Document of The World Bank Report No: 25389 IMPLEMENTATION COMPLETION REPORT (CPL-38230; SCL-3823A; SCPD-3823S; TF-23013) ONA LOAN IN THE AMOUNT OF US$ 54 MILLION TO THE BOLIVARIAN REPUBLIC OF VENEZUELA FOR A HEALTH SERVICE REFORM PROJECT March 10, 2003 Contry Management Unit for Bolivia, Ecuador, Peru and Venezuela Human Development Sector Management Unit Latin Amenca and the Caribbean Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective as of September 2002) Currency Unit = Venezuelan Bolivar (VEB) US$1 = US$ 1,500VEB US$ 0.67 = 1,000 VEB FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS A.U. I,II,III: Tipo Ambulatorio Rural (Ambulatory Rural Type) A.R. I,11,11m: Tipo Ambulatorio Urbano (Ambulatory Urban Type) DCSS: General Directorate of Health Sector GDP: Gross Domestic Product ICB: International Competitive Bidding IDB: Inter-American Development Bank MOH: Ministry of Health (MSAS and MSDS) MSAS: Ministry of Health and Social Assistance MSDS: Ministry of Health and Social Development M&E: Monitoring and Evaluation NCB: National Competitive Bidding PAHO: Pan-American Health Organization PCU: Project Coordination Unit of the MOH PEUs: Project Executing Unit of States QAG: Quality Assurance Group RHD: Regional Health Directorate SISMAI: Sistema de Informaci6n del Modelo de Atenci6n Integral (Integrated Care Model Information System) SIGHOSP: Hospital Management Information Systemn TORs: Terms of Reference WHO: World Health Organization Vice President: David de Fenanti Country Manager/Director: Marcelo Giugale Sector Manager/Director: Ana Maria A riad Task Team Leader/Task Manager: Sandra Rosenhouse VENEZUELA HEALTH SERVICE REFORM CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 5 5. Major Factors Affecting Implementation and Outcome 11 6. Sustainability 13 7. Bank and Borrower Performance 13 8. Lessons Learned 15 9. Partner Comments 16 10. Additional Information 17 Annex 1. Key Performance Indicators/Log Frame Matrix 18 Annex 2. Project Costs and Financing 24 Annex 3. Economic Costs and Benefits 24 Annex 4. Bank Inputs 28 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 31 Annex 6. Ratings of Bank and Borrower Performance 32 Annex 7. List of Supporting Documents 33 Annex 8. Government Contribution 34 Project ID: P008215 ProectName: HEALTH SERVICE REFORM PROJECT Team Leader: Sandra Rosenhouse TL Unit: LCSHH ICR Type. Core ICR Report Date: March 10, 2003 1. Project Data Name: HEALTH SERVICE REFORM PROJECT IJC/TF Number: CPL-38230; SCL-3 823A; SCPD-3823S; TF-23013 Country/Department: VENEZUELA Region: Latin America and Caribbean Region Sector/subsector: Health (94%); Sub-national government administration (5%); Central government administration (1%) KEY DATES Original Revised/Actual PCD: 04/10/1992 Effective: 02/23/1996 02/23/1996 Appraisal: 06/17/1994 MTR: 03/27/1999 03/27/1999 Approval: 12/13/1994 Closing: 12/31/2000 06/30/2002 Borrower/lmplementing Agency: REPUBLIC OF VENEZUELA/MINISTRY OF BEALTH Other Partners: STAFF Current At Appraisal Vice President: David de Ferranti Shahid Husain Country Manager: Marcelo Giugale Rainer Steckhan Sector Manager: Ana-Maria Arriagada Alain Colliou Team Leader at ICR: Sandra Rosenhouse Karen Cavanaugh ICR Primary Author: Kye Woo Lee; Sandra Rosenhouse 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: U Sustainability: UN Institutional Development Impact: M Bank Performance: U Borrower Performance: U QAG (if available) ICR Quality at Entry: U Project at Risk at Any Time: Yes 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The project aimed to improve health outcomes for the 3 million users of government health services in four project states (Aragua, Falcon, Trujillo, and Zulia), by helping the Government to: (a) redefine key government health policies related to the organization and financing of health services; (b) promote decentralization by building the capacity of the four states and their respective health facilities to plan and manage health care in a decentralized framework; and (c) enhance the quality and efficiency of government health services by rehabilitating plant and replacing basic equipment in ambulatory clinics and hospitals. The project was expected to contribute to poverty alleviation by improving the access of poor Venezuelans to good quality health care services. The development objectives were consistent with the Bank's country assistance strategy for Venezuela, discussed by the Board in November 1993, which was to reduce public sector imbalances, encourage private sector economic activities, and improve the efficiency of public programs. In the social sectors, the emphasis was on increasing the efficiency of public spending, supporting private sector delivery of services, and targeting basic services to the poor. The project objectives were congruent with the priority needs of the health sector. Even though Venezuela had made progress, health indicators were lower than would have been expected for a country at a similar level of per capita income in 1992. Venezuela was undergoing an epidemiological transition, and the health system was therefore increasingly stressed as it attempted to cope with a growing range of problems, both old and new. The Health Ministry's spending declined in real terms throughout the 1980s. In 1983, it amounted to about US$133 per capita, but it fell to US$50 in 1993. This was equivalent to about 1.2% of GDP, lower compared to almost all other countries in Latin America. The highly centralized Health Ministry's organization and resource allocation created inefficiency in service delivery and did not provide strong incentives for improving efficiency. The service delivery system was marred by the lack of a coordinated referral system and low resolutive capacity of ambulatory clinics due to the poor human resources endowment and deteriorating facilities and equipment. The project objectives supported the Government's development strategy, which aimed to: (a) restructure and downsize the central Ministry to assume a largely normative and supervisory role; (b) decentralize management of health services to the states and municipalities; and (c) strengthen the referral network of ambulatory clinics and hospitals. In addition, the Government was considering how resource allocation policies and practices could be modified to ensure cost-effectiveness and to build incentives for efficiency through greater management autonomy of hospitals and performance agreements with states. The Government also acknowledged the need to capture additional revenues through cost recoyery and private insurance schemes. 3.2 Revised Objective: The development objectives were not revised during the project implementation. 3.3 Original Components: Component 1. Policy Analysis and Reform (US$4.5 million or 5% of total project costs). This component was to support seminars, studies, and pilot experiments in four project states in four - 2 - key areas of policy reform: (a) increasing hospital autonomy; (b) rationalizing the health service delivery model; (c) improving health financing; and (d) enhancing strategic public sector image management. These studies were to identify policy options and develop recommendations in one year (by January 1996). Then, the Ministry of Health and the four project states, together with the Bank, were to agree on a specific action plan for introducing reforms on a pilot basis, beginning in 1997, and then mainstream them, incorporating lessons learned. The recommendations from the financing and service delivery studies were expected to provide the basis for the development and adoption of management systems under the second component. And subsequent to the completion of the service delivery model study, rehabilitation of facilities and equipment was to be provided for the services identified as high priorities for public financing and at the service delivery level deemed appropriate. The hospital autonomy study was to introduce alternatives for hospitals to improve management, resource allocations and performance, and to develop technical, legal and administrative mechanisms for implementation in at least one hospital per project state. Rationalization of the service delivery model study was to develop an. alternative model for the organization and staffing of health facilities, which