Document of The World Bank FOR OFFICIAL USE ONLY ReportNo. 8001-BO STAFF APPRAISAL REPORT BOLIVIA INTEGRATED HEALTH DEVELOPMENT PROJECT DECEMBER 20, 1989 Human ResourcesDivision CountryDepartmenZIII Latin Americaand the CaribbeanRegionalOffice IThis document has a resticted d6lribaion and way be used by redpknt only in the performance of their offical dutes. Its contents may nototherwise be dscdosed wtot World Bank aulhriztion. Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized
Transcript
Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No. 8001-BO
STAFF APPRAISAL REPORT
BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
DECEMBER 20, 1989
Human Resources DivisionCountry DepartmenZ IIILatin America and the Caribbean Regional Office
IThis document has a resticted d6lribaion and way be used by redpknt only in the performance oftheir offical dutes. Its contents may not otherwise be dscdosed wtot World Bank aulhriztion.
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CURRENCY EQUIVALENCY UNITS
Currency Unit - BolivianoB$1.O - US$0.35
US$1.0 - B$2.86
FISCAL YEAR
January 1 - December 31
I
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BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
STAFF APPRAISAL REPORT
Table of Contents
Page No.
ABBREVIATIONS ...................... ............. ......... ......... iiiDEFINITIONS OF POPULATION, HEALTH AND NUTRITION TERMS .............. ivBASIC DATA ........................... viCREDIT AND PROJECT SUMMARY .......................... ... vii
I. THE PROJECT CONTEXT ........................................... 1
II. SECTOR AND INSTITUTIONAL FRAMEWORK ..... ....................... 3
Organization of the Health Sector ..... ........... ................ 3Major Sector Issues ........ ............................ ............... 7Donor Activities . .............................. ............... 9IDA Assistance Strategy ........................................ 9
III. THE PROJECT ................................. ... s .......... 10
Project Origin and Objectives ...... ............................ 10Main Features of the Project ...... ............................. 10The Service Delivery Component ...... ........................... 12The Human Resources Development Component ..................... 14The Institutional Development Component .............. .......... 15Plan of Action .......................... 7................. . 17
IV. PROJECT IMPLEMENTATION .. ............................. 18
This report is based on the findings of an appraisal mission carriedout in May 1989 and comprising M. Plessis-Fraissard (Leader, LA3HR); M.Grosh (Economist, LATHR); Consultants G. De Lemos (Pharmacist), E. Guilera(Health Administrator), G. Herrera (Training Specialist), A. Karp(Sanitation Engineer), and J. Van Domelen (Resident Mission, La Paz). Theconsultants A. Webb (Sociologist), N. Wilkie (Nutritionist), and A. Zuniga-Wager (Architect), participated in the preparation mission.
This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.
Page No.
V. PROJECT COST AND FINANCING ........... ....... ****..... ...... 23
VI. BENEFITS AND RISKS ............................. ... ........ 25
Health, Efficiency and Effectiveness Benefits ......... ... 25Poverty Impact ............................................... 26Impact on Women ................ .............................. 26Environmental Impact ........................................... 26
VII. AGREEMENTS AND RECOMMENDATION ......................... . .... . 27
Agreements Reached at Negotiations .............. ............... 27Conditions of Effectiveness .............................. ....... 28Conditions of Disbursement ........................... ........ .... 28
ANNEXES
I - Public Health Facilities and Personnel2 - Sector Financing3 - Integrated Health Care Model and Organization for Maternal and
Child Care4 - Plan of Action5 - Letter of Intention6 - Project Tables7 - Hiumn Resources Development Component8 - Terms of Reference9 - Organizational Charts10 - Monitoring and Evaluation of Project Impact on Local Health and Nutrition11 - Selected Documents and Data Available in the Project File
Maps: IBRD 21669, 21670, 21671, 21672
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ABBREVIATIONS
CDS Consejo Departamental de Salud(Departmental Health Council)
CPS Comite Popular de Salud(Popular Health Committee)
EIH Encuesta Integral de Hogares(Tr.tegrated Household Survey)
EHSO Economic Management Strengthening OperationENSP Escuela Nacional de Salud P6blica
(National School of Public Health)ETS Escuela Tecnica de Salud
(Technical School of Health)FIS Fondo de Inversion Social
(Social Investment Fund)PSE Fondo Social de Emergencia
(Emergency Social Fund)HD Health DistrictIBSS Instituto Boliviano de Seguridad Social
(Bolivian Institute of Social Security)IDA International Development AssociationIDB Inter-American Development BankIHCM Integrated Health Care ModelINE Instituto Nacional de Estadisticas
(National Institute of Statistics)LSMS Living Standards Measurement SurveyMPSSP Ministerio de Prevision Social y Salud P6blica
(Ministry of Social Welfare and Public Health)NGO Non-Governmental OrganizationPAHO Pan-American Health OrganizationPEM Protein-Energy MalnutritionPFMO Public Financial Management OperationPU Project UnitRDC Regional Development CorporationSU Sanitary UnitSVEN Sistema de Vigilancia Epidemiol6gica y Nutricional
(Epidemiological and Nutritional Surveillance System)TGN Tesoro General de la Naci6n
(Nationr General Treasury)UNDP United Natiuns Development ProgramUNICEF United Nations Children's FundUSAID United States Agency for International DevelopmentWHO World Health Organization
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DEFINITIONS OF POPULATION, HEALTH AND NUTRITION TERMS
Adult Literacy Rate The percentage of persons aged 15 andover who can read and write.
Child Mortality Rate Annual deaths of children 1-4 year per1,000 children in the same age group.
Contraceptive Prevalence Rate The percentage of married women ofreproductive age who are using a modernmethod of contraception at any time.
Crude Birth Rate Number of live births per yeer per 1,000people.
Crude Death Rate Number of deaths per year per 1,000people.
Degree of Malnutrition The Gomez classification scaledistinguishes three degrees inmalnutrition, nanely:first (mild): 75-89? of expected(or standard) weight for age;
second (moderate): 60-742 ofexpected weight;
third (severe): under 60? ofexpected weigb l
Dependency Ratio Population 14 years or under and 65 yearsor over as percentage of population aged15 to 64 years.
Incidence Rate The number of persons contracting adisease as a proportion of the populationat risk, per unit of time; usuallyexpressed per 1,000 persons per year.
Infant Mortality Rate Annual deaths of infants under 1 year per1,000 live births during the same year.
Life Expectancy at Birth The number of years a newborn child wouldlive if subject to the age-specificmortality rates prevailing at time ofbirth.
Low Birth Weight Infant weight at birth less than 2,500grams. It may be associated with eitherpre-term (less than 37 weeks gestation)or full-term but small for dates (38weeks or more) of gestation.
Maternal Mortality Rate Number of maternal deaths per 1,0(Jbirths in a given year attributable topre8nancy, childbirth or post-partum.
Morbidity The frequency of disease and illness in apopulation.
Mortality The frequency of deaths in a population.
Neonatal Mortality Rate The number of deaths of infants under 28days of age in a given year per 1,000live births in that year.
Perinatal Mortality Rate The number of fetal deaths after 28 weeksof pregnancy and of infant deaths under 1month of age in a given year per 1,000live births.
Prevalence Rate (Point) The number of persons having a particulardisease at a given point in time perpopulation at risk; usually -.spressedper 1,000 persons per year.
Rate of Natural Increase Difference between crude birth and crudedeath rates; usually expressed as apereentage.
Total Fertility Rate The average number of children a womanwill have if she experiences a given setof age-specific fertility ratesthroughout her lifetime. Serves as anestimate of average number of childrenper family.
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BOLIVIA
IFTECRATED HEALTH DEVELOPMENT PROJECT
BASIC DATA
A. General Country Data
1. Area (Km2) 1,099,0002. Total Population (Million, Mid-1989) 7.13. Population Density (per Sq. Km.) 6.54. Rural Population as Proportion
of Total Population 5025. Primary School Enrollment (1986): Male 932
Female 8226. GNP Per Capita (1987) US$570
B. Population, Health and Nutrition Data
1. Crude Birth Rate (1987) 43/1,0002. Lrude Death Rate (1987) 14/1,0003. Total Fertility Rate (1987) 6.14. Life Expectancy at Birth (1986): Male 51 years
10. Proportion of Births Attended by Health Staff (1985) 36211. Proportion of Children Between 1 and 2 Years
of Age Fully Immunized (1986) 21212. Contraceptive Prevalence Rate (Modern Methods) (1983) 1O013. Prevalence of Endemic Goiter (1983-84) 65214. Prevalence of Protein-Energy Malnutrition
Among Children Under 5 Years of Age (1981) 41215. Daily Calorie Supply per Capita (1986) 2,143
Source: World Development Report, 1989, and staff estimates.Population, Health and Nutrition Sector Memorandum, 1988
(Report No. 6965-BO)
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BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
Credit and Proiect Summary
Borrowert Republic of Bolivia
Beneficiary: Ministry of Social Welfare and Public Health (MPSSP)
Amounts SDR 15.7 million (US$20.0 million equivalent)
Terms: Standard IDA terms, with 40 years maturity
Proiect Obiectives The project objective is to improve maternal and childand Description: health in Bolivia. The project would: Ci) support the
extension of the basic health services, with priorityfor the most vulnerable groups of pregnant women,lactating mothers and children under five years of age;(ii) improve the effectiveness of basic health servicesthrough the development of appropriately trained humanresources in health institutions; and (iii) strengthencentral policy making and coordination of investment inhealth within a more coherent institutional frameworkand a national health plan. MPSSP would delegate theadministration of some health districts and theoperation of facilities to municipalities, NGOs or otherprovieers of health care, who would accept to provide astandardized level of services. In this first IDAproject for the health sector in Bolivia, only the majorconstraints of the sector would be addressed whilelaying the ground for further improvement through futureprojects. Specifically, the project would include: (i)a service delivery component (US$29.6 million)consisting of extending maternal and child care in themarginal and low-income areas of La Paz, El Alto.Cochabamba and Santa Crvz. The credit would finance theextension of pre- and post-natal care, reproductivehealth care, child development and nutritional control,prevention and control of diarrheal and respiratorydiseases. The credit would finance construction,rehabilitation and equipping of ambulatory centers;supply and management of stocks of essential drugs;equipment; vehicles; logistic and maintenance system<;and the construction of one maternal and child healthfacility; (ii) a human resources development component(US$1.0 million) consisting of the development ofdecentralized training capacity, the training andsupervision of selected staff from MPSSP, municipalitiesand NGOs, and health education campaigns; and (iii) aninstitutional development component (US$6.5 million)covering the phased reorganization of MPSSP, in itsPlanning, Human Resources, Administration and Generaldirectorates, and in the regional units involved in theproject. It would establish a system for planning,budgeting and control for MPSSP, and participating
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municipalities and agencies. It would also support thedevelopment of a management information system. A Planof Action, essentialUy addressing more appropriateresource balance across levels of service and keyinstitution reforms, would reinforce the policy actionsand institutional changes of the project. Preparationand start-up actions (US$1.5 million) were completedwith IDA financing.
Benefits: The project would benefit about 790,000 women in reprod-uctive age and children currently without access tobasic health services, in the low-income neighborhoodsof the four largest cities. It would reorient publichealth expenditure in favor of basic health care andimprove the efficiency of resource use through improvedcoordination with NGOs and among donors.
Risks: The risks include possible lack of full commitment andfollow through of the Government and/or the municipalit-ies to carrying out administrative reforms and intro-ducing effective management systems. Annual reviews ofthe Plan of Action, carefully planned zechnicalassistance and donor coordination would help minimizethese risks.
Estimated Cots:t alLocal ForeiRn Total-__-____--- -US$ million ---------
1.01 Geographic Location and Characteristics. The population ofBolivia, currently 7.1 million and growing at 2.7Z annually, is the poorestof South America, with a GNP per capita of US$570 in 1987. The ethnicdiversity of the population and its uneven distribution in this largelandlocked country, the fifth largest in the continent, add to thechallenge of addressing the issues of human resources development.Overall, no more than 37Z of the population speaks Spanish at home,literacy rates are low, at 63S, and a fifth of Bolivians speak only Aymaraor Quechua. J.vt over half of the population lives in urban areas.Thirty-eight percent of the population lives in the high plains, 3,500 to4,000 meters above sea level. This population is spread around thecapital, La Paz, in mining towns, or in rural areas on lands of littleagricultural potential. In these high plains the Aymara Indian traditionis predominant. Forty-two percent of the population, with Aymara, Quechuaor European backgrounds, live in the semi-tropical valleys and foothillsand have diversified activities. The rest of the population, in whichEuropean settlers outnumber the Guarani and Amazonian Indians, is scatteredacross the sparsely inhabited lowlands which comprise a mix of fertileplains, marshlands and jungle on 652 of Bolivia's territory. A minnimaltransport system links the three regions, and large parts of the countryare accessible only by air.
1.02 Health and Nutrition Status of the Population. The population ofBolivia has the worst health indicators in the continent. Life expectancyaverages 51 years for men and 55 years for women; infant mortality is twicethe average of the region, at 110 per l,00e live births, and reaches 277per 1.000 live births in some poor communities in the highlands and lowincome urban districts. Maternal mortality, at 48 per 10,000 live birLhs,is almost twice the average for the region, and leads to 1,400 deaths ayear. It is associated with high fertility, poor health conditions ofmothers, lack of prenatal and delivery care, and an alarming incidence ofinduced abortion. Malnutrition is widespread, particularly in the rapidlygrowing suburbs of the larger cities and in rural areas. Recent surveysshow daily caloric intake averaging 602 to 652 of requirements in El Alto,the new city adjacent to the Capital, and 59Z in depressed rural areas.The contraceptive prevalence rate is low (102, modern method, 1983),especially among Quechua and Aymara communities (52). The lack of adequatebirth spacing contributes to the high rate of maternal and infant mortalityand malnutrition. Tuberculosis and silicosis are prominent public healthproblems and major causes of adult mortality. The poor health status isalso associated with the unsanitary living conditionst only about 69Z ofthe urban population and 10 of rural population have access to pipedwater, while 37S of urban and 4S of rural households have sanitation. Onaverage, 65Z of the urban population of the four major cities do not haveexcreta disposal. This proportion reaches 85S in Santa Cruz, the mostrapidly growing city. Crowded and inadequate housing is the norm, with athird of dwellings with only one room, 602 with dirt floor, and 90S withoutbathroom.
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1.03 Social Impact of the Economic Crisis. Poverty has deep roots inBolivia and living standards have declined in recent years. The socialimpact of poor economic performance since the early 1970s was compounded bythe economic collapse which culminated in 1985, and, in the mining areas,by the austerity measures taken since then. The Government, which tookoffice in August 1985, faced a country in acute economic crisis. Real GDPwas contracting for the fifth consecutive year and per capita income haddeclined by wore than 202 since 1980; inflation was reaching 24,000? peryear, international reserves were virtually depleted and private and publicinvestment was at a standstill. The Government's stabilization andadjustment program has been successful in reducing inflation, controllingthe public sector deficit, restoring external and internal financialbalance and laying the foundation for sustained economic recovery.However, about 27,000 miners from public and private mines and another15,000 to 16,000 workers from the rest of the public sector were laid off.Unemployment and under-employment peaked at an estimated 20 to 25?, withdramatic social consequences. The contraction of public expenditures andreduction of salaries, and the deterioration of the terms of exchangebetween urban and rural areas and between the country and abroad also had aregressive impact on welfare. Indicators of standards of living are notavailable on a continuous basis since 1970. There are consistentindications that, while alarming enough before the depression, infantmortality, maternal mortality, malnutrition, incidence of diarrhea andparasitic diseases have worsened until 1985. The share of the nationalproduct spent on public health care and education was also reduced until1985, and has only partially recovered since then. The proportion of thepopulation covered by social security schemes fell from 25? in 1980 to 21?in 1986. Time series of hospitalization for malnutrition showsdeterioration of the status of children between 1981 and 1985, with arecovery by 1987 only in the rural areas. In 1988, the proportion ofschool-aged children not attending school had increased 15? above the 1980level. It is estimated that currently 60? of the population lives inhouseholds whose income covers only 80? of the cost of essential food.
