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: 11 | DRAFT | ISR33476 | Created by: Maya Razat on 09-Jul-2018 | Modified by: Huihui Wang on 20-Nov-2018 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 Unsatisfactory Moderately Satisfactory Overall Implementation Progress (IP) Moderately Unsatisfactory Moderately Satisfactory Implementation Status and Key Decisions Following the government’s request for a Program restructuring dated March 19, 2018, the restructuring was finalized in June 2018 and included the following: (i) extension of the Loan Closing Date by 16 months from June 30, 2018 to October 31, 2019 to ensure sufficient time for the remaining disbursement linked indicators to be met and the Program development objectives to be achieved; (ii) cancellation of one disbursement linked indicator and associated Loan allocation; (iii) adjusting one disbursement linked indicator on centralized procurement and its Loan allocation; (iv) modification of one disbursement linked indicator on hospital accreditation; and (v) various adjustments to the Program monitoring indicators and Program action plans. The following positive progress has been noted since the restructuring: Technical audits were carried out by the Agency for Quality and Accreditation in Health Care (AQAHS) in all 28 acute care hospitals. Scoring principles were developed and applied to the technical audit data to create disease specific composite scores using quality care indicators. The hospitals were ranked overall and in three disease-specific areas based on composite score values. The AQAHS presented the scoring methodology and hospital ranking results on September 27, 2018 during the workshop organized by the Ministry of Health. The ranking methodology and the best-performing hospitals were publicly disclosed on the Ministry of Health website on November 6, 2018. Activities related to the assessment of hospitals' compliance with mandatory quality standards also being implemented on schedule, with all hospitals' staff trained on self-assessment methodology in early October and the self-assessment exercise planned to be completed by end-November. An external assessment will be carried out in early 2019 after the necessary analyses and preparation are concluded. In addition, efforts to rationalize the hospital network are ongoing, with the formal adoption of the new National Hospital Development Plan and functional integration being piloted in six pairs of hospitals. Policy environment for health care quality improvement is being strengthened through the forthcoming adoption of the Act on Health Care Quality and the Ordinance approving hospital accreditation standards and procedure. Centralized procurement of drugs is also being enhanced with the Ministry of Health's centralized procurement function for healthcare institutions whose founder is the Republic of Croatia extended to cover 10 new procurement categories, with the Ministry becoming the central procurement body for 25 procurement categories. Given the importance of the health sector reform and the Ministry of Health commitment to a successful completion of the Program, the Bank and Ministry agreed to closely monitor, on a quarterly basis, the progress of the Program for Results and the sectoral reforms the Program supports. Data on Financial Performance Disbursements (by loan) 11/23/2018 Page 1 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed P144871 IBRD-83650 Effective USD 103.50 88.38 15.12 47.71 31.37 60% 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 Responsibility Recurrent Frequency Due Date DLI# Status No 4. Percentage of all surgeries included in the elective surgeries Ministry of Health 31-Oct-2014 list performed as In Progress outpatient surgeries in the preceding six months. In progress; the MoH's centralized procurement function was extended in September 2018 to 10 new procurement Comments categories, with the MoH becoming the central procurement body for 25 procurement categories. Establishment of a quality control mechanism and define related quality and efficiency control protocol for technical Action Description audit of hospital Responsibility Recurrent Frequency Due Date DLI# Status No 5. Percentage of best- performing rationalized hospitals which are publicly MoH, AQAHS, HZZO 30-Sep-2014 Completed disclosed (including results) based on the technical audit in the preceding 12 months. 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 Responsibility Recurrent Frequency Due Date DLI# Status No 10. Percentage of MoH, AQAHS, HZZO 31-Dec-2014 hospitals with surgery Completed wards that have 11/23/2018 Page 2 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) established quality- and safety-related sentinel surveillance schemes that are reporting the rates of specific events Comments As of November 2018, quality and safety related surveillance system in place in 82% of hospitals with surgery wards. Internal financial audit units functioning in tertiary hospitals (increased in coverage by 20% each year over 5 years of Action Description the Program) Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health, Yes Yearly In Progress hospitals 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 Responsibility Recurrent Frequency Due Date DLI# Status No 2. Number of “hospital Ministry of Health 28-Feb-2014 reshaping scheme” Completed projects implemented