would ensure the provision of the most cost-effective services at different levels of health service delivery. The improved health financing study was to lay the foundation for: (a) the health services to be financed by the government; (b) resource allocation; (c) cost analysis and financing alternatives at different health service delivery levels. The strategic image management program consisted of: (a) training of health personnel in negotiations, conflict resolution, effective communication, strategic image management, and public relations; and (b) design and operation of systems for tracking public opinion. Component 2. Institutional Development (US$23.7 million or 25% of total costs). This component was to support the Government's strategy of decentralizing health service management to the states by strengthening the capacity of four states to plan and manage health care by: (a) providing basic management training to about 1,300 government health personnel from the project and other states, and complementary management training to about 4,000 project states' health personnel; and (b) designing and operating modernized systems for managing human resources, strategic planning, drugs and materials, infrastructure and equipment maintenance, financial resources, waste disposal, epidemiological information, and computerized information. The computerized information system was to be introduced in four regional health directorates, 20 health districts and a subset of 25 hospitals in the four project states. The four project states were: Aragua, Falcon, Trujillo and Zulia. The studies carried out under the policy analysis component were to provide the basis for the development of the management systems and the training programs that would support the new -3 - systems. Component 3. Strengthening of Health Service Delivery (29.6 million or 70% of total project costs). This component would finance the physical rehabilitation of about 427 ambulatory clinics (107 in Aragua, 90 in Falcon, 95 in Trujillo and 135 in Zulia) and four hospitals (one per state), including provision of equipment and furniture, for improved organization and efficiency of the facilities. 3.4 Revised Components: There were no formally revised components 3.5 Quality at Entry: The project design predates the existence of the Quality Assurance Group (QAG) and thus there is no official assessment of the project's quality at entry. Nevertheless, the ICR finds the quality of entry to be unsatisfactory. At appraisal, the project concept was consistent with the Bank country assistance strategy and the identified priority needs of the sector. Furthermore, the Government staff actively participated in the preparation of the project, which substantiated Government ownership of the project. In retrospect, however, the design of the project at entry was inadequate on two grounds. First, the project design assumed that the introduction of policy reforms (5% of total costs) and strengthening state institutions (25% of total costs) would be sufficient to ensure that the rehabilitation of health facilities and equipment at the state level (70% of total costs) would have sustainable impact on quality and efficiency of services. Accordingly, implementation of the project components was designed to take place sequentially. Therefore, successful implementation of the whole project hinged upon the successful implementation of the small yet important component, i.e., policy analysis and institutional strengthening. This was a highly risky approach, and- inappropriate for Venezuela given the poor performance of the other ongoing health operation in the country at the time. The policy reform and the institutional development components did not take place as envisaged, and the infrastructure improvement components were carried out without a proper policy framework. Consequently, the project output goals were grossly underachieved, and the attainment of the project objectives was substantially undermined. The project could have been designed differently. While designing it as two sequential projects would have been ideal (a first project, focusing on the sector policy reform and pilot schemes with substantial technical assistance; and a later project, focusing on the institutional strengthening and infrastructure improvement) as was done in two operations in Chile (e.g. Chile- Technical Assistance Project: Loan-3427, 1991; and Health Sector Reform Project: Loan-3527, 1992), this option would probably have not been acceptable to the Venezuelan Government at the time. A more realistic option would have been to reduce the number of reforms, and to introduce them in a phased manner, allowing for the simultaneous implementation of management and infrastructure improvements, also set up in phases. Second, the appraisal team agreed that baseline data and indicators for monitoring and evaluation of the project outputs and outcomes would be finalized after the sector policy reform studies were -4- to be completed. Given delays in the preparation of policy studies and the fact that many were not adequately carried out, monitoring and evaluation indicators were not developed. It is worth mentioning that the preparation team was able to accommodate the request of the Government to develop a project consistent with a project developed by the IDB after preparation had already begun. Initially, the project was conceived as a simple project: management improvement of 30 hospitals. Later in October 1993, the Government asked the Bank to broaden the scope of the proposed project objectives as mentioned above. Since the Bank had already completed a comprehensive sector study prior to the identification of this project, it easily accommodated the proposed revision of the project concept. This experience underscores the high value of a quality sector study to be used as a framework for identifying and agreeing on a project concept. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: It is too early to make a definitive judgment on the achievement of the project objectives as impact will likely be more long-term. While some project outcomes are evident, the fact that they were not measured, and that adequate health statistics to measure outcomes are limited, makes it difficult to assess the extent to which they were attained. However, it is generally unsatisfactory at this point. Available health indicators are limited and subject to different degrees of underreporting and reliability. However, available data indicate that the health status of 3 million users of publicly provided health services in the four project states has not always improved more than in Venezuela as a whole. (Data for "Venezuela" include a total of eleven states which were subject of Bank (four states) and IDB (seven states) operations out of a total of 24 states, and thus do not provide clean comparison groups, reducing the likelihood of detecting significant change). In the case of Trujillo, general mortality rates (which assume smimlar age distributions in each state and the country as a whole) show no reduction in mortality during the lifetime of the project. Infant mortality rates declined in all states although declines were greater in Zulia and Falcon than in Venezuela as a whole. Aragua and Trujillo reflected country-wide trends more closely (see Annex 1.1). To the extent that the rehabilitation and reequipping of ambulatory clinics took place, leading to sharp increases in consultations in those facilities, the project contributed to the alleviation of poverty since those clinics served mainly the poor. However, the rehabilitation and re-equipping took place in only 40% of the targets expected at appraisal. (The 40% includes 14 ambulatories that were completed after project closing or are nearing completion, and 3 ambulatories that were not financed by the Bank because the required information was not submitted on time). The unsatisfactory progress with regards towards achievement of project objectives and outcomes in the project states may be attributable to the unsatisfactory achievement of the project outputs. The policy analysis and pilot reform experimentation designed to redefine key health policies did not achieve their expected results. Although the reform policy studies were