Document of The World Bank Report No: 19154 PROJECT APPRAISAL DOCUMENT ON A PROPOSED LOAN IN THE AMOUNT OF US$52.5 MILLION TO THE ARGENTINE REPUBLIC FOR A PUBLIC HEALTH SURVEILLANCE AND DISEASE CONTROL PROJECT September 24, 1999 Human and Social Development Group Country Management Unit for Argentina, Chile and Uruguay Latin America and the Caribbean Regional Office Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
Transcript
Document ofThe World Bank
Report No: 19154
PROJECT APPRAISAL DOCUMENT
ON A
PROPOSED LOAN
IN THE AMOUNT OF US$52.5 MILLION
TO THE
ARGENTINE REPUBLIC
FOR
A PUBLIC HEALTH SURVEILLANCE AND DISEASE CONTROL PROJECT
September 24, 1999
Human and Social Development GroupCountry Management Unit for Argentina, Chile and UruguayLatin America and the Caribbean Regional Office
Currency Unit = Argentine Peso (A1R)ARS 100 <JSSI00
FISCA -' EARJanuary I tbhoug'h Derember 31
ABBREVLA ION.S AND ACRONYMSANLIS National Refrrence Laboratory (Administraci6n Nacional de
Laboratorios . s -de Salud)CAS Couintry Assistanee SirategyCDC Carters for Dltsse tontrolDALYs Disability.-Adiurst'd ' AYearsERR Economic Rate of Return
FONCODES (Peru) Sociat. D iveloprent and Compensation Fund ProjectGDP Gross Domestic PnonutGNP Gross Natiorli Piodtu'vtHIV/AIDS Human Imrnmn-Defilrciency Virus/Acquired Immune Deficiency
SyndromreHP Health PrornotionIBRD international Bank for Reconstruction and DevelopmentICR Imolementation Completion ReportIDB Inter-American Development BankLAC Latin America and the CaribbeanLACI Loan Administration Change initiativeLCSHD Latin America and thke Caribbean Social and Human DevelopmentLIL Learning anid I innovation LoanLUSIDA (Argentina) AIDS and STD Control ProjectM&E Monitoring and EvalaationMIS Managemtent Information SystemMoH Ministry of Health (Provincial)MSAS Ministry of Health. and Social Action (National)NCD Non-Communicable DiseasesNGO Non-Govermnenrtal OrganizationNI Nosocomial InfectionsNPV Net Present ValuAeOECD Organizatiorn for Lconomiic Cooperation and DevelopmentOM Oper-ational ManualPAHO Pan-Americani Health OrganizationPCMAM (Brazil) Amnazoli Basin Malaria Control ProjectPCDEN (Brazil) Endemic Disease Control ProjectPCU Project Coordination UnitPHSS Public Health Sav-tellance SystemPIP Project Implementation PlanPMRs Project Manaagement ReportsPRESSAL (Argerltina) Provi cial Health Sector Reform ProjectPROMIN (Argentina) Mateinal and Child Health & Nutrition ProjectSA Special AccrntSTD Sexually Trans.unitted DiseaseTA Technical AssistanceUNDP United Nations Developmert ProgramVIGI-A (Argentina) Pmobnlo Health Surveillance and Disease Control ProjectVIGISUS (Brazil) Disease Surveillance and Control ProjectWHO World Health Organization
Vice President David de FerrantiCountry Directo:f ¼vi-ma AlexanderSector Director XaLver CollTaski Teamr Leader A-nabela Abreu
ArgentinaDisease Surveillance and Control Project (VIGI-A)
CONTENTS
A Project Development Objective ............................................................. 2
B Strategic Context ............................................................. 2
1. Sector-related Country Assistance Strategy (CAS) goal supported by the project .22. Main sector issues and Government strategy .33. Sector issues to be addressed by the project and strategic choices .4
C Project Description Summary ....................... 6
1. Project components .62. Key policy and institutional reforms supported by the project .83. Benefits and target population .84. Institutional and implementation arrangements .8
D Project Rationale .11
1. Project alternatives considered and reasons for rejection .112. Major related projects financed by the Bank and/or other development agencies . 123. Lessons leamed and reflected in the project design .134. Indications of borrower commitment and ownership .145. Value added of Bank support in this project .14
Table A. Project Costs by Procurement ArrangementsTable Al. Consultant Selection ArrangementsTable B. Thresholds for Procurement Methods and Prior ReviewTable C. Allocation of Loan Proceeds
Annex 7. Project Processing Budget and ScheduleAnnex 8. Documents in Project FileAnnex 9. Statement of Loans and CreditsAnnex 10. Country at a GlanceAnnex 11 Public Health Surveillance in ArgentinaAnnex 12 Assessment of Laboratory InfrastructureAnnex 13 Data Telecommunications PlanAnnex 14 Training Program Summary
Map (IBRD No. 29348)
ArgentinaDisease Surveillance and Control Project (VIGI-A)
Project Appraisal Document
Region of Latin America and the CaribbeanArgentina, Chile and Uruguay Country Management Unit
Date: September 24, 1999 Team Leader: Anabela AbreuCountry Director: Myrna Alexander Sector Director: Xavier CollProject ID: AR-PE 55482 Sector: HNPLending Instrument: Standard Investment Loan (SIL) Theme(s):
Poverty Targeted Intervention: [X] Yes [1 No
Project Financing Data[X] Loan [ ] Credit [] Grant [] Guarantee [] Other [Specify]
For Loans/Credits/Others:Amount (US$m): US$52.5Proposed terms: [ ] To be defined [ ] Multicurrency [X] Single currency
] Standard Variable [ ] Fixed [X] LIBOR-basedGrace period (years): 5Years to maturity: 15Commitment fee: 0.75%Service charge: -%Front-end fee on Bank loan: 1.0%
Government 21.25 1.25 22.5IBRD 48.75 3.75 52.5
Total: 70.0 5.0 75.0Borrower: Argentine RepublicGuarantor: N/AResponsible agency: Ministry of Health and Social ActionEstimated disbursements (Bank FY/US$M):
Project implementation period: 1999-2003Expected effectiveness date: January 31, 1999 Expected closing date: April 30, 2004Implementing agency: Ministry of Health and Social Action (MSAS)
Contact person: Dr. Horacio LopezAddress: Avenida de Mayo 953, 3er piso, Bueno.s Aires, Argentina 10804
Tel: 54-1-14-345-3612/3641 Fax: same as phone E-mail: vigiapsatlink.com.ar
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A: Project Development Objective
1. Project development objective: (see Annex 1)
The objective of the project is to strengthen national, provincial, municipal and local institutionsresponsible for public health policy and practice. The ultimate goal is to reduce the disease burden,especially among the poor who suffer from a high incidence of preventable disease. It will focus on threeareas: public health surveillance', disease prevention and control, and health promotion. First, bystrengthening disease surveillance, the project will improve the capacity of the Ministry of Health andSocial Action (MSAS) to make informed decisions about prevention and control priorities and to monitorthe impact of interventions. Second, the project will strengthen provincial capacity to carry out diseasemonitoring, control and prevention for several diseases that pose a serious public health threat includingtuberculosis, dengue and hospital infections. Third, the project will help to develop a health promotionprogram focusing on education, social mobilization, and advocacy.
2. Key performance indicators: (see Annex 1)
Key performance indicators toward program objectives will be measured through a monitoring andevaluation system. Performance of the project will be deternined by selected monitoring indicators suchas: (i) tuberculosis incidence decreased 15%; (ii) hospital-acquired infections in target hospitalsassociated with catheter, urinary tract, and ventilator reduced by 20%, 10% and 10% respectively; (iii)90% of all cases of invasive meningococcal disease detected have been investigated and appropriatecontrol measures instituted; (iv) at least 200 influenza viruses per year obtained from throat swabs takenfrom patients at influenza sentinel sites; (v) regular issuance of public health bulletins; (vi) at least 6candidates trained on outbreak investigation (advanced level); (vii) at least 120 candidates trained on datafor decision making; and (viii) at least 30 candidates trained on laboratory safety. The complete set ofmonitoring indicators for the project is presented in Annex 1.
B: Strategic Context
1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1)
Document number: 16505-AR - Date of latest CASprogress discussion: November 10, 1998(CAS Progress Report No. R-98-266; IFC/R-98-233)
The project is consistent with the CAS objectives to strengthen the institutional basis for investing inhuman capital to improve social welfare and the productivity of the work force. First, the public healthservices in Argentina will be strengthened through improved disease surveillance, providing the necessaryepidemiological foundation for rational allocation and mobilization of resources, priority-setting, andpolicy development. Second, the health services will be strengthened through support for improvedmanagement, laboratory services, improved control of hospital infections, and training of physicians andnurses in prevention and treatment of selected diseases. Third, by strengthening public health and healthpromotion, the project will help to reduce morbidity and mortality and associated costs. Because theproject targets diseases that disproportionately affect the poor, it will also contribute to poverty alleviationand enhance social development objectives.
Surveillance is the ongoing systematic collection, collation, analysis, and interpretation of health data, closely integrated withthe timely dissemination of these data, to those who need to know in order that action may be taken. The tasks of public healthsurveillance include detecting new health problems, detecting epidemics, documenting the spread of disease, providingquantitative estimates of the magnitude of morbidity and mortality, identif,uing potential factors involved in the diseaseoccurrence, facilitating epidemiological and laboratory research, and assessing control and prevention activities. Summarizing,surveillance is a key tool for epidemic response, control activities, health policy and resource allocation.
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2. Main sector issues and Government strategy:
Background. Total health care spending in Argentina has long been one of the highest in Latin America,about eight percent of GDP. The overall health indicators of Argentina are good when compared withthose of other countries in the region, and have improved markedly over the past ten years. In 1995, lifeexpectancy stood at 73 years, 12 more than 1960, and in 1997 the crude death rate stood at 7.6 per 1,000.In 1997, infant mortality stood at 18.8 per 1000 births, and the maternal mortality ratio at 3.8 per 10,000births, down by 26 and 27 percent from 1990, respectively. These favorable trends suggest that thepresent maternal and child health strategy and programs should be pursued further. The relatively goodnational health indicators hide significant variations between the provinces and the different incomegroups. The poor have much worse health status than the rich, and have a different pattern of death,disease and disability. Thus, despite the recent advances, Argentina's performance, in terms of healthindicators and public satisfaction with quality of health care, still can be improved.
The roots of this discrepancy lie in the fact that Argentina is a federal state, with significant differencesamong the provinces in terms of efficiency in health care finance and delivery. To address this problem,the Government of Argentina (GoA) began to implement, in the early 90's, a series of sweeping andpromising reforms, which address some of the key issues in the sector. Specifically, the major healthsector issues have been:
* Health Status. The decrease of the infant and maternal mortality rates allowed Argentina to meet thetargets agreed between UNICEF and its member countries in 1991. The country needs to furtherstrengthen its prevention and control programs with respect to some preventable diseases includingtuberculosis, dengue and hospital infections. At the same time, Argentina has emerging healthproblems which include cardiovascular disease, cancers, and injuries which need to be addressed in amore systematic fashion.
* Surveillance Capacity. Significant effort has been made in recent years to strengthen the nationalsurveillance system, which tripled the number of communicable disease notifications. In spite ofsuch effort, the system is still under development and needs significant investments in training of itspersonnel, physical infrastructure and organization. The system needs better coordination at thenational level, as well as improvements in standardization, links between epidemiological andlaboratory data, and the data telecommunication system.
* Health Promotion. Health promotion, as a strategic component of the health system and as a tool forpolicy development, has just been introduced in Argentina. Historically, health promotion has notbeen adequately prioritized and the present challenge is to provide effective leadership, policies, andstrategies. This is the case in the area of communicable diseases as well as diseases which are theresult of life-style choices, such as smoking, poor diet, and alcohol abuse. Other problems, such asthe high incidence of traffic accidents which places a significant cost on the health care system andthe need to prevent misuse and overuse of drugs, are also not yet part of society's awareness.
* Institutional Development. Provincial ministries of health (MoHs) are generally weaker compared toother areas of the Government. Efficiency, regulatory capacity and quality control have started toimprove. A National quality control program is in place, with the participation of 214 entities, suchas universities, scientific bodies, professional committees and federations. In the early 1990's almostall hospitals were decentralized to the provinces, leaving 5-10 percent of the national health carespending is in the hands of the National Ministry of Health and Social Action (MSAS). Thedecentralization process has reduced previous inter-province inequities in health care financing,providing more resources to provinces which needed the most. The present challenge is to strengthenthe capacity of the National Ministry to fulfill its present role as regulator of the health insurancesystem, standards and quality assurance of health care delivery, motivator for compensatoryprograms, and leader in disease control and investigation.
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* Eficiency. The health system in Argentina needs to improve the management capacity of Ministriesof Health, insurance carriers, and public hospitals. Hospital infrastructure needs to be rationalized andrehabilitated, and cost containment mechanisms need to be further developed, especially at theprovincial level. The regulation of the private sector, which provides a large part of health care, needsto be updated and enforced.
* Equity. More than 30 percent of the population relies entirely on the public health sector.Strengthening the public health services would therefore help to improve the equity of the healthsystem as well as provide these people with improved access and choice of service.
The Government's strategy to address these issues, which has been under implementation since the early1990s with Bank and IDB support, includes initiatives to:
> strengthen maternal and child health programs, especially targeted to poor women and children, underon-going Bank-financed Maternal and Child Health and Nutrition Projects I and II;
> improve organization, management, and internal efficiency of selected provincial hospitals under theon-going Bank-financed Provincial Health Sector Development Project and IDB-financed operations;
> improve and promote the development of primary health care, including the development of familymedicine training and professional track (i.e. through an I.D.B. financed project);
> restructure, improve equity and open competition in the mandatory union-managed health insuranceproviders and improve the services provided to elderly, retired members under the recently completedBank-financed Health Insurance Reform Adjustment Loan;
> improve regulation of both the union-run health insurers and the private health sector under theHealth Insurance Reform operation and its accompanying Health Insurance Technical AssistanceProject;
> improve the delivery of public health services, introduction of new provider payment systemsincentives, and improvement of cost-recovery in public hospitals in selected provinces under the on-going Bank-financed Provincial Reform Adjustment Loans, which are to be extended to otherprovinces under proposed additional provincial reform operations;
> introduce health insurance for the poor, under the proposed Health Insurance for the Poor ProjectLearning and Innovation Loan (LIL);
> control selected infectious diseases, notably HIV/AIDS and sexually transmitted diseases, under theon-going Bank-financed AIDS and STD Control Project, prevent the misuse of drugs under a recentlyapproved LIL, and control other diseases under the proposed Public Health Surveillance and DiseaseControl Project; and
> strengthen public health policy and programs, especially the National Public Health SurveillanceSystem which is to be supported under the proposed project.
3. Sector issues to be addressed by the project and strategic choices:
This project addresses the need to strengthen public health policy and programs. This complements otherefforts to address the quality, equity and efficiency of the delivery and financing of health services whichare the focus of other initiatives under a number of Bank-financed on-going and planned operations. Thefocus on public health surveillance and disease control, under this project, constitutes a strongcomplement to these other initiatives as well as activities already initiated in the area of prevention andcontrol of HIV/AIDS.
Public health policy and institutions are not presently fully prepared to meet the challenges of existing andemerging diseases. The project strategy is to reinforce the basic tools of good public health practice andfocuses on three key issues: Public Health Surveillance, Disease Prevention and Control, and HealthPromotion.
Public Health Surveillance. Surveillance is a critical component of public health policy and practice. Itprovides an empirical, scientific foundation for informed decision-making about disease prevention andcontrol priorities, and it provides a means of monitoring the impact of health interventions and changes in
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health trends, while ensuring that resources are allocated effectively. This project seeks to strengthenpublic health surveillance capacity in Argentina which has some weaknesses in several areas. There is aneed to standardize data collection, investigation, recording and reporting. Currently, differentjurisdictions follow different procedures and there is little integration between different programscollecting similar or related data. The existing data collection system suffers from delays andinaccuracies. For example, in many local districts, data are hand tabulated and transmitted to the provinceby mail, fax, or vehicle. Due to the multiple levels and modes of data transmission there are significantlag times in the reporting system, and accessing or correcting data is difficult. The present challenge is toimprove analytic capability of the epidemiological system and the production of periodic bulletins, aswell as to develop a high level of investigative capacity at both national and provincial levels.
Disease Control and Prevention. The project will address the control of several diseases includingtuberculosis (TB), dengue and nosocomial (hospital-acquired) infections (NI) which pose a serious threatto public health, as well as other emerging or re-emerging diseases such as hanta virus, WHV/AIDS, andhemorrhagic dengue, which might appear over the life of the project.
* In 1997, there were 13,000 new cases of tuberculosis in Argentina. Recently, new factors such as theAIDS epidemic, increased migration of people from high prevalence areas to peri-urban areas andmulti-drug resistance, contributed to the rise in TB. The challenge is to bring the NationalTuberculosis Control Program up to a level adequate for coping with the seriousness of this situation.Non-compliance with treatment is around 20 percent, but in some areas of the country it is as high as40 percent. Although the "direct observed treatment" (DOTS) strategy for TB has proven effectiveworldwide, it is not fully implemented in all areas of Argentina. This strategy could significantlyreduce incidence and drug resistance, as well as hospitalizations (often due to non-compliance) anddrug costs.
- The recent emergence of the dengue virus in northern Argentina raises considerable concern about itspotential to spread to other areas of the country infested with the dengue vector (Aedes aegypti),including Buenos Aires. Since almost all of Argentina's population is susceptible to dengueinfection, there is a serious potential threat of the occurrence of explosive epidemics. The publichealth system needs to strengthen its dengue control activities, improve the dengue surveillancenetwork, and train its health professionals to recognize and respond appropriately to an emergingdengue epidemic.
* Nosocomial (hospital acquired) infections are a universal public health concern. Between 5 and 10percent of all hospital patients acquire hospital infections which increase length of stay and associatedcosts. Argentina has created standards for dealing with hospital acquired infections, but needs toestablish a countrywide NI control system, and baseline data.
Health Promotion. Health promotion is a broad strategy to improve health expectancy through education,social mobilization and policy advocacy. This approach to improving health, widely used in OECDcountries to improve health through information and behavioral change, has just been introduced inArgentina. Its development and implementation will be supported under the project. There is a broadagenda for health promotion, covering diet and nutrition, abuse of alcohol, smoking and other life-stylerelated factors. Among these, smoking is among the most serious: between 33% and 37% of peopleabove 10 years old smoke, and annual consumption per capita in 1995 was 59 packs, of those, 42% aremen and 28% are women.
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C: Project Description Summary
1. Project components: (see Annex 2 for a detailed description and Annex 3 for a detailed cost
breakdown)
2. Strengthening the Public Health Institution 42.4 56.5% 26.1 27%Surveillance System Building, Physical
Investment
2. Strengthening Disease Control Institution 16.4 21.8% 14.1 27%Building, PhysicalInvestment
Component I: Strengthening the Public Health Surveillance System. This component, to be implementednationally and in stages, seeks to strengthen the institutional capacity of the MSAS to make informed
decisions about prevention and control priorities, to better monitor the impact of interventions and
changes in health trends, and allocate resources more effectively. Specifically, it will:
(i) review the norms and procedures for surveillance and attempt to standardize case definitions,
reporting procedures and data collection in accordance with the new system design;
(ii) strengthen human resource capacity at all levels to carry out health surveillance activities in areas
of training including the surveillance of selected communicable diseases, chronic diseases,
behavioral risk factors and injuries (see Annex 14);
(iii) rehabilitate, expand and upgrade the existing national laboratory network (one laboratory level
III, 36 laboratories level II, and 25 level I) through the provision of technical assistance, the
acquisition of equipment and construction of civil works (See Annex 124;
(iv) improve quality of the existing health data telecommunications through provision of appropriate
hardware, software, communications equipment and the development of an internet-based
network for data transfer and storage among the federal, provincial and local levels of the public
health system, as well as training and technical assistance to the specialized staff in the laboratory
network and health facilities participating in the surveillance system (see Annexes 2 and 13) and
the establishment of linkages with other relevant health data;
2 Biosafety level I = basic level of containment, appropriate for handling microorganisms that represent little or no risk to humans, animals or theenvironment; Biosafety level 2= routine work on human pathogens not thought to be transmitted by the aerosol route. Basic physical precautionsinclude limited access to the laboratory, biohazard signs posted outside the lab, biosafety manual defining any needed waste decontamination ormedical surveillance policies, and a biological safety cabinet for use whenever agents that may splash or cause aerosols are handled.Biosafety level 3 = specialized laboratories which allow workers to safely handle more dangerous pathogens. They require all the conditions forBiosafety level 2, as well as controlled access to the laboratory. Special equipment and procedures to decontaminate all waste, wearing of specialclothing, among others. All work with infectious material is done under a biological safety cabinet, and all waste is disinfected prior to leavingthe lab, usually by an autoclave.