The second new National Hospital Development Plan (NHDP) for the period 2018-2020 (based on the National Health Comments Care 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” Responsibility Recurrent Frequency Due Date DLI# Status No 2. Number of “hospital Ministry of Health 31-Oct-2019 reshaping scheme” In Progress projects implemented In 2017, the MoH initiated the functional integration of six pairs of general and county general hospitals. An EU- Comments consultant will assess the functionality of hospitals that have been integrated; reports expected by December 2018. Action Description Training in preparation of applications for EU funds, including Energy Efficiency proposals Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health Yes CONTINUOUS In Progress Employees of the MoH and health institutions continuously attend training workshops on preparation of applications for Comments EU funds, including on energy efficiency, organized by the Croatian Ministry of Construction and Spatial Planning. 11/23/2018 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 Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health Yes CONTINUOUS In Progress 118 proposals for EU structural funds developed by the MoH and health institutions have been accepted to date by the Comments 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. Responsibility Recurrent Frequency Due Date DLI# Status HZZO Yes CONTINUOUS In Progress 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 Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 Completed The Program for Energy Reconstruction of Buildings in the Public Sector for the period 2016-2020 was adopted by the Comments 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 Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 In Progress Comments There is evidence of progress, but mostly outside of the Program's influence. Action Description Public disclosure of the best-performing hospitals based on technical audit in the preceding calendar year Responsibility Recurrent Frequency Due Date DLI# Status Yes 5. Percentage of best- performing rationalized hospitals which are publicly Ministry of Health, AQAHS Yearly Completed disclosed (including results) based on the technical audit in the preceding 12 months. 11/23/2018 Page 4 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) 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 Responsibility Recurrent Frequency Due Date DLI# Status Minisry of Health No 31-Dec-2014 Completed 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 Responsibility Recurrent Frequency Due Date DLI# Status HZZO Yes YEARLY In Progress 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. Responsibility Recurrent Frequency Due Date DLI# Status HZZO No 30-Jun-2015 In Progress 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 Responsibility Recurrent Frequency Due Date DLI# Status Ministry of Health No 30-Jun-2015 In Progress 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 sets Action Description of environmental indicators envisaged by the ESSA) through AQAHS to be subsequently included in a comprehensive accreditation system. Responsibility Recurrent Frequency Due Date DLI# Status AQAHS No 31-Mar-2015 6. Foundations are in In Progress place for accelerated 11/23/2018 Page 5 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) implementation of hospital accreditation 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). Responsibility Recurrent Frequency Due Date DLI# Status No 6. Foundations are in place for accelerated AQAHS 30-Jun-2015 In Progress implementation of hospital accreditation Restructured and on track: hospitals’ self-assessment to be completed in November 2018, external audit in April 2019, Comments and expert panel conclusions in May 2019. Monitoring system proposal integrated in accreditation standards & procedure proposal. Risks 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 -- -- -- Overall -- Substantial Substantial Results PDO Indicators by Objectives / Outcomes 11/23/2018 Page 6 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Improved quality of health care in Croatia IN00622214 ►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 0.00 40.00 40.00 Date 31-Dec-2012 28-Feb-2018 06-Nov-2018 31-Oct-2019 Disclosed on September 27, 2018 to hospitals through a workshop including MoH, quality agency and Comments hospital representatives. Publicly disclosed on MoH’s website on November 6, 2018. IN00622246 ►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 30-Jun-2018 02-Nov-2018 31-Oct-2019 On track. Comments Improved efficiency of health services in Croatia IN00622215 ►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 28-Feb-2018 30-Jun-2018 31-Oct-2019 Achieved. Comments Intermediate Results Indicators by Results Areas Quality of health care IN00626245 ►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 60.00 Date 31-Dec-2012 -- 02-Nov-2018 31-Oct-2019 Comments IN00622254 ►8. Number of counties implementing specialized services on palliative care. (Number, Custom) Baseline Actual (Previous) Actual (Current) End Target 11/23/2018 Page 7 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 1.00 12.00 17.00 15.00 Date 31-Dec-2012 28-Feb-2018 02-Nov-2018 31-Oct-2019 Comments IN00622256 ►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 28-Feb-2018 02-Nov-2018 31-Oct-2019 Comments IN00622258 ►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 64.70 82.00 60.00 Date 31-Dec-2012 07-Jun-2017 02-Nov-2017 31-Oct-2019 Comments IN00622260 ►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 28-Feb-2018 02-Nov-2018 31-Oct-2019 Comments IN00628380 ►13. Ordinance approving accreditation standards and procedure issued. (Yes/No, Custom) Baseline Actual (Previous) Actual (Current) End Target Value No -- No Yes Date 30-Jun-2018 -- 02-Nov-2018 31-Oct-2019 On track. Expected in March 2019. Comments Efficiency of health services IN00622249 ►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 78 / 20 / 1 84 / 20 / 1 90 / 19 / 1 11/23/2018 Page 8 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Date 31-Dec-2012 28-Feb-2018 02-Nov-2018 31-Oct-2019 On track. CHIF (HZZO) data as of June 30, 2018. Comments IN00622251 ►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 28-Feb-2018 02-Nov-2018 31-Oct-2019 Expected by October 31, 2019. Comments IN00622253 ►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 61.10 60.00 Date 31-Dec-2012 03-Mar-2017 02-Nov-2017 31-Oct-2019 Comments IN00626630 ►4. Percentage of primary care doctors working in group practices. (Percentage, Custom) Baseline Actual (Previous) Actual (Current) End Target Value 0.00 -- 69.06 50.00 Date 31-Dec-2012 -- 02-Nov-2018 31-Oct-2019 Comments IN00622257 ►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 08-Sep-2016 02-Nov-2017 31-Oct-2019 Comments IN00622259 ►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 8.00 9.00 32.34 Date 31-Dec-2012 28-Feb-2018 02-Nov-2018 31-Oct-2019 Comments IN00622261 11/23/2018 Page 9 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) ►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 Value 0.00 62.00 118.00 8.00 Date 31-Dec-2012 28-Feb-2018 02-Nov-2018 31-Oct-2019 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 -- 28-Feb-2018 02-Nov-2018 -- 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 -- 28-Feb-2018 02-Nov-2018 -- Not achieved yet. Functional integration is being piloted in six pairs of hospitals. The work of external consultants hired by the MoH with funding from the European Commission to assess the functionality of these pilots is underway since May 2018. Reports with findings and recommendations from the consultants on the first two pairs of hospitals are expected in November 2018, and in December 2018 for the remaining four pairs Comments of hospitals. Despite great efforts made, the level of integration of services between the visited pairs of hospitals is currently modest. Implementation of hospital functional integration measures will need to be further strengthened, including by organizing an international workshop to share with the MoH global experiences on functional integration. ►DLI 3 3. Percentage of rationalized hospitals without arrears incurred during preceding calendar year. (Outcome, 3,750,000.00, 0%) Baseline Actual (Previous) Actual (Current) Year 2019 Value 0.00 -- 0.00 80.00 Date -- -- 02-Nov-2018 -- 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. 11/23/2018 Page 10 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) ►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 61.10 63.34 60.00 Date -- 28-Feb-2018 02-Nov-2018 -- Final target achieved and full disbursement made. Comments 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 0.00 40.00 40.00 Date -- 28-Feb-2018 06-Nov-2018 -- 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. ►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 Yes Date -- 28-Feb-2018 02-Nov-2018 -- Original DLI "Percentage of Rationalized Hospitals accredited by AQAHS through the Acceptable Comments Accreditation Process" was revised with this one as part of Restructuring completed in June 2018. 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 80.00 Date -- -- 02-Nov-2018 -- 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: 11/23/2018 Page 11 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Baseline Actual (Previous) Actual (Current) Year 2019 Value No -- No Yes Date -- -- 02-Nov-2018 -- 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 -- 28-Feb-2018 02-Nov-2018 -- 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 8.00 9.00 32.34 Date -- 28-Feb-2018 02-Nov-2018 -- Not achieved yet. As of June 30, 2018, about 120 framework agreements were signed representing HRK 157.3 million to have been contracted, which represents less than 10 percent of total spending. To meet the target of 32.34%, approximately an additional HRK 700 million would need to be contracted through centralized/joint procurement. The MoH is going to put further efforts in standardizing the process, technical Comments specifications and relevant procurement and contract documents. The MoH also informed the Bank team that the centralized procurement process is affected by changes in the drug reference pricing policies, which requires further clarification and discussion. ►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 69.06 -- Date -- 28-Feb-2018 02-Nov-2018 -- Comments Final target achieved and full disbursement made. ►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 11/23/2018 Page 12 of 13 The World Bank Implementation Status & Results Report Health System Quality and Efficiency Improvement (P144871) Value 0.00 64.70 82.00 -- Date -- 28-Feb-2018 02-Nov-2018 -- Final target achieved and full disbursement made. Comments 11/23/2018 Page 13 of 13