Document of The World Bank FOR OFFICIAL USE ONLY Report No. 10937-VE STAFF APPRAISAL REPORT VENEZUELA ENDEMIC DISEASE CONTROL PROJECT OCTOBER 2, 1992 2, t~~i Uuman Resources Division Country Department I Latin America and the Caribbean Regional Office This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authornzation. Currency Equivalents (as of June 15, 1992) USS1.OO = Be 67.2 US$l million = Bs '7.2 million US$14,880 =s 1 million Fiscal Year January 1 - December 31 PRINCIPAL ABBREVIATIONS AND ACRONYMS USED CORDIPLAN Ministry of Coordination and Planning DGSS General Sectoral Directorate for Health DGSSSA General Sectoral Directorate for Environmental Sanitation EMSA Arnaldo Gabaldon School of Malariology GOV Government of Venezuela IB Biomedicine Institute MINFAM Ministry of Family M.I.VI.CA. Rural Housing Improvement Program MSAS Ministry of Health and Social Assistance PAHO Pan American Health Organization SDDs State Dermatology Departments TDR WHO/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases UCV Central University of Venezuela UNDP United Nations Development Program UNICEF United Nations Childrens' Fund WHO World Health Organization FOR OMCAL USE VENEZULA ENDEMIC DISEASE CONTROL PROJECT Table of Contents Paae No. BASIC DATA SHEET ........................................ iii DEFINITIONS ...................... ..o .................... iv LOAN AND PROJECT SUNMARY..... ............ ........v I. lN 1UCTION .................. .....................I II. COUNTRY HEALTH DEVELOPMENT. ....... ....... . ........ .. ... .2 A. Population, Health and Nutrition Status ................ 2 B. Health Sector Institutions...... ..... .o ...... ....3 C. Public Health Expenditures ............ ............. 7 D. Major Issues in the Health Sector . .........8 E. Government Strategy. ..... .......... . ......8 F. Bank Role and Strategy ...... . .... .... . ... ......... 9 G. Rationale for Bank Involvement . . .. 10 HoX Lessons Learned. .. o .. . .. .... . 10 III. ENDEMIC DISEASE CONTROL IN VENEZUELA .......... .. 13 A. Epidemiological Situation and Control Strategies ...... 13 B. Financing of Endemic Disease Control .... 17 C. Major Issues in Endemic Disease Control ....... o...... 18 Iv. THE PROJECT ... ....... ........ 19 A. Project Concept and Objectives- .............. 19 B. Main Features .... ....... ....... . ... . .. . ............. 19 C. Detailed Description... ... .. ...# ..... o.. ......o... . 20 D. Project Management and Implementation o .......... o.... 29 This report is based on the findings of pre-appraisal and appraisal missions which visited Venezuela in February and June 1992, respectively. The missions were comprised of Messrs. Bruce Carlson (Mission Leader), Sergio Dompieri (architect), Agostinho Cruz Marques (epidemiologist), and John Wilson (anthropologist). Task Manager: Bruce Carlson Division Chief: K.Y. Amoako Director: Armeane Chokei Peer Reviewers: Bernhard Liese Oscar Echeverri Stanley Scheyer Paramjit Sachdeva This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Balk authorization. li Paae No. V. PROJECT COSTS. FINANCING, PROCUREMENT AND DpISURsEMENTS ............................................ 32 A. Project Costs ........................ ...... 32 B. Financing ............................ ........ 33 C. Procurement ...................... oo.... o.. o .934 Ov. Disbursements .... .............. *..... ..39 B. Accounts and Audits....*........... *.* ....... ... 40 VI. PROJECT BENEFITS AND RISKS ..... ................ . .42 A. Environmental Impact.** ...... ............. *.** .... 42 B. Project Benefits ...........,..o.............42 C. Risks.. ...e... .. ,. ........ o o, 43 VII. AGREEMENTS REACHED AND RECOMMENDATION. 44 LIST OF TABLES IN MAIN REPORT Table 5.1 summary of Project Costs by Component Table 5.2 Summary of Project Costs by Category of Expenditures Table 5.3 Financing Plan Table 5.4 Summary of Proposed Procurement Arrangements Table 5.5 Disbursement Forecast LIST OF ANNEXES 1. Summary Cost Tables 2. Financing Plan by Year 3. Disbursement Categories and Percentages 4. Procurement Methods and Prior Review Thresholds 5. Project Implementation Schedule 6. Key Project Indicators 7. Endemic Diseases in Venezuela 8. DGSSSA and IB Expenditures on Endemic Disease Control 9. Selected Background Documents Available in Project File 10. Annual Supervision Plan Chart 1. Organization Chart of the DGSSSA Chart 2. Organization Chart of the Biomedicine Institute Chart 3. DGSSSA Project Implementation Unit Chart 4. lB Project Implementation Unit Chart 5. Project Committees MDP IBRD 24017 LLL BASIC DAA BSHET general Country Data 1. Populatlon Estimate (millions) 19.7 1988-90 2. Area ('000 km2) 912 1990 3. GNP per capIta (US$) 2,560 1990 4. GNP per caplta Average Annual Growth Rate (%) -1.0 1965-89 5. Income Share of Poorest 20% (%) 5.0 1988-90 6. Population Living in gxtreme Poverty 22.S 1989 7. Population LLving in Critical Poverty 31.4 1989 Population Data 1. Crude Birth Rate (per 1000) 28.7 1988-90 2. Crude Death Rate (per 1000) 5.2 1988-90 3. Annual Rate of Population Growth (S) 2.5 1988-90 4. Total Fertility Rate 3.56 1988-90 5. Maternal Mortality Rate (per 100000) 65 1980 6. Infant Mortality Rate (per 1^00) 34 1988-90 7. Life Expectancy at Birth (years) 70.1 1988-90 Health Data 1. Population per Physician 701 1988-90 2. Population per Nurse 1,900 1984 3. Public Health Expenditures As percent of total central government budget 9.3 1985 As percent of GDP 2.6 1985 In per capita USS 83 1987 Nutrition Data 1. Daily Calorie Supply 2,547 1988 2. Babies with Low Birth Weight (S) 9 1985 3. Calorie Intake as % of Requirements 114 1986 4. Per Capita Protein Intake (grams/day) 68 1990 5. Index of Food Production per Capita 77.6 1979-81-100 Zducation Data 1. Adult Illiteracy Rate (%) 11.9 1988-90 2. Female Illiteracy Rate (') 10.4 1988-90 3. Gross Enrollment Ratiost Primary (' of school-age group) 105 1988-90 secondary (I of school-age group) 56 1988-90 Tertiary (% of tertiary students) 22.1 1988-90 4. Public Education Expenditures As % of Total Central Government Budget 21.1 1985 As ' of GDP 5.9 1985 In per Capita US$ 139 1987 Sourcess Social Indicators of Development, World Bank International Economics Department, April 1992; World Development Report, 1991; Human Resources in LACs Basic Indicators, July 1989, World Bank. DEFINITIONS nideno2 rates The number of persons contracting a disease as a proportion of the population at risk, per unit of time. The rate is usually expressed per 1,000 or 100,000 persons per year. Prevalence rate: The total number of all individual. who have a disease at e particular time, or during a particular period, as a proportion of the population at risk. The rate in usually expressed per 1000 or per 100,000 persons per year. Active caee detections The surveillance activities by which the health services search for new disease cases through screening exams. Active came detection is usually carried out in house by house visits conducted by trained "house visitors". Passive case deteation: The surveillance activities by which the hea^.th services detect new disease cases among the population presenting with symptomatic complaints. V VENEZUELA ENDEMIC DISEASE CONTROL PROJECT LOAN AND PROJECT SUMMARY Borrower: Republic of Venezuela Boneftgiary: Ministry of Health and Social Assistance (General Sectoral Directorate for Environmental Sanitation and Biomedicine Institute) Amount: US$94.0 million equivalent Turmat Payable in 15 years, including a five-year grace period, at the Bank's standard vaviable interest rate. Proiect Obiective. and Descri$tion: The proposed project will: (i) reduce the incidence and impact of endemic diseasee in Venezuela; and (ii) strengthen the institutions responsible for endemic disease control. The project will include: (a) an Endemic Disease Control Comonent (71% of total costs) to support new and ongoing epidemiological surveillance activities; treatment of cases and preventive treatment; entomological surveillance and vector control; rural housing improvements to eliminate the habitat of the Chagas vector; health education activities; education and water treatment activities for cholera prevention; and innovative measures identified through operational research; and (b) an Institutional Strenathenino -moonent (29% of total costs) to support training at all levels; development of information systems; operational research on wontrol measures, strategies and t%chnologies; and construction of operational bases, training facilities, and central and regional headquarters. The project will finance the contracting of civil works, provision of equipment, vehicles, construction materials, drugs and pesticides, and payment of training, technical assistance, special studies, maintenance and supervision. Benef$tss The principal beneficiaries of this project will be low- income populations in rural and per$-urban areas throughout Venezuela, where endemic diseases are still an important cause of morbidity. They will benefit directly through decreased risk of disease and improved health status, and indirectly through improved productivity. The project will also improve the management and technical capacity of the institutions responsible for endemic disease control, particularly in the design and evaluation of control strategies and the cost-effectiveness of disease control interventions. vi Rlikos The major risk to successful project implementa.-.on is fron labor strikes which in recent years have resulted from long delays in payment of DGSSSA field workers, who are paid out of a large, centrally-managed "Laborers' Collective Contract". The M8A8 and the DGSSSA agree that the flow of funds would likely improve if the DGSSSA were to manage the fund. directly. The Government provided assurances at negotiations that it would maintain a mechanism, satisfactory to the Bank, providing for the management by DGSSSA of all funds for payment of its field workers. Ther is also a risk of delays in project implementation due to the Government'" lack of experience with Bank-financed projects. To help addres this problem the Bank would: (i) conduct a project launch seminar; and (ii) allocate greater resources to project supervision. Estimated Costs a/: Local Poreian Total - USS millions…------ Endemic Disease Control 54.8 54.4 109.2 Institutional Strengthening IL 20 3 45.7 Total Base 'outs 80.2 74.7 154.9 Physical Contingencies 2.4 2.7 5.1 Price Contingencies 21i5 6.S 28 Q Total Project Costs 104.1 83.9 188.0 A/excluding taxes and duties, which are negligible Financina Plans Local Foreian Total ---- US$ millions------- Government 94.0 0.0 94.0 Proposed IBRD Loan 10A1 83 9 94.0 Total 104.1 83.9 188.0 v&L Estiaited IBRD Disbursement: Bank Fiscal Year 1993 1994 1995 1996 a997 ; -------------------------- $US mi1lion ------------------- Annual 6.0 18.0 20.0 19.0 17.0 i umolative 6.0 24.0 44.0 63.0 80.0 Rate of Returns Not applicable M: WIBRD 24017 - ~~~~~~~~VENEZUEL ENDEMIC DISEASE CONTROL PROJECT | I~~~~~~~~~. INTRODUCTION 1.1 Venezuela is a largely urbanized cour.ry whose rapid economic growth has depended primarily on abundant oil resources. GNP per capita was estimated at about US$2,450 in 1990, making it one of the higheot in Latin America. The Venezuelan economy, and government revenues, have been highly vulnerable to swings in petroleum markets. The government has intervened heavily in oil and other productive sectors such as mining, power and steel. This course has proven highly inefficient and led Venezuela into a critical macro-economic imbalance in the late 1980s. In response, Venezuela began a major structural reform program in 1989 that has involved pi:ivatimation of major government holdings, overhaul of the trade regime, and financial sector reforms. 1.2 Poverty is a significant and persistent problem in Venezuela, despite relatively high per capita income. Three-quarters of the poor live in urban areab. Living conditions deteriorated during the past decade and income distribution worsened. Real household income declined for all income groups, but the poorest were disproportionately affecteds the highest income decile experienced a 17% decline over the 1982 - 1989 period in contrast to a 44% decline for the lowest decilel. In 1989, the government adopted the "Plan de Enfrentamiento de la Pobreza (PEP)" to eonfront poverty and protect the most vulnerable groups from the potentially adverse effects of structural adjustment reforms. The strategy supports decentralized design and management of social programs, increased private sector participation in service delivery, and a shift from generalized subsidies, such as food subsidies which were available to all, to subsidies targeting the poor. The PEP programs, which focus mainly on improving the nutrition and health status of young children and pregnant and lactating women, grew rapidly and by 1991 were budgeted for US$595 million. 1.3 Although these new programs represent an important effort to protect especially vulnerable groups, they do not fully address fundamental problems of poor targeting, poor quality and inefficiency that characterize social sector programs. In 1991, the government announced the launching of a wider, consolidated effort called the "Megaproyecto Social" which aims to improve the performance of existing programs as well as to introduce new ones. In the health sector, a "Proyecto Salud" will seek to combine ongoing and new initiatives to improve the performance of health sector institutions and programs. Specifically, it will support the strengthening of endemic disease control (through the proposed project), basic health services at health centers (through the ongoing Social Development Project, effective in September 1991), and the quality and efficiency of hospital services (through the Hospital Modernization Project). The proposed Endemic Disease Control Project complements the GOV's efforts to shield the poor from the adverse I OCEI Household Survey, i982-1989, and Garcia H. and Newman, J.L. "Poverty in Venezuela," mimeo, nivision of Welfare and Human Resources, World Bank, Washington, D.C., 1988. 2 effects of reform and to improve targeting, coverage and administration of social services. Xndemic disease control is automatically targeted to the poor since transmission of theme diseases is closely linkad to the social, economic, and environmental conditions associated with poverty. Investment in endemic dLieame control is also part of an important overall shift in health sector spendlng away from curative, hospital-based care and towards more cost- effective preventive health actions. 