..04 Recent Efforts to Address Social Issues. Since 1986, theGovernment bas increasingly focused on social issues, particularly those ofemergency and short-term nature. The Emergency Social Fund (FSE) createdto finance, by means of grants, small-scale employment and income-generating projects and social assistance programs was designed to benefitthose hardest hit by the economic crisis. This program, partially fuidedwith two IDA Credits (Cr. 1829-BO and Cr. 1882-BO) and major external donorcofinancing, has had a large and positive impact. By November 1989, it hadfinanced over 2,300 projects, provided at all times about 26,000 jobs withaccumulated commitments of US$145 million and employment generation of574,000 man/month equivalent. About 229,000 persons also benefited fromdirect assistance projects such as health and nutrition. The Government isseeking to reorient the emergency effort towards more investment-orientedtargets, through the creation of a Social Investment Fund (FTS). The FISis expected to be established by Tanuary 1990. The emergency fund ceasesto approve new subprojects in January 1990, and is mandated to close inDecember 1990. Drawing from the experience of the FSE, the FIS would setthe social programs within the long term social and economic developmentstrategy of the nation. The proposed project is also part of this effort.
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II. SECTOR AND INSTITUTIONAL FRAMEWORK
Organization of the Health Sector
2.01 Organization of Health Services and Share of Coverage. The healthsector comprises a multiplicity of public and private institutions servinga variety of target populations estimated to equal less than two-thirds ofthe Bolivian population. The Ministry of Social Welfare and Public Health(MPSSP), established in 1948, includes a subsecretariat of Public Healthand one of Social Security responsible for the Bolivian Institute of SocialSecurity (IBSS). In 1983, the MPSSP's public health system served about382 of the population, mostly in cities, declining more recently to about302. The social security system set up by the 1959 Social Security Code,provides wide benefits for insured workers and their relatives. Itsschemes cover wage-earners in industry, commerce, mining and governmentservices, mostly in mining areas and in La Paz. They benefited about 26Sof the population in 1982 and now about 202. hon-governmentalorganizations (NGOs) serve about 20 of the population, mostly in peri-urban and rural areas. Only a few municipalities and Regional DevelopmentCorporations (RDCs) are active in the health sector, but in Santa Cruz thecity supports, in its jurisd!ction, a more extensive health service networkthan the MPSSP. The private for-profit sector serves a small portion (nomore than 52) of the population which decreased recently with the generalimpoverishment. Traditional medicine is the only recourse of largesegments of the population, particularly in rural areas.
2.02 The Public Health Subsecretariat of MPSSP. The Public Healthsubsecretariat and its regional public health system were designed topromote basic health care, but this has not been achieved. The currentorganization of the regional public health system was adopted in 1983. Itincludes eleven Sanitary Units (SUs) covering the nine departments, withregional hospitals responsible for ambulatory and inpatient curative care;84 Health Districts (HDs) where health centers are designed to provide in-and out-patient maternal and child care, specialized ambulatory care, andserve as referral centers for a network of scattered health posts; and 426health areas in charge of the outreach activities and basic health carefunctioning in multipurpose facilities. A new plan of activities for HDswas designed in 1984, giving higher priority to basic health care. Thisapproach was subsequently developed with a shift from vertical managementat the central level to a management at the level of the SUs. Itemphasized community participation and provision of services of maternaland child care, and water and sanitation. A National Directorate of SocialMobilization was created in the MPSSP. Participation of Popular HealthCommittees (CPS) was institutionalized. Implementation, however, has beenhampered by organization problems, and by insufficient human and financialresources.
2.03 The Social Security Subsecretariat of MPSSP. The Social Securitysubsecretariat is responsible for policy making and planning of the socialsecurity system. The Social Security Code was streamlined in 1987 by theLaw 924 and the Supreme Decree 21637. The long-term benefits are newmanaged by 20 pension funds, and the health benefits by five Funds and sixinsurance schemes. The funds and insurances are characterized by a lowemphasis on basic care, and curative interssntions provided mostly inhospitals. The health benefits were reduced between 1978 and 1986. During1985 expenditures on health and maternity care fell by 502. The number ofhospitals and clinics also fell from 146 in 1983 to 112 in 1985. The fees,
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the costs of benefits received, and the facilities and services madeavailable to the beneficiaries vary between regions and funds.Administrative costs are high. Lack of coordination prevents investmentplanning and efficient use of the facilities. The growing deficit andvirtual bankruptcy of the smaller funds impose an increasing burden on thenational treasury. The long-term benefits absorb a growing portion of theexpenditures of the IBSS, with problematic trends for the future.
2.04 The Non-Governmental Organizations (NGOs). Over 300 NGOs operatein the health and tnutrition sector in Bolivia. Recent initiatives topromote coordination between them have yielded only modest results. NGOsproliferated during the last decade. They are funded primarily in theUnited States, Europe and Canada, and are managed by religious, charitableor civic institutions. Only a few NGOs have a national coverage, and mostare limited to the financing and management of a single or a few servicecenters.
2.05 The Local Governments. In the larger cities, municipalities ownalmost as many health facilities as MPSSP. La Paz and Santa Cruz haveactive health programst the city of La Paz carried out the very successfulbasic health component of the First Urban Development Project (Ln.1489-BO), and inzludes sanitation and basic health in the programs managedb- its Community Participation Directorate; Santa Cruz financed in 1987 42of all health expenditures in the city, gives ad hoc support to MPSSP'sfacilities and recently allocated increased budget to basic health care.El Alto is actively supporting community participation activities,including sanitation and basic health, with its limited technical andfinancial resources. The city of Cochabamba has not directly sponsoredhealth programs. Likewise, the nine RDCs promote economic activities intheir respective departments and are not directly involved with health.However, in the departments where mineral and gas provide revenues, such asSanta Cruz, the RDCs have played a role in planning, executing andmaintaining health facilities, principally in the rural areas.
2.06 The For-Profit and the Traditional Medicine. For-profit healthproviders have been affected by the economic recession. A large number ofprivate medical offices, catering to the middle and higher income groups inurban areas, closed recently. Traditional medicine is used by a largeportion of the population. It is practiced by about 12,000 traditionalhfalth practitioners, chemists, healers and midwives. Some training of'empirical oldwives', sponsored by UNICEF, has had a definite local impacton maternal health when coordinated with a referral institution, but thiseffort has remained marginal.
2.07 Physical Resources for Health Care. Health facilities have lowefficiency because they are unevenly distributed, often of inadequatedesign, and poorly equipped and maintained. Inadequate operating hoursalso contribute to the low usage. There are about 1,200 health facilitiesin Bolivia. There are eight beds per 1,000 inhabitants in Sucre, but lessthan one per 1,000 inhabitants in Oruro and Potosi. Overall, there areabout 1.8 hospital beds per 1,000 inhabitants, an inadequate figure belowthe 2.8 average for the region. In the proposed project area, comprisingthe urban and peri-urban areas of La Paz/El Alto, Santa Cruz andCochabamba, there are 346 health facilities, of which about 10? belong toMPSSP, 35Z to the private sector, 30? to NGOs, 72 to the Social Securityand institutions such as the police and armed forces, 82 to themunicipalities and 102 to neighbors' communities (Annex 1). Seventypercent of the health facilities have no more than two rooms, and many
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health posts have only one room. A recent MPSSP survey found that 68? ofthe facilities present some deficiencies, such as lack of water or sanitaryconnection, and that 272 of them are unable to provide adequate services.Overall, this situation is worse in Santa Cruz than in any other largecity. Public health facilities have outdated equipment and are poorlymaintained. Maintenance is mostly done through ad hoc repairs, withoutplanning or budget.
2.08 Human Resources for Health Care. HPSSP plays a central role indeveloping and financing training of health care workers, but the healthsystem suffers from an inadequate skill mix, and a skewed deployment ofpersonnel. MPSSP has 11,000 employees, which is adequate (Annex 1). Theministry provides staff to many NGOs who supplement the MPSSP salaryaccording to their own policy. In Santa Cruz for example, MPSSP payssalaries to 340 NGO staff, contributing 58Z of NGO's expenditures in thearea. Many employees cf NGO and private institutions received theirinitial training in MPSSP. Accordingly, the quality of supervision andinservice training of MPSSP staff has an impact on the entire sector. Theinadequate skill mix in MPSSP is similar to that in the rest of the sector.It is characterized by a shortage of nurses and auxiliary nurses, and alack of adwinistrative and managerial capacity. In the project area, only25Z of hospital directors have some training in administration, and thepublic health system is even more deprived of qualified administrative andfinancial skills. Finally, resources are concentrated in hospitals withonly 30? of personnel assigned to basic care.
2.09 In Bolivia organized groups of beneficiaries represent an assetcapable of overcoming to a large extent the lack of institutional capacity.These organizations include Neighbors' Councils, which are the basis forparticipation of the community in municipal, labor and politicalactivities. They are used in particular for the execution of self-helpprojects. Another drrangement is the Popular Health Committees (CPS),elected by Neighbors' Councils for matters related to health. The CPS areorganized at the district, departmental and national level and assist inthe definition of priorities, planning, execution and evaluation of healthactivities. Their coordinators provide the contact between the familiesand members of the community and the health system. The YouthParticipation Groups serve as information and motivation agents duringnational campaigns. Finally, mothers' clubs assume a major role in fooddistribution, and child nutrition and survival programs. All of theseorganizations are more active in La Paz and El Alto where 25Z of familiesbelong at least to one of them, than in Santa Cruz (20?) or Cochabamba(18?). Despite the heavy emphasis placed by MPSSP on communityparticipation in its policy statements, effective participation has beenmostly limited to vaccination campaigns.
2.10 Financial Resources for Health Care. The budgetary allocationfor MPSSP fell dramatically from 1980 to 1986 and has not returned to its1980 level. The Government recently increased NPSSP's share of the budget.In 1988, public health expenditures had grown back to 3? of national budgetand MPSSP's budget was US$20.5 million, or 55? of the 1980 budget.Overall, financial resources for the health sector, even including foodaid, are exceedingly limited in Bolivia (Table 1).
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Table Is PUBLIC FUNDING OF THE HEALTH SECTOR a/USS Million of 1987
MPSSP IBSS FSE Food TOTAL TOTAL TOTALNational budget Health Health Aid per X
per X Services Projects Capita ofUSS capita bud&at USS USS USS US$ US$ GNP
Source: MPSSP, IBSS, INE, FSE, Analysis Unit in the Planning Ministry andmission estimates.
a/ MPSSPs' figures have been deflated monthly. IBSS and GNP figures havebeen deflated only annually. The high IBSS figure for 1984 may be aresult of this discrepancy, and may not be representative of an increasein real expenditures.
_/ Amount budgeted.
2.11 The sharp reduction of public funding for health was not fullycompensated by donors activities and by the large increase in costrecovery. NGOs expenditures reached US$19.3 million in 1988. or 282 oftotal expenditures in the sector (Annex 2). Foreign aid finances 20? ofrecurrent costs and all of the investment. User fees, through charges formedical attention, drugs and supplies, increased by 6002 between 1984 and1988, rising from US$1.7 to US$10.3 million per year. The budgetaryallocation for the MPSSP now covers only half of the recurrentexpenditures. Investments, halted in 1984, have been resumed (Table 2).Financial resources at the local level are directed mostly (66?) tohospitals, while basic health care receives only between 20 and 402 ofbudget (Annex 2).
2.12 The major sector issue in Bolivia is the limited coverage ofmaternal and child care. Issues related to this low coverage include theinadequate organization and management structure and coordination among keyAgencies; the constraints related to personnel management; the poorfinancial management; the absence of a viable system for purchase anddistribution of essential drugs and medical supplies; and the inadequatetraining of medical personnel.
2.13 Limited Maternal and Child Care. Only about a third of thelolivian population receives adequate basic health care. In the proposedproject area prenatal care coverage was 201 and postnatal care coverage 61in 1988. Only 36Z of deliveries nationwide were assisted by a person withsome knowledge of medicine in 1985, and this proportion has declined. Thecoverage for vaccination is about 602 for polio 3 and DPT3 in urban areas.and ranges from 1OZ to 451 in rural areas (1987). Less than one in five oftarget families in the proposed project area have been visited by personnelof the MPSSP or other health institutions during the last year. Secondaryand tertiary services are accessible to yet a smaller portion of thepopulation. Referral is impeded by communication constraints, poorintegration of facilities and lack of outreach services in health centersand hospitals. The high cost of care in these facilities also preventsaccess to most of the population.
2.14 Inadequate Organization, Management and Coordination. Excessivecentralization has prevented MPSSP over the years from assuming itsnormative and coordinating responsibilities. Executive functions in MPSSPare concentrated in the National Directorates in La Paz. Only 201 of thebudget, consisting of the revenues generated locally, is executed in theSUs. The inefficiencies associated with central execution are exacerbatedby severe communication, constraints. This leads to inadequate informationflows and monitoring. Lack of guidelines for program implementation andlack of accountability perpetuate the weak technical and programmingcapacity at the local level.
2.15 The proliferation of self-contained project units in MPSSPdisrupts the fulfillment of its responsibility and objectives. TheNational Directorates have gained virtual independence through theexecution of projects financed by donors. The General Secretariat, whichhas not been the object of specific cooperation programs, is weaker thanthe directorates under its supervision. The weak enforcement of MPSSP'splan cf activities prevents the Ministry from integrating donors' support.This has led to the development of 16 major national programs, withoverlapping objectives and beneficiaries, and inadequate monitoring.
2.16 Poor coordination between MPSSP, the IBSS and NGOs is a complexissue at the national level, but is starting to be addressed in the SUs.In MPSSP, coordination is made difficult by incomplete interinstitutionalinformation, the numerous national programs, and the separate legal andoperational system under IBSS. The relationships between NGOs and theMPSSP have often been difficult, and occasionally marked by mistrust.Impediments to coordination include the lack of an identification andselection system for NGOs presence and activity in Bolivia, and cumbersomeand contradictory registration procedures. In the SUs, coordination ishampered by the lack of credibility of SUs as relevant partner in thedelivery of services. Poor information about MPSSP and the SUe is anotherproblem. Tn 1988, a survey in the proposed project area showed that only
452 of institutions providing health services were aware of MPSSP'sprograms. Familiarity was lowest for programs addressing maternal issues.More recently, coordination and cooperation with NGOs and local governmentsimproved. It is supported by the renewed confidence in the public sectorcreated by the funding of over 300 NGO projects by the FSE.
