.1: compliance with mandatory quality standards and 6.2: ordinance approving accreditation standards and procedure) is on track to achieve its end-targets before Program closing. DLI 6.1 6.1: Percentage of acute hospitals meeting mandatory quality standards, as defined in the Ordinance of Quality Standards and their Implementation from 2011, confirmed through prxy-accrdtion process. (Outcome, 3,750,000.00, 0%) Unit of Measure: Percentage Indicator Type: Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 0.00 0.00 80.00 Date -- 02-Nov-2018 31-May-2019 -- Comments DLI 6.2 6.2: Ordinance approving accreditation standards and procedure issued. (Outcome, 3,750,000.00, 0%) Unit of Measure: Yes/No Indicator Type: Baseline Actual (Previous) Actual (Current) Year 2019 Value No No No Yes Date -- 02-Nov-2018 31-May-2019 -- 6/25/2019 Page 12 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Comments ►DLI 7 7. Percentage of identified doctors with whom corrective course of action has been discussed on a person-to-person basis in the preceding six months. (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 20.00 93.10 93.10 -- Date -- 02-Nov-2018 30-Apr-2019 -- Comments Final target achieved and full disbursement made. ►DLI 8 8. Percentage of total public spending per fiscal year on medical consumables, drugs, and devices for hospital (in and outpatient) services made through centralized procurement and disclosed (Intermediate Outcome, 4,042,500.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 9.00 20.93 32.34 Date -- 02-Nov-2018 31-May-2019 -- On track. Opening of bids for the Special Drugs tender took place on May 27 and the bid evaluation is half- way done. The MoH is optimistic about this tender and plans to take the award decision and conclude Comments framework agreements quickly by the end of June or mid-July, at the latest. Through the completion of this tender, the MoH plans to achieve the target of 32.34% for DLI 8. ►DLI 9 9. Percentage of primary health care doctors in the Republic of Croatia working in group practices (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 69.06 69.80 -- Date -- 02-Nov-2018 30-Apr-2019 -- Final target achieved and full disbursement made. Comments Surpassed. Updated data dated December 31, 2018. ►DLI 10 10. Percentage of hospitals with surgery wards that have established quality- and safety-related sentinel surveillance schemes that are reporting the rates of specific events (Intermediate Outcome, 7,500,000.00, 100%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 82.00 82.00 -- Date -- 02-Nov-2018 30-Apr-2019 -- Final target achieved and full disbursement made. Comments 6/25/2019 Page 13 of 13