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(v) implementation of alternative surveillance methods for specific diseases including a system ofsurveillance and control of non-communicable diseases through the provision of technicalassistance and training for MSAS staff in, inter alia, the design of data collection instruments,questionnaires, scales, sampling methods, record-keeping, and data analysis and collection, andcollection of base-line data on risk factors and behavior (see Annex 2, Tables A and B);
(vi) evaluation that assesses the capacity of the surveillance system tor monitor each health event,taking into consideration sensitivity`, specificity4, efficiency, representativeness, timeliness andflexibility of the system, as well as opportunities for cost-recovery as appropriate and feasible (tobe completed and submitted to the Bank by January 31, 2003);
(vii) finance an operational research grant program for eligible biomedical research bodies to carry outresearch in epidemiological surveillance and disease control; and
(viii) evaluate effectiveness and relevance of training activities supported by the project.
Component II: Strengthening Disease Control. This component will strengthen the institutional capacityof participating provinces and the City of Buenos Aires to carry out disease monitoring, control andprevention. Specifically, it will support:(i) tuberculosis control in 10 provinces in the poorest northeast and northwest of the country,
Metropolitan Buenos Aires, and the areas of highest incidence and multi-resistance to therapy;(ii) dengue control in high risk populations located in the poor provinces such as, Jujuy, Catamarca,
Tucuman, Salta, among others, through 52 sentinel sites (selected on the basis of risk mapping,prevalence, vectors density, and population) which will monitor febrile illness including labtesting of suspected cases, (see Annex 2, Table D) and vector monitoring in areas of high riskwith high levels of vector infestation;
(iii) nosocomial (hospital acquired) infection control in 100 randomly selected hospitals (80 publicand 20 private) throughout the country, which meet specific selection criteria (see Annex 2, TableE). This will include support for: a) elaboration of the norms and procedures for NI control; b)existing infrastructure rehabilitation; c) collection of baseline data on hospital infections; d)training of professional teams for prevention and control of selected diseases; e) computers andsoftware for surveillance; f) supervision and technical assistance; and h) vehicles ; and
(iv) control of emergent and re-emergent diseases which may occur during the life of the project,through grants to eligible agencies. Criteria are defined in the Operational Manual.
Component III Health Promotion (HP) . This component will strengthen MSAS capacity to carry out ahealth promotion strategy through education, social mobilization and policy advocacy. Specifically, itwill support:
(i) strengthening the institutional capacity of the health promotion unit of the MSAS, throughtraining, equipment and rehabilitation of existing infrastructure;
(ii) training of MSAS and HP personnel in media and communications, and training of healthjournalists in the areas of disease surveillance and control;
(iii) eligible subprojects for local institutions and community groups to set up or strengthen diseaseprevention and health promotion within their communities (eligibility criteria and applicationprocedures are described in the Operational Manual);
(iv) dissemination of project objectives and activities through regular newsletters directed at thepublic health community and through workshops, conferences and technical meetings forstakeholders such as politicians, government officials, the medical and private insurancecommunity and others;
(v) over the life of the project, meetings at least on a quarterly basis with a committee of political andsocial leaders, including health journalists, to define a strategy and action plan to help ensuresustainability of the project;
3 Sensitivity is the proportion of persons with a disease/health event that are detected by the surveillance system.
4 Specificity is the proportion of persons without a disease/health event that are detected by the surveillance system.
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(vi) a media campaign against tobacco addiction to be designed and implemented on the basis of arisk factors survey; and
(vii) implementation of a plan to include private corporations in a partnership with the MSAS tocombat tobacco addiction in the employees of such corporations.
Component IV: Project Administration. The project will help finance the administrative and operatingcosts of the Project Coordinating Unit (PCU) over a four year period. This includes: (i) salaries for PCUtechnical and managerial staff, excluding the remuneration of the core technical team within MSAS; (ii)domestic and international travel and per diem for PCU staff, (iii) training of PCU staff; and (iv)equipment, materials and office supplies.
2. Key policy and institutional reforms supported by the project:
The project will help the GoA enhance the provision of currently under-funded public goods, inparticular, disease surveillance, communicable and non-communicable disease control, and healthpromotion. It focuses on strengthening relevant institutional capacity at all levels and on improvingquality and cost-efficiency in the health sector.
3. Benefits and target population:
Local, provincial and federal health agencies are the direct beneficiaries of the project, but the wholepopulation of Argentina will benefit from a strengthened system of public health surveillance and diseasecontrol.
With the expected increase in institutional capacity, it is anticipated that the project will result in reduceddisease burden, particularly for TB, dengue and hospital infections. The benefits will thus be reduced lossof disability. Most of these benefits will accrue to the poor since they are the population most affected bycommunicable diseases. When one looks at the burden of disease in terms of life lost due to prematuredeath, evidence shows that the poor die earlier and they are disproportionately stricken by largelypreventable communicable diseases. In fact, there is negative association between per capita householdincome and the years of life lost per 100,000 population due to syphilis (-0.361), diarrhea (-0.455),tetanus (-0.455), and tuberculosis (-0.361).
Furthermore, non-compliance with tuberculosis treatment and consequently multi-resistance to TB drugsis higher in the poor population due to less access to care and information, and educational background.
Risk factors associated with dengue transmission are strongly related to poor household conditions suchas lack of sanitary infrastructure, unplanned urbanization and family socioeconomic level. Higherincidence rates occur more in areas with higher poverty rates as defined by the NBI (Unsatisfied BasicNeeds) such as the provinces of Jujuy, Formosa, Chaco, Salta, Corrientes, and Tucuman, among others.
The general population will also benefit from the health promotion activities initiated under the project onthe abuse of tobacco. It is estimated that smoking is associated in 20 percent of the most common causesof death in Argentina. Consumption per capita in 1995 was 59 packs annually. Data on tobacco additionand impact on health is weak. So, a tobacco campaign will be designed after the results of the risk factorsurvey, which will defined more precisely the intended target population for this part of the project. It isexpected that the target population will be the 25 to 40 year old group and in the middle to middle-lowsocio-economic segment.
4. Institutional and implementation arrangements:
a. Executing agencies: Ministry of Health and Social Action (MSAS)b. Project management: Project Coordination Unit (PCU)
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The MSAS will be responsible for overall project implementation and administration, and will execute allproject activities except the ones executed as individual subprojects (operational research, healthpromotion, dengue control, and control of other emergent diseases). Universities and non-governmentalorganizations (NGOs) accredited by the MSAS would be executing agencies for these subprojects.
At negotiations it was agreed that a Project Coordination Unit (PCU) would be established and staffed bya new resolution of the MSAS, as a condition of effectiveness. The MSAS will appoint and maintainduring the execution of the project, core technical personnel in adequate numbers and with functions,responsibilities, qualifications and experience as may be required for the proper implementation of theproject. It was also agreed that key staff for the PCU would include a project coordinator, a generalmanager, a technical manager for each component and an administrative supervisor, who would beappointed and in place by loan effectiveness. The project coordinator would be responsible for theinteraction with the MSAS, and it was agreed that the PCU would meet on a monthly basis, or more oftenif necessary, with the project-related areas of the MSAS, the Epidemiology Unit, and the nationalreference laboratory (ANLIS). Terms of Reference for each managerial position were agreed atnegotiations. The PCU would be assisted by (i) a full time high level technician who will coordinate andsupervise project implementation in the provinces with more project activities, and (ii) amultiskilled teamthat will monitor project implementation. The full time technician should be a public health specialist orepidemiologist and will be paid by the MoHs.
The PCU will: (i) promote the project in provinces and municipalities; (ii) ensure coordination betweenthe project, MSAS, and ANLIS; (iii) maintain project records and prepare regular implementation reports;(iv) prepare terms of reference (ToRs) for consultants who will assist in implementing the projectcomponents and supervise their work; (v) coordinate the processing (identification, preparation, appraisal,approval and supervision) of subprojects presented by the beneficiaries, ensuring compliance with theOperational Manual; (vi) ensure that executing agencies comply with Bank procurement guidelines; (vii)undertake the financial management of the project; (viii) operate a management information system(MIS) to track project processing; (ix) ensure the auditing of project accounts and other audits required bythe Bank; (x) coordinate Bank supervision missions, and carry out the mid-term review of the project; (xi)organize the evaluation of the project's impact using monitoring indicators, analysis and other appropriatemethodology; (xii) accredit, hire, and manage universities, and non-governmental organizations (NGOs)to carry out subprojects; and (xiii) select and manage independent consulting firms to carry out an ex-postimpact evaluation of a sample of subprojects. The MSAS will execute all project activities except theones targeted by the subprojects (operational research, health promotion, dengue control and control ofother emergent diseases).
An external advisory board for the project (comprised of public health academicians and practitioners,provincial public health specialists, government officials, representatives from Agriculture, Finance,Tourism and other social sectors, and representatives of professional organizations) will advise ontechnical aspects of the project and will promote intersectoral cooperation. At negotiations it was agreedthat the external advisory board will be established within six months after loan effectiveness.
The Operational Manual. The PCU prepared an Operational Manual (OM) which was brought tonegotiations, providing detailed criteria and terms of reference for project implementation arrangements,including requirements and procedures for subproject proposals concerning, inter alia, proper healthprotocols, infrastructure and staffing, training plans, financing of recurrent costs, sustainability, andmeasures to ensure that the environment will not be negatively affected. During negotiations, the finaldraft was agreed, and the final version will be submitted to the Bank as a condition of loan effectiveness.
Financial Arrangements: A Financial Management Specialist has reviewed the financial managementsystem for this project. The review, which included visits to the central unit in the MSAS, which isadministering other Bank-financed projects, concluded that it has an adequate accounting system,financial reporting systems and segregation of duties to ensure the provision of accurate and timely
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information regarding project resources and expenditures. However, at present this system is notsufficient to be able to provide, with reasonable assurance, accurate and timely information on the statusof the projects "Project Management Reports"(PMR) as newly required by the Bank under the LACIsystem for PMR-Based disbursements. An action plan was prepared and it was agreed with the centralunit's Finance and Administration Manager that the system will be implemented six months after loaneffectiveness (for further detail see the document in the project files).
To facilitate the disbursement of funds, the GoA will establish a Special Account (SA) in the Banco de laNaci6n Argentina, to be operated by the PCU under terms and conditions satisfactory to the Bank. Whenthe project is considered LACI compliant and ready for PMR disbursements, the special account will bereplenished based on the PMRs submitted by the PCU, after certification by an auditor. The initialdisbursement will be based on the first six-month expenditure forecast for the first year of the proJect.
Until the project's financial management arrangements allow for PMR disbursements, to facilitatedisbursements against eligible expenditures, the Bank would, upon request, make an authorized allocationof US$3.7 million to the SA for all expenditures. Replenishment of the SA would follow Bankprocedures. The PCU would submit replenishment applications on a monthly basis, or when about 33percent of the initial deposit has been utilized, whichever occurs first. The replenishment applicationswould be supported by a bank statement of the SA and a reconciliation of the SA against the Bank'srecords. The minimum amount for application for direct payment and for special commitment would be20 percent of the authorized allocation to the SA.
The project would be audited annually, including a review of procurement by an independent auditingagency acceptable to the Bank. An independent agency or specialized consultants' services would beprocured by December 31, 1999 and the procurement and financial audit would be carried out by June 30of each year.
Procurement. Procurement activities will be carried out by an already-existing central unit in the MSASheaded by a Senior Procurement Officer and four full-time Procurement Officers (three of whom haveattended the Bank's Procurement seminar), and administrative support staff. In addition, one full timeprocurement proficient staff member of the MSAS will work in the PCU to coordinate technicalassistance components. An assessment of this unit's capacity to implement project procurement wascarried out by a procurement specialist. There are no major issues raised in the referred assessment. Theoverall risk assessment was rated "average" (for further detail see the document in the project files).
Monitoring: The PCU would be responsible for project monitoring and evaluation. It would useperformance indicators, detailed in Annex 1. At negotiations, it was agreed that progress reports,including monitoring indicators, would be sent by the PCU to the Bank every six months (by March 1 andSeptember 1 each year). Technical supervision of subprojects will be carried out by the MSAS, supportedby the PCU staff and consultants, when necessary. Monitoring indicators were agreed at negotiations, anda Supplemental Letter detailing them will be signed at the time of signing.
Institutional framework and flow of funds: The PCU would enter into three types of frameworkagreements. Provincial Participation Agreements (Convenios de Participacidn y Adhesi6n al Proyecto)are entered into between the Borrower (represented by the MSAS) and the participating provinces(represented by Provincial Governors) selected by the MSAS to participate in the project in accordancewith criteria and procedures described in the OM.
Municipal Participation Agreements (Convenios Municipales de Participacion y Adhesion al Proyecto)are entered into between the Borrower (represented by the MSAS), participating provinces, andparticipating municipalities selected by the MSAS to participate in the project in accordance with criteriaand procedures described in the OM.
Implementation Agreements (Convenios de Ejecuci6n/Cartas Complementarias) are entered into between
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the PCU and a beneficiary (hospital, health center, NGO, among others) for the execution of a subprojectselected and approved in accordance with criteria and procedures detailed in the OM.
Loan funds will not be transferred to the participating provinces. All procurement of goods, works andconsultants' services financed under the loan will be centralized and carried out by the central unit, asnoted above. Participating provinces will receive goods, works and services financed under the loan asnon-reimbursable contributions and are not providing any counterpart contribution from their respectivebudgets.
Subprojects: Loan proceeds will be allocated for the implementation of subprojects including consultants'services, training, and goods for subprojects under the following-components: (i) Health Promotion; (ii)Operational Research; and (iii) Disease Control Activities. Health promotion activities would beadministered by the Coordinator of Component III, and his/her team. Operational Research activitieswould be managed by the Coordinator of Component I and his/her team, and the actions related to diseasecontrol would be handled by the Coordinator of Component II.
D: Project Rationale
1. Project alternatives considered and reasons for rejection:
Flexible Project Design versus Rigid Structure. One alternative design for the project would have been tosupport a federal, fully-detailed and standardized national surveillance system. However this was rejectedas too rigid an approach, given the specific needs and capacities of different provinces. In addition, localneeds are often unrecognized at the central level, so a top-down approach would weaken local ownershipsince provinces and municipalities would not have the opportunity to articulate their needs as theyperceive them. On the other hand, a national surveillance system does require an overall conceptualframework and standardization of data collection, laboratory procedures, case-definitions, and basicnorms to be followed by all participants in the system. Therefore, the project is partly pre-determined (allof Component I, and parts of Components II and III) and partly to be designed as part of projectimplementation on the basis of subprojects to be presented by provinces and municipalities (other parts ofComponents II and III). Components II and III involving vector control, health education and preventionmeasures, are better suited to a targeted approach since disease patterns and institutional capacity varyacross the different regions affected. A targeted approach is more cost effective and efficient in thissituation of heterogeneous capabilities. Thus, the selected alternative balances the need for nationalconsistency with the opportunity to respond to local needs and targeting of interventions.
Comprehensive versus Focused. A strategic choice was made to limit the number of diseases to betracked. The 50 health conditions originally targeted for surveillance was not a realistic objective. Basedon the economic analysis, 29 of these 50 conditions were selected for notification and four for sentinelsurveillance. These include the diseases under international regulation and the diseases for which controlis most cost-effective. The surveillance system will also rely on alternative surveillance methods such assentinel sites. These sites will be implemented gradually (see Annex 2, Tables A & B).
Phasing by region or disease versus phasing by activity. A number of alternatives were assessed interms of how the project could be implemented given the complexity and scope of the system (even afterreducing the number of diseases) and differing capacities and needs at the provincial and local levels.Two options considered were to phase project activities either by geographic area or by disease. The firstidea, dividing the project by geographic area, was rejected by the provinces since none were willing towait. The second idea, implementing the project for a few diseases at a time, was also rejected ontechnical and practical grounds since phasing by disease would require a costly duplication of trainingefforts, standardization procedures, and many other activities related to the implementation of thesurveillance system. Instead, a third option was selected. It was decided to go forward with the fullnumber of 29 diseases in all the provinces but to introduce gradually certain project activities, (such as thechronic disease surveillance system, the sentinel networks for dengue control and injuries, thetelecommunications system, and the training program).
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Communicable versus Non-Communicable, or Both. A choice was also made with respect to how to treatnon-communicable diseases, recognizing that in Argentina these diseases are of increasing importance.One option would be for the project to address only communicable diseases, but with an aging andincreasingly urban population, Argentina is rapidly coming to the point where chronic diseases anddiseases related to lifestyle will cause the most mortality and morbidity. Understanding current diseasepatterns and related behaviors in Argentina and the long term monitoring of changes in these patterns andbehaviors over time is critical to effective planning and execution of appropriate public healthinterventions. Without adequate training, Argentina appears to be poorly equipped to mount anyconcerted public health response to these emerging chronic disease problems. Therefore, an incremental,strategic approach to chronic disease surveillance and associated risk factors is needed. The prolect willbegin by setting priorities in chronic disease control, determining staffing needs and implemeinting anappropriate training program. The chronic disease and risk factors surveillance system will then beimplemented in the third year of the project.
Private versus Public Intervention. Health surveillance and communicable disease control are publicgoods and are a core area of responsibility of the MSAS and/or its provincial counterparts (MoHs).Nevertheless, there may be ways in which private health insurers could become partners in the system andcontribute through cost-recovery. Clearly, health insurance providers have a vested interest in seeing thatdisease incidence is reduced through surveillance, control and public health programs, and may be willingto pay for these services, through contributions or levies on insurance premiums. Health insuranceproviders could be contracted to provide certain services. Although options for private participation wereconsidered, they were rejected for the time being as premature given the early stage of implementation ofreform of the union-run health insurance providers and regulation of private health insurance, as well asthe need to demonstrate results before imposing cost-recovery. Nevertheless, private hospitals and otherprivate health agencies would be eligible to participate in and benefit from several project activities andpublic-private partnerships are to be created under the Health Promotion component.
2. Major related projects financed by the Bank and/or other development agencies:(completed, ongoing and planned)
Health Insurance . Health Insurance Reform (PROS), Ln. HS S4002/3-AR
. Health Insurance TA, Ln. 4004-AR S S
Health Care Delivery . Provincial Health Sector Development S S(PRESSAL), Ln. 3931 -AR
Public Health . Maternal and Child Health and HS HSNutrition I (PROMIN), Ln. 3643-AR
. Maternal and Child Health and S SNutrition II (PROMIN2), Ln. 4164-AR
. AIDS and STD Control (LUSIDA), Ln. S S4168-AR
a Integrated Drug Prevention (not yeteffective) .
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Other developmentagencies
IDB . Modernization and Reform of PrimaryHealth Care
UNDP . Support to Health Insurance Reformand to provincial Health Sector Dev.
PAHO . Health Systems Development
GTZ . AIDS prevention in 4 municipalities ofthe Buenos Aires metropolitan area
IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory)
3. Lessons learned and reflected in the project design:
The Bank has not yet gained any specific lessons from similar Bank-financed experiences, since this isonly the second project of its kind in the Bank, the first being the Brazil VIGISUS Project (Ln. 4394-BR).However, some lessons from related projects may be applied to this project:
t Brazil: Amazon Basin Malaria Control (PCM4M) and Northeast Endemic Disease Control(PCDEN) Projects. The ICRs for these projects suggest that disease control projects should: (i)consider defining broader objectives, e.g. combining support for malaria control with control of othercommunicable diseases; (ii) include demand-driven components to finance state and municipalcommunicable disease control subprojects; and (iii) provide technical assistance to strengthen thecapacity of weaker states and municipalities. PCMAM and PCDEN also taught us that training andother forms of institutional strengthening should be implemented at least at the same pace asinvestments in civil works and equipment. This has been taken into account in the project design.