2.17 Personnel Management in the Public Health Sector. MPSSP employeesare poorly paid, but improved personnel management would be necessarybefore salary increases could contribute effectively to improveperformance. Health workers' salaries fell by 301 in real terms over thelast decade. The salaries in the Public Health subsecretariat, rangingfrom US$31 to US$240 per month, are 'the second lowest in the public sector.Accordingly, staff seeks better salaries and working conditions in NGOs andthe IBSS, and personnel turnover is 301 annually. The salary structure ofMPSSP needs improvement to reflect the priorities of the sector. Doctorsin HDs have lower status and pay than doctors with comparable training inhospitals or with administrative functions. This condition discouragesable staff to move to the areas of greater needs. Salaries foradministrative or managerial posts (such as the directors of SUs) aregrossly inadequate. Weak personnel policy and management compound thesalary issues in the public health sector: SUs and many hospitals have noadministrative committee, no organizational plan, no job description forpersonnel, erratic hiring procedures, and ad-hoc systems of personnelgratifications and salary supplements.
2.18 Financial Management. Financial management is weak because of theinadequate distribution of financial responsibilities, the outdatedstructure of the information used for budgeting, and the inefficientprocedures for budget preparation and execution. The inadequatedistribution of financial responsibilities stems from a combination ofexcessive centralization of functions within MPSSP along with an inadequatemanagement information system. Budgeting is also separated from planning,and budget categories reflect inadequately the sources and uses of funds.Sources of funds in MPSSP are now depending too much on cost recovery toensure adequate coverage of health services, and particularly of basichealth care. Programming and execution have been complicated by thedependence on project specific donations from the international community.Projects financed by donors are not coordinated or set within the nationalhealth plan. Uses of funds favor secondary and curative care and the shareof basic health care does not reflect government priorities.
2.19 Purchase and Distribution of Essential Drugs and Medical Supplies.The weak capacity of MPSSP to enforce existing legislation, and the acuteshortage of funds have led to the deficient procurement and distributicn ofdrugs, medical supplies and equipment. The Supreme Decree 21060 of 1985,article 41, exempts drug supply from the free trade regime, but localproduction of essential drugs has not developed. Quality control isinsufficient and health facilities lack financial and human resources toparticipate effectively in the rationalization of distribution and use ofdrugs. Drugs are purchased mostly using a petty cash system.
2.20 Training of Medical Doctors, Nurses and Auxiliaries. Although thecapacity to train the necessary health staff exists in Bolivia, the designof curricula does not respond to the staffing requirements for basic healthcare, and the education process is not conducive to the extension ofservices in low-income areas: the autonomous medical schools inuniversities offer a curriculum for medical doctors and nurses which is not I
directed to the epidemiological and social reality of the country. Inparticulars (i) maternal and child care, community medicine and nutritiondo not receive the necessary attention; (ii) no training is given on theadministrative and team management responsibilities of doctors and nurses;and (iii) the health personnel are often ill-prepared to deal withilliterate and non-Spanish-speaking patients. The Cochabamba TechnicalSchool of Health (ETS) and the La Paz National School of Public Health(ENSP1 train auxiliaries, nurses and technicians. These schools depend onMPSSP and their curricula is more oriented towards basic health. They arealso willing and better prepared to further improve curricula than theautonomous medical schools. The educational process is not supportive ofthe objectives of basic health care in impoverished communities. Theprofessional ties between the medical schools and MPSSP staff responsiblefor basic health are weak, unlike the ties between the medical schools and
I hospitals. Too few auxiliary nurses are trained, and few staff areprepared to serve in remote areas. In addition, no manual of standardprocedures are distributed to the graduating students, or updated for theiruse.
Donor Activities
2.21 Major donors' programs have been taken into account during projectpreparation. In addition, the World Health Organization (WHO/PAH0)participated in the preparation of the proposed project, and UNICEFadministered the project preparation fuiLds. WHO/PAHO coordinates aboutUS$1.0 million of technical assistance programs yearly. UNICEF is carryingout a US$39.9 million multisectoral pro.'ram in support of child survival.The 1989-93 program aims at reducing mortality among children and mothers,improving their nutritional status and giving them greater opportunitiesfor social development. It encourages better use of existing publicservices and the development of family services organized by the community.A 1988-1990 USAID project for Community and Child Health, amounting toUS$22 million, seeks to suppo.t the decentralization and the expansion ofservices in rural areas surrounding the proposed project zones. TheInternational Development Bank (IDB) is preparing the extension of theproposed project in the departments of Sucre, Tarija and Chuquisaca. Inorder to sustain inter-agency cooperation, a Donors Coordination Committeehas been set up during the project preparation. It is chaired by MPSSP andincludes representatives of IDA, UNDP. WHO/PAHO, UNICEF, IDB and USAID.This committee addresses the day-to-day coordination needs between majorinvestments in the sector, rationalizes their geographic distribution, andintegrates design features (para. 3.16).
IDA Assistance Strategy
2.22 IDA Assistance Strategy in Bolivia. IDA supports the Government'seconomic policy with the objectives of laying the basis for sustainedgrowth, ana improving the living conditions of the bulk of the population.This requires major investments in human resources development,particularly in health and education. The proposed project is a centralpart of the package of actions developed by the Government in coordinationwith donors to fulfill these objectives. It complements, in particular thedemand driven approach of the Social Investment Fund (FIS). It Jssupported by, and contributes to, other parallel projects which include:
(a) the Emergency Social Fund (Crs. 1829-BE and 1882-BO) which wouldbe broadened from an emergency fund to a development institutionthrough the financing of a proposed third credit. The FIS isbeing created for that purpose;
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(b) the Economic MaPagement Strengthening Operation (Cr. 1977-BO)dealing with issues of public service efficiency andeffectivenesst
(c) the Public Financial Management Operation (Cr. 1809-BO) supportingthe upgrading of the Governrent's finuncial management includingbudgeting and accounting;
(d) the proposed Water Supply and Sewerage project which is to benefitthe same area of the country; and,
(e) the proposed Primary Education Project whose institutional set-upand investment approach would be developed along the same lines asin the health sector.
2II. THE PROJECT
Protect Origin and ObJectives
3.01 Project Origin. at the request of the Government, a health sectoranalysis was carried out by the Bank in 1987 (Bolivia. Population, Health,and Nutrition Sector Memorandum, Report 6965-BO). It led to theidentification of the proposed project in March 1988. A ProjectPreparation Facility of US$490,000 was approved in April 1988. Asupplemental facility to increase the original amount to US$1,490,000 wasapproved LA January 1989. Appraisal was carried out in May 1989.
3.02 The obiectives of the project are tot
(a) improve maternal and child health by increasing the coverage ofbasic health care services, and giving priority to pregnant andlactating aomen, children under five years of age, and women atreproductive risk. This would be carried out in the mostpopulated part of the country, namely the urban and peri-urbanareas of La PazIEl Alto, Santa Cruz and Cochabamba;
(b) improve the efficiency and effectiveness of health services inBolivia through the development of adequate human resources in theMPSSP and other institutions providing health services; and
(c) strengthen central policy making and coordination of investmentin health within a more coherent institutional framework and anational health sector development program that devolve greateroperational responsibility to regional levels.
Main Features of the Prosect
3.03 The project is based on the Integrated Health Care Model (IHCM) ofthe MPSSP which essentially seeks to improve infant and child survival andmaternal health (Annex 3). Under this approach, MPSSP would focus more onpolicy formulation, coordination, monitoring, and resources mobilization.At the departmental level, the Sanitary Urits (SUs) would coordinate withlocal governments, regional institutions and NGOs, supervise, and providetechnical support to the local providers -.f health care. The provision ofbasic health cart services, with an emphasis on maternal and child care,would be organ-zed in Health Districts (HDs) of about 100,000 to 200,000
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inhabitants. About 832 of these services would be targeted to women andchildren. They would include pre- and post-natal care. promotion ofreproductive health, child development and nutritional control, preventionand control of diarrhea and acute respiratory infection, diagnostic andinitial treatment of malaria and tuberculosis and routine follow-up of riskgroups, simple odontological services. external medical consultat1on,emergency attention, distribution of basic drugs and referral to secondaryfacilities. The services would be provided in five to ten health centersstrategically located in each HD.
3.04 The project would finance the extension of basic health careservices in public or private facilities distributed according to the IHCM.The providers of health care participating in the IHCM would receivesupervision of the SU and carry out the activities corresponding to theirassigned level of service. They would benefit from the activities of theproject with upgrading, expansion or construction of new facilities,equipment, training of staff and supply of essential drugs and supplies.They would also receive additional support in staff from the MPSSP.
3.05 The outreach activities would form an integral part of the healthcare delivery system. They would be the responsibility of the HDs andwould be organized in areas of about 20,000 inhabitants, and sectors ofabout 3,000 inhabitants. They would consist mostly of promotion ofmaternal and child health, and health education campaigns. They wouldinclude activities performed by auxiliary nurses, such as vaccinations,pre- and post-natal care, identification and training of midwives,nutritional control and food distr 'ion. They would be coordinated withthe CPSs. They would take place in .isting community buildings, such asschools, parishes, community centers, and other multipurpose facilitiescalled Integrated Centers.
3.06 The project would support a few far-reaching health policydecisions. They would include a more adequate resource allocation from thenational treasury to the health sector; a revised balance of financial andhuman resources between the basic health care, mostly for the benefit ofmothers and children, and the secondary and tertiary hospital care; areview of the training curricula of the health schools to integrate thetraining with the basic care as closely as it is coordinated with hospitalcare; and a review of the status of basic care doctors and administratorsto reflect the priority of basic care, and of improved financialmanagement.
3.07 The policy decisions and the project's critical path, described bykey indicators, would constitute a Plan of Action (para. 3.16 and Annex 4).The indicators would iuclude institutional and staffing targets and servicedelivery performance indicators. Annually, a joint review of the status ofimplementation of the Plan of Action and of the investment program in theproject area would be completed by IDA and the Government. This reviewwould take place before October 31 of each year. By November 30, thefinalized project investment program for the coming year, with the proposedbudgeted counterpart, would be sent to IDA for approval. Views would beexchanged on all planned expenditures in the sector, including investmentsoutside the project area and the expansion of the IHCM and basic healthcare services within the total health expenditures (para. 7.01).
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3.08 It is also the intention of the Government during the execution ofthe proposed project, to define its medium-term objectives in the Healthsector. This includes addressing broader issues such as the coordinationwith the IBSS and the financing of the health sector, the salary structureof the MPSSP, medical education, and hospitals management and the referralsystem. This intention of the Government was laid out in a policy letter,dated October 31, 1989, and signed by the Minister of Health (Annex 5). Areview of proposed policies would be made jointly by IDA au.d the Governmentby October 1993.
3.09 Project Description. Che project would finance: rehabilitationand construCLIon of physical facilitiec, medical equipment, furniture, andsupply of pharmaceuticals to build up a stock oi basic drugs; humanresources development: and institutional reforms and managerial systemsdevelopment. The project would include three components, as follows:
(a) Service Delivery Component, to develop the IHCH in the urban andperi-urban areas of La Paz, El Alto, Santa Cruz and Cochabamba,integrating under one structure, the human resources andfacilities of MPSSP, the municipalities and NGOs;
(b) Human Resources Development Component, to ensure that the staff ofMPSSP and of the relevant health care providers, receive essentialtraining and supervision to car-y out the tasks defined i.; 'i-3IHCM; and
(c) Institutional Development Component, to assist MPSSP in assumingits normative and coordinating role at the Central level and itscoordinating, planning and executing role in the three SUs of LaPaz (covering La Paz and El Alto), Santa Cruz and Cochabamba.
The Service Delivery Component (US$29.6 million, including contingencies)
3.10 The service delivery component would be implemented in the SUsof La Paz (covering La Paz and El Alto), Santa Cruz and Cochabamba. TheIHCM defines precisely the functions of the SUs and districts, the maternaland child care and other basic services, and the staffing of the healthfacilities (Annex 3). Standard agreements satisfactory to IDA would besigned between MPSSP and local governments and NGOs to delegate theadministration of districts, and the operation of facilities to such localgovernments and NGOs. The SU would provide sectoral information,supervision and training; the implementing entity would extend the IHCMservices to the population of an agreed area. Copies of the agreementswould be available for IDA's review during supervision (para. 7.01).
3.11 The service delivery component would include:
a) Civil Works (US$8.3 million). The new construction, expansion andupgrading of about 166 facilities in the project area (Annex 6).
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Table 3: SUMMORY OF CIVIL WORKS BY FACILITY TYP':AND CONSTRUCTION REQUIREMENT
Inte- Health Health Regional Ware-grated Center Center Office house TotalCenter w/Beds
New construction 0 24 1 3 2 30Expansion 14 30 0 0 1 45Upgrading 69 6 13 1 2 91
Total 83 60 14 4 5 166
The Health Centers would follow regional prototype designs of about 300m2
each. They would include specific consulting rooms for pediatrics,gynecology and obstetrics, oral rehydration, child growth monitoring,dentistry, general medicine and first aid. They would be adapted tovarying regional climatic conditions and to future expansion needs. Inabout 48 centers a doctor's dwelling (57m2) would be attached to the hcalthcenter. The Integrated Centers would function in adapted communityinfrastructure, equipped and staffed in a joint effort with the MPSSP.Space requirements for ambulatory care would be 37m2. Proposed locationsfor the above facilities have been agreed upon. Ninety percent of siteidentification had been completed by pre-appraisal. A condition ofnegotiatione was that 802 of sites where new constructions are programmedwould have formal title or a donation agreement. Except in El Alto. healthcenters, with up to 20 beds, would represent expansions and upgradings ofexisting facilities. Ambulatory services would be those of a HealthCenter. In-patient services would consist of maternal and child careservices. In El Alto, the effective basic health care system requires amaternal and child facility of up to 50 beds. This facility would befinanced under the project. MPSSP would contract through public biddingthe operation and maintenance of this facility, according to the costrecovery policy to be defined during the project and taking account of theresults of the financial study (para. 3.15, b). MPSSP would finance theoperating budget and staff required. The project would also include theprovision of adequate storage facilities for essential drugs and medicalsupplies, at central and SU level. The Government presented to IDA beforenegotiations a model contract to ensure that physical facilities financedby the Credit would be used exclusively for the purpose of the project, inthe event that the project finances rehabilitation or construction offacilities that are not a public property. Copy of the contracts would bekept in the SU for supervision.
b) Services (US$7.6 million). The project would include the cost ofincremental personnel and the incremental salary of SU directors. Theincremental staff would be composed only of personnel who cannot bereassigned from hospital or administrative posts. This includes only theauxiliary nurses necessary to staff the districts (about 41 persons of atotal of 126 in a typical district). Doctors, dentists and nurses, ofwhich there is no shortage in MPSSP, would be reassigned from hospitals andadministrative posts. The review of the staffing of HDs would be includedin the annual review of implementation (para. 4.08). The Credit wouldfinance on a declining basis the cost of the US$80 salary of 49 auxiliarynurses and the upgraded salaries (US$1,000) of the 3 SU directors. IDA
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would finance 10OZ of these costs in 1990, and 50t in 1991. Disbursementswould be conditioned to the Government providing IDA the plan for assumingthe cost of thesa' salaries after June 1991. This would include thefinancial and administrative steps to be taken by June 1990, December 1990,and June 1991 (para. 7.03).
c) Malntenance Program (US$1.9 million). The maintenance program forproject fa:ilities atid medical equipment would consist of: the constructionand equipment of one workshop/training center; equipment and vehicles; andthe maintenance of buildings and equipment, financed in a decliningproportion. Maintenance would be contracted outside MPSSP wheneverreasonable.
d) Vehicles, Equipment and Material (US$5.4 million). The projectwould provide about 52 vehicles, including 28 four-wheel drive vehicles,five ambulances, five trucks, five station wagons, one forklift, and eighthydraulic loaders. It would also include equipment and furniture forIntegrated and Health Centers. The facilities, the equipment and vehiclesfinanced under the proposed project would be adequately maintained andwould be used only for the purposes of the project.
e) Essential Drugs ard Medical Supglies (US$6.4 million). Theproject would provide acquisition and logistic support to ensure efficientdistribution of supplies and essential drugs. In most cases, distributionof supplies and drugs would be in kits corresponding to three months ofoperation in selected areas. These sealed kits, easy to t;ansport andmonitor, would be imported and assembled locally. The adequacy of thedistribution method would be reviewed after two years and corrected asnecessary. The import of essential drugs and supplies would be cofinancedby the Government of the Netherlands through a balance of payment supportscheme (para. 5.04).