completed in four major reform areas, study recommendations were not adopted by the central and the state governments, and no pilot reform experimentation was launched. While the results of the studies conducted to develop alternative and more cost-effective models of health service organization -5 - were not implemented, information on priority interventions was utilized to develop a new model of care. The state of Aragua developed and piloted, with loan financing, a new model of care which served as the basis for the design of the Integrated Care Model introduced by the Ministry in June 1999, as a standard for all states. The Integrated Care Model sought to improve effectiveness and efficiency by reducing the verticality and duplication of many programs, reducing redundant recording of information by unifying recording into one instrument, improving indicators so that they reflect impact, not just productivity, providing services at times that are convenient to users and avoid what was current practice of making users return two or three times for separate services, and increasing the emphasis on prevention. Services were reorganized into three groups: Integrated Care for Children and Adolescents, Integrated Care for Adults, and Integrated Care for Women. An initial version of this model was piloted in 11 ambulatory centers in Aragua during 6 months in 1998, where they found productivity in some centers increased by as much as 80%, coverage increased by 60% and underreporting of information declined. Given its success, the Ministry adapted and enhanced this model of care and implemented it in all states, as of June 1999. The project financed the workshops held to design and adapt the model, the pilots to test it and the training to implement it. Training was given in all states, not just the four project states. It also developed an information system to monitor the program and evaluate its effectiveness (SISMAI, Sistema de Informaci6n del Modelo de Atenci6n Integral). SISMAI contains information on morbidity, mortality, service productivity, immunization and special programs under epidemiological surveillance. While the project did not finance the design of SISMAI, it did fund its implementation in all four states, including computer hardware, software and training. The strengthening of the health facilities' capacity to plan and manage health care in a decentralized framework was only partially achieved through the staff training subcomponent, as no management system modernization took place. However, although not measured, management capacity at the state level was clearly strengthened, as there was no management expertise at that level at the time of preparation. While decentralization of the health sector began in 1993, about 3 years before the project became effective, the project contributed to strengthening capacity in the states, thereby facilitating the process of decentralization. The improvement of health service delivery was achieved to some extent, but much less than the original project targets. Rather than achieving health sector reform, the project achieved health facility rehabilitation and some extension of coverage. 4.2 Outputs by components: Component 1. Policy Analysis and Reform Measures. Unsatisfactory. Studies in four policy areas were delayed, and only completed between October 1998 and July 1999. The study outputs consisted of 27 volumes. These studies were supposed to be completed by January 1996. Initiation of the studies was delayed mainly because the loan agreement only became effective one year later (February 1996), and the contracting arrangements with consultants took longer than expected due to the delays in budget allocations. The studies were to provide a basis for the preparation of pilot reform measures, development of training programs and management systems, and for the health service delivery systems in the four project states. However, the Government found that some study outputs were incomplete and of - 6- poor quality, and, in two cases, refused to pay the full amount of the contract. According to an analysis conducted by an external consultant hired by the Bank in August 2002, the Terms of Reference (TORs) for the studies were of very high quality and addressed 80% of component objectives. However, only two of the five studies employed adequate methodologies (hospital autonomy and improving resource allocation). Two others addressed the objectives only superficially and lacked a clear implementation strategy (shifting services to the most cost-effective level and shifting to more cost-effective services), and the last one did not respond to the TORs. The recommendations of the study on the development of a monitoring and evaluation system for the program were never adopted as they were designed for a computer system different from the one used by the Ministry of Health. .Part of the reason for the poor quality of some of the studies was the inadequate supervision of the consultancies by the PCU. The Ministry and the states sometimes lacked sufficient technical expertise on these issues, and when expertise was available, follow-up was weak. The relevance of the studies could have been improved had the Ministry of Health designated technical counterparts to follow-up on the progress of the policy studies throughout their preparation. It should have also worked more closely at all stages, with key staff in the General Directorate of Health Sector (DGSS), which was responsible for sector policy development and coordination of health services delivery at the Ministry. All key stakeholders, including state officials, Ministry officials and others also should have been brought into the discussions to define terms of reference and discuss study results. Greater participation by the states in the deflnition of the focus of the studies could have increased ownership and the possibilities that more of the results would have been implemented. The PCU paid attention mainly to the delivery of outputs and not the content of the results. Given the issues noted above, it is not surprising that only part of one of the studies was ever implemented (the study on improving resource allocation). Since the initiation of the studies was delayed, and many study results were not useful, the states developed their own health service delivery model (i.e., the integrated care model described above). Central and state governments developed training programs and a few management systems without a reform policy framework. Likewise, the strategic image management program was not implemented, except for the publicity campaigns conducted in 1998, as the program was designed to apply the policy study recommendations and the pilot program lessons to staff training programs and communication strategies. Component 2. Institutional Development: This component had two large subcomponents: one, staff training; and the other, management system development and other institutional development initiatives. Despite strong performance in the training subcomponent, overall, the performance of this component is considered unsatisfactory because of the absence of systems development and the lack of impact on project objectives. Training: Satisfactory. Compared with the appraisal targets of training 1,300 personnel at the national level on the decentralization process (basic management training) and 4,000 personnel in four project states to meet their management needs (complementary training), the project trained 18,108 staff members, far exceeding the appraisal targets. These figures, however, include the total number trained and may contain several staff members that attended several trainings. The -7 - project design planned for training staff both at the central level and in all the states. In practise, training was limited to staff in the four project states, with the exception of training for the Integrated Care Model, which was done for staff in all states. For the training program planning and preparation, the PCU coordinated state efforts and contracted WHO/PAHO to assist in its preparation. The states' Project Execution Unit (PEU) and the Regional Health Directorate (RHD) collaborated well throughout the course of the training programs. State counterparts prepared training materials