> Peru. The Social Development and Compensation Fund Project (FONCODES). Some relevantlessons from this project include: (i) independent ex-post evaluation of samples of completedsubprojects were valuable in assessing performance and impact; (ii) educating beneficiariesconcerning their role in the project and the use of services offered by the project should beemphasized; (iii) training in the operation and maintenance of completed projects should besystematized; and (iv) selecting appropriate performance indicators at the outset of the project, withan adequate monitoring and evaluation system is important.
> Argentina: Maternal and Child Health and Nutrition I and II (PROMIN). These projects have beensuccessful in reaching poor communities and involving them despite varying levels of institutionalcapacity. In the two projects, provinces manage subprojects at the municipal level through provincialimplementation units while an overall project coordinating unit (PCU) at the central level coordinatesproject implementation. While the proposed project does not have decentralized execution such asPROMIN, the central PCU will be assisted by a high level technician, who will coordinate projectimplementation at the provincial level. The PROMIN experience demonstrates that not everymunicipality can be expected to have the capacity to prepare subprojects effectively. The proposedproject will therefore provide technical assistance to weaker municipalities through the PCU, whennecessary.
Lessons from international experience have also been tapped for this project:
> Institutions in other sectors, such as the Ministry of Agriculture, Ministry of Tourism, Ministry ofFinance and others should be actively involved in strengthening the surveillance system. Extensive
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project promotion was carried out during preparation and a project steering committee, withrepresentatives from these and other ministries, has been suggested by the Bank as a way of ensuringcontinuing inter-ministerial cooperation.
> International experience has shown that early involvement of senior officials from the MSAS ensuresnational ownership of the national surveillance system. In the preparation of the proposed project, theNational Epidemiology Unit, the provincial epidemiologists and health officials and the NationalCommission of Epidemiology were all involved in the assessment of the current surveillance system.It has been agreed that formal assessments will be carried out on a regular basis involving the MoHsand international partners.
> A review of international experience in surveillance shows that surveillance systems are often overlyambitious, unrealistic and beyond local capacity. Often, too many diseases are included andinstitutions are subsequently overloaded with responsibilities that cannot be fulfilled. For theproposed project, an economic analysis was carried out to help establish surveillance priorities andappropriate methods, which found that the current system covers an impractical 50 conditions. Ofthese, 29 were selected for surveillance based on their epidemiological significance and relative cost-effectiveness of intervention. Four of the 29 were selected for surveillance by alternative methods,such as sentinel surveillance. The remainder will use traditional surveillance methods (notifiableconditions).
4. Indications of borrower commitment and ownership:
> The MSAS has taken the lead in project identification and preparation. The MSAS definedsurveillance as a priority issue to be addressed by Mercosur countries and agreed in the last MercosurHealth Ministers' meeting (November, 1998) to participate in a regional surveillance network. Theproject will support some of these regional activities.
> In November 1998, the MSAS participated in a Surveillance Workshop in Iguacu, Brazil (organizedby LCSHD in conjunction with Brazilian counterparts) and presented this project (VIGI-A).
> The MSAS has formally requested Government support to hire additional personnel at the centrallevel to carry out new surveillance activities. Provincial Health Ministries and representatives of theprovinces on the National Surveillance Committee have been actively involved in the development ofthe project proposal. No major decision concerning the design of the surveillance system has beenmade without their participation and consent.
> A Letter of Sector Policy was prepared and agreed upon at negotiations. The final signed version willbe submitted to the Bank prior to Board presentation.
> Finally, the MSASNIGI-A team has started some project activities, specifically, revision of normsand procedures of the Public Health Surveillance System. The review of those norms and proceduresshould be completed prior to loan effectiveness and discussed with the Bank during project launch.
5. Value added of Bank support in this project:
While the Bank has little prior experience with free-standing projects to strengthen national surveillancesystems, it does have considerable experience, in many countries, financing a variety of communicabledisease projects. Most of these have included support for strengthening specific surveillance activities(examples in LAC include projects in endemic disease control and AIDS/STD control in Venezuela,Argentina, and Brazil). The Bank supports other projects, such as the Health Sector Reform Project inEgypt and the VIGISUS Project in Brazil, which include health surveillance activities.
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Complementing this is the Bank's ability to tap international experience. The Bank has an ongoingpartnership with the U.S. Centers for the Disease Control (CDC) and WHO/PAHO, which have oftenprovided technical support in the preparation and appraisal of Bank-financed health projects andcontributed to this proposed project.
We can also establish within Argentina the complementarity needed between reforms in areas of healthservice delivery and financing, being supported by other Bank-financed projects, with a focus on publichealth policy and practice.
The Bank has been effective in Argentina in developing capacity for monitoring and evaluation, targetingthe poor, and involving local community groups. This has proven to be particularly useful in other socialsector programs, notably the Participatory Social Investment Fund (FOPAR), the system for theevaluation of social programs (SIEMPRO), the temporary public works employment program(TRABAJAR), the AIDS and STD Control Project, and the recently approved Drug Prevention LIL.
Finally, the Bank can use its knowledge base and established contacts with the provinces, built up overthe years under operations such as Provincial Development I and II Projects and the Provincial ReforrnAdjustment operations, to facilitate implementation and coordination at the provincial level.
E: Summary Project Analysis: (detailed assessments are in the project file, see Annex 8)
1. Economic: (supported by Annex 4)
There is a clear albeit slightly different economic justification and role for the state in each of the threecomponents of the project. The first component, health surveillance, exhibits public good characteristics.It may, however, be possible over time to engage private health insurers in a more active participation insurveillance activities (especially for communicable diseases): the data they collect to monitor their riskpool may be usefully fed into the public health surveillance system. The second component, diseasecontrol, is justified because: (i) many of the instruments that are used are almost pure public goods (e.g.,vector control); and (ii) social benefits are higher than private benefits because of the existence of positiveexternalities: treatment of infectious cases confers benefits in addition to the benefit gained by the treatedpatient. Both of these components can be economically justified on the grounds of the savings generatedby the avoidance of disease burdens as demonstrated below. The third component, health promotion,addresses the issue of under-provision of information - information is under-provided to the extent thatthere are no associated marketable products. It too can be economically justified as effective promotionactivities which can be shown to avoid health risks in the future. In addition to improving efficiency, theproject will improve equity, insofar as infectious diseases disproportionately affect the poor.
To establish priorities and to address the issue of cost-utility of the proposed interventions on which theeconomic justification of the surveillance system and control activities (combined 79 percent of projectcosts) is based, a quantitative analysis was carried out to help determine the optimal scope of surveillanceand disease control. The establishment of priorities and final recommendations as to inclusion of eachdisease in the surveillance system were based on several criteria: (i) disease impact on the nationalpopulation in DALY's; (ii) approximate cost-utility of control interventions; (iii) outbreak potential (oremergent disease); (iv) plan or potential for eradication; (v) vaccine-preventability; (vi) being an indicatoror risk factor for an important disease; and (vii) the probability that improved surveillance informationwould lead to better control (i.e. reduced impact) of the disease. This analysis was undertaken early onand had a considerable impact on the design of the surveillance system, both as to scope and method.From the original list of 50 notifiable health conditions targeted for surveillance, (too many for anefficient surveillance system) 29 were selected for notification and four were chosen to be surveyed byalternative surveillance methods such as sentinel sites.
Disease Control Component. An attempt has been made to quantify the benefits of the disease controlcomponent as this is expected to have a direct impact on disease incidence. This component accounts for22 percent of total project costs. The results of this analysis, however, are only illustrative as there are
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serious deficiencies in relevant data in Argentina on costs and disease incidents, particularly for emergingdiseases such as dengue.
During appraisal, a cost-benefit analysis was carried out for three diseases: (i) tuberculosis; (ii) dengue;and (iii) nosocomial (hospital acquired) infections.
Tubercolosis. In 1997 there were 13,000 new cases of Tuberculosis. Without the project theincidence of TB is expected to grow by 2 percent per year until 2010. If the project is successfulin achieving its goal of reducing the incidence of the disease by 15 percent, and assuming that (i)5 percent of new cases are hospitalized, (ii) each hospitalization lasts on average 35 days at adaily cost of US$15, (iii) the daily income lost for disability is US$7, and (iv) that a TB episodelasts for 548 days, the undiscounted 10 year benefit of the project is US$12.2 million.5
Dengue. Assuming (i) a conservative per capita cost of US$80 of a serious dengue outbreak6including reduction of the number of tourists in the country; (ii) a probability of such outbreakoccurring of 0.5 percent annually, and (iii) the impact of the project lasting until 2010, theexpected value of the cost of dengue is US$13.9 million in the first year, and US$256 million(undiscounted) over the period from 2001 to 2010. As the objective of the project is to reduce theprobability of an epidemic, the benefit of the project is assumed to be the savings in the potentialcosts of the epidemic arising from a reduction in the probability of the outbreak. If the project isto reduce the probability of a dengue epidemic by half then the undiscounted 10-year benefit ofthis component would be about US$128 million.
Hospital Infections. The project is expected to reduce infections acquired during hospitalizationby an average of 13 percent for the three most prevalent infections in 100 hospitals by the end ofthe project. The projected incremental inpatient costs associated with acquired infections in thefirst year for all hospitals in Argentina is US$1.3 million. This accumulates to US$28.4 millionby 2010. With the project intervention, the cost savings is expected to be US$0.042 million in thefirst year, accumulating to US$1.9 million (undiscounted) by 2010 (see Annex 4, table 3, 4, &5)7
Overall
Intervention Undiscounted 10 Year Benefit from 2001 to 2010Dengue Management $127.8 millionTuberculosis $12.2 millionHospital Acquired Infections $1.9 millionTotal $141.9 million
The economic analysis of the disease control component-under assumptions that should be consideredvery rough and approximate-shows that this component alone yields very substantial benefits, enough tojustify the whole project. Assuming that costs are incurred at the inception of the project, while benefits
sThe benefits are the savings associated with reducing the number of tuberculosis cases. The costs include only hospitalizationcosts and lost wages due to morbidity.
6 In the absence of data for Argentina, data from Puerto Rico and Cuba were used to develop a range of potential costs of adengue epidemic in Argentina.
7The benefit of the project in this case is assumed to be limited only to the reduction in hospitalizations costs (ignoring wages,morbidity, mortality, etc).
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only start at the third year of implementation, the intemnal rate of return for the disease control componentis estimated to be 63 percent. Even under the extreme hypothesis that the other project components yieldno benefits, the internal rate of return for the whole project-with a cost of US$75 million-would be 15percent.
Disease Surveillance. In addition to an expected reduction in morbidity and mortality, which are notquantifiable at this point, the strengthening of the surveillance system would have some non-additivebenefits. It would impact the epidemiological pattern of infectious diseases because it would increase thesensitivity of disease detection, quicken the detection and shorten response lags, leading to a lowernumber of serious cases requiring hospitalization. In the short run, a more effective system ofsurveillance is expected to result in an increase in reported cases and a rise in disease incidence.However, this effect should be mitigated over time, as the impact of better reporting is outweighed byimproved detection, more rapid treatment and lower costs.
Health Promotion/Tobacco Control. No attempt has been made to quantify the impact of strengthenedhealth promotion activities, particularly with regard to curbing tobacco use. Nevertheless, the experienceof other countries indicates that this is a worthwhile proposition. At present, tobacco addiction is veryserious in Argentina: about 35 percent of people age 10 and older smoke. The addiction is higher amongmen than women: 42 percent of men 10 and older are smokers while this rate is considerable lower at 28percent among women in the same age group. The estimated per capita consumption is 59 packs per yearin 1995, and it is estimated that smoking is associated with 20 percent of the most common mortalitycauses in Argentina. Though mortality data are not available for Argentina, in Latin America smoking isresponsible for an estimated 150,000 deaths per year. The project would support a risk factors survey toimprove the understanding of the current pattern of tobacco consumption, and would support a mediacampaign against tobacco addiction. A reduction in smoking would reduce illness and the associatedlosses in productivity, decrease the costs of health insurance and would have several positive externalitiesfor the society as a whole, including reduction in passive smoking and a cleaner environment.
Other Project Benefits. The estimate of the internal rate of return in the previous section is by natureconservative, and can be considered a lower estimate for the true project economic rate of return, sincemany pecuniary and non-pecuniary benefits are not included. Among other benefits associated with theproject are:
- The reduction of morbidity would increase productivity by reducing absenteeism by illness of theemployer or need to care for sick family members.
* A more efficient information system would produce savings by reducing duplication andsimplifying procedures. Timely data would also improve priority setting, and the planning andallocation of resources.
* An increase in the incidence of epidemic diseases would have a negative impact on tourism sectorand related business activities. Though the reduction of epidemic disease will not have asymmetric positive impact in terns of magnitude, minimizing the losses for the economy can beviewed as a benefit in itself.
* In addition to the positive externalities for the family, for which having a member sick imposes aburden, the whole society is better off from disease reduction, since people enjoy living in ahealthier society.
* The benefits of an efficient surveillance system go beyond the Argentina borders. Earlierdetection and control of disease and rapid information exchange would also benefit neighboringcountries, reducing imported diseases and limiting the spread of outbreaks.
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Poverty and Targeting Aspects. The poor would benefit disproportionately from better disease controland early epidemic response, since the incidence of communicable diseases among the poor isdisproportionately higher than among the better-off groups. The poor tend not to use the health caresystem. When they do, treatment compliance is often weak, which leads to dramatic lhealth outcomes suchas multi-drug resistance. The project, by establishing a system thaL uses individual surveillance mnethodsand direct observation treatment, would increase the likelihood of cure among the poor. Tobacco controlactivities would also benefit disproportionately the poor, if Argentina is like other countries., wheresmoking rates are higher among the worse-off groups. The loss of wages caused by disease is also verylikely to be higher among the poor, who often have jobs in the informal sector, where there is noinsurance for days of work lost.
Full Evaluation to be Completed During Implementation. The economic analysis summarized above ischaracterized by assumptions and estimates that indicate the type of data required to fully understand theeconomic characteristics of the activities to be financed under this project. The analysis is incomplete inthat benefits of the training activities, and the data management telecommunications, are not valuedi at all.
During project implementation, a full economic evaluation of the system would be undertaken to betterunderstand the costs and benefits of the project, both for further work in this area and to make choicesduring implementation. A more complete understanding of the costs and benefits of disease surveillance,control and health promotion will moreover contribute to assuring that these programs are adequatelyreflected in public expenditure choices which have to be made to sustain the program.
This evaluation will include (i) an assessment of the capacity of the system to monitor each healtlh eventand (ii) a cost-benefit analysis. The cost-benefit analysis would focus on the estimate of the pecuniarybenefits, namely (i) productivity gains arising from lower morbidity, (ii) econornic savings from lowermortality, (iii) savings on hospital costs, (iv) savings on direct costs associated with the disease (lostwages, transportation, medical fees, and drugs), and measuring the beneflts associated with training andbetter information systems.
2. Financial: The project's fiscal impact has been analyzed from two different perspectives. The first isthe question of whether or not Argentina has been investing sufficiently in preventative rather thancurative health programs. Given the fact that total expenditures on health in Argentina are relatively high(some seven to ten percent of GDP), and in light of its present level of income, one would have expectedthat public health programs would be at adequate levels. However, that is apparently not the case. Anassessment of the surveillance system (Annex 11) and country comparison analysis5 lead us to con:cludethat Argentina has been investing too little in this area. This can be seern by looking the table below.
Indicator Argentina PortugalPNB/Capita US$8,030 US 9,740Population 34.7 million 9.9 millionSize of Central Epidemiological 10 80Unit (Human Resources)Regional Surveillance Network No YesLaboratory Network connected by No Y{esInternetTelecommunications Network for No YesSurveillance
8 There are some constraints on country comparison, such as different epidemiological pattem. However, if we take intoconsideration that Portugal is much smaller in size and population, we believe that potential differences in disease patterns willnot impact the conclusions.
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The second way of looking at the project's financial impact is to assess its impact on the present budget ofthe Ministry of Health and Social Action. The recurrent costs implications (see Annex 4) are estimated tobe about $400,000 in year 2000, peaking during the first year of post-project operation at $3.3 million.This represents 0.6 percent of the federal health budget (which will be on the order of $574 million perannum, in 2005); and only 0.1 percent of consolidated provincial public health spending (which is on theorder of $4.4 billion per annum). A further assessment of the risks of ensuring adequate recurrentfinancing by the GoA for the project's operation is made in the section on sustainability and in Annex 4.
Despite this very small fiscal impact, the difficulties facing Argentina in terms of achieving a fiscalbalance make any change in historical spending patterns a challenge for public authorities and one thatneeds to be assessed in the context of competing demands for public services. Clearly, a solid case forcorrecting the lack of investment in the past can and should be made, especially if the project is able todemonstrate quantifiable benefits for the health system as a whole as part of the full evaluation to becarried out during project implementation. Moreover, the Government is committed to providing thislevel of funding and it is expected that provincial govemments will be responsible for, and are committedto the recurrent costs of project, including meeting identified needs for personnel.
3. Technical:
The project's technical dimensions are based on system assessment, laboratory infrastructure assessment,standard medical and health protocols, and experience from other countries. These assessments weremade with the support of experts from the US Center for Disease Control and WHO/PAHO.
The protocols used for prevention and control of the health conditions to be addressed under ComponentII were agreed during appraisal. The tuberculosis protocol is consistent with recommendations made byan evaluation performed by PAHO/WHO in late 1997 and subsequent PAHO technical missions in 1998.Dengue control activities also meet PAHO guidelines for the region, and hospital infection activities arealso in line with international experience and national guidelines. Participating public and privatehospitals are expected to follow these same guidelines.
Specific activities for control of dengue and other emergent diseases, as well as health education andpromotion will be executed through subprojects to be presented by provinces and municipalities, andeventually other organizations. To ensure that these sub-projects fit into the overall objectives of theproject, are properly targeted and are technically viable, they will be prepared and evaluated on the basisof eligibility and evaluation criteria specified in the Operational Manual which adequately addresses therelevant technical considerations.
An extensive training program has been defined to meet the needs of the future system (see Annex 14). Arevision, with collaboration from international experts, of the norms and procedures of the system will becarried out according to the design and objectives of the new system. The system will be periodicallyassessed and adjustments will be made to meet changing needs. It was agreed at negotiations that thereview would be completed and the results furnished to the Bank as an additional condition foreffectiveness.
In terms of information technology, it was determined that the Internet/World Wide Web would providethe best communication backbone for the project's communication systems since changes in software canbe made centrally and distributed automatically to field users. The communications system will: promotestandardization of data and data collection forms (which does not happen now); standardize the userinterface with the Internet browser; simplify training of field staff; allow centralization of most hardwareand software support and maintenance; require only a computer, Internet connection and browser for theuser; and improve data quality by reducing the likelihood of duplicate entry of both patient level andsummary case count data (see Annex 13).
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4. Institutional:
a. Executing Agencies: Ministry of Health and Social Action (MSAS), provincial health ministries, publicand private hospitals and other agencies.
Surveillance capacity, including physical infrastructure and personnel is highly variable across thecountry. Skills and personnel needs assessments were undertaken by the project team, provincial healthofficials, and Bank missions. The human resource capacity at the central and provincial levels iscurrently assessed as below the level needed to effectively implement the project. While the MSAS andsome provincial MoHs are satisfactorily managing Bank projects, such as the AIDS and STD ControlProject, the Maternal Child Health and Nutrition I and II Projects and the Provincial Health Project, othersare in need of strengthening which may be addressed by the proposed project.
At the central level, the staff and equipment of the national epidemiology unit are limited. Its needs havebeen identified and it has been agreed that the project will finance, on a declining basis, the salaries of thenew personnel. The number, skills, tasks and responsibilities for these new staff have been agreed (seeAnnex 2).
A careful assessment of the training needs was carried out with the participation of the provinces. Tostrengthen the skills of the existing provincial staff and also to supervise project activities, the project willfund 45 trainers/supervisors, one per jurisdiction. These key personnel will be trained in the first year ofthe project. By the last year of the project, thirty of these personnel will be funded directly by theprovinces, and the other fifteen will be supported by the project in areas with scarcer resources and highincidence and prevalence of diseases. Each participating province will be responsible for, and iscommitted to, meeting the identified needs for personnel in its jurisdiction.