The Human Resources Development Component (US$1.0 million, includingcontingencies)
3.1i This component would finance a variety of manpower developmentactivities, including: li) induction to project objectives and procedures,strengthening of the MPSSP system for personnel supervision and inservicetraining, and improvement of interinstitutional coordination; (ii) basicskills and technical training, in the form of preservice or inservicetraining of MPSSP, other public and NGO personnel, and the revision ofselected curricula in health schools, with an emphasis on an upgradededucational and training process; and (iii) training of midwives, andhealth education campaigns for community leaders (Annex 7).
3.13 Decentralized training capacity would be developed and wouldensure relevance to the local working conditions. Technical support wouldbe provided by the Cochabamba ETS and the La Paz ENSP, and by local andforeign consultants. The hosting of the training activities andcoordination with trainees would be the responsibility of the districttraining centers. The detailed training program was reviewed duringappraisal. The updated training program for each following year would besent to IDA for approval as part of the investment program (para. 7.01).Technical assistance has been designed to ensure adequate quality of thecourses through the participation of WHO/PAHO who would cofinance theformal training. The component would also be cofirtanced by UNICEF(training of midwives and health education campaigns), who would provide
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technical assistance. The project would finance consultants fees, traveland per diem. MPSSP and other trainees travel and per diem, a study, andequipment and material, including some equipment for the ETS and ENSP.
3.14 Trainlng programs would be designed as follows: (i) Inductioncourses to the IRCM and the project would be organized in La Paz and theSUs for selected staff of MPSSP, NGOs, municipalities and IBSS; theNational Human Resources Dir-ctorate in MPSSP, and human resources units inSUe would be strengthened tk jugh orientation seminars; selected curricularreform at the Cochabamba ETS and La Paz ENSP would be supported by a panelof staff with experience in basic health care, assisted by consultants.Emphasis would be put on the skills and attitudes necessary to operate theIHCM, focusing on community involvement, and interinstitutionalcoordination; (ii) basic skills and technical trainina. Basic skillstraining would be provided to about 125 nurses and auxiliaries, and 20technicians every year identified among students of the Cochabamba ETS andLa Paz ENSP, and staff in the relevant districts. Technical training wouldinclude planning, management, personnel administration and supervision,financial administration and control, and information system. A keytechnician, selected from each project SU, and three staff from MPSSP wouldreceive about three months of training in health systems planning andadministration abroad; and (iii) training of midwives would be organized bynurses to ensure referral of high-risk pregnancies and the integration ofthe midwives to the outreach program of the HD. Health education campaignswould be organized with coordinators of CPS and other relevant communityleaders such as primary school teachers. A study on traditional medicinewould also be carried out to identify actions to integrate traditionalpractitioners with the referral system (Annex 8).
The Institutional Development Component (US$6.5 million, includingcontingencies)
3.15 This component would include activities in three areas: therestructuring of the MPSSP; the administrative rationalization of theMPSSP; and, the strengthening of the financial, human and physicalresources management. It would be cofinanced partially by WHO/PAHO whowould provide technical assistance. IDA would finance technicalassistance, project data management and office equipment, and contractedworks from MPSSP directorates (para. 4.02). In addition an internationalconsultant would be financed to follow up and provide technical guidancetwice a year. Training activities, carried out under the Human Resourcescomponent, would also support these activities.
a) Restructuring the MPSSP. A new organizational structure would besent to IDA no later than December 31, 1990. It would be supported by thejob descriptions, procedures and lines of accountability of the departmentsto be restructured. The reorganization would be phased in, beginning in1990 with the directions of Planning and of Human Resources, and the threeSanitary Units involved in the project. In 1991, the Direction ofAdministration, the General Direction, and the Health Districts in theproject area would be restructured. By 1994, the revised organizationalstructure would be fully operational. The Direction of Planning wouldoversee the changes and monitor the transfer of personnel and designationof budgetary slots to complete the staffing requirements of the neworganigram (Annex 9). The project would finance: office equipment andtechnical assistance; salary supplements for HPSSP staff carrying outspecific tasks defined in terms of reference included in the annualinvestment program; commissions for the bidding agent and supervision; andsalary and costs of the Project Unit (para. 4.01).
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b) Administrative Rationalization. The functional capabilities ofthe MPSSP would be strengthened in three areas: i) planning. ii)supervision, and iii) the generation and processing of information. Aplanning format, integrating the health sector needs, service delivery andthe budgeting system of the MPSSP, would be implemented at the centrallevel by the Direction of Planning. The use of this format would beextended to each of the 11 SUe of the country, starting with those of theproject, and would facilitate the integration of public, donors and NGOactivities in the annual planning process. The three project SUs wouldelaborate their annual health plans to support and be integrated to thenational plan, starting in 1991. The project would finance officeequipment and technical assistance. Supervision norms for the IHCM wouldbe developed and implemented. with technical assistance and cofinancingfrom WHO/PAHO. The content of supervision would be reinforced to includeeducational activities, monitoring of output targets and feedback. Theproject would finance materials and supervision. An improved managementinformation system would be set up. It would integrate demographic,epidemiological, social and nutritional data, service statistics andfinancial and other management data. The gathering and elaboration of datawould be decentralized to the lDs. It would include the tracking of NGOsand other organizations operating in the health sector. The statisticalunit within the Direction of Planning would be strengthened. The projectwould finance office equipment, hardware and softvare at the central, SUand HD levels, technical assistance, a supervision budget, and studiesincluding one on nutrition status (Annex 8).
c) Management of Financial, Human and Physical Resources.Mi) Financial Resources. This would include the development of acomputerized budgeting system for basic health. It would be incorporatedin the management information system. It would be coordinated with theactivities of the IDA-financed PFMO project. While the PFMO wouldconcentrate on strengthening the budgeting and financial control at thecentral level, the proposed project would support the implementation ofinstitutional-level budgetary procedures and the generation of relevant andtimely information at the SU and HD levels. The management of financialresources would incorporate external aid and food distribution information.Unit costs of services, supplies and medicines would be monitored in asample of facilities. A study of health care financing would analyzealternative sources of financing. It would make practical recomendationsfor standardizing financing, and cost recovery policies and procedures(Annex 8). The project would finance office equipment, technicalassistance and the study. (ii) Human Resources. The personnel managementsystem would be improved, supervision would be emphasized and would bebased on the revised job descriptions. Personnel management would bedecentralized. The status of SU directors, doctors in HDs, and qualifiedadministrators to key posts of MPSSP would be upgraded, in coordinationwith the salary review of the IDA-financed EMSO project. The project wouldfinance technical assistance. (iii) Physical Resources. The management ofthe national acquisition, distribution and control of essential drugs wouldbe upgraded. Adequate supervision and control of the acquisition anddistribution of essential dru.,8 and medical supplies would be ensuredthrough training, technical assistance and institutional strengthening incoordination with WHO/PAHO. A manual of procedures would be prepared anddistributed for use in health institutions carrying out MPSSP programs. Atechnical assistance program would define procedures in the maintenancesystem in which programming, contracting and supervising would bedeveloped. The project would finance office equipment, technical
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assistance, and supervision. The project would also finance thepreparation of a project to provide water supply and basic sanitation inthe project area (Annex 8). It would consist of public standpipes andlatrines for about 36,000 beneficiaries in Santa Cruz and 50.000 inCochabamba. The design and execution of a pilot project to provideservices to approximately 4.000 people would complement the final designs.Technical assistance and the developmert of a human resources program wouldalso be included. The execution of the works is not included in theproposed project. It would be carried out by the FIS, in coordination withthe SUe of Cochabamba and Santa Cruz.
Plan of Action
3.16 The Plan of Action would set annual performance indicators andtargets for the policy decisions and the project critical path (Annex 4).In particular, it would define the priority to be assigned to basic health;the major steps of the reorganization and strengthening of MPSSP; theeffectiveness of community participation; and the integration of otherpublic and NGO resources in the IHCH. The salient elements of the Plan ofAction are presented below:
(a) Sector Health Policy. The share of the national budget allocatedto public health would increase from 32 to at least 42 by the endof the project, an increment of about US$10.0 million. Theproportion of public health expenditures allocated to basic carewould grow from between 20 and 301 to no less than the highesthistorical level of 352. This is consistent with the requirementsof the IHCM in the project area. The percentage of MPSSP budgetadministered by the SUs in the project area wouild be consistentwith the revised distribution of responsibilities. It wouldincrease from about 201 to no less than 902. The DepartmentHealth Councils (CDSs) in the project area, and the DonorsCoordination Comuittee would be kept active during projectexecution (para. 4.04). The percentage of food aid distributedaccording to MPSSP criteria would grow from between 40 and 60t to801 in the project area.
(b) Service Delivery. The percentage of SU vehicles in operationwould grow to no less than 80Z by 1991, and contracts formaintenance would be according to an agreed schedule. No lessthan 902 of health facilities would inform their districts aboutdrug distribution by the end of project implementation. The ratioof auxiliary nurses to doctors would not be less than three to onein the districts of the project area. The number of facilitieswith extended hours of attention would be according to agreedschedule. The number of health institutions with activeagreements with the SUs, and implementing the IHCM, would growaccording to schedule.
(c) Human Resources Development. The decentralization of humanresources management would be effective by 1991. All districts inthe project area would have a fully operating training capacity bythe end of project implementation. The participation of theorganized communities would be according to schedule, and no lessthan three midwives would be trained in each area of the project.
(d) Institutional Development. The improved procedures of budgetelaborab.ion and execution in districts. SUs and in the ministrywould be finalized according to the agreed timetable: all the
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local management units of the project area would elaboratecomplete financial reports by 1991, and would generate and use themanagement information system by 1992. The revised chart of thedirectorates of Planning, Human Resources and Administration wouldbecome effective according to the agreed timetables. The externalmonitoring and evaluation of the project impact on local healthwould be pursued according to schedule (paras. 4.07 and 4.08).The terms of employment of basic health care doctors andadministrators would be reviewed during 1990 and upgraded by March1991. Annual work programs of districts would be integrated inthe national health plan. The international cooperation piojectswould be formally included in MPSSP annual health plan by 1992.The investment plans of the two subsecretariats of MPSSP would becoordinated after 1994.
IV. PROJECT IMPLEMENTATION
Implementation Arrangements
4.01 The project would be managed by a Project Unit (PU) financed bythe proposed credit. The PU would be part of the Planning Directorate ofMPSSP. It would be composed of: a project manager specialized in businessadministration who would be responsible for the overall development of theproject and the interlocutor of IDA. He/she would be selected among theresponders to a public invitation; a technical director, with experience inpublic health administration, responsible for the execution of the projectcomponents; an administrator; three support staff and a chauffeur. The PUwould have an office in each SU. It would include an administrativedirector. counterpart of the project manager; the planning director,counterpart of the technical director; and one secretary. The projectmanager would report to the director of planning. Assurances were given atnegotiations that the PU would be staffed with qualified personnelsatisfactory to IDA. The replacement of the project manager and technicaldirector would be made only after IDA has approved their qualifications.Curriculum vitae of all the staff of the PU, at national and SU level wouldbe submitted to IDA prior to their replacement, and IDA would be given anopportunity to exchange views on the appropriateness of their quali-fications (para. 7.01). The Government provided a signed contract for theemployment of a satisfactory project manager and of a technical director asa condition of negotiations.
4.02 The PU would provide and receive technical support from relevantdirectorates of MPSSP. This support would, a: necessary, be contractedunder terms of reference approved by IDA to be. financed under the project.A set of professionals, normally from MPSSP staff, would also work for thePU on a part-time basis, or during specific periods of time. They wouldinclude: a statistician; an engineer/architect; and technical advisors forthe drug acquisition and related activities, the equipmentlmaterial andvehicles and their maintenance, the community participation and healtheducation campaigns, the management and development of human resources,and the institutional development and studies; and an accountant. Theprogram of contracted support from the directorates of MPSSP and otherprofessionals would be approved by IDA as part of the annual investmentprogram. All curriculum vitae and terms of reference, consistent with theannual program mentioned above, would be submitted to IDA for approvalbefore contracting. Pay policy for contracted personnel would becompetitive with the private sector (para. 7.01).
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i.03 Overall responsibility for the project would be vested in the PU.Execution would be carried out in the PU according to the reviseddistribution of responsibilities in MPSSP. Execution of the trainingcomponent would be supported by UNICEF (training of midwives and healtheducation campaigns), and by WHOIPAHO (formal training) who would providecontinued assistance to the PU. Bidding documents would be prepared by theSU and prices would be revised by the FIS. FIS has a comparative advantageto ensure adequate standards of construction materials. Procurement wouldbe carried out by a procurement agent, as required by Bolivian legislation(paras. 4.10 to 4.12). In Santa Cruz, technical supervision and control ofmaterials would be done by the RDC who has the adequate experience andcapacity to do so, and often assumes this responsibility for public works.In the other departments, supervision would be contracted to a private firmby the SU. The Municipality of La Paz has completed a Bank Loan and isexecuting an IDA credit (Cr. 1842-BO). The SU of La Paz may delegatecontracting of works to the municipality according to procedures approvedby IDA. The FIS would perform the financial follow-up of the works, andadminister the payments to the contractors. The FIS has an agile financialmanagemert system and is able to pay contractors in all the nationalterritory. As a condition of negotiations, the Government submitted to IDAthe PIS procedure manuals, and a draft agreement of cooperation betweenMPSSP and FIS. Prior to the effectiveness of the Credit, the Governmentwould submit to IDA evidence that the FIS has been established with amandate satisfactory to IDA. It would also provide evidence that the FISprocedure manuals acceptable to IDA has been adopted, and that an agreementbetween MPSSP and FIS, has been signed with terms and conditionssatisfactory to IDA (para. 7.02).
Regional Participation
4.04 Department Health Councils (CDSs) would be responsible for thedefinition of regional health priorities within the national policyframework. Although not responsible directly for project execution, theseCDSs were set up during project preparation in each SU to be forums ofnegotiations among local institutions. The major consensus to be reacheddeals with the distribution of regional resources between basic andhospital care. CDSs would also address issues unsolved at national level,such as the coordination with IBSS. They would include representatives ofthe SU, the main municipalities and the RDCs, and could include otherrelevant institutions, such as NGOs and civic organizations. The statutesof the Departmental Health Councils were finalized as a condition ofnegotiation. The creation of the CDSs would be a condition of disbursementfor expenditures in each department (para. 7.03).