1.4 Xndemic diseases, both vector and water-borne, are still an important cause of morbidity among the poor in most developing countries. The most prevalent is malaria. Although mortality from endemic diseases like malarla is low, the economic impact of theme debilitating maladies is significant. Economic studies of malaria have estimated that between five to fifteen days of labor are lost for each bout of illness and in farming areas this lmpact li aggravated by the coincidence of peak malaria transmission with the peak labor demand of harvests. Economic calculations must also consider the long-term impact of parasitic diseases on school-age children and their capacity to learn. Other important costs include the maintenance of control programs to halt and roverse epidemics, as well as the costs of treatment at the household level. Despite the continuing epidemiological significance of tropical diseases and despite technological advances that have improved the possibilities for more effective disease control, most developing countries and international agencies have not afforded adequate attention to these problems. There are a few noteworthy exceptions such as the Onchocerciasis Control Programm- in West Africa (OCP), the WHO/UNDP/World Bank Research and Training Programme in Tropical Diseases (TDR), and a handful of disease control projects in Brazil, China, the Philippines, Laos, Madagascar and others, all of which have been supported by the Bank. During the last two decades, health sector development has focused largely on other, equally important goals: expanding primary health care coverage and modernizing the hospital sector. However, the simultaneous neglect and consequent decline of disease control programs has contributed, most notably, to a major resurgence of malaria in many developing countries, including Venezuela. 1I1 COUNTRY HEALTH DEVELOPMENT A. Population, Health and Nutrition Status 2.1 &MguStlon. Venezuela's total population has risen rapidly since the Second World War from 4.2 million in 1945 to almost 20 million in 1990. The average annual rate of growth in the 1980's was 2.6% and is expected to fall to 2.2% in the 1990s. The crude birth rate declined from 29.9/1000 in 1985 to 27.9/1000 ln 1989. Total fertility has also doclined gradually from 4.0 in 1982 to 3.4 ln 1987. The population is relatively young with 38% under age 15. While urban areas contained 35% of the population in 1945, nearly 90% live in cities today. Caracas contains nearly one-fifth of the total population, which is largely concentrated in the coastal states of Miranda, Aragua, Carabobo, Zulia and the Federal District (which has 39%). Population density ranges from over l,000/km2 in the Federal District to under 10/km2 in the Federal Territory of Amazonas. 3 2.2 Health Statug. The natLon'e health Lndicators have generally lmproved over the years. The ratios of physiioans and nurses to inhabltants havo increased and growth ln hospitals and hospLtal bads ham kept pao¢ wlth population. However, a lack of complementary inputs has had a negative lmpac on some lmportant input-dopendent activLties such as immunLzation. Although infant mortal_ty has dropped sharply mince 1975, the 1990 rate of 34/1000 La still high for a country of Venezuela's Lncome level. Moreover, infant mortallty varLes greatly from state to states from 21/1000 in the Federal District to 67/1000 ln Amazonas terrltory, LLke many other developing countries, Venezuela is also undergoLng an epidemiologLcal tranaLtion. Tradltlonal childhood dLseases such as diarrhea, measles, pneumonia and malnutrition continue to be significant causes of death. At the same time, malignant cancers, heart disease, and LnjurLes have become the leadlng causes of death in recent years. Another signLficant trend is the lncreaslng transmission of certaln endemic diseases associated wlth poverty such as malaria, dengue, and cholera. The health system is therefore increasingly stressed as it attempts to cope with a growing range of problems both old and new. 2.3 NutrltLon OffLcLal surveys indicate that the proportion of malnourished children rose from 14.0% to 15.3% between 1982 and 1989 and that the proportion of the populatlon with caloric deficiency rose from 7% to 23% over the same period. In 1989, 22% of all hWuseholds could not meet minimum food needs. Infants, small children, and pregnant and nursing mothers ln the poorest areas of the country have been the most affected groups. Nutrition subsidies have been poorly targeted; at the time about 60% of subsidized goodi were consumed by middle and high-income families. B. Health Sector Instltutions 2.4 The most important public health institutLons in Venezuela in terms of coverage are the Ministry of Health and Social Assistance (MSAS) and the Venezuelan social Security Institute (IVSS). KSA8 is flnanced from the central government budget and theoretically serves the entire population. IVSS, which covers about 24% of the population, is partly financed through a universal payroll tax, partly through the Ministry of Labor budget and serves salaried employees and their families. Other social security organizations also provide health servlces such as the Institute for the Provision of Healtk Care and Social Assistance for the Employees of the Ministry of Education (IPASME) and the Health Servlces of the Armed Forces. M8AS anl IVSS together admlnlster about 73% of total public health expendltures; 52% and 21%, respectively. Despite the overlapping populatlons served, however, IVSS and MSAS have little coordination or joint planning. 2.5 The Ministry of Urban Development (MINDUR) is responsible for buildlng new hospitals and general health infrastructure. Since thetre is no formal coordination between MINDUR and MSAS, the construction of infrastructure does not necessarily follow MSAS plans for maintaining or improving health services delivery. MINDUR adminiLters about 4% of public health expendltures. The remainder is administered by various autonomous 4 institutions includings (i) the Naticral Institute for Geriatrics and Gerontology (INAGER), which provides social protection, health services, and medical attention to the elderly; (ii) the National Institute of Hygiene (INH), which provides general laboratory services to the public health system (iii) the National Institute of Nutrltion (INN) which is responsible for monitoring nutritional status, defining norms for requirements and neceosary supplements, and buying and distributing these food supplementsl (lv) the Central Office for the National Health System (OCPSS), an administrative office in charge of studies needed to implement the National Health System; (v) the Foundation for the Maintenance of Public Health Infrastructure (FIMA) which equips and maintains the existing hospital infrastructure; and (vi) the Caracas University Hcopital Institute (IAHUC), a hospital and research institution. 2.6 The multiplicity of public institutions providing health services has led to many problems such as unbalanced regional distribution of infrastructure, duplication of services in some areas and lack of services in others. Management problems are aggravated by the lack of adequate information systems and, even where access to services is good, facilities often operate below capacity for lack of personnel and complementary inputs. In 1987, legislation was enacted authorizing NSAS to coordinate and regulate the quality of public health services under a "National Health System". Implementation of this legislation has met resistance from special interest groups and thus far, the proposed system has only been implemented, as a pilot project, in the state of Anzoategui. 2.7 The relatively small private sector accounts for about 23% of all hospital beds and probably provides medical care to less than 20% of the population. MSAS and IVSS make little use of contracting out medical serviceE through the private sector. The health insurance sector has been growing rapidly, however, from about US$97 million in 1984 to US$164 million in 1989. The Ministry of Health and Social Assistance LMSAS) 2.8 MSAS has three major institutional components: (i) the General Sectoral Directorate for Health (DGSS) which coordinates general health services, including the primary health care system; (ii) the four zones (Central, Center-West, West, and East) which are comprised of the 23 Regional Health Directorates (corresponding to the states) and which are further divided into 127 health districts; and (iii) the General Sectoral Directorate for Environmental Sanitation (DGSSSA) which is responsible for the control of endemic diseases including malaria, dengue and dengue hemorraghic fever, Chagas disease, schistosomiasis and other intestinal parasites, yellow fever, cholera, and others (see Annex 7). 2.9 The General Sectoral Directorate for Health IDGSS). DGSS is comprised of five departments: maternal and child health, oncology, medical care, epidemiology and health promotion. Each of these departments is represented on the Permanent PHC Commission (CPAPS), which meets weekly to coordinate PHC activities. DGSS operates a network of about 3,500 urban and rural health facilities throughout the country. Approximately 955 of these 5 facilities are located in poor urban and rural areas.2 One of most important program undor the responsibility of DGSS is the Maternal and Child Health Program. This program encompasses: (i) infant and child health, including monitoring of growth ar.d development, immunizations, diarrheal disease control, control of acute respiratory infections, nutritional supplements, student health, and breast-feeding; and (ii) maternal health and family planning, which provides obstetrical and gynecological care with special emphasis on pre-natal care, detection of gynecological and breast cancer, prevention of sexually transmitted diseases, and contraceptive information and services. For pregnant women and infants, attention at health centers is combined with distribution of nutritional supplements, the composition and delivery of which are the r-sponsibility of the National Institute of Nutrition (INN). 2.10 For all categories of health care providers, the hospital forms the apex of a service pyramid comprised of a network of rural ambulatories Types I and II, which provide basic preventive, curative and emergency care, and urban ambulatories Types I, II, and III, which are generally equipped to provide a broader range of health services. While MSAS has administrative control over its own ambulatories, it }.as limited say regarding non-Ministry ambulatories. Moreover, it exercises only nominal authority over the ambulatories that it operates in conjunction with other institutions. 2.11 The General Sectoral Directorate for Environmental sanitation W SISSA). The DGSSSA was created in 1936 and has since been responsible for endemic disease control in Venezuela. It is headquartered in Maracay, Aragua. The Director, appointed by the Minister, also maintains an office in the health ministry in Caraca3. DGSSSA has four sub-directorates: (i) Rural Endemic Diseases, (ii) The Arnaldo Gabaldon School for Malariology and Environmental Sanitation (EMSA), (iii) Sanitary Engineering, and (iv) Rural Housing, Sewers and Aqueducts (see Chart 1). The Rural Endemic Diseases sub- directorate is responsible for control of malaria, Chagas disease, schistosomiasis, intestinal parasites, dengue, and other vector-borne diseases including yellow fever and Venezuelan equine encephalitis. It has three divisions: Epidemiology, Vector Pid Reservoir Control, and Intestinal Parasites. The Rural Housing, Sewers and Aqueducts sub-directorate executes housing and housing improvement programs. These programs are an important part of the Chagas and intestinal parasite control programs. This sub- directorate also executes rural water supply and sewer projects. The Sanitary Engineering sub-directorate is responsible for the control of air, water and ground contamination and has programs for control of solid wastes, rodents, pesticides, construction, occupational health, waste water treatment, air pollution control and others. The EMSA has trained most of the professionals, inspectors and laboratory technicians that have worked in endemic disease 2 These facilities include 68 regional and district hospitals; 480 urban health centers, and 2,954 rural health centers. Health centers are operated by physicians and nurses, except in the case of Type I rural health centers, which are run by auxiliary nurses. 6 control in Venezuela. The school also conducts research projects relevant to disease control. 2.12 The management of DGSSSA control programs is centralized in Maracay and the institution has a strong "vertical" command structure. Management and technical staff at the central level establish policy, norms, and control strategies, provide training and in-service training, manage acquisition and supply, supervise control activities, and undertake operational research. At the same time, tactical decisions about what measures to apply, when, and where, are generally delegated, in each state and federal territory, to the zone chief (jefe de zona) and his three service chiefs (jefes de servicio) for Rural Endemic Disease., Sanitary Engineering, and Rural Housing, Sewers, and Aqueducts. Thus, in each state and territory the control programs are determined by the local disease situation. Disease control activities are executed through strategically located operational bases or "demarcations" which are staffed by inspectors, spraymen, house visitors, and laboratory personnel. 2.13 The DGSSSA has a staff of about 5,600 including 725 managers, professionals and technicians, 1,500 administrative support, and 3,400 field workers (spraymen, house visitors, and laborers). Over 130 volunteers (local community leaders, shopowners, and religious leaders) also assist the malaria control program in Bolivar state by collecting blood slides and distributing anti-malarial drugs. 2.14 The Biomedicine Institute. Several endemic disease control programs are the responsibility of the Biomedicine Institute (IB), which is formally subordinate to both DGSS (General Sectoral Directorate for Health) and the Central University of Caracas (see Chart 2). The IB executes disease control programs for leishmaniasis and leprosy and is currently developing a strategy and program for onchocerciasis. it is recognized internationally for its important work in vaccine development and treatment for leprosy and leishmaniasis. It operates from a central headquarters in Caracas (at the Bosvital Vargas) but its staff are very often in the field supervising ongoing peograms. TB control program activities, primarily disease surveillance and treatment, are %.;arried out by the personnel of the DGSS's 28 state-level Dermatology Departments (SDDs). Nurses in primary health care facilities at the local level also collaborate in the leprosy and leishmaniasis programs. The IB's primary role in these disease control programs is to determine control strategy, carry out relevant operational research, and supervise control activities in the field. The combination of operational research and disease control under a single inst,.tution has been a productive and unique characteristic of the IS which has, in particular, facilitated the development and implementation of new vaccines and vaccine therapies for leprosy and leishmaniasis. The IS receives research support from and collaborates closely with the World Health Organization (WHO) and the Pan American Health organization (PAHO). The IB has a staff of 150 at the central level and is supported in the field by 318 personnel of the state-level dermatology services. 