The NGOs and other agencies to be selected to execute sub-projects will be assessed, anong othercharacteristics, on their institutional capacities. Technical assistance will be provided under the project tohelp: (i) improve preparation of subprojects; and (ii) train the beneficiaries in subproject preparation,appraisal, supervision and procurement.
More generally, the surveillance system will be implemented in a gradual fashion to take into account thehighly variable and in some cases weak capacities. The development of chronic disease and risk factorsurveillance will also be implemented gradually giving priority to training and the process of settingpriorities in chronic diseases (see Annex 12).
b. Project Management: The PCU would be created by a new resolution of MSAS as a condition of loaneffectiveness. The key staff to be hired for the PCU would include a project coordinator, a generalmanager, a technical manager for each component and an administrative supervisor, with terms ofreference and experience acceptable to the Bank. The unit in charge of procurement implementation is anexisting decentralized part of the MSAS set up especially to unify administration of externally financedprojects. This agency is familiar with Bank procedures and already manages procurement for threeprojects. Recent improvements have been made to this unit as a result of a procurement audit of the on-going Provincial Health Sector Development Project.
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5. Social:
The project was designed with active participation and consultation with the main stakeholders, notablythe central and provincial health ministries as well as other professional organizations and private healthparties. Provincial health officials were fully engaged in project preparation and participated in thedecision-making process. During implementation, the project will sponsor a number of promotionactivities for the participation of multiple stakeholders, such as the private sector, insurance companies,Obras Sociales, NGOs, and the community. Edition of regular newsletters directed to the public healthcommunity, raising awareness of key health messages, and workshops and conferences withpresentations from peers in foreign countries about benefits of surveillance and successful corporatetobacco control programs, are examples of those activities. The external advisory group is another projectfeature which is designed to encourage involvement of stakeholders, in areas such as agriculture, tourism,and finance. At negotiations, it was agreed that this advisory group would be established six months afterthe effectiveness date.
It is also important that the specific public health promotion activities be designed with a clearunderstanding of the social issues and context in which they will be undertaken. Thus, the project willsponsor a study of the social and other risk factors related to public health issues such as addiction totobacco and will cany out the ensuing promotion activities with those factors taken into account.
6. Environmental assessment Environmental Category [ ] A [ I B [X] C
The project would have a positive environmental impact by specifically addressing the issue of safehandling of insecticides and laboratory and medical materials and waste, including the development of aneffective biosafety program. Beneficiaries would have to present adequate environmental and safety plansaddressing such issues as: handling the products listed above, storage facilities for hazardous materials,transportation and disposal, and training of personnel on environmental and safety issues. Training in theproper handling and disposal of hazardous materials and waste would be provided through the project.
7. Participatory approach:
Preparation Implementation Operation
Central and Provincial Governments IS, CON, COL IS, CON, COL IS, CON, COL(Health officials of both levels of government werefully engaged in the decision-makingprocess andproject preparation)• Academic Institutions IS, CON CON, COL COL* Professional Associations IS, CON COL COL• Private Sector (hospitals) CON COL COL. Community IS COL COL* Other Donors/PAHO/UNDP COL COL(PAHO and UNDP helped the local team prepare the project, and will be involved in training)* CDC COL COL COL(CDC assisted the Bank missions in the project preparation, and will be involved in training)IS: Information Sharing CON: Consultation COL: Collaboration
F: Sustainability and Risks
1. Sustainability:
As explained earlier, Argentina needs to make an expanded investment in public health programs, like theone being supported under the proposed project. Better surveillance will correct for underreporting ofdiseases and may therefore increase health care costs in the short to medium term. In the long run, therecurrent costs are expected to stabilize and/or decrease if only because epidemics are contained earlier.While the economic and social benefits of such an increase in investment are clear, the decision to shiftpublic resources - especially during times of economic recession - are not easy for policy makers giventhe competing demands for reduced resources. An on-going public expenditure review being conducted
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by the Government, with Bank-financed technical assistance, should help to lay the ground for this andother public programs.
The burden of recurrent spending generated by the proposed project on total public health spending is inrelative terms modest and under normal circumstances should be feasible within expected resourceenvelopes available to the health sector. The recurrent expenditures are expected to rise from about$400,000 in the first year of the project to about $3.3 million upon project completion. Nevertheless, theprevailing financial crisis introduces an important element of uncertainty into growth projections forArgentina, and consequently into those of public finance.
Present estimates of the prospects for the health budget indicate that funds will be available to meet theincremental, non-Bank financed, recurrent costs generated by the project. However, sheer availability isno guarantee that these funds will effectively be made available for the activities generated by the project.The issue of additional recurrent costs and their adequate financing by the GoA therefore needs to beclosely monitored, especially towards the end of and after the project implementation period. In the caseof more acute financial difficulties in the future, the project will review the implementation plan, andmake appropriate adjustments to focus on priority activities.
With a view to ensuring the long-run sustainability of the system and its enhancement over time, theproject will also support promotion of the financial involvement of the private sector and if successfulthese initiatives could help to reduce the incremental financial burden on the public sector.
To reinforce sustainability, stakeholders were involved in project preparation and were part of the systemassessment and decision-making process. An external advisory board for the project (comprised ofpublic health academicians and practitioners, provincial public health specialists, government officials,representatives from Agriculture, Finance, Tourism and other social sectors, and representatives ofprofessional organizations) will advise on all three project components and may be helpful in advocacy.Support for technical assistance in operations and maintenance will be included under the project to helpprovinces and municipalities ensure sustainability of subprojects. The management and monitoringcapacity of provinces and municipalities will be strengthened. Surveillance capacity will be strengthenedat all three levels of the system, through extensive training, upgrading of facilities, provision of equipmentand establishing a data management communication system. New personnel will also be contracted.
2. Critical Risks: (reflecting assumptions in the fourth column of Annex 1)
Lack of Government Commitment Low Involvement in project preparationand implementation
Insufficient MSAS/PCU capacity Medium Technical Assistance/hiring newpersonnel; training
Incapacity of MSAS to retain the key personnel High Larger salaries will be paid to keyat central level personnel, and the data
telecommunications system serviceswill be contracted out
Insufficient availability to meet the incremental High The project will finance a study torecurrent costs explore options to ensure
sustainable financing of surveillanceactivities, including the re-allocation of funds within theMSAS
Page 23
From Outputs to ObjectiveNumber and variety of actors involved Low/Medium Assigning clear project management
responsibilities to be coordinated bythe PCU, flexible project design andclear definitions of the majorparticipants' role in the project
Approval of poor-quality subprojects on the Low/Medium Using transparent eligibility andbasis of political patronage evaluation criteria for the selection
of subprojects; independentmonitoring; and financial audit
Insufficient provincial or municipal capacity Medium Technical Assistance/Intensive______ ______ ___ _ _Training/45 supervisors
Overall Risk Rating MediumRisk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk)
3. Possible Controversial Aspects
The tobacco-related activities to be developed under the public health component are likely to raise somecontroversy. Tobacco industry opposition may in fact be a reliable barometer of project effectiveness andcontroversy with respect to tobacco should not necessarily be avoided, but rather considered part of thecosts of undertaking tobacco control.
G: Main Loan Conditions
1. Effectiveness Conditions:
(i) Approval of the project's Operational Manual by the Bank and adoption of the Manual by MSAS;(ii) Establishment of the Project Coordination Unit (PCU), and key staff, namely a project
coordinator, a general manager, a technical manager for each of the three components managers,and an administrative supervisor, with terms of reference and qualifications satisfactory to theBank are appointed and in place.
(iii) The core technical personnel of the MSAS required for project implementation selected (threeepidemiologists, two communicable diseases specialists, and a statistician), including at least 20trainers/supervisors at provincial level (physicians, public health specialists or epidemiologists)have been selected.
(iv) Review of the norms and procedures for surveillance completed, and results furnished to theBank.
(v) All necessary actions taken by the Borrower to permit the procurement of goods, works andservices required and financed by the Project to be carried out in accordance with Bankprocurement guidelines and procedures.
Other: (classify according to covenant types used in the Legal Agreements)
(i) Mid-term review in May 31, 2002. The PCU will, no later than March 30, 2002, prepare andsubmit a summary report to the Bank as an input to the mid-term review;
(ii) PCU will submit to the Bank semi-annual progress reports no later than March 1 and September 1each year starting March 2000;
(iii) The Borrower will contract an independent auditor with terms of reference and qualificationsacceptable to the Bank to carry out annual procurement and financial audits of the project;
(iv) The LACI system has to be in place no later than six months after the effectiveness date;(v) The PCU will, no later than December 31, 2002, prepare the terms of reference for the carrying
out of the system evaluation, and the PCU will carry out the evaluation of the system by January
Page 24
31, 2003; and(vi) Procurement of an agency or specialized consultants' services for carrying out the annual
independent procurement and financial audit of the project by December 31, 1999, and carryingout the audits by June 30 of each year,
H: Readiness for Implementation[x] 1. The Project Implementation Plan has been prepared for the entire project time life (project files);[x] 2. A task catalog, including, identification of the task, location, objectives, dates, responsible staff forimplementation, budget and procurement methodology was also elaborated for the time life of the project(project files);[x] 3. The terms of reference to develop the monitoring and evaluation system of the project under LACIsystem are approved (project files).
I. Compliance with Bank Policies. This project complies with all applicable Bank policies.
Team e: abela Abreu
Sector ir ctor: Xavier Coll
Coun e Myrna Alexander
Annex 1: Project Design Summary
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
Hierarchy of Objectives Verifiable Indicators Means of Verification ImportantAssumptions
Sector-related CAS Goal: Sector/country Reports: (from Goal to BankImprove the health of the MSAS Statistics Mission): Sustainable,population by reducing efficient and adequatemortality and morbidity health surveillance and
disease prevention andcontrol system
Project Development Project Reports: (from Objective to Goal)ObjectiveStrengthen national, provincial * Notifiable disease data * SINAVE data * Surveillanceand local institutions appropriately utilized: * Project Supervision * Personnel trainedresponsible for public health 90% of cases of invasive * Surveillance normspolicy, planning and action meningococcal disease and procedures
(meningitis or revised and adoptedmeningococcemia) detected * Datahave been investigated and Telecommunicationsappropriate control measures system implemented(chemoprophylaxis) instituted
* Bulletin development andproduction (36 bulletins)
* TB incidence decreased 15%
* Hospital-acquired infectionsin target hospitals associatedwith catheter, urinary tract andventilator reduced by 20%,10%, and 10%, respectively
Output from each component: Project Reports (from Outputs toObjective)
**A stronger Public Health * Surveillance system detects * SINAVE Data * SurveillanceSurveillance System at least .75 cases of invasive * Project Supervision * Personnel trained
meningococcal disease * Surveillance norms(meningitis or and proceduresmeningococcemia) per revised and adopted100,000 pop., and this level * Datashould be met or exceeded in Telecommunications-75% of the provinces system implemented- 75% culture confirned * Ministry of Health- 90% of isolates sero- will be able to hiregrouped and maintain key
* 3 cases of bacterial personnel at centralmeningitis reported for every levelcase of meningococcal * Availability ofdisease recognized funds to meet the- 50% culture confirmed incremental recurrent
* An etiologic agent identified costsin at least 3% of stoolcultures obtained from allpersons identified withdiarrheal diseases at sentinelsites
* At least 200 influenzaviruses per year obtainedfrom throat swabs taken
Hierarchy of Objectives Verifiablej Idicators* Mens of Verifiato Importantl: __________________ : A ssumptions
* Data definitions and . SINAVE dataCoding standards definedand adopted
* Sentinel network fully * Project supervisionimplemented (50 sites for . Procurementcommunicable diseases, and records20 for injuries)
* Laboratory network * Project supervisionUpgraded (one national labupgraded to BSL-3, 36upgraded to BSL-2, and 25upgraded to BSL- I, andequipped)
* 80% of the provinces are * Project supervisiondeveloping 4 surveillancebulletins/year and central13/year, availableelectronically via theInternet
**Improved Disease Control in * Direct observed treatmnent . Project statistics * Availability of TBSelected Areas Coverage for TB: 80% * Project supervision drugs
(+20%)
* BacteriologicConfirmation of TBpulmonary cases increasedup to 85% (+15%)
* Sentinel network forDengue control fullyimplemented (52 sites)
* 300 key personnel trainedin hospital infections,prevention and control
* 2000 field workers trainedin TB and dengue control
* 800 health professionalstrained in epidemiology anddiagnostic testing for TBand dengue
Hierarchy of Objectives r Verifiable Indicators Means of Verification Important,__________ ____ __ _ _____Assumptions
Health Promotion Unit have keypersonnel trained as follows:
**lmproved Health Promotion a Health Communication: 10 * PCU reports * Governmentl Procurement support for therecords evolving role of
Health journalists trained in . PCU reports health promotionbasic surveillance and * Project missioncontrol: 10 * Government and
Tobacco media campaigr . PCU reports Civil Society supportexecuted . Project supervision for the involvement
of the private sectorI Pilot tobacco control study
on 1private corporationexecuted
Advocacy group . Minutes of theConstituted and active meetings
Project Components/Sub- Inputs (budget for each Project Reports (from Components tocomponents component) Outputs)
**Strengthening the Public US$ 42.4 - Project costs * Timely availability ofHealth Surveillance System - Financial Monitoring counterpart funds
**Health Promotion I US$ 9.7 financial reports**Project Administration US56.0 -Contracts
Annex 2: Project Description
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
Component I: Strengthening the Public Health Surveillance System. (US$ 42.4 million) This component,to be implemented nationally and in stages, seeks to strengthen MSAS institutional capacity to makeinformed decisions about prevention and control priorities and to monitor the impact of interventions.Specifically, it will:
(i) review the norms and procedures for surveillance and attempt to standardize case definitions,reporting procedures and data collection in accordance with the new system design;
(ii) strengthen human resource capacity, at all levels, to carry out all health surveillance activity areasof training including the surveillance of communicable diseases, chronic diseases, behavioral riskfactors and injuries (see Annex 14);
(iii) rehabilitate, expand and upgrade the existing laboratory network (1 laboratory level III, 36laboratories level II and 25 level I) through the provision of technical assistance, the acquisitionof equipment and construction of civil works (see Annex 12);
(iv) improve the quality of the existing health data telecommunications through provision ofappropriate hardware, software, training and technical assistance to the specialized staff in thelaboratory network and health facilities participating in the surveillance system (see Annex 13).An internet based network will be developed for data transfer and storage for the intermediate,provincial and central levels. This network will link to laboratories, control programs, vitalstatistics, and maternal and child health in addition to epidemiology and surveillance groups. Itwill be password protected and have appropriate security;
(v) improve the rationale of the current system by implementing alternative surveillance methods andreducing the number of conditions under surveillance (see Table A) through the provision oftechnical assistance and training for MSAS staff in, inter alia, the design of data collectioninstruments, questionnaires, scales, sampling methods, record-keeping, and data analysis andcollection, and collection of baseline data on risk factors and behavior. The options were basedon quantitative analysis (see Annex 4), other countries' experiences and bibliography. Thesentinel network will be implemented gradually (Table B) for four communicable conditions andinjuries. This will allow surveillance to be phased in, for initial sites to assist in training groupsfrom subsequent sites, and for the efficient implementation of necessary corrections to datacollection and disease monitoring. Other health conditions can be added to the system accordingto epidemiological patterns of disease in Argentina;
(vi) evaluation of the technical and economic aspects of the surveillance system ( to assess thecapacity of the system to monitor each health event, taking into consideration sensitivity,specificity'", efficiency, representativeness, timeliness and flexibility of the system); atnegotiations, it was agreed that this would take place by January 31, 2003;
(vii) finance operational research in epidemiolog-cal surveillance such as assessment of therepresentativeness and completeness of disease reporting; timeliness; adherence to establishedcase definitions; patterns of diseases not on the current monitoring system list to determinewhether they should be added; review and tabulation of reported outbreaks, and other topics, andalso disease control. Selection criteria are specified in the Operational Manual; and
(viii) evaluate effectiveness and relevance of training activities supported by the project.
9 Sensitivity is the proportion of persons with a disease/health event that are detected by the surveillance system
10 Specificity is the proportion of persons without a disease/health event that are detected by the surveillance system
Annex 2 Page 2 of 5
Component II: Strengthening Disease Control. (US$ 16.4 million) This component will strengthen theinstitutional capacity of participating provinces and the City of Buenos Aires to carry out diseasemonitoring, control and prevention. Specifically, it will support:
(i) tuberculosis control in 10 provinces and Metropolitan Buenos Aires, the areas of highestincidence and multi-resistance to therapy (Buenos Aires, Santa Fe, Cordoba, Mendonza, Ciudadde Buenos Aires, Salta, Jujuy, Rio Negro, and Santa Cruz);
(ii) dengue control in high risk populations, through 52 sentinel sites (see Table D) (selected on thebasis of risk mapping, prevalence, vectors density, and population) which will monitor for febrileillness including lab testing of suspected cases, and vector monitoring in areas of high risk withhigh levels of vector infestation ( Salta, Catamarca, Jujuy, Tucumin, Corrientes, Misiones, SantaFe, Capital Federal, Cordoba, Chaco, Formosa, Entre Rios, Buenos Aires, Santiago del Estero, LaRioja)
(iii) nosocomial (hospital acquired) infection control in 100 randomly selected hospitals (80 publicand 20 private) which meet specific selection criteria (see Table E). This will include support for:a) elaboration of the norms and procedures for NI control; b) rehabilitation of existinginfrastructure; c) collection of baseline data on hospital infections; d) training of professionalteams for prevention and control of selected diseases; e) computers and software for surveillance;f) supervision and technical assistance; and h) vehicles ; and
(iv) control of emergent and re-emergent diseases which may occur during the life of the project,through subprojects financed by grants.
Component III: Health Promotion (HP). (US$ 9.7 million) This component will strengthen MSAScapacity to carry out a health promotion strategy through education, social mobilization and policyadvocacy. Specifically, it will support:
(i) strengthening the institutional capacity of the health promotion unit of the MSAS, throughtraining, equipment and rehabilitation of the existing infrastructure;
(ii) training of MSAS and HP personnel in media and communications, and training of healthjournalists in the areas of disease surveillance and control;
(iii) subprojects to be implemented by local institutions and community groups to set up or strengthendisease prevention and health promotion within their communities (eligibility criteria andapplication procedures are described in the Operational Manual);
(iv) dissemination of project objectives and activities through regular newsletters directed at thepublic health community and through workshops, conferences and technical meetings forstakeholders such as politicians, government officials, the medical and private insurancecommunity, and others;
(v) over the life of the project, meetings of a committee of political and social leaders, includinghealth journalists, to define a strategy and action plan to help ensure sustainability of the project;
(vi) a media campaign against tobacco addiction to be designed on the basis of a risk factors survey;and
(vii) a plan to include private corporations in a partnership with the Ministry of Health to combattobacco addiction in the employees of such corporations. This plan will include; a) identificationof studies detailing economic cost of tobacco addiction from a corporate perspective; b) a tobaccocontrol conference, with participation of key executives of major Argentine corporations; c) usingevidence of the studies, identification of an Argentine corporation willing to serve as astudy/intervention site; d) analysis of the economic cost of tobacco addiction within thecorporation; e) development of a tobacco control program for the corporation; and (f) replicationfor other corporations.