and identified public and private entities for the supply of instructors. Between project states, training materials and experiences were shared informally, enriching their training courses and institutional capacities. In the case of the Integrated Care Model, staff from Aragua, who had had more experience in implementing the new model of care, assisted in the training of other states. Course topics were numerous, ranging from equipment maintenance, staff motivation, basic and advanced management tools, strategic planning, and information technology, to epidemiology, health communication, waste management, integrated care model and community participation. As a result of project activities, the states became more confident in their ability to plan and organize training programs for staff at all levels. As training experience accumulated, logistics and course materials improved, and staff morale was enhanced. Such training, however, needs to be offered regularly as most medical doctors (generalists) in the rural and suburban areas stayed on only one or two years to satisfy their compulsory service requirements, and then returned to practice in urban areas or to pursue further specialized studies. Some efforts are being made to reduce physician turnover in rural areas through a policy introduced in 1999 to attract and retain physicians in rural facilities by offering them financial incentives. Sustainability of the strengthened institutional capacity will be tested in the future. Despite its institution building impact, this component had some weaknesses. The bulk of the training courses were organized and conducted during the first few years of implementation (1997-1999), without the benefit of a policy framework. There was insufficient coordination of training at the national level. Lack of coordination was also evident in that staff received information technology training without having access to computers, as the computerized management and information systems were not installed in time. Also, the effectiveness of the training was never evaluated. The evaluations conducted were assessed the quality of the trainers, facilities, and course materials. Little or no emphasis was placed on the evaluation of the impact of the training courses on the trainees' job performance. A Bank supervision mission in the last year of implementation made some specific suggestions on how to develop an instrument to assess immediate impact, but no instruments were developed. Part of the problem was that the PCU lacked staff with the necessary skills to guide and provide technical support to a large-scale training program. Training course offerings slowed down in recent years, and it is uncertain if the courses would be offered on a continuing basis due to the uncertainty of future training budgets. Management Systems Development: Unsatisfactory. Although management systems were supposed to be developed and adopted in nine specialized management areas, such systems developed and financed as part of the project. However, some states developed some information systems on their own, financed with their own funds, such as SIGHOSP, a hospital management information system. SISMAI was developed by the Ministry with inputs from the experience of - 8- implementation of the Integrated Care Model in Aragua. SISMAI was then expanded to most states in the nation. Although the design of SISMAI was not a product of project investments, trining for its implementation and the necessary hardware was financed with project funds. All states except Zulia installed computer networks including 447 computers and 333 printers, and training 1,253 users, although they have not developed a network yet. With the exception of Falcon, the computerized information system has been developed mainly for human resources management and administrative purposes at the state RHD and district levels. Component 3. Strengthening Health Service Delivery. Unsatisfactory. Although 4 hospitals (one in each of the four states) and 427 ambulatory clinics were to be rehabilitated and re-equipped to. strengthen health service delivery in the four states, only 2 hospitals actually initiated rehabilitation and considerably fewer ambulatory centers were rehabilitated. The two hospitals under rehabilitation (one in Aragua and one in Zulia) had, by loan closing, attained 57% and 50% completion, respectively. Equipment for these hospitals was purchased with project funds. Three other hospitals that were not rehabilitated were equipped with project funds (one in Aragua and 2 in Falcon). A total of 151 ambulatory clinics were rehabilitated, and 158 ambulatory clinics were re-equipped, and thirty-two of the 158 ambulatory clinics that were re-equipped were not rehabilitated under the project. Another 15 ambulatory clinics and two hospitals were still under construction as of loan closing. In addition, 3 ambulatory clinics were completed with local funds as the information needed to include expenditures for these works under the loan was not submitted to the Bank on time. Nine of the ambulatory clinics under construction at loan closing have been completed. Should the remaining 6 ambulatory clinics be completed (construction had been suspended for some time in at least two, and completion rates vary between 36% and 65%), appraisal targets would have been met by 40%. Although the states requested an extension of the closing date or a new loan to finance the remaining clinics, these requests were not accepted by the Bank since the closing date had been extended twice already, with insufficient progress after each extension. Most ambulatory clinics rehabilitated under the project were designed in 1997 and 1998 in the first phase of the rehabilitation program. In 1998, the Government and the Bank became aware that only some ambulatory clinics originally designated for rehabilitation could be financed by the project. While there were discussions regarding the need to restructure the scope of the rehabilitation program, the component was not restructured. Although less than half of the original number of clinics were rehabilitated or reconstructed, nearly double the project funds for this subcomponent were spent. The unit cost of rehabilitation and equipment per clinic, respectively, increased, on average, almost five times in nominal terns over the appraisal estimates. Overall adjustments to contracts were greatest in Trujillo (55%) and Zulia (35%). In the case of Zulia the number of unfinished civil works was twice that of the other states. In the case of the hospital under rehabilitation in Zulia (Hospital General del Sur) while no increments were made to the value of the original contract, 2 out of the 5 floors of the hospital were eliminated from the contract in order to be able to cover expenses with the contract in force. Some of the contracts in Zulia were increased by as much as 114%. The sharp increases in costs can be attributed to many factors. First, the original estimates -9- assumed primarily rehabilitation, i.e. repair of roofs, walls, floors, correction of water and electrical supply, improvements in ventilation and air conditioning, and improving patient flow and waiting areas. Many facilities required more serious rehabilitation and as many as 10 were totally reconstructed. Second, the designs with which ambulatory works were bid were primarily architectural plans. Given that no rigorous engineering studies were conducted prior to bidding, and as a rule, no soil nor environmental studies either, many contracts had to be adjusted upwards in order to accommodate the findings of these studies. Third, lax supervision led to considerable lack of compliance by contractors, leading to further delays in execution and higher costs. All construction contracts had to be extended at least once. Fourth, a price escalation clause was included in earlier civil works contracts although they were to be completed in half a year. In reality, most rehabilitation works were completed in a year or so, and inflation rates were high. This was corrected only for the contracts made after the 1999 Bank supervision mission. However, the most important factor responsible for the sharp cost increases over the appraisal estimate was the expansion of the size of ambulatory centers by at