7 C. Public Health Exnenditures 2.15 Public spending on health declined sharply in real terms over the 1980.. Per capita public spending on health fell from about US$113 in 1983 to US$55 in 1988, and remained at this level through 1990. The MSAS budget for health services, for example, declined by over 40% over the decade. In addition, M8AS annual financing has been highly unstable due to the federal budget's dependence on oil revenues. Some MSAS hospitals recover a small fraction of costs from patients and have organized foundations to receive donations. IVSS depends largely on its Medical Assistance Fund which is financed by federal and employer contributions and payroll taxes. Although IY88 financing has been more stable in recent years (partly because the Medical Assistance Fund ham run a large deficit), it decllned 13% in real terms during the 1980a. 2.16 Most public financing for health is from the federal level; only 2.5% was from state and municipal governments in 1990. The states presently provide limited support in terms of personnel and equipment. They have recently received tax authority, however, and are thus expected to play a greater role in the future. 2.17 Spending in the health sector is strongly biased towards the least cost-effective ways of reducing mortality. Hospital., for example, absorb over 80% of the public health budget. In the 1980e, MSAS spending on overhead (support, planning and administration) has grown while spending on service delivery (medical attention, disease control and prevention, and environmental sanitation) has declined. Between 1980 and 1988, spending on personnel rose from 52% to 73% of total M8AS expenditures while spending.for operations and maintenance fell from 43% to 22% of total MSAS spending. 2.18 The present allocation of resourcee reduces the availability of complementary inputs and is reflected in serious shortages of pharmaceutical and other supplies in the public health system. Persons seeking medical attention at a public hospital, for example, must provide their own medicines, cotton, and bandages. This constitutes a form of direct user paymen. which bears no relationship to ability to pay, or to any criteria of what sh tld be publicly financed. Such direct payments effectively obstruct access to the system for the poor. In addition, underfunding of maintenance has taken its toll: a 1989 MSAS survey found that 46% of existing physical infrastructure and euipment were severely run down and another 46% in need of minor repairs. Only 8% of the existing physical plant and equipment were judged to be satisfactory. 2.19 Budgeting in the public health sector is largely a process of political bargaining. This occurs at the level of the Council of Ministers which determines the total budgetary allocation for the health sector. The process is complicated by the fact that the two principal providers of health services, MSAS and IVSS, have different institutional affiliatLons and operate on the basis of distinct and independently established priorities and polLcies. First priority is given to funding personnel expenditures, and then to highly visible new programs. The remaining funds are allocated to the operation and maintenance of ongoing programs Lack of coordination in 8 planning and budgeting among the large number of agencies involved in the sector hae often undermined the efficiency of investments in health infrastructure and equipment. Expansion in capacity, for example, has not been accompanied by commensurate allocations to operations and maintenance. The resulting shortages of complementary inputs (vaccines, drugs and other medical supplies) is perhaps the single most serious constraint facing Venezuela's public health system today. D. Ma1or Isues in the Health Sector 2.20 The major problems in the health sector can be divided into five broad categoriess (i) resource allocation: inefficient and inequitable resource allocation, reflected in a bias towards curative medicine and hospital care at the expense of preventive and primary health care, an expanding share of personnel expenditures at the expense of operations and maintenance, and increasing overhead costs at the expense of medical attention, environmental control, disease control and prevention; (ii) institutional weaknesses including, poor planning, over-centralization, lack of coordination and an inadequate information system; (iii) inequitable geographic distribution of both physical and human resources, combined with a weak referral system and an incapacity to provide the proper mix of high technology and low technology care; (iv) inappropriately skilled manpower; and (v) mismanagement of hospitals and lack of complementary inputs in both hospitals and health posts. E. Government Strateav 2.21 The GOV strategy for the social sectors, in general, focuses on strengthening the supply of health, nutrition, education and housing services, targeting the most vulnerable groups, and promoting private sector and community involvement.3 In the health sector, in particular, the GOV recognizes the need to redirect health spending towards preventive health care and to better target underserved populations and areas. This includes strengthening of endemic disease control. In 1992, the government launched a new program, the "Megaproyecto Social", which includes a number of health projects. The latter comprise a "Proyacto Salud" which includes the proposed Endemic Disease Control Project, the proposed Hospital Modernization Project, and the health component of the Social Development Project. 3 The GOV' s Poverty Alleviati ° Plan focuses on (i) improving living conditions in poor urban areas through construction and repair of schools and health centers, and through credit for housing improvements in the poorest areas; (ii) expanding coverage of maternal and child health care by increasing the number of consultations and distribution of food supplements through health centers; (iii) expanding the community-based child day-care by opening additional centers and training of personnel; (iv) increasing pre-school enrollments and introducing school-feeding at that level; and (v) setting up a new program of nutritional grants (Beca Alimentaria) which benefits children in the first six grades in poor urban and rural areas. 9 2.22 Several steps have been suggested to make the public health delivery system function more officientlys (i) integration cf the existing health subsystems under a single National Health System as provided by law (see para. 2.6 above); (ii) remedying the current regional disparities in the coverage and quality of health services by strengthening the sectoral policy formulation and services standardization functlons of the Ministry; (iii) improving the budgetary allocations to operations and maintenance and away from personnel; and (iv) shifting resources gradually from the hospital-based tertiary care to the ambulatory-based primary care and preventive public health programs. F. Bank Role and Strategy 2.23 In 1989, the Bank'. lending program to Venezuela was resumed, after a 15 year hiatus, and agreements were reached between the Bank and the GOV on macro-economic management, financial sector reforms, and social programs. Much of the essential restructuring and deregulation of the Venezuelan economy was completed in 1991. The Bank's efforts are now directed towards encouraging the GOV to follow prudent fiscal and monetary policies and to continue privatization, restructuring and deregulation efforts. In the social sectors, the Bank strategy has been to assist the GOV to cushion the poor from the effects of adjustment, and to improve the efficiency and equity of programs. The Bank's sector work has shown that the incidence and severity of poverty increased significantly in the last decade and that social spending has suffered from inefficiency and mistargeting. Several crucial areas have been neglected: preventive health care, pre-school and primary education, and nutritional needs of lower income groups. At the same time, a large proportion of public social spending has ultimately benefitted middle and high-income groups. Considerable room for improvement exists without excessive financial strain, but this implies reversing past trends, improving implementation capacity and strictly monitoring the impact of social programs. 2.24 In an effort to reduce the adverse impact on the poor of stabilization and adjustment programs, the GOV prepared a Social Sectors Action Program which constitutes the basic policy framework of the Bank- financed Social Development Project (Loan 3270-VE) effective in September 1991. In addition, the Technical Assistance for Preinvestment Loan (Loan 3225-VE), effective in June 1991, was designed to strengthen the GOV's capacity to select, prepare and implement sound investment projects and to build up a pipeline of projects, including health and education projects, suitable for financing by the Bank.4 Technical Assistance Loan resources were used to hire two consultants to prepare the draft Public Credit Law for the proposed project and to contract a management study of DGSSSA. A Public Sector Investment Review, covering capital and recurrent expenditures in the social sectors, as well as a Public Administration Study and a Poverty Study were recently completed. A Health Sector Study is also underway and will be completed within two months. The results of these studies will assist in the identification of issues, policies and investment needs in the social sectors, 4 Also approved in FY90 were a Financial Sector Loan and a Public Enterprise Reform Loan. 10 and strengthen dialogue on major issues. The Health 8ector Study, in particular, will provide a framework and strategy for a lending pipeline in the sector and to help the GOV design a coherent investment program. Thus far, two projects have been identified in the course of the Health Sector Studys the proposed Endemic Disease Control Project and a Hospital Modernization Project, now in preparation. 0. Rationale for Bank Involvement 2.25 The Dank's assistance strategy in Venezuela is to support policies and investments that will encourage economic growth and social development in a context of macroeconomic stability. The emphasis is on efficient resource allocation, increased efficiency in the public sector, support for private sector development, and the appropriate targeting and delivery of support systems to the poor. The proposed project would directly support this strategy by improving the planning and management capacity of public health institutions to control endemic diseases, improving the health status of low- income populations, and reducing economic losses due to lowered productivity. It should also be noted that disease control projects, such as this one, have high externalities; the reduction of malaria incidence in one region, for example, brings benefits of reduced risk of disease to populations in other regions as well. H. Lessons Learned 2.26 The Bank has no completed health projects in Venezuela from which relovant lessons can be drawn, since the first Bank-financed human resources project for Venezuela, the Social Development Project, became effective in September 1991. There are, nonetheless, important lessons from the latter project, from the Dank's experience with endemic disease control, and from completed Bank projects in the health sector in general. Human Resource Proiects in Venezuela. 2.27 Goverment Exp mrienc. Bank experience with the ongoing Social Development Project has shown that the government has limited experience in project implementation, particularly in the social sectors. This should be taken into account in project design and in the early stages of project implementation. Supervision needs will be above average and training seminars on Bank policioe and guidelines will be especially important. Senior staff turnover in Venezuela has also been high; the Bank should therefore seek assurances of staff continuity in the Project Implementation Unit and in other key managerial and technical positions at the central and state levels. 2.28 The Public Credit Law. Implementation of the Social Development Project initially met some obstacles because the text of the Public Credit Law was not fully consistent with the loan agreement. The detailed project description and implementation arrangements, as described in the text of the draft law, should receive careful consideration. In particular, appropriate flexibility should be built into the text of the law, thereby allowing for possible adjustments in project design or strategy which may become necessary in the course of project implementation. Project costs must be expressed in ll US dollar equivalents with a referential exchange rate. The Law should be drafted as early as possible in project preparation, with appropriate modifications being made as necessary. Bank Exoerience in Endemic Disease Control 2.29 Flexiblltv. Bank experience in malaria control in Brazil and onchocerciasis control in West Africa has demonstrated the importance of operational flexibility in successful disease control. Disease situations tend to change, sometime. rapidly. People migrate and modify the environment, disease vectors and parasites develop resistance to pesticides and drugs, new control technologies are found. Endemic diseases are moving targets. This has important implications for project design and for the organization and management of disease control: program managers must have the technical _apacity to recognize and respond to important epidemiological and technological changes, as well as the administrative capability to implement strategic changes as needed. 2.30 Research. Accordingly, support for operational research is of paramount importance. It has been a key component of successful disease control programs supported by the Bank in the past, providing an institutional mechanism for the systematic adjustment of control strategy. For malaria control in Brazil it has led to improved treatment schemes, new methods of vector control, and better otratification of areas at risk. For riverblindness in West Africa it has led to better treatment schemes and more effective vector control. 2.31 Human Resources. The Rondonia Health Project (Ln. 2061-BR), executed in a remote region of Brazil, facrd many difficulties in staffing, training, management and supervision. The completion report for this project notes that frequent and flexible programming of Bank supervision helped deal with these problems. Programs in remote areas of Venezuela face similar constraints. The executing agencies for the proposed project and Bank supervision missions should give special attention to the preparation, supervision and maintenance of staff who work in remote areas. Assuring the adeqyate compensation of trained workers in such areas can help reduce worker turnover in remote places which are often key targets for disease control. NSAS must also take whatever steps are necessary to remedy the delays in payment of workers that have resulted in recent labor strikes, before the project is underway. General Health Proiects 2.32 Less Comolexitv. In several completed health projects5, Bank experience has demonstrated that a few separate and simple projects are better than a very large and complex project that tries to solve many problems at once. This and Government inexperience in project implementation reinforce the need for simple project design appropriate to management capacity. The 5 For example, the Tunisia Health and Population Project, the Bangladesh Population and Family Health II Project. 