4.05 A Summary Reference Document of the Health Project would beprepared by each SU. In order to ensure adequate regional disclosure ofthe health priorities, project objectives, and responsibilities of localhealth providers under the IHCM, the three documents would be published nolater than June 1990. The text of these documents was sent to IDA as acondition of negotiations. The Credit would finance the publication of theSummary Reference Documents. Leaflets describing the progress made in theimplementation of the project, and any development in the extension of theIHCM would be distributed quarte-ly to all BUs.
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Community Participation
4.06 The participation of the communities, and in particular expectantmothers and women with young children, would be ensured through theactivity of the Popular Health Committees (CPSs). The districts would beresponsible to ensure the formation and continued activity of the CPSs ineach area. CPS Coordinators would receive health education and wouldpromote maternal and child care and sanitation among the women of thecommunities. The CPSs would participate in the quality control of theservices delivered. They would define the community responsibilitiesduring the execution of works and operation of the facilities.Participation would be in kind, such as manpower, supervision or control,maintenance and operation. It would have particular importance for foodand drug distribution. CPSs would clarify with the communities the costrecovery scheme and the care provided to indigents and persons unable topay a full fee. The effectiveness of the CPSt would be monitored as partof the Plan of Action and would be included in MPSSP's managementinformation (Ann x 4).
Monitoring and Evaluation
4.07 Monitoring and evaluation would be accomplished by means of a two-part system. The first is internal to MPSSP and consists of the Monitoringand Evaluation of Services Supplied. It is an improved information systemwhich would integrate finance, service, epidemiological, nutrition and drugdata. It would also indicate the level of community commitment to healthprograms. The second part of the system is the Monitoring and Evaluationof Project Impact on Local Health. It is based on the Integrated HouseholdSurvey by the National Statistical Institute (IKE) financed under IDA'sEconomic Management Strengthening Operation (Cr. 1977-BO). The householdsurvey would supply at regular intervals information on householdexpenditures, health and nutrition statub, use of health facilities, andcoverage of outreach programs. The survey would also cover the healthfacilities in the project area. Indicators would include immunization andpre- and post-natal coverage, basic health care coverage, and percentage ofhouseholds knowing about oral rehydration therapy and iodization of salt.The two parallel monitoring systems would make possible a comprehensivetracking of key indicators, and provide a foundation for information-basedmanagement (Annex 10). A preliminary survey of the project area during thefirst year of the project would provide a baseline for subsequentevaluations.
4.08 Reporting. The PU would send to IDA every March and September amid-year report according to an agreed format (para. 7.01). It wouldinclude information on the implementation of each component, information onthe status of the Plan of Action, the staffing of the HDs, and an executivesu9mary of the monitoring and evaluation data as it becomes availableduring project implementation. It would also make a general statementabout the financial, managerial and technical status of the project at thecentral level and in each SU. The maintenance of updated project archivesin the PU and each SU would also be required.
Procurement
4.09 The Government requires that public institutions use internationalagents specialized in procurement to carry out all bidding, includinglocally advertised bidding. The procurement of civil works and of goods(except drugs) utilizing LCB and ICB procedures would be through one of
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these agents, under the coordination of the PU. The credit would financethe fee of the procurement agent (about US$.8 million). The contract withthe procurement agent would include the timing requirement for the bidaward recommendation. It would also specify the staff that the procurementagent would employ full time to support the project.
4.10 Civil Works. Except for the me-rnal and child facility in ElAlto (US$1.2 million) which would be proLared through ICB, civil worksconsist of predominantly small facilities, widely scattered in the projectarea. These are unlikely to be of interest to foreign bidders, andcontracts for the construction of these facilities totalling about US$1.7mi'lion and with a contract value of between US$100,000 and US$400,000,would be awarded on the basis of LCB acceptable to IDA. Foreigncontractors would not be excluded. Prior review by the Bank would berequired. The contracts size would range from approximately US$120,000 toUS$380,000 equivalent. The construction, expansion and upgrading offacilities, with a maximum value of US$100,000, not exceeding US$5,650,000in the aggregate would be done through shopping with at least three pricequotations, according to the FIS agreed procedures. Some otherimprovements of small magnitude, some of which would be performed withcommunity participation or force account mechanisms, would be manageddirectly by the SU. These contracts carried out under force account wouldnot exceed US$10,000, with an aggregate value of US$400,000 and would befinanced entirely by the Borrower (Annex 6).
Table 4: PROCUREMENT ARRANGEMENTS(US$ Million)
Procurement Procedures TotalCategory of Expenditure ICB LCB Other NA Costs a/
Civil Works 1.20 1.69 6.04 8.93(1.20) b/ (1.18) (3.85) (6.23)
a/ Totals represent total estimated costs per category including price andphysical contingencies.
b/ Numbers between brackets reflect IDA financing.
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4.11 Goods. Procurement of materials, equipment and furniture withcontracts exceeding US$30,000 would be made by the procurement agent, andICB procedures would be required for purchases over US$100,000. Priorreview by IDA would be required for contracts exceeding US$100,000. Othercontracts would be subject to selective post-award review. Materials,furniture and other goods valued less than US$30,000 may be acquiredlocally by the SUs, through local shopping with three price quotations, ifeach ;;ndividual purchase does not exceed US$30,000 up to a total of US$1.3million in the aggregate. Drugs costing in the aggregate no more thanUS$4.1 million would be procured through International Shopping by WHO/PAH0that would be acting as the procurement agent. PAHO is well suited tocarry out these procurement actions and has an excellent record of economyand efficiency. Contracts would be awarded on the basis of comparison ofprice quotations solicited, on the basis of detailed technical and qualityrequirements, from a list of at least six potential eligible suppliers witha wide geographical representation. These drugs would be financed by theGovernment of the Netherlands (para. 5.04). Acquisition of locallyproduced drugs such as creams, syrups and serums valued between US$30,000and US$100,000 would be procured through LCB procedures acceptable to IDA.Foreign eligible bidders would be allowed to participate and a 15Z marginof preference would be applied for national products. Technical assistancewould be financed and executed by WHO/PAHO, or, when financed by IDA,contracted following the IDA guidelines for the use of consultants(Annex 6).
Disbursements
4.12 The proposed credit would be disbursed over an eight and a halfyear period. This corresponds to the regional disbursement profile for thesector. Project completion would be in March 1996 and the closing datewould be December 31, 1996. Proceeds of the credit would be disbursed asfollows: (i) 80X against local expenditures of contracted civil works, and100X against foreign expenditures; (ii) 802 of local expenditures forequipment and furniture, materials, drugs and supplies, and 1002 forforeign expenditures; (iii) 1002 of total expenditures for technicalassistance, training, studies, commissions and supervision contracts; and(iv) 1002 of eligible costs of the PU, contracts within MPSSP and eligiblesalaries of auxiliary nurses and SU directors during 1990, and 502 of suchsalaries during 1991. Disbursements for civil works contracts, all otherlocal expenditures with a contract value less than US$200,000 equivalent,and foreign expenditures with a contract value less than US$50,000 would bemade on the basis of certified statements of expenditure. Supportingprocurement documentation for these expenditures, including procurementdocumentation, would be retained in the PU, and made available for periodicreview by Bank staff. Disbursements on all other items .ould be fullydocumented. Retroactive financing for an amount not exceeding 102 of thecredit amount would be permitted for expenditures made after February 1,1989, for technical assistance, training, engineering, civil works and thepurchase of goods (Annex 6).
Special Account
4.13 A Special Account would be established in the Central Bank in USdollars. The Association would make an initial deposit of US$1.0 million,equal to four months of estimated disbursements. The Central Bank wouldsubmit monthly statements on this account to IDA. The FIS would have
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access to the Special Account for payment of the civil works contracts.The FIS would prepare and submit the corresponding reimbursement requestsand inform the PU of the financial flow of funds under the project. Forpayment of all other items, the PU would have access to the Special Accountand would prepare and submit the reimbursement requests (para. 7.01).
Project Account
4.14 The PU and FIS would maintain separate sub-accounts for allexpend4 ures of the project. Within MPSSP, such accounts would be clearlyidentified within the ministry's accounting system and be adequate torecord, monitor and report on the financial transaction of the project,including local and IDA financing. The counterpart expenditures of thenation, consisting of salaries, would be identified through accountreconciliation.
Audits
4.15 The project sub-accounts would be audited by independent auditorsacceptable to IDA in accordance with terms of reference provided by IDA.Such audit would include in particular a separate opinion on the statementsof expenditures. The audit would include a review of supportingprocurement documentation, in particular in respect of statements ofexpenditures. The Auditors' report would be furnished to IDA no later thanfour months after the close of each fiscal year. The Borrower would havethe Special Account audited by independent auditors acceptable to IDA, andwould furnish such audits no later than four months after the close of thefiscal year. The cost of the audit would be financed out of the proceedsof the Credit (para. 7.01).
V. PROJECT COST AND FINANCING
Project Costs
5.01 Investment Costs. Total project costs are estimated at US$38.6million, excluding taxes and duties. All costs are calculated in US$ ofNovember 1989. Consultant costs, including fees, travel and subsistence isexpected to be US$10,000 per month for international consultants, US$6,000,for WHOIPAHO and UNICEF financed consultants. Fees and expenses for localconsultants are expected to range from US$45 to US$60 per day. Physicalcontingencies range from 52 for equipment and vehicles to 122 forinfrastructure. The maintenance costs include 0.5Z for infrastructure,from the year following construction; 4.0Z for equipment, and 16.52 forvehicles starting from the year of installation or purchase. The foreignexchange component is US$11.15 million, or 292 of total costs. Pricecontingencies have been calculated based on the forecast internationalprice trends: for 1989-1995, 4.92; for 1995 and thereafter 3.72 (Annex 6).
5.02 Recurrent Cost and Budget Requirement. Total incrementalrecurrent costs over the project life are US$16.9 million. They represent,for the first year of implementation (1990), 5.72 of the treasury 1989public health allocation. This proportion would reach 10.42 in real termsin 1992, and decline afterwards. About 602 of total incremental recurrentcosts are for salaries. Salary costs grow steadily throughout the projectas additional facilities are brought on line. The share of IDA financingof recurrent costs would be declining accordingly from about 482 in 1990 to
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about 242 in 1996. Other recurrent costs include the nutrltlon andcomaunity partLcipation activLtLes, the monitoring and evaluation, thetechnLcal assistance, the maintenance. and the cost of drug and supplies(Annex 2).
FLnancLng
5.03 Project fLnancing would include an IDA credit of US$20 millionequivalent (522 of total estimated cost). Bolivian counterpart fundingrequlrements would be shared among the MPSSP and the regional developmentcorporatlons and municipalLties in the project area. Local financialcapacity has been estimated conservatively (paras. 5.06 and 5.07). Thefinancing plan la shown ln Table 5.
Table 5: FINANCING PLAN(US$ millions)
IDA 20.0Government of Bolivia 1/ 9.5Public Regional Entities 2.9Government of the Netherlands 6.2
Total 38.6
1/ Includes lWHO/PAHO, US$0.8 million; and UNICEF, US$1.3 million.
Cofinancing Arrangements
5.04 The Government of the Netherlands has agreed to finance, withparallel cofinancing, the implementation of the project in one HD of ElAlto (US$2.1 million). The foreign acquisition of basic drugs would alsobe financed using the balance of payment support scheme financed by theGover:ment of the Netherlands (US$4.1 million). WHO/PAHO would continueproviding technlcal assistance to MPSSP within the framework of the projectand would finance part of that assistance (US$0.8 million). UNICEF wouldfinance part of the education health campaigns and promotion of thesanitatlon in Santa Cruz and Cochabamba (US$1.3 million). Duringnegotiations assurances were obtained that cofinancing arrangements wouldbe finalized promptly.
5.05 The MPSSP/Treasury Contribution. The financing plan assumes thatincremental recurrent expenses would be covered by the Treasury throughMPSSP receiving a larger budget share. This is because possibilities forreallocating within exslting public funding are limited. Specifically: (i)monies in the contributory schemes of the social security system are notfungible and cannot support MPSSP's eervice network; (ii) while curativecare consumes two-thirds of MPSSP expenditures, efficiency gains are onlyindirectly supported in the project. These gains should be reinvested inthe institutions producing them as an incentive and in order to improve thequality of care provided. Furthermore, the creation of a basic health caresystem and referral network can be expected to increase demand for hospitalservices.
Cost Recovery
5.06 Prospects for further cost recovery are uncertain. During thelast five years. cost recovery increased dramatically but basic health careservices was not able to generate a large amount of self-financing. The
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substantial share of household expenditures made for health care among thepoor suggests that a higher percentage of cost recovery in the basic healthcare system would price substantiAl portions of the target population outof the market (60S of households in the project area spent 10 of theaverage household income for the area in health services in July 1988). Itis assumed that 20? of the cost of drugs and 102 of other recurrent costscan be met through cost recovery. Demand information obtained through themonitoring and evaluation during the first two years of the project wouldpermit a more prscise formulation of cost recovery policies and financialprojections for the outer years of the project.
Replicability
5.07 The proposed project would create a basic health care network toserve 2.1 million people. The project costs can be broken into threecategoriest (a) costs for the benefit of the whole population, which wouldnot have to be replicated when extending the coverage of the IHCM (i.e.most of the institutional development costs). They represent 102 of theproject cost, or about US$0.5 per capita; (b) investment costs for theproject population (i.e. health facilities in the project area). Theyrepresent 342 of the total costs, or about US$6 per beneficiary; and, (c)incremental recurrent costs for the project population (i.e. incrementalsalaries of health facilities staff in the project area). They reachUS$1.5 per beneficiary during the peak year of project execution. Theextension of the project to the remaining 5.0 million in the populationwould require total investment representing 12 of GDP. The incrementalrecurrent costs of US$10.2 million per year would be met by raising MPSSP'sshare of a constant treasury budget from 3.1? in 1987 to 4.62 in 1993.This is slightly higher than its 1980 share, and still below the averagefor the region. If the budget growth forecast in the Country EconomicMemorandum (Report 7645-B0) is achieved, the share of budget resources forMPSSP would need to rise only to 4.1? by 1991. At this level, the projectis affordable for Bolivia on a national basis. Furthermore, thecoordination procedures established during project preparation with otherdonors seek to ensure that parallel projects maintain a similar level ofper capita costs.
VI. BENEFITS AND RISKS
Health, Efficiency and Effectiveness Benefits
6.01 The project would have two sets of benefits: it would improve thehealth status of the mothers and children in the low-income neighborhoodsof the four larger cities of the country; and it would upgrade theefficiency and effectiveness of the health sector. The project wouldprovide for the first time, or improve, access to maternal and child healthcare for about 790,000 women in reproductive age and children of mostlyperi-urban areas of La Paz, El Alto, Cochabamba and Santa Cruz. Of these,68? have been identified as a high risk population with high maternalmortality, infant mortality and malnutrition. It is expected that theexpansion of the network of facilities, the improvement of health careservices and the supply of essential drugs will lead to an increase inutilization of health services and a reduction of morbidity and mortality.The project proposes to increase the percentage of women receiving prenatalcare and adequate attention during delivery to 40?, to reduce infantmortality to 70 per 1,000 live births, and maternal mortality to 33 per10,000 live births in the project area (Annex 3).