least 100% of the original designs agreed upon at appraisal. In Zulia, some facilities were 3 times larger than originally estimated. Although some supervision missions noted problems with increased unit cost of the rehabilitation of ambulatory clinics, neither the Bank nor the PCU reviewed the designs as part of the approval process. In fact, the PCU did not review designs until the year 2000, and the Bank only did so in the final year of implementation. Both the Bank and the PCU approved the bidding documents without considering their implications for recurrent costs. Field visits would have noted the over-dimensioned nature of new structures early on. In making their decision to proceed with significantly larger ambulatory centers, the states apparently took into account the expected increases in demand for health care in the future. Moreover, the Bank supervision reports at that time noted that state governors were eager to demonstrate their capacity to expand health service delivery before the forthcoming election in 1998. However, the constraint on public finances and health budget did not allow commensurate increases in the number of doctors (e.g. less than 5% annual increase in Aragua during 1996-2000). While some incentives to work in more remote facilities have been given since 1999, it is evident that more nei-ds to be done to fill the gap. Consequently, the expanded facilities are often under-utilized. 4.3 Net Present Value/Economic rate of return: N/A 4.4 Financial rate ofreturn: N/A 4.5 Institutional development impact: Modest. There were several positive institutional impacts of the project. The rehabilitated and re-equipped hospitals and ambulatory clinics have strengthened capacity for health service delivery. State health authorities in four project states have strengthened their capacity to plan and organize -10- their health service networks and make investments on a project basis, especially in collaboration with bilateral and multilateral assistance agencies. Experience gained from Bank procurement processes also strengthened local procurement capacity. Both central level staff and state level staff benefited by learning a methodology to supervise civil works in the field and how to collect and analyze data to assess program progress. The methodology employed is now being utilized in the recently approved Caracas Metropolitan Health Services Project. Significant improvements were made in the financial management system that the project employed. The Integrated Care Model is fully implemented in all four states with a supporting information system. The project, especially the institutional development component, very likely facilitated the Government's efforts to further decentralize public health services. However, the goal of decentralization is still far out of reach. The majority of state health personnel (between 70%-90%) are still on the federal payroll, and only 20% of state health operational budgets are available for inputs other than personnel remuneration. And in states where budgets have been assigned to hospitals and municipalities, their budgets as well as those of their ambulatory clinics are often being executed centrally by the state health authority. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: Political and economic developments in Venezuela over the second half of the 1990s have been disruptive and continue to be so. Fluctuating oil prices, economic instability and political disturbances have had adverse effects on project implementation through shortage of counterpart funds, unstable tenure of sector leaders, and delays in execution. 5.2 Factors generally subject to government control: During the project implementation period, the Minister of Health changed frequently (seven times in 7.5 years of implementation). Each new Minister started with little understanding of the project, no ownership of the project (especially the policy reform component), and little or no confidence in the project implementation team. The PCU Coordinator was changed by every new Minister, altogether a total of 8 times during the project implementation period. Additionally, both central and state governments failed to provide adequate counterpart funds in a timely manner, in particular in the start up year of 1996. From 1997-2001, the health budget as a percentage of the total government budget and Gross Domestic Product (GDP) was stable or increased slightly, but the project was allocated inadequate budgets with delays. 5.3 Factors generally subject to implementing agency control: There was no commitment to project objectives on the part of the government except initially during the project design. As a result, the PCU did not take adequate charge of the project, except during the last 8 months of implementation when, as part of an internal evaluation of what the project had accomplished to date, it became evident that implementation had been weak and supervision insufficient. Part of the problem was that given the frequent changes in Project Coordinator, PCU staff roles and responsibilities were frequently modified and several importat tasks requiring supervision were left unattended. This was identified in 1998 and again in 2001. No staff members were assigned specifically to follow up on the policy analysis and reform component of the project even after the Bank requested that this be done. And field visits by PCU staff were discouraged by management, thus only limited supervision took place. Only as late as in March 2002, at the request of the Bank, were two engineers hired to make regular visits to the civil works sites in the four project states. S.4 Costs andfinancing: Total expenditures incurred for the project, including some pending works to be completed with Government funds after loan closing (the cost of additional works for the 2 hospitals and 7 ambulatory clinics that were incomplete at project closing is estimated at US$1.2 million), were US$87.2 million, which is 80% of the total project cost estimated at appraisal (US$108.0 million). A total of US$50.5 million were disbursed out of the US$54.0 million loan. The appraisal team expected that project expenditures would reach 50% of the total cost by the end of the third year of implementation (1997). However, the actual expenditures incurred by that time reached only 3% of the actual total project expenditures. Consequently, the project implementation period was extended from the appraisal estimate of 6 years to 7.5 years. The much smaller actual total project expenditures were due to delays in project implementation and lack of counterpart funds. It is important to note that cumbersome procedures at the Central Bank and the Ministry of Finance have severely affected the performance of whole Venezuelan portfolio in the past. This led to the transfer of all Bank-funded Special Accounts to the Banco de Desarrollo in August 2001. The total project cost was to be financed by the Government and the Bank at a 50% to 50% ratio. However, in the end, the Government financed only 42%, and the Bank 58% of the actual total expenditures. The actual Bank financing percentage was higher than envisaged, as the Government requested the Bank, in October 1998, to increase its disbursement percentages for civil works due to the lack of counterpart funds. While discussions were held during two missions in 2001 regarding the need to decrease subsequently the Bank's disbursement share in the civil works category, the Ministries of Finance and Planning never sent the corresponding request to the Bank. Counterpart financing was to be shared equally between the central Government and the four project state governments (at 25% each). Given increased financing by the Bank, the central Government and the states shared at 21% each. Despite delays in providing counterpart funds, the states have discharged their financial responsibilities faithfully, and the cost sharing arrangement has been successfully implemented in accordance with the decentralization policy. The most prominent procurement method envisioned at appraisal was international com.petitive bidding (ICB: 35% of total costs), followed by other methods (33%) and national competitive bidding (NCB: 17%). In reality, ICB was used for only 24% of the total cost, while NCB was -12 - used for as much as 50% of total costs. While more equipment than expected at appraisal was procured through ICB, more civil works were procured through NCB.since the thresholds and ceilings for NCB had been amended in the legal agreement. 