12 Bank will follow this strategy in Venezuela. The proposed project wlll focus narrowly on strengthening disease control programs and inotitutions. It will complement other efforts, however, ouch am the primary health care component of the ongoing SocLal Development Project (which supports maternal and child health care, immunization programs, and prevention of diarrheal dLease, *exually transmitted diseases, and acute respiratory infections) and the Hospital Modernization Project, now Ln preparation. 2.33 CLJil Works. Adequate planning and budgetLng for civil works (Ln the case of the proposed project, the construction of new operatLonal bases at the fiold level) Ls critical to timely implementation. Project implementation is often slowed by delays in civil works. This has particularly serious consequences when other project components hinge on their completlon. For the proposed project, it was therefore agreed that detailed plans for new construction during the first year of the project would be prepared, and legal title to bullding sites acquired, prior to LmplementatLon. 2.34 MaLntenance. Adequate maintenance is a key factor for sustaLning project impact and project desLgn should include measures to encourage the continuatLon of maintenance beyond the project period. The Brazil Northwest Integrated Development Project, for example, noted that the failure of the project design to provide for adequate maintenance of facilities and equipment led to their deterioratLon and a loss of Lnvestment. 13 III. EM3D1IC DISEASE CONTROL IN YNBZUELA A. Eoidemiolggical Situation and Control Stratoaies overview 3.1 Malaia. Malaria is a major public health problem in Venezuela and the problem has worsened considerably in recent years6. In the 1980s, the number of malaria casee reported in Venezuela rose dramatically from about 4,200 in 1982 to nearly 47,000 in 1990. Resurgent malaria in Venezuela is primarily associated with gold mining and rainforest settlement where human modification of the environment causes proliferation of the malaria vector and where there in a high degree of human-vector contact. The high mobility of the mining population, in particular, has been the primary cause of malaria's dispersion to other parts of the country. Malaria tranumission is highest in the mining camps of Bolivar state in the east, in parts of Tachira, Zulia, Merida, and Apure states in the west, and in the coastal state of Sucre in the northeast. 3.2 Despite the present resurgence of malaria transmission and the reinfection of areas where the disease had once been eliminated, the DGSSSA maintains the long-term objective of eradicating malaria in Venezuela. Current objectives, however, take into account important constraints which are largely defined by the characteristics of the principal vectors, the behavior and susceptibility of affected human populations and the limitations of existing malaria control technologies. These objectives are to: (i) reduce the level of malaria transmission in the federal territory of Amazonas and Bolivar state; (ii) interrupt transmission definitively in Sucre state (i.e. eradication); and (iii) to reduce transmission in the western states of Tachira, Merida, Zulia, and Apure to residual levels (i.e. to control or limit the problem to rare and isolated outbreaks). Once these goals are achieved, DGSSSA would maintain epidemiological and entomological surveillance and intervene as necessary to eliminate new foci of transmission. 3.3 Malaria control strategy in Venezuela has relied primarily on diagnosis and treatment of cases, intradomiciliary spraying, aerial fogging in selected areas (where the vector is particularly exophilicT, such as A. aouasalis in coastal Sucre state, or where few sprayable surfaces exist), elimination of breeding sites (through larviciding and drainage works) and health education geared to promoting vector avoidance behavior and community participation in breeding site control. Control efforts have proven especially difficult in 6 The malaria parasite (primarily Plasmodium falciparum and Plasmodium vivax) is transmitted by the Anopheles mosquito and causes debilitating flu-like symptoms (fever, chills, sweats) that often come in cycles. The parasite attacks and destroys red blood cells and, if untreated, can be fatal (especially P. falciparum). 7 An "exophilic" vector prefers to rest out doors after feeding. "Exophagic" vectors prefer to feed out doors. "Endophilic" and "endophagic" vectors prefer to rest and feed indoors, respectively. 14 minlng camps and new ralnforeet settlement areas characterlzed by mobile populatLons and prscarious dwelllngs. IntradomLcLliary spraying has been loes effective in such areas and paraelte resistance and behavioral adaptation. of the vector to insecticide use also pose important new ch&llenges. In addition, financial constraints and labor dloputes have hampered the cor.eitent applicatlon of control measures. The malaria control program now requires a major lnvestment to Lmprove and adapt control technologles to new situations in the flild, to strengthen the DGSSSA's human resources, and to generally strengthen the organizatLon and management of dLeease control. 3.4 Chacas Dlsease. Chagas dLsase is also a publlc health problem in Venezuela. It is borne by triatomLne bugs (Rh2diaus prolxusa and Triatgma maculata) which transmit the paraslte Trypanoeoma cruzi. The Chagas paraelte causes irreversible damage to the heart, resultLng in debllitation and death. Symptoms may not appear for many years after infectlon and there is no known cure. The vector's principal habitat ls the palm thatch and mud walls of traditional houaes among the rural poor. TranamLssLon li known to occur ln the states of Barinas, Merida, Trujlllo, Portuguesa, Lara, Zulia, Yaracuy, Cojedes, Carabobo, Miranda, Guarico, Aragua, Falcon, Anzoategui and Sucre. About 1,500 new cases have been reported in each of the last five years. Underreporting is high, however, due to a decline in surveillance activities in recent years. The Chagas control strategy focusem on treatment of infected individuals, spraying of infested houses and assoclated structures, promotion of housing improvements to reduce vector density in human dwellings and health education focused on community participation ln the timely reporting of reinfestation. "Unfortunately, the Chagas control program has suffered serious cutbacks in recent years because of the priority allocation of DGSSSA funds to malaria and dengue control. Greater support for Chagas control will be necessary to eliminate the vector and dlsease transmlislon. This will only be achieved through a more complete coverage of areas at risk, intensified education efforts and expanded housing improvement activities. 3.5 Intestinal Parasites. Ascaris and other intestinal parasites are also common among low-income populations and especially affect chlldren. Control efforts have focused on mass dlstribution of antL-helminthLc drugs to school children and on latrine construction programs among the rural and peri- urban poor. Latrine constructlon has fallen precipitously ln last decade: from over 10,000 latrines per year in the late 1970. to less than 800 in 1990. At present, the DGSSSA li solely responsLble for intestinal parasite control in Venezuela. Coverage could be expanded and further improved through the involvement of the local primary health care network of the general health services in the dietributlon of anti-helmlnthic drugs. 3.6 SchistosomLasie. Intestinal schLitosomLasie (SchLstosomiasis manognL) is transmitted to human populations when they are exposed (through work or leisure) to waters infested by an (infected) intermediate host snail, BiouhlsaiLa olabrata. The parasite undergoes part of its lifecyc.'e in the snail and is eventually released into the water. At another stage in the cycle, the snails are infected when paraeites return to the water ln human waste. The area most affected in Venezuela is the densely populated *enter- north region, including the Federal District and parts of the states of Aragua, Carabobo, Guarico, and Miranda, as well as isolated focl in Portuguesa 15 and Monagas. This debilitating disease, over a period of years, gradually causes damage to the liver, spleen, and intestlnes. In soms poor rural communLties, as much as 40% of the population may be lnfected. Epldemlologlcal surveys have traditlonally been carrled out by t-etlng fecal samples. More recently, *erologlcal methods have been developed which suggest that prevalence is much higher than was evldent from feces exams. Support for now and wlder epidemLologLcal studies is therefore needed and would help to better target lnterventlons. Although the long-term goal li to eradlcate schistosomialis in Venezuela, the present objective is to control the transmissLon of dl-ease in the endemic area and to eliminate any new actlve focl as they appear. The control stratogy involvess (i) determining the frequency and distribution of Lnfection using more senoltlve (serological) diagnostL tools; (ii) treatment of cases (using Praziquantel)l (iii) snail control (molluncLcidLng) using chemleal and biological agents; (iv) mlnor drainage works to eliminate lnfected snail populations and to reduce human contact wlth Lnfested waters; and (v) health educatlon focused on improved hygLone, proper dLiponal of human waste and avoidance of snall-lnfested waters. Olven the great diffleulty of keeping people and infested waters apart and of impeding the infectlon of snail populations through the improper dLeposal of human waste, especially in poor areas, education becomes a partlcularly crucial component ln the schLstosomiasiL control strategy. It is also important that snaLl control, based on appropriate epLdemiologieal surveys, be limited to areas of epidemiolog'cal significance. 3.7 Denaue and Donous Hemorrhaaic Fever. Dengue fever is caused by an arbovirus transmitted by the A9dfi aegovti mosquito. In its most severe form, dengue hemorrhagic fevor, the disease is often fatal. Since the late 1970s, when the last epidemic occured, the Aoeg aegy=t eradication program was gradually cutback until coverage was limited to three states. A decade later, between October 1989 and March 1990, Venezuela suffered an epidemic outbreak of dengue with over 12,220 reported cases. For the first time in Venezuela, these included 2,780 cases of dengue hemorrhagic fever, which caused 73 deaths. Over 70% of the national territory was affected during thie opidemic. A second epidemic occured in late 1991, despite entomological surveillance efforts, and spread into new areas including Bolivar and Amazonas states. In light of these events, DaSS8A has recognized and advocated the need to establish a Nat..onal Dengue and Adeg aeggJi Control Program. Such a program would involve a number of public health institutions including the National Hygiene Institute (INH), the Venezuelan Scientific Investigation Institute (IVIC), and DGSS, all of which would have an important role in virological, serological, cilnical and epidemiologieal surveillance. Within this program, DWGSSA would undertake Aedec aeusati surveillance (to monitor the vector population, its seasonal variation and sensitivity to posticides in use) and vector control activities including intradomiciliary spraying and aerial fogging. In addition, the dengue control strategy places special emphasie on the creation of a permanent program to involve local communities in reducing vector density through better solid waste disposal and elimination of breeding sites. The eventual program goal is to reduce Aede aeovnti to a level incompatible with dengue transmission and thereafter to maintain *pidemiological and entomologlcal surveillance and vector control as needed. 16 3.8 Cholga. The recent cholera epidemLc in South Amorica spread to Venezuela in 1991, when 14 casee were reported. In 1992 (January to June), a total of 869 cases and 18 death. were reported. The states most affected have been ZulLa (667 caese), Aragua (103 cases) and the Federal Dletrict (59 cases). Cholera cases have also been reported ln Miranda, Carabobo, Tachira and Apure statoo. The DGS8SA strategy for cholera control wlll includes (i) promotLon of better hyglene among populatlons at risk through education activitLe involving both publLc and prLvate LnstitutLons; (i) clorLnation of drinking water supplies to guarantee the qualLty of drLnking water (LLi) sanitary surveillance of recreatlonal waters; and (lv) maLntenance of adequate solid waste collectLon and dLposal Lncluding surveLllance of sewage and sewage treatment. 3.9 Yellow Fery . Like dengue, the yellow fever arbovirus li transmLtted by the Aedos 6g.ytL mosquLto. Although not presently a publlc health problem in Venezuela, yellow fever can still be found Ln non-human primate populatlons. No human cases of yellow fever have been reported in decades. The control program aime to maintain eradicatLn of the dieease through: (i) public vaccination programs, especlally of populatlons near enzootic fociL (iL) entomologlcal surveillance of Aedeg aegyL; and (iii) health education focused on promotion of voluntary vaccinatlon. 3.10 Le2ro&y. Leprosy li also a public health problem in Venezuela. It is transmitted through prolonged human contact and is caused by Mygobacteri 19M&2 Over a poriod of years, leprosy causes severe skin lesions, loos of skin sensLtLvity, nerve lesions leading to muscle weakness and atrophy, especially in the hands and feet, and often has a seriouc psychological and social impact on the families affected. In January 1991, there were 13,616 registered cases and the states most affected were Merida, Tachira, Trujillo, Barinas, and Apure. Although leprosy is treatable with a new multi-drug therapy (MDT), and promising work on immunotherapy and Lmmunoprophylaxie is underway, coverage needs to be improved in Venezuela's more remote areas such as T.F. Amazonas and Bolivar, where the state-level health services are weak. The leprosy control program is carried out by the state-level Dermatology Departments of DGSS/MSAS and managed by the IB. The control strategy focuses ons (i) the timely treatment of cases; (ii) monitoring and protection, through experimental vgccination, of intradomiciliary and extradomiciliary consanguineal contacts of confirmed casee; and (iii) targeted health education. The IB also has runs a rehabilitation program for leprosy patients. 3.11 Leishmaniasis. Leiahmaniasie, a parasitic disease transmitted by sandflies, has two major forms, L. teaumentar amoricana or LTA (also known as cutaneous and mucocutaneous leishmaniasis) and L. visoeral (Kala-azar18. LTA is more common in Venezuela. Its symptoms range from simple skin ulcers to major tissue destruction, especially of the nose and mouth. Some forms can 8 L. visceral is rare in Venezuela. About 50 new cases are reported each year. It is usually fatal if untreated and is more difficult to treat than other forms of the disease; lts symptoms include fever, malaise, weight lose, anemia, and owelling of the spleen, liver and lymph nodes. 