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6.02 The project would improve the efficiency of the health sector byimplementing an improved and affordable Integrated Uealtth Care Model. Theexplicit policy framework and the coordination of investment in healthwould support increased resources for the sector and better use of theseresources. (i) Increase resources for the sector. The external resourcemobilization would be eased by the devolution of operational respons-ibilities to regional levels and NGOs. Adequate allocation of budgetaryresources would be ensured through the annual review of the Plan of Action.An adequate and fair cost recovery would be sought through the review offees and the introduction of consistent recovery procedures within eachinstitution. (ii) Better use of the resources of the sector. Publichealth expenditures would be reoriented in favor of basic health care.Considerable waste would be avoided by the coordination of investment andthe integration, at regional level, of all health providers into an annualhealth plan. Usage of facilities would be made more effective through theincreased demand for services. The effectiveness of the medical staffwould be improved through redeployment, training and enhanced supervision.
Poverty Impact
6.03 About 801 of the total project expenditure would benefit the poor,and 602 the extreme poor. This is if the poverty distribution in theproject area is assumed to be the same as nationwide, in the absence ofbetter data. About 762 of project costs would be for basic health servicedelivery in the project area, and the remaining would have an indirectnational impact.
Impact on Women
6.04 About 70t of the adults using basic health services providedthrough the project would be women. The services would seek to address thecore of the precarious health condition of women in Bolivia, and curbmaternil and infant mortality. In addition, women would represent up to90S of the beneficiaries of the health education campaigns. The projectwould alsor have a positive social Impact on women through the promotion ofmidwives and CPSs. About 85 of the members of CPSs are women. CPSsconstitute a social participation opportunity for the poorer women, andhelp them assume their full social role. Social services provided in theIntegral Centers would also support the greater economic integration ofwomen. Their growing participation as providers of health services (up to68Z of the staff), would be encouraged through the formal trainingprograms, not only as auxiliary nurses, nurses and social workers, but alsoas doctors and at the levels of decision making. Other services providedin the project would also help women indirectly. They include attention tothe school age children, nutrition and food aid, and the promotion ofimproved hygiene, sanitation and better environmental conditions.
Environmental Impact
6.05 The project would have a positive environmental impact. Healthposts and health centers would be designed with an incinerator to ensurethat they do not contaminate the vicinity. When centers and posts haveaccess to a sewerage system with adequate treatment plant, they would beconnected to such system. In the majority of facilities where no seweragesystem is available, they would be equipped with septic tanks or improvedlatrines. Training on environment issues and protection would be an
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integral part of the promotion activities in the communities. Finally, abasic sanitation project would be prepared and promoted through theproject.
6.06 The main risk includes possible lack of full commitment and followthrough of the Government and/or the municipalities to carrying outadministrative reforms and introducing effective management systems.Annual reviews of the Plan of Action, focusing principally on financial andadministrative management, and carefully planned technical assistance anddonor coordination would help mitigate this risk.
VII. AGREEMENTS AND RECOMMENDATION
Agreements Reached at Negotiations
7.01 During negotiatAons, assurances were obtained that:
(a) a Plan of Action would be carried out, including sector healthpolicy, service delivery, human resources and institutionaldevelopment actions (paras. 3.07 and 3.16);
(b) annually, a joint review of the implementation of the Plan ofAction and of the investment program in the project area would becompleted by IDA and the Government; the finalized projectinvestment program for the coming year would be sent to IDA forapproval; and views would be exchanged on all planned expendituresin the sector, including the expansion of the IHCH (para. '.07);
(c) agreements would be signed between MPSSP and the institutionsundertaking the responsibility to admanister a district, oroperate a facility, to include mutual obligations (para. 3.10);
(d) the updated yearly training program would be sent to IDA forapproval as part of the yearly investment program (para. 3.13);
(e) the PU would be staffed with qualified personnel satisfactory toIDA (para. 4.01);
(f) the program of contracted support from the directorates of MPSSPand other professicnals would be approved by IDA as part of theannual investment program. Curriculum vitae and terms ofreference would be submitted to IDA for approval beforecontracting (para. 4.02);
(g) the PU would send to IDA every March and September a project mid-year report according to an agreed format (para. 4.08);
(h) a Special Account would be established in the Central Bank with aninitial deposit of US$1.0 million (para. 4.13); and
(i) audits would be made by independent auditors acceptable to IDA andin accordance with terms of reference satisfactory to IDA. Suchaudit would include a separate opinion on the statements ofexpenditures, and a review of supporting procurement documentationin particular in respect of statements of expenditures (para.4.15).
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Conditions of Effectiveness
7.02 Prior to effectiveness of the Credit, the Government would submitto IDA:
(a) evidence that the FIS has been established with a mandatesatisfactory to IDA (para. 4.03);
(b) evidence that the FIS procedure manuals acceptable to IDA havebeen adopted (para. 4.03); and
(c) a algned agreement between MPSSP and FIS with terms and conditionssatisfactory to IDA (para. 4.03).
Conditions of Disbursement
7.03 Disbursements against salaries of auxiliary nurses and SUdirectors would be conditioned to the Government providing IDA the plan forassuming the cost of these salaries after June 1991, including thefinancial and administrative steps to be taken by June 1990, December 1990,and June 1991 (para. 3.11).
7.04 The creation of the CDS would be a condition of disbursement forexpenditures in each department (para. 4.04).
7.05 Given the above conditions and agreements, the project would besuitable for an IDA Credit of SDR 15.7 million to the Republic of Bolivia.
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ANNEX 1Peg 1 of 8
BOLIVIAINTEGRATED HEALTH DEVELOPMENT PROJECTPUBL'C HEALTH FACILITIES AND PERSONNEL
Tabl- 1: EXISTING INFRASTRUCTUREBY OW4ERSHIP AND RESPONSIBILUTY OF MANAGEMENT
HeaIthOwnership of Integrated Health CentersFacility City Center Center With Beds Total
MPSSP La Paz 1 2 2 20lISS El Alto 1 8 2 11Other govern. 26 2 4 82NOD 8o 7 0 87Community 52 1 2 SS
Private 6 1 28 30
Sub-total l18 21 a8 18S
UPSSP Cochabamba 0 a 2 5IBSS 0 10 4 14Othor govern. 0 1 0 1NOO 6 8 a 1e
Table 5: PERCENT OF RESOURCES GENERATEDTHROUGH COST RECOVERY
Hospitals 2984 1985 1986 1987 1988
La Pas z 1 1 1
Centro Gastroenterologico 13 40 56 31 67Hospital de Cllnicas 3 13 29 22 37Instituto Nacional del Torax 5 18 33 24 49Hospital 20 de Octubre 3 18 28 41 25Instituto Nacional de Oftalmologia 9 28 55 37 69Hospital del NifLo 3 11 33 24 38
Cochabauba
Hospital Viedma 19 40 73 49 26Maternidad German Urquidi 49 76 89 75 74Centro Gastroenterol6gico 38 62 89 69 86Psiquittrico de San Juan de Dios 4 25 39 20 20
* Government of BolivisEmrgency Social Fund (Disbursed) 782,816
Subtotal Government ot Bolivia 762,616 4.05
TOTAL EXCLUDINO USAID PL480 19,820,052 100.00TOTAL INCLUDING USAID PL480 48,706,052
Source: Mission estimatesI/ Doe not Include water and sanitation expenditures./ Aseume that 10X of the 01.8 millton spent by German churches In 19t8 goes to health.
O/ Rough estimat of church contribution from the U.S., Italy, Spain, etc.J May Include Indirect government finaneing not included In the bilaterel totals above.
Estimate bae d on general Impr.eiera of number and ls" of external NCOo operating in
Bolivia for which Information was not avallable.
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BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
Table 7t MPSSP EXPENDITURES BY CATEGORY(US$ Millions of 1987)
Table 8S SHARE OF MPSSP EXPENDITURES BY DESTINATION (2)
Cochabamba
Destination 1984 1985 1986 1987 1988
Administration 41 28 19 25 14Preventive Basic Care 13 12 9 14 19Secondary Care 46 60 72 61 67
La Paz
Destination 1984 1985 1986 1987 1988
Administration 10 11 13 7 6Preventive Basic Care 35 31 33 37 28Secondary Care 55 58 54 56 66
Santa Cruz
Destination 1984 1985 1986 1987 1988
Administration 16 10 11 13 9Preventive Basic Care 34 16 20 14 23Secondary Care 50 74 69 73 68
Source: Mission Estimates
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ANNEX 3Page 1 of 5
BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
INTEGRATED HEALTH CARE MODEL AND ORGANIZATION FORMATERNAL AND CHILD CARE
I. Objectives of the Integrated Health Care Model (IHCM) and Role of MPSSP
1. The Integrated Health Care Model (IHCM) defines the health systemin which preventive and basic health services are to be provided to allBolivians on the national territory, particularly women and children. Itsobjective is to improve infant and children survival and maternal health,which are at the core of the national priorities. The IHCM has threedimensions, one of services, one of administrative structure and one offinancing. The IHCM describes a pyramid of services of increasingcomplexity and cost, sufficient to improve the current health status ofwomen of reproductive age and of children. It redefines the role of MPSSPfrom that of a provider of care, to that of a normative, coordinating andfund raising agent. It serves as a framework to integrate within oneprogram the activities of the numerous providers of health services,particularly the maternal and child care of the NGOs. With the gradualimplementation of the IHCM, redundant services in the sector would beredeployed, and the sector effectiveness and efficiency would be improved.
II. The Characteristics of the IHCM
2. The IECH is based on the following premisest
(a) the objective of the IHCM is to improve infant and childrensurvival and maternal health in Bolivia;
Cb) the target population of the public health system consists ofpregnant and lactating mothers, children under five years of ageand the women at reproductive risk, and also the population withno access to any health services;
(c) maternal and child care is the core activity of the basic healthcare services;
(d) the access to health services is a basic right of the population,whether in the urban or rural areas;
(e) the promotion of health, the preventive care, the curativeservices and the rehabilitation of patients are integral parts ofthe health care system. All health facilities, from healthcenters at local level to specialized hospitals, need to begradually integrated into one system;
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(f) the promotion of public, family and personal health, and theprevention of illness through health education campaigns is animportant element of the IHCH. In particular, the mobilizationand social participation is essential to ensure mitigation ofsocial and environmental causes of pathology, and effective accessto servicest and
(f) the decentralization of responsibilities within MPSSP is necessaryto ensure the implementation of the IHCK.
3. The basic health care programs of the IHCM include:
(a) integral maternal and child health care. This is the largest andmost important program, corresponding to about 83Z of all thebasic health services. It encompassess prenatal attention,nutritional supplementation, and promotion of breastfeeding;obstetrical care according to risk category, and care of the newborn; promotion of reproductive health; preventicn and treatmentof abortion; reproductive maternal and child health education;detection and treatment of genital and breast cancer; preschooland school-age health care including immunization, growthmonitoring, complementary feeding, oral rehydration, detection andtreatment of iodine and vitamin deficiencies, nutritional anemias,acute respiratory infection, and parasitic diseases;
(b) nutritions food technology, goiter, anemias, production ofnative foods, cammunity and family gardens, hypovitaminosis A,RfluorLzation, school and popular meals, milk centers and lntegralchildren centers;
tc) control of infectious diseases: tuberculosis, Chagas disease,leprosy, AIDS; and control of vectors of the yellow fever,malaria, dengue, leishmaniasis, hemorrhagic fever, exanthematoustyphus;
(d) general medicine and odontology; oral and mental health;adolescent health care including detection and treatment ofvenereal diseases; and
(e) epidemiological surveillance and environmental sanitation,promotion of latrines.
III. The Sanitary Unit (SU)
4. The eleven Sanitary Units (SUs) correspond mostly to the de-centralized departmental offices of the MPSSP. More specifically, the roleof the Sanitary Unit includess
(a) the establishment of the regional health policy norms. SUs areresponsible for interpreting the IHCM in their circumscriptionaccording to the local epidemiological profile and institutionalcapacity. SUs zone the health services according to localdevelopment plans and the distribution of communities withoutaccess to basic health care;
(b) the promotion of intersectoral and interinstitutional coordinationtc improve the use of resources in Jse health sector. The SUs
- 39 - ANNE 3Page 3 of S
promote the Developmental Health Council as the instrument ofinterinstitutional coordination and regional policy development.They negotiate with the various providers of basic health,municipalities, other public institutions, IBSS and NG00, theirparticipation in the IhOG. The SUs contract such institutions tomanage HDs, or promote the contracting of such institutions tomanage specific health facilities vithin their assigned level ofservice; and
(c) the development of a management system to strengthen local healthservices. They support the programing. budgeting and executionof basic health care services in the health districts (HDs). Theymanage the distribution of essential drugs at the regional leveland the purchase of those drugs acquired locally. They supportthe human resources management of the HDs, particularly thehiring, in-service training and supervision of medical andadministrative staff. They provide assistance and technicalsupervision to the providers of health care in the department.They administer the MPSSP personnel assigned to SUs and HDs.
IV. The Health District (HD)
5. There are 84 districts in Bolivia (between two and 17 districts ineach SU). The HD administration represents the apex of the district levelhealth system. The districts are the central piece of the IHCM becaupsthey are responsible for extending the maternal and child health care, andmore generally the preventive and tasic care. They are responsible forgeographic areas with a population of 100,000 to 200,000 inhabitants. Theyensure epidemiological surveillance, carry out needs assessment, programplanning, coordination of maternal and child care, prevent.ve and basicservice delivery, and evaluation. HDs report to the SUs and can becontracted out, typically to municipalities or NGOs. The HD administrationis directed by a public health physician and staffed by an epidemiologist,a nurse, an administrator, a social worker, a nutritionist, a statistician,a sanitation specialist as necessary, and supporting staff.
6. The roie of HDs includes:
(a) developing a management capacity to execute the ICHC at locallevel. The HDs support the programming, budgeting and executionin the various health facilities and areas. They promote,supervise and evaluate the application of health ncrms;
(b) promoting the intersectoral and interinstitutional coordination toensure efficient use of resources in the sector. They ensure theimplementation of the referral system. They coordinate within thesector with NGOs, hospitals. IBSS and other health agencies in thedistrict to avoid duplication and maximize efficiency. Theycoordinate with other sectors and local governments on all healthrelated matters, including nutrition and sanitation. They maynegotiate with health providers the operation of facilities withinthe IHCM;
(c) assisting the administration of personnel, including hiring andtraining of staff. They facilitate district levei training ofauxiliaries and health professionals with the health schools.They promote and coordinate in-service training and popular healtheducation campaigns;
- 40 - A i 3Page 4 of 5
(d) producing the basic management information for MPSSP. HDs areresponsible also for the epidemiological control, and forprocessing the corresponding information. They analyze andinterpret sociodemographic and clinical information collected inthe areas. They conduct special surveys to probe diseaseoutbreaks, r'sk factors or problems in service delivery. Theyreport to the SU and provide feedback on the district healthsituation to area pnysicians, hospital directors, NGOs and otherrelevant agencies; and
(e) providing logistic support to all the levels of the IHCM.