6. Sustainability 6.1 Rationalefor sustainability rating: Unlikely. The policy analysis and reform measures are not likely to be sustained since few recommendations of the Policy studies were adopted, and no pilot reform measures were selected. The training subcomponent of the institutional development component is likely to be sustained if the budget for training is provided annually. The institutional arrangements for training have been established and some of the necessary knowledge and experience have been acquired by state level staff. Training specialists still need to be incorporated to develop improved training plans and evaluation instruments. Few modernized management systems were adopted, and therefore they are not likely to be sustained. Some new management systems adopted partially, such as the limited epidemiological information system and the hospital administration and human resources management systems. These are likely to be sustained in the future. The strengthened health delivery facilities are likely to be sustained if additional medical professionals are appointed and adequate operating budgets, including those for maintenance, are provided. 6.2 Transition arrangement to regular operations: In all project states, the PEU staff members have been absorbed into the autonomous state-level health authorities or the state health secretariat. The PCU has been preparing a plan for future operations of the project institutions with adequate monitoring and evaluation indicators. 7. Bank and Borrower Performance Bank 7.1 Lending: Unsatisfactory. Bank performance in lending was mixed. On the positive side, the Bank project team identified a project consistent with the sector needs of the borrowing country and the Bank's country assistance strategy and sector policies. And the Bank team conducted the necessary analytical work to permit it to adapt the focus of the project in line with the new request of the Government. However, the project design and the quality of the project at entry were less than satisfactory, and these deficiencies should have been identified by the peer reviewers and management during the Banl's review processes. At the design stage, it should have been recognized that the project development objectives were unlikely to be attained given the difficult implementation experience of other Bank operations in the country and the project's reliance on the adequate execution of a policy component whose results might be difficult to adopt politically (see 3.5 Quality at Entry section). 7.2 Supervision: Unsatisfactory. In general, Bank supervision efforts were less than satisfactory. First, the adverse effects of frequent changes in project management teams in the borrowing country were aggravated by the unusually short tenure of each Bank task manager. During the project's 7.5 years of implementation, there were five Bank task managers. By the time task managers were familiarized with the country and the project, they were changed. Task managers had insufficient time to build working relations with the project management teams and to provide adequate - 13 - guidance and technical assistance. Second, despite the fact that considerable technical assistance was given by the Bank to project staff in the preparation of TORs for project monitoring and evaluation (M&E), and for the evaluation of the project, the Borrower did not consider this a priority despite the Bank's insistence. The Bank failed in not insisting on the importance of this. Thus, lacking adequate tools to measure progress, task managers focused on the progress in disbursements and neglected the progress in policy analysis and pilot reform programs. Consequently, the project's status and development impact were continuously assessed as "satisfactory" mainly on the basis of the progress in disbursements until the most recent task manager raised a red flag, and downgraded the project to "unsatisfactory" during the last year of project implementation. While project objectives were not adequately met, is worth noting that Bank supervision support had some important positive impacts in the management and execution of the various project components, particularly with regards to the financial management information system, and the civil works management information system. Third, although project implementation progress was unsatisfactory and project cost increases were mentioned repeatedly in project supervision reports, task managers did not update the project costs or reestimate the extent to which the project would achieve its outputs and outcomes given the cost increases. Only in the last year of implementation did the Task Manager hire a consultant engineer and prepare a basis for the PCU to estimate the actual project costs. Fourth, the Bank never proposed that the project be restructured. The poor outcomes of the studies conducted under Component 1 made it evident that the initial design was flawed. The presence of a new government in the end of 1998 would have given the Bank a good opportunity to propose a restructuring of the project objectives and content. The mid-term review was the right tool to initiate this discussion, however a formal mid-term review was not conducted. Rather, a supervision mission carried out in March 1999 was declared a midterm review given the perceived project progress. The Quality Assurance Group (QAG) reviewed the project three times and was concerned with the unsatisfactory performance and supervision of the project. The last review in 2000, however, reluctantly gave a "satisfactory" rating, although all the review records pointed to an unsatisfactory state of project implementation and supervision. This upgraded rating could possibly have influenced the intensity of subsequent Bank supervision: in 2000, there was only one limited supervision mission. The supervision budget did not seem to have been used optimally or appropriately. Despite project implementation problems, Bank supervision missions focused on conducting dialogue in the capital city (Caracas), rarely visiting the four project executing states. Only one mission was conducted in 1997 and in 2000. The 2000 mission consisted of a limited supervision mission, in conjunction with supervision of another project and preparation of yet another. In 1999, one of the two missions was also a limited supervision mission shared with other projects. The Bank supervision efforts appear to have started following a routine, twice-a-year format only since June 2000. Moreover, the staffing of supervision missions was not adequate: despite the size of the -14 - infrastructure component, from January 1998 through January 2002 no missions included an engineer or architect. Bank management decided in June 2001 to lend for a health service decentralization project in the Caracas metropolitan area. It may have been better to complete the on-going project and obtain sufficient lessons before proceeding. 7.3 Overall Bank performance: Unsatisfactory. Borrower 7.4 Preparation: Satisfactory. The Borrower's performance was considered satisfactory as it actively participated in project identification and preparation processes. 7.5 Government implementation performance: Unsatisfactory. For the reasons described in Section 5.2 (frequent staff turnover and lack of counterpart funding) the Government's implementation performance was considered unsatisfactory. 7 6 Implementing Agency: Unsatisfactory. Although the implementing agency's performance improved in the project's latter years, for the reasons described in Section 5.3, its overall performance was considered unsatisfactory. 7.7 Overall Borrower performance: Unsatisfactory. 8. Lessons Learned 8.1 Given the country's weak capacity to design and implement complex health reform, it would have been preferable to proceed with simplified and phased reforms coupled with management and infrastructure improvements, rather than preconditioning the other components on the successful implementation of the policy analysis and pilot experimentation component. This approach would have reduced the risk of costly delays and would have permitted the phased construction of a policy framework to guide further institutional development, while allowing for the strengthening of the health service delivery network and management improvements. It would have also reduced the commitment fees for the Borrower (Section 3.5). 