17 heal by themselves, but often leishmaniasis requires difficult, expensive, and lengthy chemotherapy. In 1989, there were about 1,900 reported cases of LTA in Venezuela. However, according to the Ir, underreporting of LTA may be as high as ten to one. The IB's control strategy for ITA, carried out by the SDDa, involvess (1' active case detection utilizing trained community leaders and local health services personnel; (Li) development of new diagnostic techniquesj (iii) register, t eatment and follow-up of casesl (iv) epidemiological studies and studies of the veoctor and parasite reservoirs in areas of known transmission; and (v) health education. The IS is also undertaking studies of a leishmaniasis vaccine, as well as studies on the potential use of the same vaccine for treatment. Both studies are supported by the TDR program. Vector control is not presently part of the control strategy but this option is under study. The design and implementation of vector control first requires greater knowledge of the vector, its habits, and non-human reservoirs of infection. In order to lmprove the LTA control strategy, the IB plans to conduct studies of the frequency and distribution of LTA and its relationship to ecological, economic and cultural factors, as well as studies of the relationship between parasite and host. 3.12 onchocerciasis. Onchocerciasis, which is caused by a filarial parasite transmitted by blackflies (jiwJ1iJ), is also found in Venezuela. The adult parasites (macrofilariae) form nodules under the skin and produce millions of offspring (microfilariae) which migrate through the tissues causing severe itching and debilitation. Eventually these microfilariae may reach the eyes, causing ocular damage and blindness. The impact of the disease is worse in areas where repeated reinfection occurs. The states known to have onchocerciasis are the eastern states of Anzoategui, Monagas, and Sucre, the central states of Aragua, Miranda, Carabobo, Guarico, Cojedes, and Yaracuy, and the southern states of Bolivar and Amazonas. The IB estimates that there were approximately 70,000 cases of onchocerciasis in Venezuela in 1990, but a comprehensive and systematic mapping of the disease, and of the incidence of onchocercal blindness, has yet to be carried out. The IB plans to begin a treatment and surveillance program under the proposed project, using the microfilaricide, ivermectin (also known as Mectizan). Studios of the feasibility of vector control, jointly with DGSSSA, are also planned. The goal of the proposed onchocerciasis control program would be to eliminate the transmission of onchocerciasis in Venezuela by the year 2011. S. Flnancina of Endemic Disease Control 3.13 DGSSSA Financina. The DGSSSA endemic disease control programs are funded from several sources (see Annex 8)s (i) MSA8 (Li) the Guayana Regional Development Corporation (CVG - a parastatal company operating in Bolivar and Amazonas); and (iii) the state governments. The state governments contribute primarily to the rural housing, aqueducts and sewers programs. The central government, through MSAS, finances most of the specific disease control campaigns, EMSA, and administration. In addition, the CVG provides a significant contribution to malaria control in Bolivar and Amazonas. Total DGSSSA expenditures for endemic disease control declined over 30%, in real terms, between 1985 and 1990, from about US$32 million to about US$16 million (1990 US dollars). In 1991, financing of these programs increased to about US$25 million but still remained considerably below the 1985 level. The 18 budget situation wor.ersed again, however, between 1991 and 1992. Although t 1992 budget included a 20% inflation adjustment for personnel expenditures, the remalnder did not. In real terms, this represents an addLtional 20% decline in the DGSSSA budget for operations. As a percentage of total M8A8 expenditures, funding for endemic disease control (both DWSSSA and IB expenditures) declined from over 12% in 1972 to lees than 3% in 1992. 3.14 IB FinancLnc The IS is financed primarily by two lnetitutions, MSAS and the Central University of Venezuela (UCV). The World Health Organization (WHO) funds part of the leprosy and leishmaniasis programs. In addition, the U.S. Agency for International Development (USAID) has supportet onchocerciasis treatment among indigenous populations and NIH and Rotary Cluk have each supported IB research projects. IB expenditures have declined 7.5w between 1985 and 190), primarily due to declining MSAS contributions. Total IB expenditures in 1990 fox managing the leprosy, leishmaniasis and onchocerciasis programs were about US$800,000 (excluding the SDDs expenditure and other DGSS expenditures for treatment of these dLeases through the general health services). C. Maior Iasues in Endemic Disease Control 3.15 At present, the major issues and principal constraints for endemi dLsease control programs in Venezuela are: (i) insufficient financing for all essential operations and programs (acute problems such as malaria and dengue quickly consume most of the available resources); (ii) insufficient higher level personnel, especially epidemiologists, entomologists, social scientists and management specialists; (iii) insufficient capacity to t:rain mid-level ani field personnel; (iv) insufficient resources for essential operational research on control technologies and strategies; (v) an outdated information system; and (vi) labor strikes due to delays in payment of field workers. 19 IV. THE PROJECT- A. Proiect Conceot and Obiectives 4.1 Public health institutiors in Venezuela today face many challenges, among them are the vied to restore an appropriate balance betweeu curative and preventive care, to strengthun the human reoources and institutions necessary to execute effective public health programs, and to better target health programs to the poor. The project will therefore suppor specific public health prograass for endemic disease control that have lost ground in recent years due to fiscal constraints and worsening epidemiologica condition.. The objectives of the project are: (i) to reduce the incideu.ce and impact (health and economic) of endemic diseases including malaria, Chaga disease, intestinal parasites, schistosomiasis, dengue, cholera, yellow fever Venezuelan equine encephalitie, onchocerciaeis, leishmaniasis, and leprosy; and (ii) to strengthen the two principal institutions rusponsible for endemic disease control in Venezuela, the DGSSSA and the IB. 4.2 The main beneficiaries of the project will be rural and peri-urba populations throughout Venezuela, especially those in areas with high levels of endemic disease transmiesion. The poor will derive particular benefit since they are the population most exposed to risk of these diseases. The project will also lead to improved management and technical capacity of the institutions responaible for endemic disease control. In particular, it will help the IB and DGSSSA to improve the design and evaluation of control strategies and the cost-effectiveness of dieease control interventions. B. Main Features 4.3 To meet these objectives the project has two components: (i) an Endemic Disease Control Component (71 percent of total project costs); and an Institutional Strengthening Component for DGSSSA and IB (29 percent of total project costs). Endemic Disease Control ComDonent (US$133.2 million including contingencies) 4.4 The Endemic Disease Control Component will support: (i) new and ongoing epidemiological surveillance activities for all of the endemic diseass control programs (including cholera); (ii) treatment of cases and preventive treatment; (iii) entomological surveillance and vector control to interrupt the transmission of malaria, dengue, and other vector-borne diseases; (iv) rural housing improvements to eliminate the habitat of the Chagas vector and thereby reduce transmission of Chagas disease; (v) health education activities to enliat individual and community participation in the control of endemic diseases; (vi) education and water treatment activitles for cholera prevention; and (vii) innovative measures identified through operational research. 20 Institutional Strengthenina Component (US$54.8 million including contingencies) 4.5 The institutional Strenathening Cgmoonent will support: (i) training activities to improve humcn resources at all levels, from central maniagement to house visitors and spraymen in the field; (i) development of information systems to strengthen epidemiological analysis (including computerized epidemiological mapping capabilities) and logistics management; (iii) an operational research fund for special studies to develop and test new control measures or to improve on existing strategies and technologies; and (iv) construction of new operational bases, training facilities, and central and regional headquarters (for DGSSSA) to support expanded program coverage. 4.6 The project will support both components through provision of vehicles, equipment, construction materials, supplies and fuel; development and purchase of educational materials; and payment of costs for vehicle operation, maintenance, technical assistance, salaries, per diems, travel and project supervislon. The Endemic Disease Control Component will also support the purchase of drugs and pesticides. In addition, the Institutional Strengthening Component will support: contracting of civil works; provision of computer equipment and software; and payment of costs for training and in- service training courses, domestic and foreign fellowships and operational research. C. Detailed Descrintion Component A: Endemic Disease Control 4.7 The project will include a disease control component to strengthen field operations including epidemiological and entomological surveillance, treatment of cases, vector control, and IEC activities. The project will support traditional operations such as intradomiciliary spraying for malaria and Chagas control, as well as innovative measures such as impregnated bednets for malaria control, serological studies for surveillance of schistosomiasis, and immunoprophylaxis and immunotherapy for treatment and prevention of leishmaniasis and leprosy. Subcomponents to be Imolemented by DGSSSA 4.8 Malaria Control. In recent years, malaria control efforts in Venezuela have been hampered by a number of problems. These include: (i) environmental modifications which create more favorable breeding conditions for the mosquito vector; (ii) increased human-vector contact because of the expansion of certain economic activities, especially gold mining and rainforest colonization, and the precarious types of housing associated with these activities; (iii) frequent migration of infected individuals; (iv) parasite resistance to anti-malarial drugs and changes in vector behavior; and (v) a decline in resources available to maintain adequate coverage. Resources are needed to reinforce traditional control strategies, as well as to develop and implement new ones. Therefore, the malaria control subcomponent will support: (i) epidemiological surveillance (active and passive case detection), treatment and education activities including promotion of personal protection 21 measures such as the use of bed note; and (ii) entomological surveillance and vector control actLvities Lncluding intradomiciliary pesticide application, selective ultra-low-volume (ULV) fogging (e.g. in mining camps), larviciding and biologi,:al control measures (the pesticides are DDT wettable powder 60%, Tomephos, Phenitrothion C.3. 50%, Phenitrothion wettable powder 40%, and Malathion C.N. 94%). These activities will be strengthened throughs the purchase of vehicles (pickup trucks, jeeps, small boats, outboard motors, motorcycles), equipment (including spraying equipment and microscopes), drugs, pesticides, fuel, and supplies; the payment of coots for vehicle operation, vehicle and equipment maintenance (at 4% of cost of new goods), rental, salaries and per dLems for field personnel (inspectors, visitors, spraymen, and laborers), travel and project supervision. 4.9 Dencue Control. Dengue fever reappeared in Venezuela in 1989 after a decline in Aedes auy.ti control efforts. The latest epidemics also brought Venezuela's first experience with dengue hemorraghic fever, a very serious and often fatal manifestation of the disease. Field operations have not had sufficient personnel or resources to maintain adequate coverage. After two serious dengue epidemics since 1989, DGSSSA now recognizes the need for a National Dengue and Aedes aeqvti Control Program. The dengue control subcomponent of the project will therefore support epidemiological and entomological surveillance and vector control activities including pesticide application against larval and adult forms of the mosquito (Malathion C.E. 94%), small source reduction projects, solid waste disposal (undertaken by local governments) and IEC activities9. The project will support these activities through the purchase of vehicles, equipment, pesticides, fuel, and supplies; development and purchase of instructional materials; the payment of costs for vehicle operation, vehicle and equipment maintenance (at 4% of cost of new goods), salaries, per dieme, travel and project supervision. 4.10 Chacas Disease Control. Despite general improvements in rural housing and many years of indoor spraying for vector control, Chagas disease is still an important public health problem in Venezuela. An estimated 3 million persons are still exposed and at risk because of poor housing condition. (mud and thatch) which provide the principal habitat of the triatomine bug, the Chagas vector. The principal control measures undertaken by DGSSSA and which will be supported by the project include epidemiological and entomological surveillance (treatment of Chagas patients is carried out by DGSS through the health care system, using the drugs Nifurtimox and Benznidazol), vector (triatomine) control using H. C H. (Hexachlorociclohexano) and Dieldrin (to date, effective biological vector control methods have not been found). The project will support these activities through: the purchase of vehicles, equipment, fuel, pesticides (Phenitrothion wettable powder 40% and Phenitrothion C.S. 50%) and supplies; payment of costs for vehicle 9 DGSSSA is only responsible for the prevention of dengue, i.e. for reducing transmission through vector control and for maintaining epidemiological and entomological surveillance. Clinical care for dengue is carried out by other institutions, public and private, in the health care system. Support for dengue control under this project will be limited to support for actions carried out by DGSSSA. 22 operatior, vehicle and equipment maintenance, per diems, travel and project supervision. The project will also support the M.I.VT.CA. program (Programa para el Hejoramiento Integral de la Vivienda Campesina). This program begins with education activities in poor rural areas focusing on the need to eliminate the Chagas vector (Rhodnius prglixua or "el chipo") which lives in cracks in mud walls and in palm thatch. N.I.VI.CA. therefore supports minor housing improvements such as covering cracked mud walls with wire mesh and cement and replacing thatch roofing with sheet metal. Voluntary participants sign a loan agreement to repay the costs of construction materials provided by the program, which also provides the necessary technical guidance to ensure proper construction. At the same time, the program promotes latrine construction which has many other health benefits. The project will support the M.I.VI.CA. program through the purchase of construction materials (including sand and cement for floor pavings and wall coatings, steel sheets for roofs, precast concrete sludge pits, latrines, lavatories and WCs, wooden doors and windows)10, vehicles, fuel, mobile power generators for audio- visual presentations in target communities; and payment of costs for vehicle operatlon, vehicle and equipment maintenance, per diems, and project supervision. 