Component IV: Project Administration. (US$6.0 million) The project will help finance the administrativeand operating costs of the Project Coordinating Unit over a 4-year period. This includes: (i) PCU
Annex 2 Page 3 of 5
technical and managerial staff, with the exception of the core technical team within MSAS, (ii) domesticand international travel and per diem for PCU staff; (iii) training of PCU staff; and (iv) equipment,
materials and office supplies.Diseases and Surveillance Methods
Table A
rImmuno-Preventible -Zoosi 0- Polio and Flaccid Paralysis - Intensive - Rabies (human) - individual- Diphtheria - Individual - Rabies (animal) - # of cases- Measles - Intensive - Psittacosis - Individual- Tetanus (adult and neo-natal) - Intensive - Anthrax - Individual- Mumps - # of cases - Hydatidosis - # of cases- Rubella - # of cases - Hemorragic Fever - Individual- Whooping Cough - # of cases (Argentina)
Implementation of Sentinel Sites by ConditionTable B
~Condition Year 2 Year 3~ Year4 T6(tal ProvincesDiarrhea 5 10 5 20 Santiago del Estero (2), Salta (2), Jujuy, Chaco, Formosa, Santa
Fe, Buenos Aires Region V, VI and Vlla, Mendoza, Rio Negro,Neuquen, Corrientes, Tucuman, Misiones, Entre Rios, C6rdoba,La Pampa
Influenza 6 6 12 C6rdoba, Buenos Aires III, VI, Vila and VIII, Capital (2), SantaFe (2), Mendoza, Neuquen, Santa Cruz
Lower 6 5 I 11 C6rdoba, Buenos Aires VI and VIII, Capital, Santa Fe, Mendoza,Respiratory Misiones, Chaco, Tucuman, Rio Negro, Santiago (serology willInfections be done in 3 of these sites)Chlamydia 4 3 - 7 Capital, C6rdoba, Misiones, Mendoza, Santa Fe, Salta, CorrientesAccidents 5 10 5 20 Buenos Aires Region IV, V, VI and VIla, C6rdoba, Santa Fe (2),(auto and Capital (2), La Pampa, Mendoza, Chubut, Formosa, Corrientes,household) Santa Cruz, Neuqudn, Rio Negro, Chaco, Catamarca, Salta
1 Surveillance will be carried out by the LUSIDA Project (the National AIDS and STD Control Project)
Annex 2 Page 4 of 5
New Personnel to be Paid by the Project 12
(Later integrated as MSAS staff)Table C
Description Year 1 Year 2 Year 3 Year 4Surveillance SystemCentral Level
* Epidemiologists 4 4 3 3* Infectious Disease Specialists 2 2 1* Statisticians I I 1* Trainers 2 2 2 I* Editor/Illustrator I - - -
* Administrative Support 2 1 1* Administrator of Telecommunication Network - 1 I * I Entomologist
+ I Biologist Contracted by task* I Sanitation Engineer* I Biochemist Support from ANLIS
(on an as-needed basis)Provincial Level
* Trainers/Supervisors 45 45 15(30 others to be
paid by provinces)
Sentinel Sites for Dengue ControlTable D
Year Sites EstablishedYear 1 . 8 sites in NOA
. 8 sites in NEA* 6 sites in Central Argentina. 8 sites in Metropolitan Buenos Aires
Year 2 . 7 sites in NOA. 7 sites in NEA. 4 sites in Central Argentina. 4 sites in Metropolitan Buenos Aires
NOA=Northwest Argentina (Jujuy, Salta, TucumAn, Santiago del Estero, Catamarca, La RiojaNEA=Northeast Argentina (Formosa, Chaco, Santa Fe, Entre Rios, Corrientes, Misiones)
12 Tasks and responsibilities of this personnel were reviewed and accepted by the Bank.
Annex 2 PageS of5
Site Selection Criteria - DengueTable D(a)
> Health Centers with more than 100 ambulatory patients daily> Health Centers in areas with vector infestation rate above 5%
((# of water infected supplies/Total # of Households Inspected) xlOO}
> Laboratory available to identify Dengue cases
Hospital Selection CriteriaTable E
> Hospital must have an Infection Control Committee> More than 50 beds, and an occupancy rate greater than 70%> Hospital must have an intensive care unit
Annex 3: Estimated Project Costs
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
1.Strengthenlingmthe Public Health Surveillance System 35.9 2.3 38.22. Strengthening Disease Control 14.2 1.0 15.23. Health Promotion 8.2 0.4 8.64. Project Administration 5.1 0.3 5.4
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
A two-part economic analysis was carried out for the Argentina Disease Surveillance and Control Project:an impact/cost-utility and a sustainability analysis. This annex summarizes the main assumptions and therecommendations. The detailed analyses can be found in the Project file.
Impact and Cost-Utility Analysis
Main Analytical Steps and Assumptions:
1. Using estimates from the Global Burden of Disease (GBD) Study, and building on mortality datafrom 1996, estimates are made of the current impact of several diseases (stated in YLL's or Years of LifeLost, and DALY's or Disability-Adjusted Life Years). The impact analysis includes infectious diseasesas well as non-communicable diseases and injuries. The results should be considered very approximate;their importance lies in the fact that they can give a general sense of the scale of different diseases andtheir impact relative to each other. They do not intend to demonstrate the absolute burden of diseases. Toavoid this confusion, the word impact, and not burden, has been used throughout the analysis, eventhough the unit used is Disability-Adjusted Life Years.
2. The quantification of impact is complemented by cost-utility data (in dollars per DALY averted)gathered from different sources, to arrive at an approximate ranking of diseases both by impact, and bypriority of investment. Not all diseases are evaluated due to lack of data. The major source of data usedis Jamison et al. (1993) which collects and compiles a significant amount of cost-utility data fromdifferent studies.
3. The establishment of priorities and the final recommendation as to the inclusion of each diseasein the surveillance and the disease control components are based on a few criteria. The quantitativecriteria are: (i) disease impact, and (ii) cost-utility, and the non-quantitative are: (i) outbreak potential (oremergent disease), (ii) plans or potential for eradication, (iii) vaccine-preventability, (iv) being anindicator or risk factor for an important disease, and (v) the probability that improved surveillanceinformation would lead to better control (i.e. reduced impact) of the disease. Outbreak potential is muchmore difficult to quantify than the current impact of a disease. For many diseases, mathematical modelshave been created for the projection of future patterns, most notably for HIV/AIDS. However, this is nota practical path for the design of surveillance and control programs because (i) the construction of eachmodel is laborious and time-consuming, and (ii) it is not easy to verify the accuracy of these models.One option is to simply examine the diseases on a case-by-case basis and using the observed behavior ofeach disease in the past (within or outside the national territory), or suspected biological characteristics inthe case of newly recognized diseases, determine the necessity of surveillance. Often, a simplequantitative indicator can serve as an adjunct to this decision process. The indicator chosen for this studyis the ratio of maximum to minimum incidence for the period for which incidence data is available. Thisgives a very approximate bearing of the outbreak potential of some diseases with the followinglimitations: (i) diseases which have had a zero incidence during one or more years cannot be included, (ii)diseases which have been well-controlled will not show their true potential for spread, (iii) diseases whichthreaten to enter the country but have not yet done so will not be included, and (iv) diseases with verysmall numbers could show very large ratios with even a small increase in absolute number of cases.
Annex 4 Page 2 of IOMain Recommendations:
Based on the quantitative criteria (impact and cost-utility), and some complementary non-quantitative criteria (forexample diseases with plans for eradication), a recommendation is made for the inclusion or not of diseases in each of theepidemiological surveillance and disease control components of the Project.
1. For the surveillance component, of the original list of some 50 notifiable diseases, 31 are recommended forgeneral surveillance, and 6 indicated for sentinel site surveillance. Two important points to be considered in thesediscussions are the potential for spread of these diseases, and more importantly, the probable effect of surveillance onchecking the spread of the disease. Depending on the peculiar characteristics of the disease in question, and specificsocioeconomic and political characteristics of the regions where it occurs, surveillance may have anywhere from great tolittle or no effect on its control. In the latter case, its inclusion in thenotifiable disease list might be inefficient and burdenthe surveillance system without tangible gain. The recommendations for the epidemiological surveillance system aresummarized in table I below.
TABLE 1: SUMMARY OF RECOMMENDATIONS FORTHE SURVEILLANCE COMPONENT
SUmVEXUJANCE M lT'O,ttenive Ind-d.al Number e6 'a . ent,Polio and Flaccid Diphtheria Mumps Diarrhea Enteric ToxinsParalysis (outbreaks, red tide,
trichinosis) - outbreakinvestigation
Measles Typhoid Fever Rubella Influenza HIV/AIDS - program
Tetanus (adult and Botulism Whooping Cough Lower Respiratoryneo-natal) Infections
Cholera Tuberculosis Syphilis (adult and Chlamydiacongenital)
Leprosy Gonorrhea Accidents (auto andhousehold)
Hepatitis A, B, C, and Rabies (animal) Injuries (self-inflicted)othersRabies (human) Hydatidosis Injuries (violence-
and adult)Hemorragic Fever(Argentina)HantavirusLeptospirosisMeningitis (bacterial& viral)MalariaLeishmaniosisYellow FeverTyphusPlague
2. For the disease control component, 17 diseases are recommended, complemented by another 8 vaccine-preventable illnesses. Although Argentine hemorrhagic fever is included, it is advisable that the specific situation, presentnecessity of and prospects for effective control be discussed in the Ministry of Health before a definitive decision is made.Although immunizable diseases are not necessarily a responsibility of the VIGIA Project, they are included here to becomplete. Eight such diseases are included, with tuberculosis a potential ninth candidate which is already mentioned in
Annex 4 Page 3 of 10
the first list. Mumps and rubella do not cause a large impact in the population, however with the use of the MMRvaccine, their control can be achieved at low incremental cost, thus their inclusion in this list.
TABLE 2: SUMMARY OF RECOMMENDATIONS FORTHE DISEASE CONTROL COMPONENT
NON. 'ACCINE EI!TABLz.ISE ,IIvACC VNASl
Tuberculosis PertussisSyphilis PoliomyelitisChlamydia DiphtheriaGonorrhea MeaslesHIV TetanusDiarrheal diseases MumpsBacterial meningitis and meningococcemia RubellaHepatitis B and hepatitis C Neonatal TetanusMalariaChagas diseaseLeishmaniasisLeprosyDengueLower respiratory infectionsCholeraTyphoid FeverArgentine Hemorrhagic Fever
Annex 4 Page 4 of 10
Disease Control Component - Cost-Benefit Analysis
Dengue (Information Adapted from Shepard and Halstead in Jamison et al. 1993)
Direct costs associated with the disease include vector control, vaccinations, diagnosis, and outpatient treatment of mildcases (which are 10 to 50 times more common that reported severe cases), and intensive care of the severely ill, includingintravenous fluids, blood or plasma transfusion, and polypharmacy, with average hospital stays of 5 to 1O days for severecases. Adults lose work to attend to children's illness, and there is a large risk of mortality particularly forhemorrhagicdengue fever. In addition, there is a substantial likelihood of losses associated with reduction of tourism and relatedbusiness activities.
In 1987, more than 600,000 cases of dengue hemorrhagic fever were reported in Southeast Asia, with 24,000 deaths (adeath rate of 4 percent). Venezuela experienced 1,000 cases in a 1989-90 outbreak, including 50 deaths (a death rate of 5percent). A 1981 outbreak in Cuba caused 116,000 hospitalizations, more than 1 percent of the population, during a 3-month period. Puerto Rico experienced a major outbreak in 1977 and has had recurring outbreaks in the 1990s.
There are two estimates of the cost of the 1977 epidemic in Puerto Rico ( with a population of 3 million people). The firstincludes the direct costs for medical care and vector control measures and indirect costs for lost production due to illnessand absenteeism by patients and by parents caring for sick children. Total estimated costs on this basis range between$6.0 million and $16 million. Another estimate that includes losses due to lost tourism raises the cost to $100 to $150million. Costs of the 1981 outbreak in Cuba (with a population of 10 million) have been estimated at $103 million. Incurrent dollars, the amount would be about triple, in both cases.
Argentina experienced an epidemic of dengue fever in 1998, with an estimated 800 cases. Deaths due to the epidemic arenot known; knowledge of what actually happened is scarce because of poor surveillance. This small epidemic wasprimarily self-limiting.
Given that we do not have good information on which to base a detailed economic analysis for Argentina, we will use thePuerto Rican and Cuban cases to develop a rough idea of the range of potential costs of a dengue epidemic in Argentina.These are relevant because the goal of the MHAS is to prevent a serious outbreak, with the belief today after the 1998outbreak that there is a reasonable probability of an outbreak occurring in densely populated Buenos Aires Province,which would be disastrous. In Buenos Aires metropolitan area, there are 12 million at high risk, where it has beenobserved household infections rates above 30%. The risk of hemorrhagic dengue is higher with the recent introduction inthe country of the serotype 2, and the occurrence of epidemics in the neighboring countries.
In the Puerto Rican case, the cost per capita if we assume the lower bound cost of $100 million (from the estimateincluding tourism losses, as the experience in Argentina in 1998 was a significant loss of bookings in hotels), was about$33 per capita in 1977, or about $100 per capita in 1999. In the Cuban case, the cost per capita was about $10, or about$30 per capita in 1999. Argentina is probably much more similar to Puerto Rican case in terms of income and impact, solet us assume a cost of $80 per capita in current monetary units of a serious dengue outbreak in Argentina.
If we further assume that probability of a serious outbreak of dengue fever is 0.5 percent (one-half of one percent)annually, and the benefits of the project last until 2010, the expected value of the cost of dengue would be about $13.9million in the first year (.005 times $80 times 34.7 million people) and $256 million over the period from 2001 to 2010(undiscounted). If the project is able to reduce the probability of a serious dengue outbreak by half (to 0.25 percent), wewould expect approximately half of these costs to be saved. The table below indicates the sensitivity of theundiscountedbenefit to the assumed probability of an outbreak.
Annex 4 Page 5 of 10
Table IProbability of an Outbreak Undiscounted 10 Year Benefit of Project: Reduction by Half of the
Probability of an Outbreak of Dengue Fever0.005 $128 million0.004 $102 million0.003 $77 million0.002 $51 million0.001 $26 million
In effect, with this project, Argentina is trying to reduce the probability of an epidemic, so we feel this is a valid way toapproach the potential benefit of the project.
Tuberculosis
For tuberculosis, there were 13,000 new cases in Argentina in 1997. We project that the incidence of the disease willgrow by 2 percent per year until 2010 if there is no intervention. The project's goal is to reduce the incidence of thedisease by 15 percent at the end of 4 years, over what it would otherwise have been. This benefit is assumed to persist to2010, so that in 2010 there are 15 percent fewer cases than there otherwise would have been. In this analysis we ignoremortality. We focus only on the direct costs of hospitalization and lost wages due to morbidity (that means ignoringclinical costs for those who are not hospitalized, or after hospitalization). We make the following assumptions:
Table 2Variable AssumptionProjected Hospitalizations 5 % of new casesLength of Stay Per Hospitalization 35 daysCost Per Day $15Average Days of Morbidity for TB 548Disability Weight for TB 0.294Daily Income Lost for Disability $7Reduction in Incidence by Project 15 % over 5 years
The total projected inpatient costs and lost income associated with the 13,000 new cases in 2001 is $8.0 million. By 2010,the total is $95.2 million (undiscounted). If the project reduces cases by the planned percentage, savings in 2001 will be$0.4 million. The savings will accumulate to $12.2 million (undiscounted) in 2010.
Hospital Infections
The project is expected to reduce infections acquired during a hospitalization by an average of 13 percent for the threemost prevalent infections in 100 hospitals by the end of the project. The benefit of the project in this case is assumed tobe limited only to the reduction in hospitalization costs (ignoring wages, morbidity, mortality, etc.). The assumptionsused are as follows:
Table 3Variable AssumptionTotal Number of Hospitalizations (1% of Population) 347000Percentage of Acquired Infections 0.05Added Length of Stay Due to Infection 5 daysCost Per Day $15Average Reduction Due to Project (grows to .133 by the fifth year, then persists 0.05at that level to 2010)Percent of Infections Covered by Project 0.8Percent of Cases Accounted for by Project Hospitals 0.8
Annex 4 Page 6 of 10
The projected incremental inpatient costs associated with acquired infections in the first year for all hospitals in Argentinais $1.3 million. This accumulates to $28.4 million by 2010. With the project intervention, the cost savings is expected tobe $0.042 million in the first year, accumulating to $1.9 million (undiscounted) by 2010.
Overall
Table 4Intervention Undiscounted 10 Year Benefit from 2001 to 2010Dengue Management $127,833,059Tuberculosis $12,204,183.03Hospital Acquired Infections $1,886,125Total $141,923,367
If the logic of the analysis is agreed to, and the assumptions are agreed to be reasonable, the benefits of the disease controlcomponent are substantial and in fact can carry the whole project. We assume further that costs are incurred in calendaryears 1999 and 2000, but with no benefits received until 2001. The internal rate of return for the disease controlcomponent (cost of $16.4 million) is 63% (the discount rate that would drive the stream of net benefits to 0). If weassume that the rest of the project produces nothing of value beyond the benefits of the disease control program (at a costof $75 million), the internal rate of return would be 15 percent.
1. Incremental recurrent costs are calculated based on five broad categories (Table 1). The estimate for salaries isbased on the manpower necessary to maintain the system given the gradually declining number of staff hired by theProject, both at the central and the provincial level. Maintenance of the sentinel units is assumed to cost $4,000 per yearfor each injury unit and $10,000 for other units. Surveillance of risk factors and communicable diseases begins in thethird year; annual costs are assumed to be constant into the post-Project period and will be financed by theMoH from2003 onward. The telecommunications system involves brings about costs for equipment maintenance and update and forinternet and telephone use; with the expected deregulation, costs are assumed to decrease by 20% in 2003, 30% in 2004,and 35% in 2004. DOTS for tuberculosis involves medication and supervision costs; training at the local level will becompleted by Project end and will not be a source of any incremental costs. Although the number of cases of TB isexpected to increase initially, incidence, abandon of treatment, and recrudescent cases are all expected to decline,therefore medication costs are not expected to increase. There is a possibility that surveillance of non-communicablediseases increases the number of recognized cases thus elevating treatment costs, however it is too early to speculate onthis issue. The incremental recurrent costs of the Project start at $386 thousand in the year 2000, peak during the firstpost-Project year at $3.3 million and then, due to projected drops in telecommunications costs, decline to about $3.1million by the year 2005.
Table 1- Incremental Recurrent Costs of the VIGIA Project (in 1,000 US$)'-3
Salaries - 36 144 774 1,062 1,062 1,062Maintenance of Sentinel Units - - - - 580 580 580Implementation of Risk Factor and Non- - - - - 500 500 500Communicable Disease Surveillance I I IMaintenance of Telecommunications System - 350 1,660 1,310 1,048 917 852DOTS (Tuberculosis) - - - - 69 69 69
Between 80 and 90 percent of the incremental recurrent costs will be incurred by the provinces. Unfortunately, noconsolidated information about provincial public spending on health surveillance exists at central level. Althoughanalysis of project sustainability at provincial level could not be achieved during project preparation because it requires aseparate investigation of spending on health surveillance in each of the twenty-three provinces and the federal capital.Sustainability at provincial level, however, is not an issue: the incremental recurrent costs associated with VIGIArepresent only about 0. 1 percent of annual health spending by the provinces ($ 4.4 billion/year, excluding transfers fromthe federal government and excluding spending by Obras Sociales). The real issue is not the provinces' ability to financethe incremental recurrent costs, but their willingness to do so. The analysis below supposes, hypothetically, that theprovinces are unwilling or unable to finance the incremental recurrent costs and that the federal Ministry of Health has topick up the tab. The analytical strategy adopted here is to argue that if the project is sustainable in the absence ofprovincial financing - although it is clear that the provincial governments are responsible for part of these recurrent costs -it is a fortiori sustainable when provinces pick up their share of the incremental recurrent costs. Note that the analysismust not be read to mean that the federal government should pick up the tab; rather it should be read as a worst-casescenario that the project appraisal team does not expect to happen. In order to minimize the risks, the participationagreements (cf. section C.4 of PAD) that will be signed between the provinces and the federal Ministry of Health containexplicit clauses to ensure that the provinces will deploy the necessary financial, personnel and administrative resources forthe implementation of the project. The risk that particular provinces refuse to sign these agreements and refrain fromparticipating in the project is negligible: all the provinces have expressed a strong interest in participating in the schemewith no further delay (cf. section D. 1 of PAD).