7. A health center with beds serve the population of a healthdistrict. It is staffed by general physicians, a pediatrician, anobstetrician, social worker, a registered nurse, and auxiliary nurses. Thedistrict health centers take referrals from the integrated health centersin addition to servicing residents of the immediate neighborhond. Althoughthe health center is primarily an ambulatory care facility for maternal andchild care, some may have inpatient services. Those services would not beadded through the project, but would be continued and upgraded when theyalready exist. They would be centered around maternal and child healthservices (deliveries and oral rehydration). They would pay particularattention to the cultural background of the patient, the familyparticipation, and reproductive maternal and child health education.Clinical problems that cannot be resolved in the health centers arereferred to hospitals and specialized institutes in the district orelsewhere in the city. Patients referred from the health centers wouldhave access to hospital care, patients who demand outpatient services athospitals would be referred to health centers when appropriate.
V. The Health Area
b. Health areas have a population of 10,000 to 20,000. They areserved by health posts which are the first fixed installation of the healthcare system. They are staffed by one or two physicians, a part-timedentist, and no less than three nurses and auxiliary nurses per physician.Nurses coordinate and supervise the activities of the auxiliary nursesworking in the community. They plan outreach activities for women ofreproductive age and children, surveys and special campaigns. Auxiliarynurses assigned to health posts assist in clinical care and carry outspecific tasks such as the promotion of pre- and post-natal care, childgrowth monitoring and vaccination.
9. The responsibilities of the health area are:
(a) maintaining up-to-date information on sanitation, nutrition andhealth status of the area through periodic surveys, progressiveenrollment of the population and development of an appropriaterecord system;
(b) developing appropriate preventive programs in keeping withdistrict priorities;
(c) supervising and supporting the activities of the entire areahealth team. The area supports popular health campaigns; and
- 41 - Page 5 of 5
(d) providing clinical care to patients whose problems cannot besolved by auxiliary personnel.
VI. The Local Services
10. The base of the service pyramid is located in the community andorganized in sectors. It consists of the activities of volunteer popularhealth workers and local health committees (CPS) guided by auxiliarynurses. At the end of the project implementation, there should be aboutone popular health worker per 500 inhabitants. Services are organized inexisting community infrastructures, such as schools, community centers,nurseries, milk centers, integral child :enters, or popular food centers.These integrated facilities are usually provided by the community or NGOsand serve about 3,000 persons. The auxiliary nurses operate out of thesefacilities. They promote pre- and post-natal care, maternal and childhealth care including prenatal sorting, monitoring of infant and childhealth, nutrition, vaccination, oral rehydration. family healthassociations and simplified medicine. They also refer clients to healthposts or health centers for child growth monitoring, educational activitiesand treatment of more complex problems. They identify and train midwivesand integrate them in the referral system. The auxiliary nurses provideinstruction to popular health workers and consolidate household levelinformation collected by them. They report to the health post nurses.
11. The services provided 1. the integrated centers includet
(a) infant and child care, vaccination, attention to diarrheas,respiratory infections, control of nutrition and foodcomplementation;
(b) attention to pregnant women and mothers, identification andreferral of high risk pregnancies, identification of women atreproductive risk, reproductive maternal and child healtheducation, and follow-up of midwives;
(c) attention to school children, with defarasitation; and
(d) attention to the population in general according to theepidemiological profile, with care of tuberculosis and otherendemic illnesses, first aid, and simple pathologies.
VII. Expected Outcomes
12. The project objectives are to ensure that, by the end ofimplementation, the health district reach the following targetst
- 40Z of pregnant women receive prenatal care;- 402 of women receive attention from qualified personnel during
delivery;- 80 of one-year-old children are fully immunized;- infant mortality decreases to 70/1,000;- 602 of persons reported ill receive care; and- maternal mortality decreases to 33 per 10,000.
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MINISTERIO DE PREVISION SOOAL Y SALUD PUBLICABolivia
LETTER OF INTENTION
Mr. S. Shahid HusainVice-President of Latin Americaand the Caribbean
World Bank
OBJECTIVEs The Development of Health Sector Policy During theNext Five Years as Part of The Integrated HealthDevelopment Project.
INTRODUCTION.
The Integrated Health Development Project is intended to serveas the framework for the restructuring of the Health sector withreference to public health and primary health care. Nevertheless,the project has left open the definition of other sector issur3osuch as the social security system, financing policies at eachlevel of health care, coordination of health worker training,incorporation of the university level medical faculties, and theintegration of health sector investments with the Goverment'sbroader social policies. Such policies and their relationship toan integrated health system had not been defined during thepreparation phase of the project.
The proposed project presents an opportunity for continuedpolicy dialogue with the International Development Association(IDA) and further internal coordination in the Ministry of Health(MPSSP) to develop the essential elements of these policies. Itis the intention of the Government of Bolivia that these policiesbe elaborated during the course of the project, with the goal ofpreparing a second IDA project which has a wider sector focus.This letter outlines the primary policy issues which will need tobe further developed in the course of the next five years.
ANNEX 5Page 2 of 3
CiGte No .P 182
MINISTERIO DE PREVISION SOCIAL Y SALUD PUBLICABolivia
OJECTIVES CF THE INTEGRTED HEALTH DEVELOPMENT PROJECT
The proposed project aims tos
i) redefine the role of the Ministry of Health ateach level of responsibility, enabling theMPSSP to fulfill its role as normative head ofthe sector,
ii) develop the managerial capacity of the MPSSPin order to assure improved efficiency andeffectiveness of its activities and theactivities of other actors in the sector.
iii) encourage a more optimal use of inicialresources, and a reconsideration of overallsector spending levels in order to assurefinancing both from the National Treasury andfrom international donors which is sufficientto cover sector needs. Within this framework,the Government intends to extend the healthcare model to the other regions of Bolivia,including rural areas, through externalfinancing already partially identified,
iv) improve the capacity of the human resourcesworking in the health sector, both within theMPSSP and in other government and non-governmental institutions,
v) extend the coverage and quality of primaryhealth care services in the major urban areasof the departments of La Paz, Cochabamba andSanta Cruz, covering 100% of the population atrisk in these areas.
HEALTH SECTOR POLICY
The Government of Bolivia has charged the MPSSP with theelaboration and implementation of national policies in thefollowing areass
- 48 -ANNEX 5Page 3 of 3
CeN0PIDS-1185-2/.11.89.............
MINISTERtO DE PREVISION SOCIAL Y SALUD PUBLICABolivia
i) incorporation of the social security systemwithin overall sector policies and servicedelivery, defining its financial and socialrole within the sector;
ii) establishment of a mechanism which regulatesat each level of the health sector theparticipation of the government, the regionand the community based on an analysis ofefficiency and equity;
iii) definition of the needs, in terms of quantityand quality, of human resources in the healthsector, including revision of curriculumcontent as well as in-service training needs;
iv) coordination between the MPSSP and the SocialInvestment Fund to optimize planning, executionand monitoring of public and private investmentin the health sector.
Sincerely,
Dr. Mario Paz ZamoraMinister of Social Securityand Public Health
- 49 -ANNEX 6Page 1 of 4
BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
PROJECT TASLES
Table 1: CIVIL WORKS AND MADINENANCE
Typ of Integrated Health Hblth Regional Ware- Matntenance TotalWorks Centers Centers Center. Office. houses Facility
Compon-nt Contract Amount Number Average Value Type ofof Contracte of Contracts Procurement
(US$) (USS)
Civil Works Lsen than10,000 70 6,714 Force Account
Betwoon 86 68,600 Shopping10,000and 100,000
More than 100,000 7 240,000 LCBand les than400,000
More than 400,000 1 1,200,000 ICe
Furniture, Vehicle. Less than 80,000 97 13,400 Shoppingand Equipment
Between 30,000 and 80 46,000 LCB100,000
More than 100,000 8 275,000 ICe
Table 3: FOREIGN COMPONENT BY CATEGORY OF EXPENDITURE(USS Million)
CStenory of Expenditure Local Foreian Total
Civil Works 7.0 1.9 8.9Furntiture, Vehicles and 6.0 2.1 7.1Equlpment
Table 4: UNIT COSTS (Base costs)
WHO/PANO and UNICEF Consultants US88,000/monthOther International Consultants USS1O,000/monthFees A Expense for Local Consultants US146-60/dayBasic Drugs PAHO price listEquipment and Vehicles Quotation from providersConstruction of Health Centers and Ex- ( US8193/m2 In La Paz and Cochabambapansion of Integrated A Health Centers ( US1202/m2 In Santa Cruz
Upgrading of Integrated A Health Centers US360/m2Doctor's Dwelling ( US8125/m2 in La Paz A Cochabambo
( USS185162 in Santa CruzEl Alto Maternal A Child Facility USD850/a2
Upgrading of Regional A National USD100/i2
W rehouse
- 51 -ANNEX 6Page 3 of 4
BOLIVIA
INTEGRATED HEALTH DEVELOPMENT PROJECT
PROJECT TABLES
Table 5s DISBURSEMENT FORECAST
IDA Fiscal Year Disbursementsand Semester Semester Cumulative 2 Semester
1. The human resources development component of the project isdesigned to address the inadequacy of the quality and quantity of humanresources in the primary health care network, both in the delivery ofservices and in its planning and administration. The National Directorateof Human Resources would constitute the normative level of the trainingsystem. The human resources offices in the SUs would in light of thenational norms be responsible for planning, supervising, and evaluatingbasic and continuing training. The training offices in the SUs would bestrengthened under the supervision of the regional human resources offices.They would receive technical supervision and training from the nationalhealth schools, would be in charge of carrying out induction and continuingand designing health education campaigns. The training would be hosted inHDs which would have the responsibility to identify and gather thetrainees. The national health schools would provide basic training toincrease the numbq o.f nurse auxiliaries and technicians. Advancedtraining for a limited number of professionals would be provided outside ofBolivia. A summary of planned training activities is provided in Table 1.
Table 1 TRAINING COURSES
Subiect Persons Trained Length Years
INDUCTION
Induction Workshop all new project personnel 2 dy. allRevision of Curriculum forTraining of: trainers-Nurse Auxiliaries 3 dy. 1-Sanitation Technicians 3 dy. 1-Administrative Technicians 5 dy. 1
Management Info. Systems 15 info. system personnel 5 dy. all
BASIC TRAINING
Coordinators CPS 600 allNurses and Auxiliaries 75 10-12 mo. allAdministrative Technicians 15 10-12 mo. allSanitation Technicians 15 10-12 mo. allMaster's in Public Health * 6 Area physicians 12 mo. all
- 54 -
ANNE 7Page 2 of 2
Subiect Persons Trained Length Years
CONTINUING EDUCATION
Public Health 90 Health Area employees 3 mo. allHuman Resource Planning ** 3 SU Human Resource Dir. 3 mo. 1,2,4,5Hospital Administration ** 4 Hospital Coordinators 4 mo. 2,3,5Pharm. Quality Control** 1 Dir. of National Lab 3 mo. 2Hospital Pharm. Man. ** 3 Hospital Pharmacists 1 mo. 3Health Planning ** 3 SU & 1 MPSSP planners 3 mo. 4Epidemiology ** 3 SU Epidemiologists 2 mo. 3Epidemiology 15 MPSSP & SU epidemiologists 3 mo. 5Supervision-Regional 120 mid-level managerb 4 wk. 1,2Supervision-District 120 Dist, Area, Hosp, pers. 4 vk. 3Eval. of Supervision System 90 mid-level man. & trainers 5 dy. 3Management & Admin. 120 mid-level managers 4 wk. 1,2Community Education-Nat'l 25 MPPSP & SU personnel 7 dy. 2,4,5
0 " Regional 80 SU personnel 5 dy. allO U District 100 District personnel 3 dy. all
Events in Community Programs community various all
-District 120 district & area personnel 4 wk. 1,2Coord. of Continued Education 20 continued Ed. workers 3 dy. 1,2,3Evaluation of Con't Education trainers, managers 5 dy. 3Training and Feedback 120 course graduates 4 vk. 3
* University of San Andr6s, La Paz** Outside of Bolivia
ANNEX 8- 55 - Page 1 of 6
BOLIVIAINTEGRATED HEALTH DEVELOPMENT PROJECT
TERMS OF REFERENCETRADITIONAL MEDICINE
1. In Bolivia, about 362 of the deliveries were attended by personnelof health institutions in 1985, but this proportion has decltned since.The attention during childbirth is carried out normally by emiiric midwiveswith no formal training. The personnel of MPSSP and of other healthinstitutions often views the services provided by the midwives as competingunfairly with the poor resources of the formal sector. Attention bymidwives has also diminished during the 1980s, due to the generalimpoverishment of the population. As a consequence, a growing number ofdeliveries, estimated at 601, are attended by family members of the mother,with no training or preparation whatsoever.
2. The lack of coordination between this informal medicine and theinstitutional providers of health care has grave consequences for thehealth of the mothers and children. The midwives represent an importantasset for health care which is not adequately used. It would beparticularly valuable for health campaigns and for the promotion of healthcare. This personnel could be trained at a low cost to improve hygiene,thereby diminishing the high ircidence of tetanus and infection. It wouldalso ensure adequate and early referral of pregnancies with high risks tomedical facilities, thereby reducing the mortality of women and children.Finally, it could be used to try and reduce the number of unattendeddeliveries.
3. The training of midwives and the provision of essential kits forthe deliveries have been successfully Implemented in isolated cases, withthe San Gabriel Foundation for instance, and under the sponsorship ofUNICEF.
4. The study would seek to make concrete recommendations on thetraining of midwives, and on the integration of their activities with theformal sector. Thsse recommendations would concern the improvement of thequality of the services provided in the informal sector, better access ofwomen and children to adequate health services, better use of modernmedicine in the informal sector, and better understanding of the informalsector in health institutions.
5. The consultant would look at the positive experiences which havebeen developed. He/she would explore opinions in the communities as wellas among providers of services in institutional and traditional systems.
6. The output of the study would be the detailed design of:
- a training program, including curriculum, organization, procedures,information campaien, and cost;
- a system of integration of the work of midwives to the formal sector,with supervision, provision of basic materials and kits as necessary,continued training and feedback, and the extension of respon-sibilities to midwives for the coverage of health areas; and
- the description of tasks to be carried out in the health areasby the auxiliary nurses, nurses and doctors, for the successfulimplementation of the above.
7. The total cost of the study would be US$40,000.
ANNEX 8- 56 - Page 2 of 6
BOLIVIAINTEGRATED HEALTH DEVELOPMENT PROJECT
TERMS OF REFERENCENUTRITION STATUS AND SUPPLEMENT TARGETING
1. The limited capacity of MPSSP to assume its coordinating andnormative role has practical consequence for the distribution and targetingof food aid. A 1988 survey revealed that in Cochabamba less than 601 offood aid is directed to MPSSP priority groups of pregnant and lactatingmothers and children. If all such aid was targeted as dictated by ministe-rial po3Jcy, it would be enough to complement the basic diet of thepriori.y groups. In El Alto, the proportion of food aid adequatelytargeted is less than 402. These statistics exclude the large food forwork programs which do not target food by demographic status, andillustrate the scope for improved efficiency of food aid.
2. The Nutrition Status and Supplement Targeting studies would serveto inform the policy agenda in the nutrition activities and to monitor theeffectiveness of supplement targeting improvements. The studies would beconducted bi-annually to measure changes in program coverage, design, andtargeting.