4.11 Schistosomiasis Control. Schistosomiasis control efforts have been negatively affected by budgetary cutbacks and reallocation of resources to more acute problems such as malaria and dengue. Schistosomiasis is still a problem is some areas which could be eliminated through a concerted effort of case treatment, snail control and health education. The control measures to be supported by the project therefore include epidemiological surveillance and treatment, malacological (snail) surveillance and molluscicide application and 23C actlvities. These activities will be supported through: the purchase of vehicles, equipment, fuel, supplies, pesticides (Baylucid), and drugs (Praziquantel); and payment of costs for vehicle operation, vehicle and equipment maintenance, per diems, travel and project supervision. 4.12 Intestinal Parasite Control. The prevalence of intestinal parasites in Venezuela is high, despite a gradual and significant decline over the past few decades. Latrine construction programs contributed to this decline but have been cut back severely in recent years. The existing program to distribute antihelminthic drugs to schools and communities has also had difficulty in maintaining adequate coverage. Latrine construction, drug dlitribution, and rEC activities must be expanded to meet present and future needs. The project will help to achieve this through: the purchase of vehicles, quipment, supplies, construction materials for 50,000 latrines, and drugs; and payment of costs for rent, vehicle operation, vehicle and equipment maintenance, per diems, travel and project supervision. 4.13 Yellow Fever Control. Yellow fever is not presently a public health problem in Venezuela and no cases have been reported in many years. Maintenance of eradication requires continued vaccination and surveillance of *nzootic forms of the virus. The project will therefore support ongoing 10 Construction materials for the M.I.VI.CA. program will be purchased with government counterpart funds. 23 preventlon efforts which lnclude immunization campaigns (the goal La 100% coverage of the populatlon at rlsk), entomological survilllance of selvatLc vectors and reservoirs, A2d-s a evltL control, and IEC activities. The pro!sct wll support these activities through: the purchase of vehicles, equipment, fuel, vacecnes, and supplies; and payment of costa for vehicle operatLon, vehLl- and equipment malntenance, salaries, per dieme, travel and project supervLsion. 4.14 Chol ra Control The present cholera pandemic ln Latin America has already affected Venezuela. In 1992 (January to June) a total of 869 case were reported with 18 deaths. The states most affected were Zulia (667 casesp. Aragua (103 cases) and the Federal District (59 cases). Cholera cases have also been reported Ln Miranda, Carabobo, Tachira and Apure states. The project wlll therefore support ongoing sanitation and education efforts which aim at the proventlon of cholera, through: the purchase of vehicles, fuel, water pumps, and chlorinatlon and other supplies; and payment of costs for vehLile operation, vehicle and equipment malntenance, salarles, per diems, travel and project supervision. Thle subcomponent focuses exclusively on DGSSSA's responsibilities in cholera prevention; the treatment of cholera (oral rehydration therapy) is carried out by other health sector institutLons which are not among the executing agencles of this project. 4.15 Other DaSSSA Disease Control Proarams. The project wlll also support entomologlcal surveillance and vector control activitles for Venezuelan equine encephalitls, Venezuelan hemorraghic fever, onchocercLasis, and leishmaniasis through: the purchase of vehicles, equlpment, fuel, supplies, and pesticides (Phenitrothion C.E. 40%); and payment of coats for vehicle operation, vehicle and equLpment maintenance, per diems, travel and project supervision. 4.16 DGSSSA - Information. Edugation and Communicatlons (IEC). Thli subcomponent will support DGSSSA efforts to strengthen and expand programs to educate the public about endemic dliease control and to promote community partlcipatlon. Specifically, the subcomponent will support a health oducation unit (whLch has already been constituted and staffed) at the central level, the formation of health education teams at the regional level and educational programs to increase community awareness of actlons that communltles and indivlduals can take to reduce the spread and impact of endemic diseases. The now IZC unit will provlde guidance and technical assistance to all of the DOSWSA die-ase control programs, helplng control program staff to integrate, strengthen and execute INC actLvitLes in the ongoLng control program strategLes. Of partlcular importance is the contracting of INC experts to provide technical assistance and carry out special studies and surveys. The activities of this subcomponent will be supported through the purchase of vehicles, equlpment, fuel, and supplies; development and purchase of instructional materials; and payment of costs for vehicle operation, vehicle and gquipment maintenance, technical asesetance, salaries, per diems, travel and project supervision. 24 Suboom=onents to be Imolemented by the IB 4.17 Leishmaniasis Control. Underreporting of leishmaniasis in Venezuela is high. Its frequency and distribution and the ecological, economic and social factors in its transmission are still poorly understood. The leishmaniasLs control s.bcomponent will therefore supportt (i) strengthening of epidemiological surveillance including active case detectior (involving house visitors, rural physicians, nurse auxiliaries, and local communities); (ii) registration, treatment, and control of cases; (iii) epidemiological studies of foci and cases, especially in areas affected by epidemic outbreaks where special measures may be needed; (iv) analysis, interpretation and dissemination of epidemiological information including publication of trimestral bulletins and annual reports; and (v) entomological and parasitological studies. These activities will be supported throughs the purchase of vehicles, equipment, fuel, drugs, and supplies; and through payment of costs for vehicle operation, equipment and vehicle maintenance, rental of space for field bases, salaries, per diems, travel and project supervision. 4.18 Leorosv Control. The existing leprosy control program needs to b expanded especially in areas where the primary health care system is less developed. The leprosy control subcomponent will aim to reduce prevalence an incidence of the disease through the adequate and opportune treatment of case and the protection of contacts at high risk of developing the disease. Subcomponent activities will includes (i) treatment of casea and vaccination of high risk contacts; (ii) investigation and control of contacts; (iii) epidemiological surveillance, including socio-epidemiological studies in area of high incidence . The project will support these activities through: the purchase of vehicles, equipment, fuel, drugs and supplies; and payment of costs for vehicle operation, vehicle and equipment maintenance, rental of space for field bases, salaries, per diems, travel, and project supervision. 4.19 Onchocerciasis Control. The frequency and distribution of onchocerciaeis in Venezuela is also poorly understood and there is no specifi4 plan currently in place to treat its victims or to reduce transmission of the disease. The onchocerciasis control subcomponent will initiate control activities in Venezuela and undertake the necessary studies to develop an appropriate disease control strategy. Specifically the subcomponent will supports ($) mass distribution of ivermectin for treatment of cases (this may also have some impact on transmission); (ii) epidemiological surveillance including active case detection, registration (and treatment) and follow up ol cases, and epidemiological studies of transmission foci in order to better understand transmission situations and devise appropriate control strategies; (iii) entomological surveillance and studies (vector behavior, distribution, transmission potential); (iv) studies of possible vector control activities ir areas of high transmission. The project will support the above through: the purchase of vehicles, equipment, fuel, drugs and supplies; and through payment of costs for vehicle operation, vehicle and equipment maintenance, rental of space for field bases, salaries, per diems, travel and project supervision. The project will contract 18 new public health inspectors (10 for the northeast, 8 for the center-north), an entomologist to undertake vector research (for both onchocerciasis and leishmaniasis) and two sociologists. 25 4.20 IB - Information. Education, and Communications. A subcomponent for information, education and communication (IZC) activities for all the IB programs will aim to strengthen health education and community participation in disease control. In addition, the project will support appropriate training of local health service personnel and applied social research. The IB is planning to hire two health education specialists to prepare educational materials and develop INC methodologies, in collaboration with the ID's epidemiologists and public health administrators. The health education specialists will work closely with rural physicians, inspectors, auxiliary nurses, and health promoters. The 1 is also expecting to hire and train 60 health promoters, four sociologists and three public health nurses. The above will be supported through: the purchase oL vehicles, equipment, fuel, and supplies; and payment of costs for vehicle operation, vehileo and equipment maintenance, salaries, per diems, travel, and project supervision. Component B: Institutional Strenathening 4.21 The project includes an lnetitutional strengthening component to help DGSSSA and IB to improve their understanding of disease situations and their determinants, to develop and improve the human resources needed to carry out control programs, to improve, through operational research, the tools needed to combat endemic diseases, and to improve infrastructure. Subcomoonents to be Implemented by the DG8SSA 4.22 DGSSSA - Trainina and In-Service Training. The project will support the following training activities to be carried out primarily by the Arnaldo Gabaldon School of Malariology and Environmental Sanitation: (i) training courses for managers, administrative personnel, and field personnel in management, administration and field operations, as well as a new entomology course; (ii) preparation and production of Instructional materials; (iii) fellowships in epidemiology, parasitology, entomology and other specialized areas (domestic and foreign); and (iv) creation of three field research and training stations in Amazonas, Barinas and Sucre states (see DGSSSA - Infrastructure subcomponent below). These activities will be supported through: the purchase of vehicles, equipment and fuel; payment of costs for vehicle operation, vehicle and equipment maintenance, fellowships (foreign and domestic), salaries, per diems, technical assistance, and training courses; and development and purchase of instructional materials. 4.23 DGSSSA - Strenathenina Administration and Manaaement. This subcomponent will provide for technical assistance to strengthen DGSSSA management through hiring of consultants and contracting of special studies. It will also finance contracting of auditing firms. Assurances were obtained at negotiations that DGSSSA wouldt (i) carry out a management study, not later than March 31, 1993, to review the organization and management structure of DGSSSA and make recommendations to improve such structure; (li) not later than June 30, 1993, based on the above-mentioned management study and the Bank's comments thereon, present an action plan, satisfactory to the Bank; and (iii) thereafter implement such action plan in a manner and under a timetable satisfactory to the Bank (para 7.1g). Assurances were also obtained at negotiations that the executing agencies would carry out studies, not later 26 than March 1, 1993, to develop appropriate Lndicators of the impact of institutional development activities supported under the project (para 7 1h). 4.24 DOGSSA - InformatLon Systems DLveloment. Conventional manual method. of information management are no longer adequate to the needs of DGSWSA, given the large volume of epidemiological and administrative Lnformation generated by its disease control programs. Development of DGSSSA's information systems capacity is urgently needed to help the institution develop and impl eme nt better disease control strategies and programs. In particular, a computerized epidemiological mapping system would greatly enhance disease control efforts. Applied research carried out by DaSS8A would also benefit. Furthermore, up-to-date information systems technology and training would also provide DGSSSA wlth improved access to national and international health sector information networks that would be useful in combating endemlc diseases. This subcomponent will enhance DGSSSA information systems through: the purchase of computer equipment, software, and supplies; and payment of costs for maintenance, salaries, per dieme, technical assistance, travel and project supervision. 4.25 3OSSSA - Onerational Research. The project will support operational research for the DWSSSA. Proposed studies will be submitted to a Research Steering Committee comprised of experts in endemic disease control research (para. 4.36). This subcomponent will include support for payment of salaries and per diems, as well as for purchase of supplies, vehicles, equipment and other goods or services essential to the research activities. It will also support renovation of facilities up to a maximum of US$5000 per proposal. DGSSSA has already identified a number of possible research projects and priorities: (a) Malariat (i) studies of risk factors (socLal, entomological, parasitological, and therapeutic), in order to achieve a m'ore accurate understanding of the malaria problem in Venezuela and, consequently, to better stratify affected areas; (Li) evaluation of new diagnostic techniques (parasitological, Immunological, molecular) for population studies; (iii) studies of new biological and chemical alternatives for vector control. (b) Chagas Diseases (i) studies of housing types by region; (ii) longitudinal studies of life expectancy in Chagas patients; (iii) evaluative studies of K.I.VI.CA. rural housing improvement program's impact on Chagas transmission; (iv) studies of alternative materials to reduce housing improvement costs; (v) studies on improving the local "bahareque" (mud and thatch) construction technology. (c) Schistosomiasid: (i) studles of factors in schistosomiasis transmission in the human and intermediate snail host; and (ii) studies of biological control alternatives (e.g. introduction of plants lethal to giom.halaria alabrata such as Rhyt2lacca octandra, or introduction of other snail species such as Thiara tubargulata and Tlhara granifera, which compete with the intermediate snail host). (d) Deng-s: ($) studies of combined dengue/yellow fever control efforts in rural and urban areas; (ii) follow up studies concerning densities 27 and vector potential of A2d2m agavgti and other eventual vectors (i.e. Aedes Albopictu); (ill) studies of horizontal and vertical transmision potential of local vectors; (Lv) suaceptLbility of A2do aeggoti to commonly used pesticLdes; and (v) appllcation of molecular biology in diagnoois of dengue and yellow fever. (a) Istestinal Paragites (L) studles of the efficacy of new antihelminthlc drugs; (LL) evaluation of tho impact of control efforts on prevalence and parasite loads; (LLL) studies of impact of sanitation efforts and education programs on pre-and primary school students. 