8.2 Some key indicators to measure basic outcomes (such as increased coverage, quality and efficiency) should have been agreed upon as part of appraisal and not left for development during project implementation. Once the project was under implementation, the project implementation unit was preoccupied with the project progress in the short-term and not intent on long-term implementation efficiency and project impact evaluation (Section 3.5). 8.3 The preparation of policy studies should be carefully supervised. There should be active participation of future beneficiaries of study results in the design of the studies and - 15 - the results should be openly discussed with stakeholders. In this project, the PCU was concerned with delivery of outputs, but not much with the quality and relevance of the outputs. The PCU did not have qualified counterparts to guide and monitor the policy studies. Few state officials were asked to be closely involved in the preparation of the studies. International consulting firms were often hired, but it appeared that they either did not know the local situation well or did not monitor carefully the changing policy environment. Furthermore, the study results were not openly discussed with the future users of the study results. Consequently, policy makers at the state as well as central levels were not fully informed of the recommendations of these studies and the rationales behind them (Section 4.2). 8.4 Projects should be restructured when government policy and priorities change to ensure relevance and impact. This is especially relevant when faced with a new Government administration. Given the poor performance of the policy component, the Bank could have taken advantage of the presence of a new government to restructure the project to align it with the Government's new priorities. This would have ensured greater Borrower commitment and ownership, and relevance of results. The opportunity could have been used to improve other aspects of implementation (Section 7.2). 8.5 The design of training programs should include an evaluation scheme as an integral part of the overall training program. Ensuring that the training offered addresses existing gaps, and measuring the impact of the training programs on staff attitude changes and on-the-job performance, would have been crucial to evaluate the training program's effectiveness and relevance (Section 4.2). 8.6 When sector leaders and the project implementation team coordinators change frequently in the borrower country, the Bank should make an extra effort to cushion the project from the adverse impact of such frequent changes. Bank supervision missions may organize induction sessions, project launch seminars, or other innovative attempts to incorporate new implementation actors. The Bank may also make extra efforts to maintain the same task manager for a reasonable time period (Sections 5.2 and 7.2). 8.7 The Midterm review should be used in a planned and strategic manner for efficient project implementation, impact evaluation, and, if needed, restructuring of the scope and content of the project (Section 7.2). 8.8 Bank supervision missions should make a strategic plan to visit project sites and measure the results on the ground throughout the entire implementation period (Section 7.2). In addition, the composition of those teams needs to be appropriate to address key implementation issues. 9. Partner Comments (a) Borrower/implementing agency: The Borrower's comments to the draft ICR were incorporated into the text. The Borrower's own contribution to the ICR is in agreement with the Bank's overall assessment of project performance, and is included in Annex 8. - 16 - (b) Cofinanciers: N/A. (c) Other partners (NGOs/private sector): N/A. 10. Additional Information ICR Team Sandra Rosenhouse (ICR Task Leader) Helen Saxenian (Health Economist) Kye Woo Lee (Consultant) Carolyn Shelton (Junior Professional Associate) Natalia Moncada (Program Assistant) Comments provided from: Patricio Marquez (Lead Health Specialist) David F. Varela (Country Manager, LCCVE) Suzana Campos Augusto (Lead Operations Officer) Mark Hagerstrom (Prior Country Sector Leader, LCSHD) Daniel Cotlear (Country Sector Leader, LCSHD) Karen Cavanaugh (Prior Task Team Leader) PCU Staff - 17 - Annex 1. Key Performance Indicators/Log Frame Matrix *NOTE: This annex is reproduced from Table IV C in the SAR Subcomponent Evaluation Indicators At Appraisal ActualLatest Estimate Hospital hospitals in project states with legal and administrative utonomy Study autonomy Service Delivery volume and type of services shifted from inappropriate to Model study appropriate facility levels in each state Improved hare of health budget in each project state redistributed to inancing more cost effective services umber of project states receiving health observation budget esources from MSDS through performance agreements by nd of project hare of hospitals and ambulatory clinics by type in each te receiving resources rom state through performance agreements by end of projec hare of hospitals and ambulatory clinics by type in each tate operating cost accounting system by end of project verage share of net income of hospitals and ambulatory linics by type in each state whLich comes from insurance _ayments and users fees by end of project trategic Image blic Opinion about quality and efficiency of health Management ervices in project states by end 1997 Dther Initiatives overment has developed project proposal for Caracas ; trengthening health services in Caracas etropolitan Health Management hare of trained personnel whose performance improves ervices Project Training ccording to training objectives approved June 2001 Program . Management dicators to be developed for measuring impact of: improved waste Systems proved resource management disposal uccessful use of strategic planning tools proved use of improved management of materials epidemiological improved maintenance formation mproved financial management improved use of improved waste disposal anagement improved use of epidemiological information formation "proved use of management inforrnation titutional Actions taken on basis of studies financed in each state evelopment upport Fund trengthening of dicators to be developed for measuring impact of: Health ehabilitation and equipping of 427 ambulatory clinics ervice Delivery habilitation and equipping of 4 hospitals .. - 18- Annex 1.1 (a) Infant Mortality Rates by Project State Infant Mortality Rates by Project State 0 40 .' 35 --Venezuela a) 30 - 25 7SU dt I4WW- * -3-Aragua 20 0 - - a Falcon X 15 C ' 10 _ ~: -*Trujillo 1992 1995 1996 1997 1998 1999 2000 Annex 1.1 (b) General Mortality Rates by Project State General Mortality Rates by Project State *~~~~~~~~~~~~~~~~4 W 1 Vnezuelal o j - I- 4. ___ _ . = = = - Aragua S 3- - -l- X 2 _ > 2 = | > - ~~~~~~~~~~~~Falcon O 1*- Zulia 1992 1996 1997 1998 1999 2000 - 19- Annex 1.1 (c) MSAS Consultations per capita per year in project states I_____ _ Aragua I Falcon I Trujillo Zulia Venezuela At Actual/LatesJ At Actual/Latest At Actual/Latest At Actual/Latest At Actual/Lates Appraisal Estimate Appraisa Estimate Appraisal Estimate Appraisal Estimate Appraisal Estimate __,2-__. .u r,. - r Population 13069 106,971 673,701 764,526 544,201 612,697 6 5 0000 08 Consultations 600 000 2,749,576 500,000 923 744 370,000 492,553 11121,972 1,566,361 947 Unavailable Consultations/capita 05 1.8 0.7 1.2 0.7 0.8 0.4 0.5 0.5 Unavailable Annex 1.2(n) Key Performance Indicators: Outputs Number Estimated Number Completion Outputs Indicators Estimated At Completion Date Completed Date L__________________________ Appraisal At Appraisal _ _ _ I _ A. l/oliky Anialysis and Reform 1. Hospital Autonomy Study 07 Products I-Oct-97 07 Products I-Dec-98 2. Health Service Delivery Models NOT DEVELOPED 3. Improved Health Financing 3A. Priority Health Services for 04 Products 17-Mar-97 04 Products 16-Oct-98 Financing & Timetable 3B. Mechanisms for Resource 07 Products 1-Sep-97 07 Products 1-Apr-99 Allocation 3C. Costs and Financing 11 Products 1-Aug-97 07 Products 31-Jul-99 Alternative -_ _ _ 3D. Performance Agreements 03 Products 1-Aug-97 02 Products 31-Jul-99 4. SIMEI - Impact Measurement 05 Products 15-Aug-97 04 Products 15-Apr-98 and Evaluation System _ 5. Strategic Image Management Publicity Campaigns were conducted in 1998. Y 6. Other Health Policy Initiatives NOT DEVELOPED B. Institutional Development I_ _ __ ________ Throughout 5 1. Management Training Program 5300 Participants To be determined 18108 years of .