13 The referred incremental recurrent costs are not financed by the project.
Annex 4 Page 9 of 102. The effects of the global financial crisis from the third trimester of 1998 onward introduce an important elementof uncertainty into any projection of future economic growth, and consequently of future public finance. As a result of thefinancial crisis, the overall public sector budget in 1998 has been reduced by about one billion dollars, with healthexpenditure being reduced to an estimated $463 million as opposed to an initial budget of $509 million. In 1999, totalpublic expenditure and health expenditure is expected to remain about the same in absolute values as the modifiedexpenditure of 1998. Two scenarios have been developed to estimate the resources available for health: 1) a baselinescenario using CAS projections of GDP growth (2% in 1999, 4.5% in 2000, and 5% from 2001 onward) and a non-lineardecline of the ratio of public expenditure to GDP stabilizing at about 23% by the year 2003; 2) a pessimistic scenarioassuming GDP growth of 2% from 1999 onward with a constant public expenditure to GDP ratio from 1998 onward. Inboth scenarios, it is assumed that health expenditure remains a constant proportion of total public sector expenditure using1997 as the point of reference. It is also assumed that the proportions of overall health expenditure allocated to theMoHbudget and to disease control and surveillance remain constant with relation to the previsions for 1999.
Main Results
1. As can be seen in Tables 2 and 3, there is a positive financial margin of maneuver in both projected scenarios.The margin of maneuver is calculated as the difference between the additional resources available any particular year tothe MoH (relative to 1998) and the additional recurrent costs generated by the project. With baseline assumptions, themargin of maneuver drops to a low of $1 million in year 2000. The pessimistic scenario would leave a minimum marginof maneuver of $800,000 in year 2000. Incremental recurrent costs are expected to decline after the implementationperiod because improved surveillance helps check the spread of epidemics earlier and thus contributes to lower health carecosts.
2. According to these projections, the project is judged to be marginally sustainable both during its lifetime and inthe period after its completion. However, the financial cushion is very thin and warrants close and continuous monitoringof the evolution of both public finances and project-related incremental costs. In addition, the availability of funds at theMoH level does not in and of itself guarantee that these funds will be directed towards project-related activities. It istherefore strongly recommended that plans be made for the allocation of specific recurrent budgets to ensure the adequatefinancing of project-related activities during and after the implementation period. If public finances do not meet currentexpectations, the project should revisit the sequence of implementation and focus on priority activities.
Table 2- Sustainability of the VIGIA Project: Baseline Scenario (in 1,000 US$)
Argentina: Public Health Surveillance and Disease Control
Procurement
Procurement for the proposed project would be carried out using standard contract documents acceptable to theWorld Bank, and the "Guidelines for Procurement Under IBRD Loans and IDA Credits", published in January1995 (revised January/August 1996, September 1997 and January 1999); and "Guidelines: Selection andEmployment of Consultants by World Bank Borrowers", published in January 1997 (revised in September 1997and January 1999), and the provisions stipulated in the Loan Agreement. Procurement arrangements aresummarized in Table A.
Procurement activities will be carried out by an existing central unit in the Ministry of Health and Social Action.The Operational Manual will include, in addition to the procurement procedures, the standard bidding documentsto be used in each case, as well as standard contracts to be awarded on the basis of quotations."4
Procurement of Goods
Goods including computer hardware and software, vehicles, office equipment, fumigation and laboratoryequipment, chemicals, medical equipment, teaching and training material, brochures and public informationdocuments for the total amount of US$9.725 million, out of which the Bank will finance US$6.72 millionequivalent shall be procured in accordance with:
(a) Intemational Competitive Bidding (ICB). Contracts for laboratory equipment, hardware, surveillancesoftware, and chemicals among others estimated to cost more than US$350,000 equivalent per contract shall beprocured following ICB procedures, using the Bank's standard bidding documents.(b) National Competitive Bidding (NCB). Contracts for training material, technical information, documentation,and office equipment estimated to cost less than US$350,000 equivalent per contract shall be procured followingNCB procedures using model bidding documents acceptable to the Bank up to an aggregate amount not to exceedUS$2.7 million equivalent.(c) Price Comparison (National /International Shopping). Goods such as, laboratory software, laboratoryequipment, vehicles, and bulletins among others, estimated to cost less than US$100,000 equivalent per contractup to an aggregate amount of US$0.775 million equivalent would be procured through price comparison.
Procurement of Civil works
The project will finance small civil works for the total amount of US$5.45 million equivalent, out of whichUS$3.715 million will be financed under the loan. These civil works comprise the refurbishment and upgradingof physical infrastructure of existing laboratories.
(a) National Competitive Bidding (NCB). Civil works, including upgrading of existing infrastructure andlaboratories estimated to cost more than US$350,000 equivalent per contract shall be procured following NCBprocedures, using model bidding documents acceptable to the Bank.
Procurement of Small Works(b) Price Comparison (PC). Civil works, including upgrading of existing infrastructure and laboratories expectedto cost less than US$350,000 equivalent per contract may be procured through comparison of at least threequotations from qualified contractors under lump-sum, fixed-price contracts, up to an aggregate amount ofUS$0.9 million equivalent. No civil works contracts are expected to cost more than US$1.8 million equivalent.
4 Where no relevant standard contract exists, other standard forms acceptable to the Bank
Annex 6 Page 2 of 8
Consultants' Services
Consulting services including, among others, technical assistance, sector studies, scholarships and trainingactivities, development and maintenance of a database telecommunications system, and a risk factors survey, forthe total amount of US$37.3 million equivalent, out of which the Bank will finance US$29.74 million equivalentshall be contracted in accordance with the Bank's "Guidelines: Selection and Employment of Consultants byWorld Bank Borrowers" (January 1997, revised on September 1997 and January 1999).
(a) Consultants' Services for sector studies will be hired through Quality-and-Cost-based Selection (QCBS)for contracts estimated to cost US$200,000 equivalent or more, totaling about US$15.4 million equivalent.
(b) Small contracts with firms for technical assistance not to exceed US$200,000 would be contractedfollowing QCBS or Least-Cost Selection (LCS), as the Bank may reasonably determine, and very small technicalassistance or training contracts with organizations not exceeding US$100,000 equivalent would be contractedunder Least-Cost Selection (LCS) up to an aggregate amount of US$5.3 million. Contracts for training notexpected to exceed US$45,000 each up to an aggregate of amount of US$3.5 million equivalent shall be awardedon the basis of Selection based on Consultant's Qualifications (SCQ).
(c) The project will also finance regional workshops throughout the country and high-level research projectsunder Component I. Operational Research Fund, for a total of US$3.0 million allocated to subprojects submittedby NGOs, research organizations, and public and private universities'5. Grant recipients will be selected based onthe criteria outlined in the Operational Manual.
Individual consultants, trainers and visiting professors for an aggregate amount of approximately US$5.54 millionwould be hired on the basis of their qualifications, in accordance with the procedures described in Section 5 of theConsultant Guidelines. Whenever possible, the Project may publish requests of interest in individual assignmentsin national and international media.
Prior review thresholds (Table B)
The Bank's prior review would be required for:
(a) Goods:(i) all contracts to be awarded under ICB; and(ii) the first contract awarded following NCB for each year.
(b) Civil works:(i) all NCB contracts estimated to cost more than US$750,000 equivalent; and(ii) the first NCB contract each year regardless of the amount.
(c) Consultants' services:(i) for consulting firms, all contracts estimated to cost US$100,000 equivalent or more;(ii) for individual consultants, all contracts estimated to cost US$50,000/year or more;(iii) contracts of a critical nature, regardless of the estimated cost, as may be reasonably determined by theBank; and(iv) key staff positions in the Project Coordinating Unit.
(d) all contracts with Universities for subprojects under Component I estimated to cost US$500,000 or more.
15 Public universities being awarded research grants, will have as eligible expenses only the ones related to the research objectives (i.e.incremental costs resulting from research), and not already budgeted in national funding, as per the GoA guidelines.
Annex 6 Page 3 of 8Under current prior review arrangements it is expected that 12% of the contracts for goods, 22% of the contractsfor civil works and 38% of consulting services contracts would be subject to prior review, representing 68%, 56%and 44%, respectively of funds allocated to each category.
Procurement Plan
At appraisal, the Borrower developed a procurement plan for project implementation which provided the basis for theaggregate amounts for the procurement methods. This plan was agreed to at negotiations. At the beginning of eachcalendar year, the Borrower shall update the Procurement Plan with a detailed procurement schedule for the coming yearwhich shall include ICB and NCB procedures, smaller procurement and consulting services and training as well as thenumber and estimated costs for the subprojects to be financed under the proposed loan in accordance with the originalProcurement Plan.
Procurement Audits
Annual procurement audits will be carried out by an independent extemal firm under terms of reference agreed with theBank, in order to determine compliance with Bank's guidelines in project procurement. These procurement audits may becombined with the annual financial audits or carried out independently, as the Bank may reasonably determine, andsubmitted to the Bank no later than June 30 of each year of project execution. The agency or specialized consultants'services would be procured by December 31, 1999.
Assessment of the agency's capacity to implement procurement
An assessment of the agency in charge of implementing procurement actions for the project has been carried outidentifying the organizational structure of the proposed PCU, the interaction between the project's Procurement Officerand the Ministry of Health's central unit for administration and finance (Unidad Central deAdministraci6n y Finanzas)and were found acceptable. The project's risk factor is considered Average. The assessment has been cleared by theRegional Procurement Advisor and is available in the project files.
Disbursement
The proposed loan will disburse over a period of four years. The closing date is April 30, 2004, and thecompletion date October 31, 2003. Disbursements will be made for (i) 70% of civil works other than subprojects,including refurbishment and upgrading of physical infrastructure of existing laboratories (totaling US$3.4 million); (ii)70% of goods including vehicles, computer hardware and software, office equipment, fumigation and laboratoryequipment, chemicals, medical equipment, teaching and training material, brochures, and public information documents(US$6.1 million); (iii) 80% of consulting services and training (US$26.8 million); (iv) 80% of withdrawals under ProjectAdministration until withdrawals under this category reach an aggregate amount equivalent to $1,200,000; 70% untilwithdrawals under this category have reached an aggregate amount equivalent to $2,200,000; and 30% thereafter; (v) andthe front-end fee (US$ 0.525 million). The retroactive financing amount was established at US$2,500,000. Assuming thatloan signing will be no later than September 1, 1999, all expenses (goods, consultant services and project administration)incurred from September 1, 1998 are eligible for retroactive financing since they are in accordance with the Bank'sprocurement guidelines.
Allocation of loan proceeds (Table C)
The project is expected to be completed over a four-year period. Funds will be disbursed according to thecategories and percentages shown in Table C of this annex. The Government's counterpart funds needed for each fiscalyear to cover the share of total project expenses not financed by the Bank will be allocated in each year's budget madeavailable for the Project.
Use of statements of expenses (SOEs):
Disbursements of the loan proceeds for contracts for goods other than subprojects valued at less than US$350,000for goods, US$750,000 for civil and US$100,000 for consulting firms and US$50,000 with individual consultants;
Annex 6 Page 4 of 8training, and project administration costs will be made against Statements of Expenditures (SOEs). The documentationsupporting claims under SOEs will be retained by the PCU and made available for review and examination by auditorsand Bank supervision members. This will be phased out when the project is converted to PMR disbursement, as per theplan of action agreed upon.
Special account:To facilitate the management of funds, the Government will establish one Special Account (SA), to be opened in
Banco de la Naci6n Argentina and operated by the Ministry of Health and Social Action (PCU) under terms andconditions satisfactory to the Bank. Where the project is considered LACI compliant and ready for PMR disbursements,the special account will be replenished based on the PMRs submitted by the PCU, after certification by an auditor. Theinitial disbursement will be based on the first six-month expenditure forecast for the first year of the project. When theproject's financial management arrangements do not allow for PMR disbursements, to facilitate disbursements againsteligible expenditures, the Bank would, upon request, make authorized allocation of US$ 2.0 million to the SA for allexpenditures. Replenishment of the SA would follow Bank procedures. The PCU would submit replenishmentapplications on a monthly basis, or when about 33 percent of the initial deposit has been utilized, whichever occurs first.The replenishment applications would be supported by a bank statement of the SA and a reconciliation bank statement ofthe SA against the Bank's records. The minimum amount for application for direct payment and for special commitmentwould be 20 percent of the authorized allocation to the SA. The project would be audited annually, including a review ofprocurement by an independent auditing agency acceptable to the Bank.
The Bank Financial Management Specialist has reviewed the financial management system related to this project. Thereview, which included visits to the project unit, concluded that the unit has an adequate accounting system, financialreporting systems and segregation of duties to ensure the provision of accurate and timely information regarding projectresources and expenditures. However, this project does not have in place an adequate financial management system thatcan provide, with reasonable assurance, accurate and timely information on the status of the project's "ProjectManagement Reports"(PMRs) as required by the Bank under the LACI system for PMR-based disbursements. An actionplan was defined and it was agreed during negotiations with the Finance and Administration Manager that the system willbe implemented no later than six months after the effectiveness date (for further detail see the document in the projectfiles).
Note: N.B.F. = Not Bank-financedOther = National or International ShoppingDetailed procurement methodologies in Table Al below
Figures in parenthesis are the amounts to be financed by the Bank loan/IDA credit
*Project Administration includes: (i) PCU technical and managerial staff, with exception of the core technical teamwithin MSAS; (ii) domestic and international travel and per diem for PCU staff; (iii) training of PCU staff, and (iv)
equipment, materials and office supplies.
16 For details on presentation of Procurement Methods refer to ODI 1.02, "Procurement Arrangements for InvestmentOperations." Details on Consultant Services can be shown more easily in the Table Al format (additional to Table A,where applicable).
Note: QCBS = Quality- and Cost-Based SelectionQBS = Quality-based SelectionSFB Selection under a Fixed BudgetLCS Least-Cost SelectionCQ =Selection Based on Consultants' QualificationsOther = Selection of individual consultants (per Section V of ConsultantsGuidelines), Commercial Practices, etc.
N.B.F. = Not Bank-financed.Figures in parenthesis are the amounts to be financed by the Bank loan.
Annex 6 Page 7 of 8
Annex 6, Table B: Thresholds for Procurement Methods and Prior Review17
uJS thousands US $ millins1. Civil WorksReffirbishment and >350 NCB First contract each yearupgrading All >750
<350 Three quotations None
2. GoodsHardware & soft., >350 ICB Alloffice eq, chemicalsmedical eq., training 100-350 NCB First contract each yearmaterial, brochures
Frequency of procurement supervision missions proposed: One every 4 month(s)(includes special procurement supervision for post-review/audits)
17 Thresholds generally differ by country and project. Consult OD 11.04 "Review of ProcurementDocumentation" and contact the Regional Procurement Adviser for guidance.
Training4. Grants 8.3 80% of amounts disbursed5. Project 2.7 80% until withdrawals underAdministration* this Category have reached an
aggregate amount equivalent to$1,200,000; 70% untilwithdrawals under thiscategory have reached anaggregate amount equivalent to
_________________________ _$2,200,000; and 30% thereafter
6. Unallocated 4.675
7. Front-end Fee 0.525Total 52.5
* Project Administration includes: (i) PCU technical and managerial staff, with exception of the core technical teamwithin MSAS; (ii) domestic and international travel; (iii) training of PCU staff; and (iv) equipment, materials andsupplies.
Annex 7: Project Processing Budget and Schedule
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
Time taken to prepare the project (months) 12 21First Bank mission (identification) 3/6/98 3/6/98Appraisal mission departure 2/27/99 2/27/99Negotiations 4/19/99 06/1_1/99Planned Date of Effectiveness 8/1/99 01/31/00
Prepared by: Ministry of Health and Social Action (MSAS)
Preparation assistance: none
Bank staff who worked on the project included:
Anabela Abreu Task Team LeaderAlexandre Abrantes Country Sector LeaderXavier Coll Sector DirectorCharles Gri n Lead Specialist, HealthMyma Alexander Country DirectorChristian Hurtado Engineer/MIS SpecialistGirindre Beeharry Economic AnalysisDariush Akhavan Health EconomistStephen Ostroff Epidemiological SurveillanceDenise Koo Health Information SystemsMeade Morgan TelecommunicationsJames LeDuc Laboratory ExpertFrancisco Pinheiro Biosafety SpecialistDavid McQueen Chronic Disease SurveillanceBernard Montaville Surveillance SpecialistRjurik Golugatnikov Surveillance SpecialistMaria Clara Rillos-Mendes Institutional AssessmentJose Moscoso Procurement SpecialistTeresa Genta-Fons Senior Legal CounselThomas Novotny Peer ReviewerPrabhat Jha Peer ReviewerMarlo Libel, External Reviewer (PAHO)John Wilson ConsultantDiana Weil Tuberculosis SpecialistAracelly Woodall Project CostingMarian Kaminskis Team Assistant
Annex 8: Documents in the Project File*
Argentina: Public Health Surveillance and Disease Control (VIGI-A)
1. Institutional Assessment. Maria Clara Rillos-Mendes. May, 1998.2. Data Telecommunications Plan for Project VIGI-A. Meade Morgan. December 28,
1998.3. Assessment of Laboratory Infrastructure. James LeDuc and Francisco Pinheiro. June
27-28,1998.4. Public Health Surveillance in Argentina. Stephen Ostroff and Denise Koo. July 1998.5. Chronic Disease Surveillance in Argentina David McQueen. November, 1998.6. Procurement Capacity Assessment. Jos6 Moscoso. April, 1999.7. Financial Management Assessment. Susana Cirigliano. April 1999.C. Other
*Including electronic files.
Annex 9Statement of Loans and Credits
Argentina Disease Surveillance and Control Project (VIGI-A)Difference Between
expected
Original Amount in US$ Millions and actual Last PSR
Fiscal disbursements a/ Supervision Rating
Project ID Year Borrower PurposeIBRD IDA Cancel. Und Orig Frm Rev'd Dev Imp
isb Obj Prog
Number of Closed Projects: 59
Active Projects
AR-PE-5968 1987 SEGBA SEGBA V 276.00 0.00 0.00 50.82 50.82 0.00 HU U
AR-PE-5977 1991 ARGENTINE REPUBLIC WTR SUPPLY II 100.00 0.00 36.00 17.25 53.25 17.25 S S
AR-PE-6036 1993 GOVERNMENT YACYRETA II 300.00 0.00 0.00 .48 .47 0.00 HU U
AR-PE-6003 1993 GOVT OF ARGENTINA INA RD MAINT & REHAB SCT 340.00 0.00 0.00 25.61 18.63 0.00 S S
AR-PE-6062 1994 MIN OF ECONOMY CAPITAL MKT TA 8.50 0.00 0.00 2.37 2.35 0.00 S S
AR-PE-6025 1994 GOVT OF ARGENTINA INA MTNAL CHILD HLTH & N 100.00 0.00 0.00 8.05 4.75 0.00 HS HS
AR-PE-6060 1995 GOVT OF ARGENTINA MUNIC DEVT II 210.00 0.00 0.00 152.71 -21.27 0.00 HS HS
AR-PE-6018 1995 ARGENTINE REPUBLIC PROV DEVT II 225.00 0.00 0.00 167.65 4.65 0.00 S S
AR-PE-5992 1995 GOVT OF ARGENTINA INA SECONDARY ED I 190.00 0.00 0.00 130.46 114.17 0.00 S S
AR-PE-45687 1996 REP. OF ARGRNTINA H.INSURANCE TA 25.00 0.00 0.00 4.29 .19 0.00 HS HS
AR-PE-38883 1996 REPUBLIC OF ARGENTINA ENT.EXPORT DV. 38.50 0.00 0.00 17.73 17.72 3.50 S S
AR-PE-37049 1996 GOVT OF ARGENTINA PUB.INV.STRENGTHG 16.00 0.00 0.00 15.32 10.32 0.00 U U
AR-PE-34091 1996 REP OF ARGENTINA HIGHER ED REFORM 165.00 0.00 0.00 112.85 79.61 61.86 S S
AR-PE-6057 1996 GOV'T OF ARGENTINA SECNDARY ED 2 115.50 0.00 0.00 99.02 52.82 -16.48 S S
AR-PE-6055 1996 GOVT. OF ARGENTINA MINING SCTR DEVT 30.00 0.00 0.00 6.36 -2.54 0.00 HS HS
AR-PE-6040 1996 GOVERNMENT FORESTRY/DV 16.00 0.00 0.00 11.51 .42 0.00 S S
AR-PE-6030 1996 REPUB OF ARGENTINA PROVCL HLTH SCTR DEV 101.40 0.00 0.00 81.95 53.94 0.00 S S
AR-PE-46821 1997 GOVT.OF ARG PENSION TA 20.00 0.00 0.00 11.64 -.99 0.00 S S
AR-PE-43418 1997 REPUBLIC OF ARG AIDS PREV.&STD CTRL 15.00 0.00 0.00 9.20 -.56 0.00 HS HS
AR-PE-40808 1997 GOA N.FOREST/PROTC 19.50 0.00 0.00 17.81 -.89 0.00 S S
AR-PE-39584 1997 GOVT OF ARGENTINA B.A.URB.TSP 200.00 0.00 0.00 177.34 29.35 0.00 S S
Argentina & Carib income Development diamond'1997Population, mid-year nmitions) 35.2 494 571 Life expectancyGNP per capita (Atlas methori, USS) 8,570 3,880 4,520GNP (Atlls~method, USS bil/ions) 302.0 1,917 2,584 TAverage annual growth, 1991-97
Populationi (V.)'1 1. 1.I 1.5 GNGrsLaborforce (%) 1t9 2.3 1.9 per p Gross
Most recent estlmate (latest year available, 1$01.97) capita enrollment
Poverty (% of population below national povewy line) 2.Urban population (%oftotalpopulation) 88 74 73Life expectancy at birth (years) 73 70 70Infant morteaity (per 1,000 live births) 22 32 30Child malnutrition (% of children under 5) 2 .. .. Access to safe waterAccess to safe water (% of population) 64 73 79Illiteracy (1 ofpopulation age 15+) 4 13 15 _ eiGross primary enrollment (% of schod-age population) 107 t11 107 Argentna
- The diamonds show four key indicators in the country (in bold) compared with its income-group average. If data are m issing. the diamond willbe incomplete.