4.26 DGSBSA - Infrastructure. The DGSSSA infrastructure subcomponent wlll include completlon of construction of a new central headquarters in Maracay, a project which has been underway for eight years under the aegis of MINDUR. The new headquarters would serve the important purpose of physically consolidating all DGSSSA departments, which must work in close coordination, but which are presently spread out across the clty of Maracay. The long delay Ln completlng the new headquarters has been due to the fact that it must compete annually with other MINDUR priorities (not DGSSSA priorities). Although the headquarters may be a DGSSSA priority, the institution has been unable to sustain sufficient fundlng from MINDUR to complete the project in a reasonable period. Support for the new headquarters under the Endemic Disease Control Project is therefore essential. The project will also support the construction of nine regional headquarters, 25 operational bases, and three field-training bases. In addition, the project will support the expansion of the ENSA research center (ENSA Research Divislon) and the civil works services required to install the DGSSSA Information System. The project will support these activities through the contracting of construction firms, purchase of equipment, and payment of equipment and building malntenance costs. Subcomonents to be Imolemented by the IB 4.37 IB - Trainina and In-Service Trainina. The project will support training and in-service training for the leprosy, leishmaniasis and onchocerciasis programs including training for physicians, public health auxillarLes, health promoters, and forelgn fellowships. 4.28 The project will support the above actlvlties through: the development and purchase of instructlonal materials; purchase of equipment; and payment of costs for equipment maintenance, foreign fellowships, salaries, per dLems, travel, technical assistance, and project supervision. 4.29 lB - Information Systems. The IS currently employs 15 information systems personnel including one oyscem englneer, two system analysts, one computer programmer, and eleven data entry technicians, and has three computer networks, three servers, and 15 stations. The IB has developed and uses specialized software systems for the management of the Leprosy Immunoprophylaxle Program, the National Leprosy Register, the Leprosy Chemotherapy Program, the LeLshmanlasis Immunoprophylaxis Program, the LelshmanlasLe Register, and the Lelshmaniaeis Immunotherapy Program. At the state and local level, however, only the Dermatology Service of Apure state has a computerLzed lnformation system. Expansion of dieease control 28 activities will increase the ID's information systeme needs. Therefore, the project will support comprehensive development of IB information systems includings (i) development and implementation of a computerized epidemiological mapping system; (Li) establishment of an information system for the onchocerciasle control program; and (iii) development of the information systems capacity of the Dermatology Services at the state level. These activities will be supported through: the purchase of new computer equipment, software, and supplies; construction of the necessary civil works for computer installation; and payment of costs for equipment maintenance, technical assistance, salaries, per diems, travel, and project superviion. 4.30 IB - Strengthgnino Administration and Manaagmnt. The project will provide management and administration training to physicians and administrative support staff of the control programs executed by the Dermatology Services in all states. Training will include three-day modular courses on specific activlties for personnel at the state and local levels and appropriate courses for administrative personnel at the central level (in areas such as inventory and personnel administration). In addition, the project will provide for three-month higher level management training courses for each of the directors of the national leprosy, leishmanLasie and onchocerciasis programs. The project will support these activities through the purchase of equipment and supplies; development and purchase of instructional materials; and payment of costs for salaries, per diems, travel, rental of training sites, and project supervision. Assurances were obtained at negotiations that the executing agencies would carry out studies, not later than March 1, 1993, to develop appropriate indicators of the impact of institutional development activities supported under the project (para 7 1h). 4.31 IB - Operational Research. The project will support operational research for the IB. This subcomponent will include support for the same items, and utilize the same review process, as described in para. 4.25 above and 4.36 below. The IS has identified a number of priority areas for study: (a) Leishmaniasis: (i) clinical, immunological, and etiological studies in high risk areas; (ii) studies of reservoirs; and (iii) studies in immunoprophylaxis, immunotherapy, and other alternative therapies. (b) Loproevs (i) risk factor studies; (ii) socio-epidemiological studies (especially in Apure, Tachira, and Nerida states); and (iii) studies of immnuns deficiency in leprosy patients and its relationship to different forms of the disease. (c) Onchocgrciasis: (i) studies in epidemiology, ophthalmology, immunology, drug toxicity, and parasitology; and (ii) studies of vector (Simulium) distribution and transmission potential. (d) Socio-Epidemioloaical Researchs Studies aimed at the improvement of health education and community participation. 29 4.32 In - Infrastructure. The project will support the construction o six training centers and 41 rural houses which will provide fundamental support to the work of the Dermatology Services in areas of high transmission of leprosy, leishmaniasis, arnd onchocerciasis. This will facilitate field operations and reduce transport and personnel costs, eLnce all programs are presently planned and executed out of state capitals. The training centers will provide training for public health auxiliaries in dermatology and in prevention and rehabilitation of disabled leprosy patients. A rural house will also be constructed adjacent to each of th- five training centers. The remaining rural houses will serve an operational bases and provide housing fo the public health auxiliaries of the control programs. Construction will be executed by the DGSSSA/Rural Housing Directorate. Sites will be solicited, a donations, from local municLpalities, or will be purchased. The schools and half of the houses will be built in 1993, and the remainder in 1994. The project will support the above through the contracting of construction firms through the DGSSSA and will include building maintenance costs on a basis of two percent per year of the cost of new construction. The project will also support purchase and maintenance of equipment on the basis of xour percent pe year of the cost of new equipment. D. Proisct Manaoement and Implementation 4.33 Proiect ManAaement. The project will have two executing agencies the IB and the DGSSSA, which will be responsible for implementation of the project. Each agency will have a separate Project Implementation Unit (see Chart 3 and Chart 4). The heads of these two agencies will serve as co- directors of the project and will delegate authority for project implementation to project managers in their respective Project Implementation Units. Bach project manager will be supported by a small staff of five or siL persons and will rely largely or existing personnel and administrative mechanisms. Under the project, the DGSSSA will hire a project manager, three assistant managers, and three supervisors, and the IB will hire a project manager and one assistant manager, to complement existing staff. The project managers and staff dedicated to project implementation will: (i) ensure effective and timely implementation of )roject activities; (ii) monitor and coordinate overall progress and disbursement of the Bank loan; (iii) submit tc the Bank annual physical and financial reports on the status of the project; (iv) coordinate with public and private institutions; (v) manage the procurement of works, goods and services, including ICB, ln accordance with Bank guidelines; (vi) arrange for timely audits of project accounts; and (vii) prepare Part II of the Project Completion Report. 4.34 In addition, the MSAS will establish and maintain a Project Steerlng Coammittee (see Chart 5) for purposes of the overall coordination of the project. It will be comprised of the directors of the executing agencies, the managers of the project implementation units, and a representative of the Proyecto Salud/MSAS. The MSAS wlll also establish and maintain a Project Procurement Committee (see Chart 5) for purposes of assisting the executing agencies in all procurement activities under the project. It will be comprised of representatives from both executing agencies and other officials of the MSAS. Assurances were obtained at negotiations that the executing agencies would maintain the Project Implementation Units, Project Steering 30 Committee, Procurement Committee and Research Steering Committee throughout the executlon of the project (para. 71-e). 4.35 Assurances were obtained at negotiations that the executing agencies will participate in annual reviews (by March 30 of each year), jointly with the Bank, focusing ons (i) evaluation of progres in project execution and achievement of project objectives, based on the implementation schedule and agreed monitoring indicators (see Annexes 5 and 6)p (ii) review of proposed annual budgets for the project and for endemic disease control programs for the subsequent year; (iii) any changes in project design and implementation that may be necessary (including the possible effects of decentralization in the health sector); and (iv) the mechanism providing for the management by DGSSSA of all funds for payment of DGSSSA's field workers. Upon the Bank's recommendation, any required adjustments would be made in project implementation in order to attain the agreed objectives (para. 7.1b). 4.36 Ocerational Research steorina ComMittee. The operational research subcomponents will be managed by a Research Steering Committee. The Steering Committee will be comprised of experts on research in endemic disease control who will be selected by the executing agencies. The executing agencies will use a model research proposal based on the TDR format (WHO/UNDP/World Bank Special Program for Research and Training in Tropical Diseases). The Research Steering Committee will approve or not approve proposals based on their scientific merit and compatibility with operational research priorities as defined by the IB and DGSSSA. Prior to their submission to the Steering Committee, the research proposals will be sent to the Dank for comment. The executing agencies brought to negotiations Operational Research Regulations which set forth the criteria and procedures for regulating the operation of this subcomponent. Assurances were obtained at negotiations that the executing agencies will implement the operational research subcomponent in accordance with the Operational Research Regulations (para. 7. 1d). 4.37 Imglementation Schedule. The proposed project will be implemented over a period of approximately five and a half years and is expected to be completed by December 31, 1997. The closing date will be June 30, 1998. The cost schedules prepared for the various components (see Annex 1) and the implementation schedule (Annex 5) will serve as a basis for planning of project implementation and will be updated regularly during the course of the project. Throughout project implementation and during regular project reviews with Government, the Bank will give particular attention to the effectiveness and efficiency of implementation of project components and agreed actions, and changes will be agreed and implemented as needed. Assurances were obtained at negotiations that the executing agencies will, by March 1 of each years (i) submit a report to the Bank, for its review and comments, on progress in implementation of all project components and any proposals for adjustments in project implementation; and (Ui) submit to the Bank, for its review and approval, a proposed annual investment program providing for the activities, implementation schedule and targets, and proposed project budget for the then upcoming year, based on the implementation schedule in Annex 5 (para. 7. 1a). 4.38 Assurances were obtained at negotiationi that the Government will, in respect of endemic disease control programs? (i) during the last quarter of 31 each fLocal year, exchange vlewr wlth the Bank on budgetary needs, through the executlng agenciesl (ii) ln each fiscal year, furnish evldence satLsfactory to the Bank showlng that the final proposed N8AS budget lncludes adequate allocatlons ln the oplnlon of the Bank, not later than 15 days after the Mlnlitry of Flnance has received the respective fLnal proposed budget of MSAS8 (iiL) not later than May 31 ln each fiscal year, furnLsh evidence satlsfactory to the Bank of the flnal proposed budget for the then followlng flscal year, submitted by the Borrower's xecutlve Branch to the Borrower's Congress; and (Lv) not later than March 1 in each fiscal year, furnLsh c-idence satisfactory to the Bank showlng the amount of expendltures Lncurred ln the then prevlous flical year (para. 7.1l). 4.39 Monitoring and Evaluation. A llit of key input and outcome LndLcators of =roject lmplementatlon to be used in regular implementatlon reviews is provlded ln Annex 6. Implementation of project actLvLtLes will be regularly monitored, coverlng all dLsease control programs and all subcomponents of the instltutLonal strengthenLng component. Both executing agencies wlll carry out studies, during the fLrst year of the project, to develop approprlate lndlcators to monltor the impact of LnstLtutional development actlvltles. 32 V. PROJECT COSTS, FINANCING. PROCEMtENT AND DISBURSEMENTS A. Proiect Costs 5.1 The total project costs including contingencies and an estimated US$83.9 million (44.6%) in foreign exchange costs, is estimated to be US$188.0 million equivalent. Tables 5.1 and 5.2 summarize the estimated costs by project component and cat-gory of expenditure. Detailed costs are presented in Annex 1. 