___ __ __ __ __ __ _ __ __ __ __ __ _ __ _ __ __ __ __ ___ Im plem entation Regional Health Progressive Management Systems Directorates (DRS) development over 5 - 20 Districts - 25 years of project Hospitals implementation -20- 2A. Design of Information Systems for: evelop 1 system Progressive Human Resource Management f each type in eears of project ach project state mplementation Strategic Planning Drugs and Materials Management Infrastructure and Equipment Waintenance Financial Administration ll facilities have a olid waste system Some taining Solid Waste Management System ncorporated0 into cometrammg municipal sewer y stem Falcon, throughout 5 Epidemiological Information States ears of Implementation, others, after 2000. SISMAI: information system o support integrated care model Management Information to ontaining data to upport above systems onitor and valuate the model, including pidemiological data ince 2000. e following were Progressive installed: CompnInstallation and User stall 370 dvogressive r 47 Computers Aragua trained in Computer omputers and evelopment over 5 18 Servers 1999 - Trujillo & ra3ning rain 740 users ears of project 33 Printers alc6n in 2002 users mplementation 65 Regulators 1253 Users trained n Progressive 26 Studies including oughout 5 3. Institutional Development Support State development over 5 cholarships, ears of Support Fund Health Studies ears of project onferences, implementation _______ _______ _______ _ _____ _____ implementation workshops .s i eg il it Iiiiig. tiealtb Servicv Rehabilitated Hospitals (Zulia Hospital Geneal del oughout 5 l. Hospital Rehabilitation and 4 Hospitals (I in ro be determined Sur 51% - Aragua years of Equipment ach project state) Hospital de Villa de implementation Cura 57%) H3[ospitals Equipped (Falc6n _ -21 - 166 Rehabilitated Clinics: 151 ambulatory clinics 100% completed (141 rehabilitated & 10 totally reconstructed) - 15 27 Ambulatory clinics under Clinic Rehabilitation d Clinics (Aragua construction. [ For Throughout 5 Equipmlc Rentbllltatlon and 107 - Falc6n 90 - Fo be determined percentage years of Dquipment Trujillo 95 - Zulia completion for the implementation 135) 15 clinics and 2 hospitals see Annex 1.2 (b).] 158 Ambulatories equipped, of which 32 were not rehabilitated by the project. -22- Annex 1.2 (b): Civil Works Not Completed as of June 30,2002 He % Completion World Bank MSDS States Total Amount Stat -alh CtgrCoInvestm ent Facilo Completed Date Investment (Bs.) (Is.) Investment (Bs.) Invested (Bs.) Mendoza Fria A.R.I1** 900/o 15-07-02 61,408,195.58 63,830,867.86 31,309,765.86 156,548,829.31 Bambues A.U.I*** 80% 30-10-02 102,570,492.00 34,190,164.00 34,190,164.00 170,950,820.00 TRUJILLO La Mata A.R.I1 85% 30-08-02 81,569,408.98 94,280,715.71 27,189,802.99 203,039,927.68 Kilometro 23 A.RII 92% 15-09-02 95,899,089.02 90,561,962.77 31,966,363.01 218,427,414.79 La Esperanza A.R.11 90% 15-09-02 91,133,803.56 98,213,195.95 30,377,934.52 219,724,934.03 SUBTOTAL 5 432,580,989.14 381,076,906.29 155,034,030.38 968,691,925.81 La Misi6n A.U.I 35% 30/11/02 47,741,135.67 15,913,711.89 15,913,711.89 79,568,559.45 Uni6n A.U.I 65% Suspended 101,144,672.52 33,714,890.84 33,714,890.84 168,574,454.20 Federaci6n A.R.II 80% 31/08/02 114,506,782.57 38,168,927.52 38,168,927.52 190,844,637.62 Hospital General del HOSP. IV 51% 4/30/03 1,041,963,369.46 347,321,123.15 347,321,123.15 1,736,605,615.77 Sur . . ZULIA* El silencio A.U.III 65% Suspended 417,275,828.63 139,091,942.88 139,091,942.88 695,459,714.38 Carorita A.U.1 700% 11/15/02 86,429,639.56 28,809,879.85 28,809,879.85 144,049,399.26 Soliva A.U.1 900/o 31/08/02 128,774,631.57 42,924,877.19 42,924,877.19 214,624,385.95 Soiearra Maestra A.U.I 92% 31/07/02 97,306,559.57 32,435,519.86 32,435,519.86 162,177,599.29 Curazaito A.R.I 85% 31/07/02 52,278,672.76 17,426,224.25 17,426,224.25 87,131,121.26 Corito II A.U.II 90%/0 31/08/02 152,232,009.00 50,744,003.00 50,744,003.00 253,720,015.00 SUBTOTAL 10 2,239,653,301.31 746,551,100.43 746,551,100.43 3,732,755,502.18 Ampliaci6n A.U.I 95% 15-09-02 270,433,050.17 90,144,350.06 90,144,350.06 450,721,750.28 ARAGUA San Casimiro__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ HOSPVleCura HOSP.II 57% 30-12-02 375,000,000.00 125,000,000.00 125,000,000.00 625,000,000.00 SUBTOTAL 2 645,433,050.17 215,144,350.06 215,144,350.06 1,075,721,750.28 TOTAL 17 3,317,667,340.62 1,342,772,356.78 1,116,729,480.87 5,777,169,178.27 * Suspended works in Zulia are awaiting approval of resources from the State ** Ambulatorio Rural Tipo lI *** Ambulatorio Urbano Tipo I - 23 - Annex 2. Project Costs and Financing Annex 2a.1 Total Project Cost bv Component LA I ., . .i A 4 .&iA atA' .. Hospital Autonomy 0.20 0.10 0.30 0.87 0.15 1.01 0.87 0.15 1.01 434 146 338 Rationalization of Service 0.40 0.20 0.60 0.01 0.00 0.01 0.41 0.20 0.61 2 0 1 ImprovedHealth?Financing 1.20 1.10 2.30 2.42 0.86 3.28 2.80 1.23 4.03 202 78 143 Strategic Image 0.30 0.80 1.10 0.01 0.19 0.20 0.01 0.19 0.20 3 24 18 Other Initiatives 0.10 0.10 10.20 10.00 10.60 10.60 10.00 10.60 10.60 0 1600 1 300 Subtotal 2.20 2.30 4.50 3.31 1.80 f 5.11 4.09 12.37 -6.45 1501 78 1 113 Management Training 2.50 1.50 4.00 1.94 1.02 3.93 1.94 1.98 3.93 78 132 98 State Mana-gement-SYstems 3.55 5.35 8.90 0.14 0.40 0.54 1.54 1.80 3.34 4 8 6 Institutional Development 2.07 3.83 5.90 0.49 0.29 1.15 0.49 0.66 1.15 24 17 19 Project Management 1.68 3.22 4.90 10.14 1.06 11.72 10.14 1.58 11.72 603 49 239 Subtotal 9.80 13.90 23.70 12.71 2.781 17.34 14.11 16.02 20.14 1130 133 73 I ~ _ Hospital Rehabilitation an 22.34 14.06 36.40 0.37 4.15 4.52 4.20 18.90 23.10 2 30 12 Ambulatory Clinic 12.76 16.84 29.60 33.25 20.12 53.37 68.00 87.40 155.50 261 119 180 Subtotal 35.10 30.90 66.00 39.49 24.79 59.28 72.20 106.30 178.60 96 79 88 Physical Contingencies 3.60 3.60 7.20 0.00 0.00 0.00 4.10 3.10 7.20 0 0 0 Price Contingencies 3.30 3.30 6.60 0.00 0.00 0.00 3.90 2.70 6.60 0 0 0 Operating costs 0. 00 5.48 5.48 0.00 0.00 0.00 150 8 11 C4'A .g, LT - --- r - Managementraining 254, 10 a 4.0 1.94 1.0 3.93 1.4 120.98 3.93 1 78 12 go9 24- Annex 2b1. Project Costs by Procurement Arrangements (Appraisal (SA) Estimate) (US$ million equivalent) . : - ,.- 'Pr r IL J II i' ki . Method wB LCB Other Non-Bank Total Cost . . . . _. . . . B~~~~~~~~~inanced A. Civil Works 8.7 7.9 5.1 21.7 (5.2) (_4.7) (3-1) (13.0) B. Medical & Non-Medical Equipment and Vehicles 26.9 10.5 1.0 2/ 38.4 .(16.1) (6.4) (0.6) (23.1) C. M1S Equipment 2.6 2.6 (2.6) (2.6) D.1 Training 9.2 9.2 (4.6) (4.6) E. Consulting Services 21.3 21.3 (10.6) (10.6) Operations 3.6 3.6 G. Consumable Materials 0.3 0.3 Maintenance 10.9 10.9 TOTAL 38.2 18.4 36.6 14.8 108.0 .______________________________________________________ (24.0) (11.1) (18.1) ._ . _._ (54.0) I/Shopping and direct contracting 2/Shopping () Bank Loan funded Annex 2b2. Project Costs by Procurement Arrangements (Actual At Closing) (US$ million equivalent) * \- . aS6^nKf/PMDUeWI1} Method j ~~~~~~~~Apure )Bol-ivar KILOMETERS, I lo I0 < GUYANA Approximate Scale { JAW ''~ ; > Atlantic .(\, A f t~~ ' . ', t \ ~~~9~ |4 Project States RICA. tZUELAh .c < \ ~~~~~~~~~~Amazonas National Capital ., XCO O,S1IA 7IA9 ' /> State or Federal Territory Boundaries ECtA h International Boundaries .: . t < ~~~~~~~COLOMBIA Jand the scale is approximate. . - X v _ * _ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Therefore the areas ot the States and E,RU-t B R A Z I L _ -\rFederal Territories are approximate only. <- ^ x Z 3 \\ ~~~~~~~~~~~~~~~~~~~~The bo-7id`OieS, colors, denominations and arny other information ; x"^; t isouvlS BIL @ f ~~~~~~~~~~~~~~~~~~Group, any judgment on the egal stou of ony territory, or any . dhltCt, ~~~~~~~~~68' 64° 60" Repoet No.: 25389 Type: ICR