Argentina
PRICES and GOVERNMENT FINANCE1976 1986 1996 1997 Inflation (°)
Total imports (cif) .. .. 22,179 24,619 'Food .. .. is cooh i i IFuel and energy .. .. 1,009 1,022 5,00_Capital goods .. 5,249 5,996
91 92 93 94 95 95 97Export price index (1995=100) . .. 104 104Import price index (1995=100) .. . 104 106 *Exports *importsTerms of trade (1995=100) .. .. 101 98
BALANCE of PAYMENTSi 976 1986 1996 1997 Current account balance to GDP ratio (%)
(USS millions)Exports of goods and services 4,609 8,433 27,037 29,318 °Imports of goods and services 3,468 6,486 27,910 34,899Resource balance 1,141 1,947 -873 -5,581 u
Net income -508 -4,808 -3,248 -4,005Net current transfers .. 2 334 346 t1 1 1 1Current account balance 657 -2,859 -3,787 -9,240 i3
Financing ntems (net) 261 1,976 7,563 12,302Changes in net reserves -918 883 -3,776 -3,062 X4
Total debt service 1,616 7,323 14,965 17,264 _D:4,767IBRD 44 210 608 635IDA. 0 0 0 0 E: 11,215
Composition of net resource flowsOfficial grants 0 3 ..Official creditors 42 268 1,449 758Private creditors 1,078 375 4,709 6,690Foreign direct investment 0 574 1,936 3,000Portfolio equity 0 0 F 50,194
World Bank programCommitments 115 724 946 1,221 A-IBRD E-BilateralDisbursements 20 408 1,077 797 B - IDA D - Other multilateral F - PrivatePrincipal repayments 19 134 282 299 C - IMF 0 - Short-termNet flows 1 273 795 498Interest payments 25 75 326 335Net transfers -24 198 469 162
Development Economics 9/16198
Annex 11Argentina Disease Surveillance & Control Project
Public Health Surveillance in Argentina
General BackgroundArgentina is a federal republic composed of 23 provinces and a capital district containing apopulation of approximately 35 million persons. There was no organized, national surveillancesystem for health monitoring until 1960; the current system was established by law at that timeand has been intermittently modified since then (most recently in 1993).
Data systemsThere are essentially five systems used for health monitoring in Argentina. They are (1) the birthregistration system, (2) the death registration system, (3) the hospital discharge data system, (4)the national reference laboratory system, and (5) the notifiable diseases system.
Sistema Nacional de Vigilancia Epidemiologica (SINA VE)
Policies and conditions under surveillanceThere are nearly 50 conditions which are nationally notifiable in Argentina. The list of notifiablediseases is based on the 1993 revisions to the reporting law plus diseases which have been addedsince that time (i.e., hantavirus). The conditions which are monitored are established inconsultation between the national epidemiology unit and the provincial epidemiologists, whomeet twice per year. (There is also a smaller group, the Comisi6n Nacional de Epidemiologia,that meets on a bimonthly basis with MSAS staff; this group, which includes 6 provincialepidemiologists, also advises the MSAS on epidemiology and surveillance issues).
Organization of the systemAt the provincial and national level, a central epidemiology unit (Direccion de Epidemiologia atthe national level) is responsible for receiving and recording disease reports. There are also anumber of vertical programs with responsibility for control of specific diseases or healthproblems, many of them located in this same unit.
Reporting proceduresAt the national level, there are essentially only two commonly utilized "forms": the L2 forn, usedfor recording and reporting laboratory results, and the C2 form, used for recording and reportingnotifiable diseases. The national epidemiology group has developed a model C2 form, but thishas been modified in the provinces, and as such there is no form standardization. Due to themultiple levels and modes of data transmission, coupled with personnel deficiencies, there aresubstantial lag times in the reporting system. Cases will often not reach the provincial level forseveral weeks (although this depends on the disease), and further delays may occur intransmission to the national level.
Capacity issuesSurveillance capacity, including personnel and physical infrastructure, is highly variable inArgentina. In many local districts, data are hand-tabulated and transmitted to the district orprovince by mail, telephone, fax, vehicle, or any combination of these. Capacity at the provinciallevel is also quite variable. Many provinces have computers to enter data and generate reports.Some simply use the computer for data entry but still generate hand-tabulated reports. Most of
' This annex is based on the report prepared by Stephen Ostroff and Denise Koo, July 1998
Annex 1I Page 2 of 3
the provinces submit weekly summary tables by fax in various formats. Some submit a list withonly those diseases identified during the reporting period, and the epidemiology unit assumes ifthe disease is not listed the value is zero. The current system usually requires repeatedcommunications between the provincial and national levels to interpret submitted data, changenumbers, or collect missing information.
At the national level, the central epi unit staffing and equipment appears limited. There are only11 staff members: 2-3 persons responsible for data input and tabulation (one is training to be acomputer specialist); 6 physicians responsible for the analytic and some of the program work, butonly four of whom work full-time; and one person who compiles data from the nationallaboratory system.
Data dissemination and qualityThe national epi unit produces simple summary reports of weekly and annual data. These dataare distributed to other MSAS staff and to the provinces each week. However, there are notsufficient staff to perform regular analyses of the data (except for meningitis, measles, hantavirus,and dengue during the dengue season). In addition, there is no regular epidemiologic bulletin thatdiscusses current diseases, problems of interest, or interprets surveillance information. Some ofthe provinces produce annual or half-yearly reports. One province produces its own weeklyreports.
Data use: disease investigationsInvestigative capacity at the national and provincial level appears quite limited. At the provinciallevel, outbreak investigation and control is the responsibility of the municipality or district if theproblem does not transcend jurisdictional lines. If the outbreak is big, localities may call adjacentdistricts for assistance. In some instances, personnel from the province may be called upon, ormay go, to assist. However, because of personnel limitations, often these investigations are briefand control measures are not based upon systematically collected or analyzed data.
Other forms of surveillanceThe major alternative to notifiable disease surveillance in Argentina is the network of provincialand regional laboratories developed under the auspices of the national reference laboratory center(ANLIS).
General issues/assessment of needs
> Coordination/standardization. The current surveillance system needs and deservesleadership and coordination from the national level. There is a need to collect nationallyrepresentative data in uniform fashion, for appropriate analysis and interpretation. Currentlyeach jurisdiction does things in different ways, including data collection, investigation,recording, and reporting. There is a need for a standardized document which clearly stipulateshow diseases are defined for purposes of surveillance, how data are collected, and how thedata should be reported. The current revision of the SINAVE manual will address this typeof action.
> Integration. Although communications exist between SINAVE, the disease-specificprograms, and ANLIS, each component appears to be functioning independently and noteffectively sharing information. An efficient means to clearly link epidemiologic andlaboratory data at the provincial and national level is necessary, and to efficiently linkprogrammatically collected data and SINAVE data.
Annex 11 Page 3 of 3
) Communication. The current system introduces delays and inaccuracies, and there is nocurrent method to easily query or correct data except through laborious telephone or faxcontact. Building an efficient network for data collection and transmission is considered ahigh priority for the project, in conjunction with the revision of the system.
> Consolidation/assessment. The current number of diseases and the frequency of occurrenceof the disease syndromes (i.e., diarrhea, respiratory infections) places enormous strain on thesystem to collect and compile disease reports. For some diseases, information collection maybe appropriate at the local level, but the need for such reports to move through the system isnot needed. A number of the conditions on the current list can be questioned in terms ofessential factors like accuracy of diagnosis, timeliness of reporting, reliability,generalizability, and importance. Whenever possible, the notifiable disease list should betruncated and consolidated, and efforts made to develop alternative data collection methodswhich would provide higher quality data in a more efficient manner, in order to appropriatelytarget control programs.
> Training and capacity building. There is a great need to have well trained personnel at alllevels of the system. At present, the number of persons involved in disease monitoringappears to be insufficient to generate necessary data. At the local level, many cases are notproperly investigated. At the national level, there are personnel shortages. Even withsimplification of the disease reporting burden, there will still be critical staffing needs,particularly for greater oversight of data collection and quality, conducting training,computerization, and data analysis.
t Analytic capability. The current system is geared to generating numbers and producingdisease rates, generally at the expense of data analysis and interpretation. There is minimalanalytic capability at all levels of the system.
t Quality control. Since the system generates only summary numbers for most of thesyndromes, even at the local level, it is not possible to determine what proportion of casesmeet case definitions for disease.
> Investigation. In addition to insufficient analytic capability, the current system's ability toconduct meaningful investigations is limited. This includes outbreak response capacity at alllevels of the system, and epidemiologic studies to address priority diseases.
> Reporting of data/feedback. At present, other than summary tables, the Argentine systemdoes not produce periodic bulletins or provide consistent feedback to disease reporters.
> Alternative surveillance methods. There is a need to determine the best methods to collectdata of sufficient quality for use in development of control programs. In many instances, thiscould be accomplished through alternatives to notifiable disease surveillance.
The Role of VIGI-A
The VIGI-A project is an attempt to address and rectify identified deficiencies by building aflexible, responsive surveillance system which can provide the data needed to guide appliedresearch and development of prevention and control strategies for the country. VIGI-A containsmany objectives that fall into three major areas: a) laboratory infrastructure enhancement; b)disease surveillance capacity enhancement; c) surveillance and control of specific diseases; and(d) health promotion.
Annex 12Argentina Disease Surveillance & Control Project (VIGI-A)
Assessment of Laboratory Infrastructure2
1. National Network of Laboratories for Control of Infections Transmitted by Transfusions.This network was originally begun to ensure that blood used for transfusion was free ofTrypanosoma cruzi, causative agent of Chagas' disease. Subsequently, the network has beenexpanded in scope of agents tested so that blood is routinely screened not only for Chagas'disease, but also for hepatitis B and C, human immunodeficiency virus (HIV), syphilis andbrucellosis. This network only manages the data received from testing laboratories and is notdirectly involved in either laboratory testing or maintenance of quality control of the bl]oodsupply.
Communication among the members of the network is primarily by post or fax, often with afollow-up telephone call to request reports. Computers and routine use of email are not available,although having this capacity is a goal for the future.
2. National Network of Laboratories for Influenza and Respiratory Infections. This network iscomprised of three major laboratories (Buenos Aires, Mar del Plata and Cordoba), six secondarylaboratories, and an additional six laboratories just recruited into the network this year. Theobjective of the network is to isolate influenza viruses currently in circulation. The majorlaboratories are able to isolate and fully characterize influenza virus strains, conduct appropriateresearch activities, and do limited molecular analyses. Secondary laboratories are able to conductrapid diagnostic tests and obtain clinical material to be forwarded to the central laboratories.
The laboratory facilities in Buenos Aires were extremely cramped for the work being conducted.A total staff of seven individuals works in the influenza section: 3 professionals, 3 techniciansand I administrator. The laboratory was comprised of two small rooms, one containing a hood,and a small administrative work area. All work is conducted in these rooms, including virusisolation and molecular analysis (including polymerase chain reaction (PCR) tests, which are wellknow to be easily cross contaminated).
The staff members were personally extremely well qualified, were conducting state-of-the-artresearch activities and clearly were of international stature.
3. Network of Laboratories dealing with Hepatitis Infections. This laboratory is primarilyfocused on research and service activities associated with hepatitis B and C viruses, and alsoincludes a small section working on viral gastroenteritis, primarily rotaviruses and Norwalkviruses.
4. Network of Laboratories to Monitor Resistance to Antimicrobial Agents. This network is apart of the WHONET designed to monitor antimicrobial resistance around the world usilng astandard computer program to accumulate resistance data. At the present time, 29 hospitals fromall but 8 provinces contribute to the system. These hospitals are drawn from both the public andprivate sectors. External partners, in addition to WHO, include PAHO and the Canadian publichealth laboratory, the Laboratory Centre for Disease Control (LCDC).
2 This annex is based on the report by James LeDuc and Francisco P. Pinheiro, June 1998
Annex 12 Page 2 of 4
The network maintains its own quality control program by distributing validated bacterial strainsfrom the American Type Culture Collection (ATCC), as well as participating in an externalquality control program coordinated by WHO and CDC.
5. Network for Nosocomial Infections. The Ministry of Health recently approved theestablishment of a dedicated national network for the surveillance of nosocomial infections, and apilot demonstration project involving 25 hospitals has been started. The network is patternedafter the US National Nosocomial Infection Surveillance system (NNIS), and the demonstrationproject is closely linked with the WHONET antimicrobial resistance network discussed above.This network is being developed and managed jointly by groups in Buenos Aires and in Mar delPlata, and there appears to be good coordination and collaboration. However, improvements arealso needed in the computer software used to manage the system, and a program of externalevaluations for quality assurance and control will be established.
6. Network for Cholera and other Diarrheal Diseases. The cholera network was begun in 1992during the outbreak of cholera and has been developed since then so that today a total of 25reference laboratories are in place, with at least one in every province. Adding to this networkare 133 level 2 provincial collaborating laboratories located primarily in hospitals and 284 level 1lower laboratories of lesser capabilities in rural clinics and small hospitals.
The cholera and other diarrheal diseases program at ANLIS is located in 5 cramped laboratoriescurrently occupying approximately 100 m2 in total. These facilities are clearly not appropriate forthe level of activity being undertaken.
7. National Laboratory Network for the Surveillance of Tuberculosis. The network comprises 24.provincial central laboratories, 112 laboratories of intermediate complexity, 600 primary healthlaboratories, one regional reference laboratory and two national reference centers. These are theINER "E. Coni" located in Santa Fe and the INEI located in Buenos Aires. A few privatelaboratories perform the diagnosis of a small number of cases but are not integrated in thenetwork. The objectives of the network are to perform the bacteriological diagnosis oftuberculosis in order to provide support for case-finding activities and the epidemiologicalsurveillance of the disease including data collection, to provide diagnosis and orientation for therapid treatment of special cases, and to assure adequate biosafety conditions to all laboratoriesthat integrate the system.
8. Laboratory Network for Hantaviruses. ANLIS laboratories in collaboration with CDC haveconducted extensive epidemiological and ecological studies which were most helpful tounderstand the natural history of HPS in Argentina. Further to the molecular characterization ofAndes virus, ANLIS was able to obtain a recombinant virus protein which has been used for thediagnosis of HPS infections in a capture MAC ELISA IgM and an ELISA IgG format.
9. Laboratory Network for the Surveillance of Emerging Arboviruses. Several arboviruses ofpublic health importance are present in Argentina such as SLE, WEE and EEE. The recentemergence of dengue virus in northern Argentina raises considerable concern of its spread toother areas of the country infested with Aedes aegypti, including Buenos Aires. Since almost theentire population of Argentina is completely susceptible to dengue infection, there is a seriousthreat to the occurrence of explosive epidemics. The INEVH has human resources andcapabilities to perform field and laboratory studies of arboviruses, including dengue. Also theINEVH houses the National Dengue Reference Laboratory.
Annex 12 Page 3 of 4
10. Laboratory Network for Brucellosis: The Brucellosis laboratory of the ANLIS/ Malbranserves as national reference laboratory for the disease. In this capacity the laboratory isresponsible for the standardization of the serological diagnosis of the infection, control of thequality of the commercial reagents, production and distribution of reference reagents,development of bacteriological diagnosis methods, provision of training and technology transferand dissemination of information.
11. Laboratory Network for the Surveillance of Zoonosis. A project has been elaborated todevelop a laboratory network for the surveillance of zoonosis. The project will includelaboratories in nine provinces for the diagnosis of toxoplasmosis, hydatidosis, trichinosis,toxocariasis and fascioliasis. In addition, guidelines will be established for the diagnosis of fivezoonosis (hydatidosis, trichinosis, toxoplasmosis, fascioliasis and toxocariasis).
12. Network on Chagas' Disease, Leishmania and Malaria. This network involves 370laboratories and 24 reference centers located in all provinces, with the greatest distribution oflaboratories concentrated in the areas where Chagas' disease is endemic.
13. Visits to Local and Provincial Laboratories It is evident that local staff are willing tocollaborate with ANLIS scientists as primary focal points and reference resources for nationalsurveillance efforts. Clearly this willingness to collaborate with a single national reference centerwill be critical to the success of the VIGI-A initiative. Many of the laboratories visited sufferedfrom similar space shortages as those noted in the ANLIS in Buenos Aires, although the visit to arecently constructed pediatric hospital in Corrientes showed excellent laboratory facilities.
Conclusions and Recommendations
1. The ANLIS staff of each national reference center are, in almost all cases, headed by seniorscientists of world-class stature that direct small but dedicated groups that are conducting state-of-the-art research and public health activities. The high quality of the staff is an essentialstrength and resource which will be a critical component in the overall development andimplementation of the VIGI-A program.
2. The ANLIS leadership and staff are fully engaged in the development of national networks forsurveillance of specific diseases such that each national reference centers have defined criticalissues unique to the diseases for which they hold responsibility, and each center has producedclear, relevant plans to implement development of these disease-specific networks.
3. The problem seen in virtually all reference centers at the ANLIS is the lack of appropriatelaboratory space to adequately conduct the routine duties expected of them. This often leads topoor conditions of biosecurity, inefficient use of expensive equipment, and significant limitationson the workload able to be maintained.
4. Space problems were not limited to the reference facilities at the Malbran. In the provincialcenters visited and at the local hospital laboratory level, space was consistently the first thingmentioned when staff was asked to list their top two or three problems. Most laboratories arehoused in hospitals or dedicated buildings that were constructed at a time when the laboratoryoffered little in the overall care of patients.
5. Specific request is made under VIGI-A for construction of two biocontainment facilities, onein Buenos Aires and one in Pergamino. Given the routine work with highly pathogenic agentscurrently underway in Pergamino (Junin virus, cause of Argentine hemorrhagic fever,
Annex 12 Page 4 of 4
hantaviruses, arboviral encephalitides and others requiring at least BSL-3 containment) and thesignificantly larger staff, we feel it prudent to ensure that containment facilities are present inPergamino first before investing in similar facilities in Buenos Aires.
6. BIOSAFETY. As indicated throughout the text above, the staff at the ANLIS as well as at thelocal and provincial levels are all well aware of biosafety precautions to be used when handlinginfectious material, as well as the biocontainment needs for safe laboratory procedures. Traininghas been offered and has generally been well received. In ANLIS, the primary problem is lack ofspace and infrastructural needs to consistently meet biocontainment standards.
7. PROFICIENCY TESTING. Virtually every network we discussed has as a central componentof its program an ongoing quality control and proficiency testing program. These appeared to bewell organized and welcomed by the subordinate laboratories.
8. NEEDS OF NATIONAL REFERENCE LABS IN OUTBREAKS. The national networks wediscussed appeared to have good ongoing communications with their members in the provinces,including adequate specimen transport for reference and technical assistance.