3. The studies would be carried out using data from the IntegratedHousehold Survey (EIH) which would provide, for the same households, infor-mation on demographic and socio-economic characteristics, participation ofthe family members in food supplement programs, household expenditures, andanthropometric measurements. The survey data may be complemented with datafrom the Sistema de Vigilencia Epidemiologica y Nutricional (SVEN) andprogrammatic information as available.
4. A combination of bi-variate snd multi-variate techniques should beused to answer the following questions:
Ci) What are the characteristics of the beneficiaries of the differentkinds of food supplement programs? Are they malnourished? at risk? poor?
(ii) What percentage of the food distributed through the distinct kinds ofprograms reaches the malnourished? those at risk? the poor?
(iii) What are the characteristics of the malnourished that can be easilyobserved to make future targeting decisions?
(iv) Can the impact of food supplement programs on health or nutritionstatus be noted?
5. A local consultant shall be contracted for about thre- months foreach study. The consultant should have experience in the planning andevaluation of nutrition programs, and a working knowledge of bi-variate andmulti-variate statistical techniques. Nutritionists and economists (aswell as specialists of other allied fields) would be eligible.
6. MPSSP would provide as counterpart such information as reasonablyavailable from the National Directorate of Nutrition. The CPU, in conjunc-tion with these directorates would ensure that the EIH household questionn-aire contains questions adequate to form the basis for the research.
7. The study is scheduled to be implemented in stages in 1989, 1991and 1993. The consultant's costs are estimated at US$9,000.
h ,8Page 3 of 6
BOLIVIAINTEGRATED HEALTH CARE PROJECT
TERMS OF REFERENCEHEALTH CARE DEMAND
1. The health care demand study would be a key input in theevaluation by the Ministry of Social Security and Public Health (MPSSP) inBolivia of its cost recoverv policy. The principal objective is to predictthe possible trade-offs between different levels of cost recovery and theuse of services for different age, sex, and income groups.
2. The study would have two outputs:
(i) a report outlining the results of the analysis conducted, in aform suitable for use by Bolivian policy makers and health careadministrators. Annexes to the report would contain the completedescription of the economic and econometric modelling suitable foruse by health economists; and
(ii) a user-friendly simulation program which graphically demonstratesthe possible alternatives. The simulation program would beaccompanied by insLructions suitable for a policy-maker/user andthe more detailed documentation which would allow atechnician/programmer to update or refine the program as more databecome available.
3. The policy analysis would consider total costs to the user ofhealth care services (fees for service, fees for medicines, travel costs,value of travel time, value of waiting time) insofar as modeling andinformational constraints allow. Health care options would be classifiedinto a limited number of groups. The exact definitions and number ofgroups would be determined by exploration of the data. They could includelow quality clinics, high quality clinics, and hospitals. The principaldeterminants for the use of health care of distinct qualities would beidentified. For the principal combinations of characteristics (e.g. byexpenditure level, age, and sex) elasticities of demand wouald be calculatedfor changes in the total costs to the user of health care services and itsmost important components. A discrete choice specification for the demandfor medical care would be based on a utility maximization model. Theconditional utility function would allow for a non-constant rate ofsubstitution between health and consumption, i.e. price effects would bedependent upon income. Similarly, the demand function specification wouldallow for non-constant cross-price elasticities. In essence, the studywould replicate Gertler and Van der Gaag's I The Willingness to Pay forMedical Caret Evidence from Two Developing Countries' (forthcoming) withappropriate extensions due to the more complicated modeling of choiceimportant in the urban areas of the Project.
4. The basis of the study would be the data collected in the expandedhealth module of the Integrated Household Survey (EIH) (Annex 10)complemented with a census of health infrastructure concentrating on
- 58 - Page 4 of 6
quality indicators (such as staffing, grade of facilities, availability ofdrugs, etc), prices, and catchment area.
5. MPSSP would provide as counterpart to the study part of the timeof the monitoring expert within the Integrated Health Care ProjectImplementing Unit, who would be a principal interlocutor for MPSSP in thedetailed definition of thn analysis. He/she would facilitate, insofar asreasonable, requests for institutional information not available from theEIH. As part of the consultant contract, the MPSSP interlocutor should betrained in the use of the simulation program developed, so that the MPSSPcan use it in future policy analysis.
6. The consultant would work in two phases. In the first phase, ofabout one month, the consultant would work with MPSSP to define morespecifically the study and how it can best answer the motivating policyquestions. In this phase the consultant would provide the main impetus todefining with MPSSP and INE the questionnaires for the household andfacility surveys. In the second phase, of about five contracted months,the consultant would elaborate the report and simulation program asdescribed in paragraph 2. Full compliance would be within ten calendarmonths of the time that the data are made available to the consultant.
7. The consultant would have experience in constructing similarmodels as demonstrated in at least two other countries. The technicalquality and ease of utilization of the previous work would be principaldeterminants of the selection of the consultant. Spanish is not strictlyrequired, but the consultant would as part of the contract price, beresponsible for providing translation and interpretation as needed.
8. The study scheduled in 1992 is estimated to cost US$125,000.
Page 5 of 6
BOLIVIAINTEGRATED HEALTH DEVELOPMENT PROJECT
TERMS OF REFERENCEBASIC SANITATION
1. The Integrated Health Development Project, to be financed by acredit of the International Development Association (IDA), includes animportant water and sanitation component directed to the benefit of low-income populations for the cities of Santa Cruz and Cochabamba.
2. It is estimated that there exists in both Santa Cruz and Cocha-bamba, more than 100,000 low-income populations which remain unincluded intheir respective water and sanitation master plans. The water companies ofthose cities wish to serve those populations through the traditional waysin which the remainder of the cities' populations are served, that is,through house connections and conventional systems; however, they do nothave the ability to obtain financial resources and they also recognize thatthose populations do not have the monetary capability to cover investmentcosts as well as operation and maintenance costs.
3. One of the best low-cost alternatives to serve those populationsis through public water standp4 pes and sanitary latrines. However, the useof these types of non-traditional systems requires intense social activityand community organization that the water companies under their presentstructure cannot provide. Another aspect to define under this alternativeis the financial scheme for the works and the recovery of cost.
4. A preliminary identification of the project proposes that the mostappropriate solution for the water supply would be the installation ofpublic water standpipes which would be supplied through small distributionsystems from deep wells so as to avoid polluted waters. In some caseswhere it would be possible to draw water from shallow wells, hand pumpswill be installed. Sanitation facilities would be provided for in the formof improved sanitary latrines. A preliminary investment estimates thatwith US$4.6 million, about 36,000 people in Santa Cruz and 50,000 in thecity of Cochabamba would benefit with water and sanitation services. Theproject also includes 180 latrines for schools and 40 latrines for publicmarkets.
5. Since it is necessary to define a methodology for projectexecution which includes: institutional arrangement, community parti-cipation, financial scheme, cost recovery, execution of works, mostappropriate technologies, etc.; it has been suggested that a pilot projectshould be undertaken with the goal of demonstrating with precision thepreviously mentioned aspects. For the development of studies, theconsultant should involve the water companies and make use of specializedentities existing in the country such as the Department of Sanitation ofthe Ministry of Health or UNICEF.
6. Based on this background, the consultant should prepare atechnical and economical proposal for the execution of a pilot project witha maximum duration of six months and prepare for a project to be developedin four years, as follows:
- 60- ANNEX 8Page 6 of 6
(a) Preparation of a final project to provide water supply andsanitation through public standpipes and latrines, toapproximately 86,000 low-income populations in the cities of SantaCruz and Cochabamba, in coordination with the Integrated HealthDevelopment Project. There will be a coordination among targetpopulations, and the timetable for execution of the water andsanitation projects will be integrated with the timetable forexecution of the districts and health areas within the healthprojects.
(b) Design and execution of a pilot project in the cities of SantaCruz and Cochabamba to provide services to approximately 4,000people.
(c) Technical assistance during execution of a final project.
(d) Development of a human resources program including training forsocial workers in coordination with the activities of populareducation from the Integrated Health Development Project.
7. The consultant should present a detailed proposal for theexecution of the above-mentioned services, describing for each activity itscost estimate and a timetable for its execution.
MONITORING AND EVALUATION OF PROJECT IMPACTON LOCAL HEALTH AND NUTRITION
1. Monitoring and evaluation of the project has three basiccomponents--an internal information system for MPSSP, small evaluations ofvarious components, and the Integrated Household Survey.
MPSSP Information System
2. An integrated information system for MPSSP has been designed. Itprovides for a regular, adequate follow-up of information from the areahealth centers to the central ministerial level. The design is based onfunctional necessities, with the lowest feasible level processing andutilizing information in its decision-making process. The systemintegrates information from all areas of the ministry--i.e. servicedelivery, epidemiology, nutrition, human resources and financialadministration and is described in the Institutional Component.
3. The Project would provide training for the staff in charge ofmanaging the system nationwide, a main-frame computer for MPSSP andpersonal computers, printers and software to the national directorates, SUsand district administrative offices in the project area.
Component-Specific Evaluations
4. Several activities of the project have built-in evaluations toguide their progress. In the field of nutrition, for example, two yearsafter the planned institution of nationwide fortification of salt with ironand sugar with vitamin A, small studies are planned to compare iron andvitamin A levels in the population to their pre-fortification levels andprovide feedback to the program. These specific studies are contemplatedin the work programs of the individual components.
5. Additionally, a small sum (US$20,000 per year), divided equallyamong the Project's SUs and the central level would be used to carry outother studies in response to demands as they arise. For instance, a smallstudy using participant observation or discussion groups to investigatefactors influencing the use and acceptance of Western medicine in relationto traditional medicine has been suggested. The terms of reference andwork programs for the use of this money would be agreed annually as part ofthe investment program.
Integrated Household Survey
6. In order to establish more clearly the living conditions of thepopulation, and to serve as a basis for policy analysis in several sectors,the Integrated Household Survey (EIH) is being instituted by the NationalStatistical Institute (INE) with support from the Economic ManagementSupport Operation (EMSO) project. The EIH is patterned after the LivingStandards Measurement Survey (LSMS) developed by the World Bank andimplemented in several countries (COte d'Ivoire, Peru, Ghana, Mauritania,Jamaica and soon to be started in Morocco).
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7. In its fully developed form the LSMS measures consumption,including the value of home production and imputed rent from homeownership, in considerable detail. It Is designed to collect data on avariety of topics such as education, health, fertility, agriculturalproduction, and can be modified to collect data on other topics as desired.Household information is complemented with information on local conditionsand the availability of public services (schools, health facilities,potable water, waste disposal, public transportation, etc.) as well aslocal prices from a community questionnaire. Households are visited twiceto clarify any errors or omissions. Turn-around times between interviewsand completed data analysis are remarkably short, on the order of onemonth. The survey is conducted on a rolling sample basis throughout theyear. The flexibility in incorporating or making changes in modules andthe year-round implementation allow the LSMS data to serve as a basis foranalysis of many sectoral issues, including relationships between sectors,and to avoid biases caused by seasonal variation in expenditures. Theprincipal advantages of the LSMS format ares (i) the high quality of thedata; (ii) the quick turn-around time; (iii) flexibility of questionnairedesign; and (iv) the relatively low cost.
8. In Bolivia, the Integrated Household Survey is the vehicle forconverting the former labor force survey (Encuesta Permanente de Hogares)into a full LSMS. The process comprises several steps, at tae end of whicha full LSMS would be in place. An urban household survey with emphasis onthe social sectors and including an anthropometric module is scheduled forSeptember, 1989. A nationally representative sample would be achieved by1990. At intervals the household survey would be supplemented with acensus or survey of health facilities. This would measure the supply ofhealth care services and allow correct modeling of the choices made byhealth care consumers.
9. The September 1989 EIH in the project areas would give a gooddescription of the target population's health status, practices andknowledge, which would serve as the base line and point of comparison forlater evaluations of the Integrated Health Development Project. The on-going EIH will serve as an excellent vehicle for continuous monitoring ofthe project during its implementation. Indicators such as vaccination,prenatal care coverage, levels of malnutrition, degree of targeting of foodsupplement programs, penetration of health education as measured by use oforal rehydration therapy, iodized salt, Chagas or dengue controlprocedures, use of health facilities by income and age groups, etc. wouldserve as the basis for adjustments in health policies and actions.
10. The EIH would also serve as the basis for a series of policystudies:
(a) a demand study based on the use of health care and costs (feesfor service, travel and waiting time) borne by the household,differentiating patterns by income level, age and sex. The studywould provide projections of alternate cost recovery/utilizationof services scenarios and serve as the basis for the determinationof a cost recovery policy by MPSSP, and as information to NGOs andother actors in the sector (Annex 6);
ANNEX 10- 65 - Page 3 of 3
(b) An analysis of the prevalence of malnutrition, associated riskfactors, and the targeting of food supplement programs. The valueof food donations distributed through these programs exceeds thebudget of MPSSP and, as they currently operate, food supplementprograms are badly targeted and ineffective. The informationprovided by the EIH would be used as a basis to set priorities intargeting and distribution mechanisms (Annex 6); and
(c) health care financing options would be further explored at the endof the project using the experience gained, and with a view towardinforming the design of possible subsequent health projects.Emphasis would be put on questions of insurance, co-insurance, andfee-at-time-of service alternatives. The cost is estimated atUS$50,000 in 1994.
11. The basic cost of the EIH would be borne by INE, with financingfrom IDA's EHSO project. Additional costs incurred by the requests ofNPSSP would be borne by the Integrated Health Development Project. Thesemay include the costs of field trials, training, interview, or dataanalysis over and above what INE would do in the absence of the specialmonitoring of health for the Project. Specific arrangements for eachsurvey would be negotiated annually with the joint work program. Theestimated cost for the proposed project is US$25,000 per year.
12. INE would provide periodically to MPSSP summary statistics andsimple cross-tabulation analyses of interest to health planners as part ofits service to economic management. More sophisticated analyses would beprovided for through two channels: (i) for a negotiated fee, INE wouldexecute studies under terms of reference from MPSSP; and (ii) INE wouldprovide the full data set to MPSSP for analysis in-house or by consultants,at MPSSP's request.
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Page 1 of 2
BOLIVIAINTEGRATED HEALTH DEVELOPMENT PROJECT
SELECTED DOCUMENTS AND DATA AVAILABLE IN THE PROJECT FILE
A. Selected Reports and Studies on the Sector
Number ofAuthor Title Date Pages
MPSSP Diagn6stico Estrategico de 911988 34los Hospitales en Bolivia
Walter E. El Sistema Boliviano de 5/1988 81Schulthess Seguridad Social - Pautas
Para Su Reforma
IBSS Documentos Sobre La Salud 1988 238en la Seguridad SocialSoliviana Presentados en elSeminario-Taller de Cochabamba
IBSS Selected Statistical Information 1989 35on the Health Sector in Bolivia
MPSSP Analisis financiero y Presupuestario 1989 39del Sector Salud, Fuentes y Usosdel Gasto Pliblico en Bolivia
B. Selected Reports and Studies Relating to the Project
Number ofAuthor Title Date Pages
MPSSP Proyecto de Fortalecimiento 1989 109Institucional y Desarrollo de &Servicios - MPSSP/Banco Mundial AnnexesPropuesta y Desarrollo Estrategico
BID Proyecto Desarrollo y 10/1988 11Fortalecimiento de los Serviciosde Salud en los Departamentos deChuquisaca, Potosi y Tarija
MPSSP Mejoramiento de los 9/29/88 16Servicios Basicos Nutricionales
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