Annex 13Argentina Disease Surveillance & Control Project (VIGI-A)
Data Telecommunications Plan3
Current Surveillance Systems
There are two primary surveillance systems that must be supported by the network. The first isthe national notifiable disease surveillance system (Sistema Nacional de VigilanciaEpidemiol6gica, or SINAVE), which at the federal level is the responsibility of the centralepidemiology unit (Direccion de Epidemiologia). The second is laboratory-based surveillancesystem, which is the responsibility of the national reference laboratory (Administraci6nNacionalde Laboratorios y Institutos de Salud, or ANLIS).
The primary sources of data for the SINAVE system are local health clinics and hospitals.Individual patient records or aggregate case counts are reported from these site to the surveillanceprograms run by the provincial MoHs. For the larger provinces, there are also intermediateadministrative health districts (or "zonas") which first receive the information.
Data reported to the federal level generally involves only aggregate data by type of disease andweek of diagnosis. In some instances case totals may be broken down by additional variablessuch as age category and sex. The tuberculosis program is also collecting more detailed patientlevel data at the national level. Reporting to the provincial MoHs may be either as aggregatedata or as patient level data, depending on the needs of the health ministry. The health clinics andhospitals may also collect either patient level or aggregate data depending on the need. Whenpatient level data are collected, the Epilnfo package from the CDC and the World HealthOrganization (WHO) has generally been used. Reporting is generally by fax; very little (if any)electronic means for communication currently exists.
The laboratories do not yet have a standard data management system for surveillance. They haverecently been considering the use of the Public Health Laboratory Information System (PHLIS),developed at the CDC. However, the laboratories have received new funding in the past year andare in the process of creating their own network for reporting a variety of data including thoseused for surveillance. The system they are designing will be Internet based.
In addition to reporting through the notifiable disease and laboratory surveillance systems. theVIGI-A project will also support the development of new systems for nosocomial infectionsurveillance and control. The electronic telecommunications must support that activity as well.Current plans call for the system to be developed in Epilnfo version 6.
Design of the Telecommunications System
Several initial requirements for the telecommunication system were identified. They include:
1) providing the ability to report surveillance data in batch mode using the Epilnfo and PEILISsystems,
2) allowing enough flexibility to add new systems such as those for business administrationwithin the VIGI-A project,
3) supporting e-mail services between health departments, laboratories, health clinics, and otherpersons and institutions involved in public health,
3This annex is based on the report prepared by Meade Morgan, December 1998
Annex 13 Page 2 of 6
4) allowing "health alerts" and other textual information to be rapidly disseminated, and5) providing the ability to electronically distribute reports both to public health staff and, as
appropriate, the public at large.
In addition to these requirements that are specific to telecommunications, the VIGi-A funds arealso being considered as a mechanism to upgrade computer hardware and software in thesurveillance department at the national level as well as in the provincial and local healthministries and clinics. A total of 641 workstations with printers are being requested, togetherwith 11 laptops. The Plan Informatico describes where throughout Argentina these newworkstations will be located, though only in general terms.
Initial Recommendations:
Basically three distinct and yet related activities are proposed. They are:
1) to use the public Internet as the communication backbone connecting the nationalsurveillance program, the provincial and district health ministries, laboratories, and healthclinics,
2) to upgrade the microcomputer hardware and software in these locations to better support theInternet connections and to be able to use newer Windows '98 applications, and
3) to build a local area network within the Direccion de Epidemiologia to support theSurveillance unit of the Direccion de Epidemiologia with additional connections foraccessing data from workstations in the Statistics Unit and the Maternal and Child HealthUnit.
Use of the Public Internet
Selecting the Internet as the communication backbone for VIGI-A is, without question, thecorrect choice. Use of the Internet is growing rapidly in Argentina as well as throughout theworld. The Internet is a flexible communication medium and can allow for virtually unlimitedgrowth, both in terms of the number of workstations connected to it and the variety ofapplications that can be supported through it.
Internet Design Plan
This plan would provide for the "real-time" on-line entry, management and analysis ofsurveillance data through the Internet World-Wide-Web (WWW). Raw data would be reportedthrough the Internet to a single server located at the National Ministry of Health and SocialAction. While the server would be physically located in at a single location, the softwareproviding access to data on the server would be written so that each area would only have accessto the information within their appropriate jurisdictions. The information would not be madeavailable to the next higher level (including the federal level) until the lower level authoritiesapproved that access. Hypertext mark-up language (HTML) data entry screens would be writtento allow the data to be entered and edited, and for both standardized and ad-hoc analyses to beperformed. Furthermore, the use of the WWW and the associated Internet browser technologyw;ould allow for health alerts and other bulletins to be easily posted. This system would looksimilar to other Internet based data entry applications such as those used for electronic purchasingand to search the web for documents.
Annex 13 Page 3 of 6
Providing Internet Connections
Connections to the Internet will be provided for every user that transmits surveillance data.Internet connections in Argentina are expensive and this is likely to be one of the major costs ofthe telecommunications network.
Overall costs for Internet access, assuming only the use of either local providers with a flat ratestructure or the 0800 toll-free numbers, are shown in the table below. For simplicity it is assumedthat only 600 users will need connections and that the others (such as those within DE) will haveother methods of access. As stated earlier, Internet connections in Argentina are expensive.Communications will be one of the major costs to the project (slightly under US $1,000,000 peryear) and are an expense that the Ministry of Health must be willing to support once the VIGI-Aproject ends. Overall costs for Internet access, assuming only the use of either local providerswith a flat rate structure or the 0800 toll-free numbers, are shown in the table below.
Table 1:Estimated cost for telephone lines and Internet service for 600 users, by month and by year.
F Tpeof Conetii Niuther Cost per mnh TtIotpr Ttlcs e
Telephone lines 600 $48 $28,800 $345,600Local ISP access 575 $48 $27,600 $331,2000800 toll-free lines 5 $48 base + an 200 total hours $46,080
additional .30 per (assuming 8 hoursminute usage for each of 25charge workstations)
One other major part of the VIGI-A project is to upgrade personal computer workstationsavailable to epidemiology and laboratory surveillance personnel. ThePlan Informcitico proposesthat 641 workstations and 10 laptop computers be purchased and installed over the three years ofthe VIGI-A project. The new workstations will be phased in throughout the three years of theproject. The need to upgrade computers in the health departments is supported by a series of sitevisits made to six provinces and described in a report titled "Evaluaci6n de los Servicios deEpidemiologia en Seis Provincias Argentinas".
Recommendations for the "minimum" required workstation were developed based on currentlyavailable technology. These workstations would have a Pentium II processor with 64 megabytesof RAM, a 4 gigabyte hard disk drive, a 4 megabyte graphics card, 14 inch color monitor, and acolor ink jet printer. A 56K modem would also be required for users who will be accessing theInternet using dial-up lines. These systems, if purchased in the U.S., would cost about $2,500each with the Windows '98 and Microsoft Office software already installed.
Annex 13 Page 4 of 6
Direccion de Epidemiologia Network
In addition to the Internet network, the Plan Informdtico also proposes the development of a localarea network for the Direcci6n de Epidemiologia., This network is long overdue. There are anumber of specific issues related to the hardware and software which would be addressed in theproposal as part of the network design. One of the most important issues is enhanced securitywhich should be built into the network. The Internet design would include a standard asymmetric(public-private) file encryption package such as Pretty Good Privacy (PGP), and would alsoinclude the use of the browser secure socket(SSL), together with an additional level of encryptionfor all sensitive data. Digital certificates should also be used to authenticate the workstationswhich have access to the system, and use-IDs and passwords should be built in to authenticateusers.
Personnel needed to support the system:
LANAdministration and Management (I person)This person will be responsible for managing the LAN hardware and software, joining useraccounts, providing training, etc. He or she needs to have experience in installing and managingMicrosoft Windows NT networks.
Programmingfor the Surveillance System (2 persons)These individuals will be responsible for developing the software to be used for data collectionand management. They must have experience in developing and maintaining SQL databasesystems, dynamic HTML entry screen development supported by Java applets or MicrosoftActive-X/DCOM components for editing checking.
Help Desk and Training (2 persons)The number of users of the system nationwide will be fairly large (over 600 by the third year), soit will be important to set up a help desk to assist in resolving problems. Also, these individualsmight help in writing system documentation and user guides. General knowledge of computers,strong interpersonal skills, and ability to write clearly are requirements for the position. Theseindividuals would need to be able to visit the field sites to resolve problems when necessary.
Internet Web Master (I person)This individual will be responsible for preparing documents, pages, and other textual andgraphical information in HTML and posting it on the Internet. He or she should have experiencein web page design and management. (The Web Master position is generally considered a lowerlevel person than the programmers mentioned above.) The job of the Web Master is usually tomanage the basic "look and feel" of the web site and to format basic web pages.
Data Manager (1 person)This person would be responsible for monitoring of the data and providing quality control andassurance. If problems are found (such as obvious errors, or failure to report for several weeks),this individual would contract the Province, district or local site to determine the cause of theproblem and assist in correcting it.
Programmingfor the VIGI-A Administrative System (I person)This person would be responsible for implementing the VIGI-A administrative system. He or sheneeds to have experience in whatever application development system is chosen for developingthat system.
Annex 13 Page 5 of 6
Table 2: VIGI-A Telecommunications Project Tasks. Time Line, and Estimated Costs **
nventory sites to connecte to t e esgn an comp ete inventorytelecommunications network months from start of project). Costs
includes support from current VIGI-A staff.$20,000
Develop "final" cost estimates for Use inventory to determine overlap _$0000VIGI-A network assuming it is built between Nationaj Laboratory,onto of the National Laboratory or ANMAT and VIGI-A networksANMAT networks . (should be complete by month 4$10,000Standardize data collection forms and Standardization should be Maintain standards Maintain standards Maintain $0 00data formats in collaboration with completed by 6 months into the standardspartners; finalize decision for Intemet project. Costs include staff supportdesign option #I or #2 (preferred) and and a national meeting withwhe to build on top of lab or Provincial partners.ANMAT network $50,000Develop and maintain data entry and Develop prototype data entry Finalize data entry Finalize entire Maintain the (costs coveredanalysis software application using one or two application and prototype application application in
diseases as examples data analysis software 'programmers'(cost covered in programmers below)
below)
Develop and maintain training Develop prototype documentation Finalize training matenals as Maintain Maintain (costs coveredmaterials and training materials (cost covered far as is possible documentation and documentabon in 'help desk'
by help desk staff below) training materials and training below)matenais
Develop a security plan (if such a Develop the plan in time for Maintain the security plan Maintain the security Maintain the (costs coveredplan does not already exist) for presentaion and discussion during plan security plan in the 'designprotecting access to and the national meeting with Provencial of theconfidentiality ofthe surveillance partners. network'data. below)Purchase a total of1641 Pentium JI 214 computers ( $2,700 each 214 computers totaling 213 computers $1727T700class personal computer workstations totaling $57780od $577,800 totaling $572,100
Install and upgrade workstation 21 computers ( $500 each 418 computers totaling 641 computers 641 computers $ 1,084:500hardware and software totaling $120,500 S241,00 totaling S361,500 totalin
_ , ~~~~~~~~~~~~~~$361,500Design the Direccion de $20,000 contract $ 20,000Epidemiologia local area network,including the Interaet componentsHire LAN administrator $65,000 salarv and benieits $65,000 $65,000 $70,000 $ 265.000Design and wire the DE Local Area S240,000' for network servers $ 260u000Network, including the Intennet SAS software, etc. + $20,000components. contract for wing totaling
6' months usage @ usage @ $2,000$2,000 each totaling
'__________$S0.000 t160.000Hire programmers (assumes option I person mid-ear 6, sala 2 persons $130,000 $130,000 ,140 000 S04300#2) and benefits 3250 for 6 months) ,_,_,Create and staff a user help desk I person , $4U,000 and about $50 2 persons @ $S0,000 $80,000 85,000F - 285,500(assumes option #2) for software to track calls and
problem resolution totaling $40,500Hire Intemet Web Master person mid -year (#L $60,UO0 $60,000 $60,0000
($30.0 for moiths$HiOh-speed Intennet connections for 6months @ $20,000 per month 12 months totaling $240,000 2 - -$ 4000the DELAN totaling $t120000e S240 000 Provincial, district, and local 200 computers@$96 per month tor 200 computers for the full 400 computers for the 600 computers $ 72s ooconnections to the Interaet, excluding 6 months, totaling $115,200 year + an additional 200 full year + an for the full Year,0800 numbers computers for 6 months additional 200 totsling
totaling $345,606 computers for 6 $691,200months totaling
____________ ___________ 576,000Hire a surveillance data base manager I nerson (3)0 $35.000 $35.000 $35,000 $40000 $ 145,000Hire a programmer for VIUI-A I person ( S$65 000 $65 000 - $702000 $ 265:000administrative data system
ra w >'~~~~~~~~~~~~~~~~~~~~Rz
** At appraisal it was decided that telecommunications services would be provide by external providers
4The $240,000 for network servers, hubs, sofiware, etc. is simply an estimate. The final network design document should list specifically all equipment and softwarethat will be needed, together with estimated costs. It should also include a plan for handling security at both the local level as well as for the Internet components thatthe reporting sites will using to access their data.5 The 0800 lines would be installed at the end of the project only if there remained sites that still did not have the ability to connect locally.
Annex 13 Page 6 of 6
Hardware Architecture
National Level /l S\(Surveillance, Statistics, and (docume data
Mother and Child Health) analysis files, etc.)
WebC Communications) CSrver
~~Server ~~Windows NT based I100 Mbit/sec Ethernet _ QL Data
Local Area Network Server
Application Se|(SAS. etc.)l
At most~ ~ ~ ~ ~ ~~~~eelpen n
\ / | ~~~~~~~~~~~~~~Testinp, Server l
TCP/IP | Internet FirewallCommunicationsl
Server _Proxy Server for Accessing
_ = = _ ~~~~~~~~~~~~~~~~~~~~~~Data and Applications
:! ~~~~~~~~~~~~~~~~~~~~~~~~through the Firewall
; _ _ I t t | l < ) I~~~~~~~~ or 2Mbit/sec Internet Connection
0800 Toll Free Voice Grade Telephone Lines (with
"autoroll" capability that will \give caller next available line) ( Commercial Internet
25-0 sService Provider
The 0800 numbers would only be added, rduring the final year of the project, if needed.
( ~~~Internet andA..f ~~World Wide Web V
Province and Local Levels\
Worktatins:Connections Connections Connections
At most!.. ll
25-50 PCs550 or more PCs
Annex 14Training Program Summary
Argentina Disease Surveillance and Control Project (VIGI-A)
Train :in;;Li>i>000|g i a g te ergsotinl: t lt;tl; 000; ?: 0 i4 0drovider Cost
Basic Epidemiology* Health indicators 4,400 local (health D.E.N./ 1,144,180* Information systems center/hospital), Intermediate, D.E.PROV* Initially, 60 people would be trained in a Provincial and laboratory
national course and would become the personnel, and the Outbreak Curriculumfuture trainers Control Team developed by
(8 two-week trainings in 36 jurisdictions with DEN & PAHO15 people per class)Intermediate Level Epidemiology Training* Methods of epidemiology 60 professionals at the central D.E, MSAS 310,000* Epidemiological studies and types of and provincial (field courses)
and chronic illnesses CDC(Two 3-4 weekfield courses, followed by 2 (national coursesnational 4-week courses with international w/ internationalinstructors) instructors)Long Distance Epidemiology Course* Principles of epidemiology & statistics 700 Provincial and Intermediate INE 1,037,600* Information processing and analysis and local personnel, and health* Epidemiological studies professionals+ Health Surveillance+ Programming(Three 9-month trainings. The first coursewill be followed by an evaluation)Basic Principles of Outbreak Investigation(Level I)+ Case analysis 120 Intermediate level doctors DE, PAHO 220,000+ Description of outbreaks & nurses who would be future* Types of causes trainers* Epidemic curves(Two, 7-month trainings, consisting of 2-weekcourses, separated by six months of hands-onapplication)Principles of Outbreak Investigation (LevelII)* This will consist of 2 two-week courses, 72 Provincial personnel, health D.E, International 152,800
separated by a 6-month field project, and specialists, and outbreak organizationa one-week follow-up course control team who would be (CDC, etc.)
future trainersOutbreak Investigation(advanced level)The Bank recommends a training program of 6 epidemiologists at central CDC 936,000no less than 12 months epidemiological unitLaboratory Bio-Safety* One national and one international 30 laboratory personnel who ANLIS 34,300
instructor would provide training on would become bio-safetyinstrument handling, and methods and specialists in their labs,
(USS)equipment for bio-safety providing training to other
(1-week national training) personnel.Laboratory Reporting Systems 62,400* Use of new computerized laboratory 39 Future trainers from I ANLIS,
reporting system provincial laboratory and 15 VIGI-A(1-week national trainingfollowed by a 3-day national laboratoriesevaluation, held 6 months later)Training in Information Systems for 29,180Provincial Workers 24 Provincial operators who DE, VIGI-A+ E-mail and the Internet will then train and support+ Network security provincial operators at the* New applications central and intermediate level.(I national 3-day course)Software for Surveillance Systems* Basic operations and use of the Operators of notification DE, VIGI-A 187,200
surveillance network software* Transfers and protection of databases 2 at the national level+ Basic maintenance 36 at the provincial level* Data input and output 80 at the intermediate level(I-week national trainingfollowed by a 3-day (divided into three groups)evaluation, held 6 months later)Data for Decision Making* Collection, analysis and use of data. 120 heads of epidemiology, D.E 426,600(6 regional courses w/ international working w/ provincial CDC, PAHOinstructors - 20 students per course) programs and statistics, and
public health specialists fromnational institutes and theMSAS
Management Course+ Improvement of management skills at the 60 Directors of epidemiology University 228,000
provincial level programs and provincial and(2 trainings given. Each course lasting two national laboratoriesweeks per month, with 4 months betweentrainings)Publication of Bulletins/Reporting Systemfor Surveillance Data 36 at the provincial level DE 37,160* Design standards 3 at the national level+ Presentation of tables and graphics* Report Writing(1-week training course)Surveillance of Nosocomial Infections* Principles of Surveillance 300 Physicians, Nurses and PCIN, Consulting 377,500* Data processing and analysis Microbiologists from sentinel org.,* Outbreak identification centers in 5 regions VIGI-A(Ten 5-day courses)Nosocomial Infection Prevention andControl 400 Physicians, Nurses, National 488,500* Norms and methods of control and Microbiologists and health consultants
prevention administrators at the sentinel* Standard precautions centers, who would be future* Nosocomial outbreak control trainers(Ten 5-day courses)
i ' TariCost
Tuberculosis and Dengue Control* Diagnostic testing 820 Physicians, Nurses, INEI, INER, 36,860* Epidemiological Laboratory workers and INEVH, PNCT,* Management Epidemiologists PNCV+ Training of field workers 2,400 field workersTraining to Implement Chronic Diseaseand Risk Factor Surveillance Public Health Professionals Local and external 184,500* Establish data needs, priorities and consultants
management needs for non-communicable disease control
+ Training in data collection* Design of instruments (questionnaires,
* Data format, record keeping, aggregation,data analysis, etc.
Training for Health Promotion* Communication skills Unit staff Local and external 34,650* Computers and software TV and radio journalists consultants* Basic training in surveillance and control
Total Spent on Training: $5,927,430.0% of Total Project Cost: 7.8%
Note: During the life of the project, the training activities will be monitored and evaluated. In follow-up courses,students will initially be tested on material covered in prior training.
D.E.N Direcci6n Epidemiol6gica Nacional INE Instituto Nacional EpidemiologiaD.E.PROV Direcci6n Epidemiol6gica Provincial ANLIS National Reference Laboratory CenterDE Direcci6n Epidemiol6gica PAHO Pan-American Health OrganizationPNCT National Plan for Tuberculosis Control PNCV National Plan for Control of Vectors
DiseasesINEI National Institute of Infectious Disease INER National Institute for Respiratory
DiseasesINEVH National Institute of Human Viruses PCIN National Plan for Control of
Nosocomial Infections
MAP SECTION
IBRD 29348
70' * ~~~~~~~~~~~~60' 50'
BOLIVIA
NPARAGUAY/ San Salvador B A I~de, Jujuy RA Z IL
I" OSal~~~~~ta
',ormosa/
n0Tudum6n
CA O Resistencia 6...Posadas X~Santirggo del Estero. Corrientes~ ~ t~