5.2 Base Costs and Continaoncies. Base costs are expressed in June 1992 prices, and exclude taxes and duties, which are negligible. Civil works costs were based on estimated unit costs for the type of buildings proposed. The costs of construction materials were based on the experience of MSAS. Equipment and furniture costs were based on prices for similar imported or locally available items. The costs of drugs and pesticides were based on the procurement experience of MSAS. Overseas and domestic training and costs of foreign and local consultants were based on current standards. operating costs were based on current estimates of salaries and operating requirements. Total contingencies of US$33.1 million represent 21.4% of base costs. Physical contingencies (US$5.1 million) represent 3.3% of base costs; price contingencies (US$28.0 million), about 18.1% of base costs, were estimated on the basis of the implementation schedule and expected annual price increases as follows: (a) localt 25% for 1993, and 20% for 1994, and 15% for subsequent years; and (b) foreign: 3.9% for 1993 and 1994 and 3.8% for subsequent years. The exchange rate estimates for the midpoint of each calendar year are as follows: Bo 67.2 for 1992; Be 74.5 for 1993; Be 78.9 for 1994; Be 83.8 for 1995; Bs 88.9 for 1996; and Be 94.2 for 1997. Able 5 1s SUMMARY OF PROJECT COSTS BY COMPONENT a/ (US$ million) Foreign Total Component Local Foreign Total Exchange Base Cost A. Endemic Disease Control 54.8 54.4 109.2 49.8 70.5 B. Institutional Strengthening 25 4 203 45.7 44.4 29.5 TOTAL BASE COSTS 80.2 74.7 154.9 48.2 100.0 Physical Contingencies 2.4 2.7 5.1 52.8 3.3 Price Contingencies 2135 6.5 2810 21 18 1 TOTAL 104.1 83.9 188.0 44.6 121.4 a/ net of taxes and duties which are negligible. Notet Exchange rate of Be. 67.2 - US$1.00. 33 TabU1k5.2. SUMMARY OF PROJECT COSTS BY CATEGORY OF EXPBNDITURE (US$ million) Foreign Total Category Local Foreign Total Exchange Base Cost Civil Works 8.9 6.5 15.4 42.0 10.0 Constructlon Materials 15.9 4.1 23.0 31.0 14.9 Equipment 0.5 4.6 5.1 90.0 3.3 Instructional Materials 0.7 0.3 1.0 27.0 0.6 Vehicles 1.1 9.5 10.6 90.0 6.8 Drugs 0.0 7.8 7.8 100.0 5.1 Pesticides 0.0 22.1 22.1 100.0 14.3 Technical Assistance 1.5 1.5 3.0 50.0 1.9 Operational Research a/ 4.4 4.5 8.9 50.0 5.7 Training 1.4 1.5 2.9 52.6 1.9 Project Management 1.7 0.2 1.9 10.0 1.2 Supervision 8.3 0.9 9.2 10.0 5.9 Maintenance Materials 2.0 2.2 4.2 53.0 2.7 Operating Costs 33.8 I6 39.8 15.0 2S.7 TOTAL BASE COSTS 80.2 74.7 154.9 48.2 100.0 Physical contingencies 2.4 2.7 5.1 52.8 3.3 Price contingencies 21. 6.5 280 23.1 1 TOTAL 104.1 83.9 188.0 44.6 121.4 a/ includes support for renovation of laboratories, laboratory equipment and vehicles (see para. 5.9 and Table 5.4) 5.3 Foreion Exchanae Costs. Direct and indirect foreign exchange costs are estimated at about US$83.9 million equivalent, including contingencies. Based on Bank experience with similar projects in the region, the foreign exchange component for the major categories was estimated as follows: (a) civil works, 42%; (b) construction materials, 31%; (c) equipment, 90%; (d) tochnical assistance and operational research, 50%; (a) maintenance, 53%; (f) domestic training, 50% and overseas training, 100%; (g) instructional materials, 27%1 (h) operating costs, 15%; (i) pesticides and drugs, 100%; (j) vehicles, 90%; and (k) supervLison and project management, 10%. B. Financina S.4 The proposed loan of US$94.0 million will finance the equivalent of 100% of the foreign exchange component of the project and about 9% of the local cost. The Bank loan will be made to the Republic of Venezuela which will provide counterpart funds as necessary to complete the project. The loan will be for 15 years including a five-year grace period. Eligible expenditures made after March 9, 1992 and ln accordance with Bank procurement 34 guidelines, up to an amount of US$9.4 million, would be flnanced retroactively. The fLnancing plan anti loan allocations by category of expendlture are pr e-nted in Table 5.3. Z5-l-5S 3 t FINANCING PLAN (US$ million equivalent) Proposed Categorv of Expenditure Governanot I ZTotal JRLD (JI Civil works 9.1 9.0 18.1 50 Construction materials 24.9 4.8 29.7 16 Equipment and instructional materials 0.7 5.9 6.6 90 Vehicles 0.0 10.9 10.9 100 Drugs 0.0 9.1 9.1 100 Pesticides 0.0 25.6 25.6 100 Technlcal assistance and operational research a/ 0.0 14.1 14.1 100 Tralning and project management 0.0 5.7 5.7 100 Supervision and maintenance 8.1 8.9 17.0 52 Operating costs 51± 2 a 0 TOTAL 94.0 94.0 188.0 50 a/ Operational research includes support for renovation of laboratories, laboratory quipment and vehicles (see para. 5.9 and Table 5.4). 5.5 Recurrent Costs. Incremental recurrent costs, including contingencies, are estimated at about US$68.2 million. This total includes some US$17.0 million for supervislon and maintenance (for buildings, equlpment and vehicles) and about US$51.2 mllion in operating costs, which consist mainly of salaries, per dieme, fuel and supplies. About US$8.9 million of the supervislon and maintenance costs would be financed from the Bank loan on a declining basis. The operating costs would be financed entirely from the MBAS budget throughout the life of the project. C. Procurement, 5.6 Civ~LJjWoks. The cost of civil works under the project (about US$18.1 mllion , including contingencLes) would lnvolve construction of: a central headquarters Ln Maracay (two buildings totalling some US$7.0 million), nine (9) regional offLces (at about US$1.1 million per building), expansion of DGSSSA's research center (at about US$0.2 million) and a number of smaller works (totalling US$1.0 million). Contracts for works exceedlng US$3.0 million would be procured through international competitlve bidding (ICB) procedures. otherwise, most other works, would be awarded accordlng to local lThis figure does not include the estimated US$0.3 million for facility renovation under operational research (para. 5.9) 35 competitive bidding (LCB) procedures, acceptable to the Bank, whlch would allow foreign bidders to particlpate, up to an aggregate mount of US$10.1 million. To the extent practicable, the constructlon of regional offlces wl be grouped in packages of US$3.0 million or more. The smaller works (most of which are below US$25,000 and none of which exceed US$100,000), lncludlng three field training bases, 25 operational bases, 6 trainlng centers and 41 rural houses, would be procured by the DaSS8A through force account procedure based on predetermined labor unit costs and competitlve procurement of constructLon materials from a liat of approved suppllers, up to an aggregate amount of US$1.0 million. The MSAS would be responsible for procurlng the civil works and for contracting engineerLng flrms to supervise the constructLon of major civll works. The DGSSSA would use lts own experienced and qualifled engineers, of its Rural HousLng Dlrectorate, to supervLie the smaller works. 5.7 Gogo The total cost of goods (lncludlng construction materials, equipment, instructional materials, and vehicles and excluding chemicals) is estimated at about US$47.2 milllon12, including contingencies. Of thls total, about USS20.1 milllon (construction materials for the rural housing program) would be financed entlrely by the Gov. Of the remaLning goods (aboul US$27.1 million), more than one-half (US$14.4 mllion) would be procured through internatLonal competitive bidding (ICB) procedures in accordance with Dank guidelines and the remainder (US$12.7 millilon) through ICB or local shoppLng procedures satisfactory to the Bank. Contracts in excess of US$200,000, and vehicles, would be awarded on the basis of ICB. Groups of items estimated to cost less than the equivalent of US$200,000 would be procured in accordance with LCB procedures, up to an aggregate amount equivalent to US$1.0 milllon. Items estimated at less than US$25,000, including equipment, instructional materlals and constructlon materials for some 50,000 latrines, would be procured on the basLi of quotations from at least three suppliers. These items would not exceed an aggregate total of US$11.7 million equivalent. 5.8 Chemicals. The total cost of drugs is estimated at about US$9.1 million. Drugs, up to an aggregate amount equivalent to US$8.0 mllion, would be procured through an agent following limited lnternational bldding procedures on the basis of evaluation and comparLson of blds Lnvlted from a list of at least three qualified suppliers. The signing of a services agreement between the MSAS and a procurement agent will be a condition of dlsbursement. Drugs would also be procured from the United Natlons Chlldrens' Fund (UNICEF) ln accordance wlth procedures acceptable to the Bank, up to an aggregate amount equlvalent to US$1.1 mllion. Most of the pestLcLdes (total cost estimated at US$25.6 milLon) would be procured through international competltive bidding (ICB) wlth prequallflcatlon, acceptable to the Bank. The DGSSSA would malntaln a lLst of prequallfled suppliers whlch would be updated yearly, and the time allowed for submLssLon of blds would not exceed 15 days. 12ThLe figure does not Lnclude the estimated US$3.0 mllion for equipment nor the estLmated US$0.5 mllion for vehLcles under operatLonal research (para.5.9). 36 The Bank would only finance the procurement of pesticides Lncluded in an agreed pesticide list. 5.9 Technical Assistance and Onerational Research. The total cost of consultants, inpluding auditors, and studies (operational research) is estimated at US$14.1 million. The selection and appointment of consultants for studios and technical assistance will be in accordance with the August 1981 "Bank Guidelines for the Use of Consultants." Foreign consultants would not be subject to prior registration as a condition of their participation in the selection process. Reglstration would be a pro-condition, not of selectLon, but of contracting of consultants' services. The operational research component would include funding for equipment (principally laboratory equipment), the renovation of laboratories (maximum of US$5,000 per research proposal) and vehicles for field activities. The equipment for operational research projects (estimated at US$3.0 million) would be packaged, as far as possible, in groups of items valued at US$200,000 or more and procured through ICB. Groups of items costing less than the equivalent of US$200,000 (given the specialized and diversified nature of the equipment) would be procured through international shopping (at least three price quotations from at least two countries), not to exceed an aggregate total of US$0.9 million. Basic euipment items in bid packages estimated at less than US$25,000 would be procured on the basis of quotations from at least three suppliers, not to exceed an aggregate total of US$100,000. The contracts for the renovation of facilities (estimated at US$0.3 million) would be awarded on the basis of comparison of price quotations obtained from at least three eligible contractors. The vehicles (estimated at US$0.5 million) would be procured in accordance with LCB procedures acceptable to the Bank. 5.10 Trainino and Pgoiect Management. The costs of traLning and project management are estimated at US$5.7 million. The major expenditures are as follows: (i) training would include fellowships (domestic and international), courses, workshops and seminars, etc *and related travel and per diems; and (Li) project management would Lnclude the costs of managers and technicians on fixed-term contracts for the life of the project. 5.11 Miscellansous Costs. The costs of supervision and maintenance (estimated at US$17.0 million) would cover the travel and per diems of personnel of the Executing Agencies in connection with project supervision, and the maintenance of buildings, equipment and vehicles financed under the project. These costs would be financed by the Bank on a declining basis. The total cost of operating costs (salaries, per diems, fuel and supplies) is estimated at US$51.2 million and would be financed by the GOV. 5.12 Maroin of Preference. For the purpose of compar4ng foreign and local blds under ICB, domestic manufacturers will be allowed a margin of preference equal to the existing rate of customs duty applicable to competing imports or 15% of C.I.F. price at port of entry, whichever is lower. 5.13 Procurement Law. A Country Procurement Assoement Report was completed in June 1990. Subsequently, in August 1990, the GOV issued a Procurement Law which expressly states that all contracts for goods, works, and services which will be totally or partially financed by international 37 organisations wlth thelr own procurement guldelines will be undertaken ln accordance wlth such guldellnes. 5.14 Bank Rvigw Rauiremnts. The Dank would review and approve before contract award all procurement documentatlon for works, goods and pestlildes to be procured through ICB, for goods estLmated to cost more than US$200,000 equlvalent, for drug. estimated to cost more than US$100,000 qulvalent and for the flrst two contracts each project year for procurement of goods under LCD whlch exceed US$100,000 equivalent. Prlor Dank review of procurement documentatlon for contracts for works above US$500,000 equlvalent would also be requlred. Prior Dank revlew of procurement documentatlon would cover about 80% of the total amount of works, goods and chemicals financed by the Dank. For consultants' contracts below US$25,000 equLvalent (except for research projects), the Bank's prlor revLiw would cover only terms of reference. Other contracts and bld evaluatlons would be subject to selectlve post-award revlew by Bank staff. Agreement was reached at negotLatLons that all procurement for goods, works and servlces will be made on the basie of standard blddlng documents, satisfactory to the Bank. 5.15 RelortLno Procurement information wlll be collected and recorded as followes (a) prompt reportlng of contract award informatlon by the lmplementing agencLesu (b) comprehensive semi-annual reports by the borrower, indicating any revision ln cost estimates for indivldual contracts and the total projecti any rev$isons in the timing of procurement actions; and compliance wlth aggregate limlts on specified methods of procurement; and (c) a completion report by the borrower within three months of the closlng date. S.16 The aforementloned procurement arrangements are summarLsed in Table 5.4 belows 38 Table 5.4s Summary of Proposed Procurement Arrangements (US$ million equivalent) Procurement Method Total Project Element ICB LCD Other N.B.F. Cost 1. Works 1.1 Buildixgs 7.0 10.1 1.0 a/ --- 18.1 (3.5) (5.0) (0.5) (9.0) 1.2 Laboratory Renovation 0.3 b/ --- 0.3 (0.3) (0.3) 2. Goods 2.1 Construction Materials -- 9.6 b/ 20.1 29.7 (4.8) (0.0) (4.8) 2.2 Equipment 3.5 1.0 0.9 b/ --- 5.4 (3.2) (0.9) (0.8) (4.9) 2.3 Instructional Materials --- --- 1.2 b/ --- 1.2 (1.0) (1.0) 2.4 Vehicles 10.9 --- --- --- 10.9 (10.9) (10.9) 2.5 Equipment for Op.Rsrch. 2.0 --- 1.0 c/ --- 3.0 (2.0) (1.C' (3.0) 2.6 Vehicles for Op.Rsrch. --- 0.5 --- --- 0.5 (0.5) (0.5) 3. Chemicals 3.1 Drugs --- 9.1 d/ --- 9.1 (9.1) (9.1) 3.2 Pesticides 25.6 e/ --- --- --- 25.6 (25.6) --- (25.6) 4. Consultancies 4.1 Technical Assistance --- --- 3.5 f/ --- 3.5 (3.5) (3.5) 4.2 Operational Research --- --- 6.8 f/ --- 6.8 (6.8) (6.8) 4.3 Training --- --- 3.4 g/ --- 3.4 (3.4) (3.4) 4.4 Project Management --- 2.3 h/ --- 2.3 (2.3) --- (2.3) S. Miscellaneous 5.1 Supervision l.S i/ --- 11.5 (6.0) --- (6.0) 5.2 Maintenance --- --- 5.5 i/ --- 5.5 (2.9) (2.9) 5.3 OperatLng Costs --- --- --- 51.2 51.2 (0.0) (0.0) TOTAL 39.0 11.6 66.1 71.3 188.0 (35.2) (6.4) (52.41 (0.0) (94.0) See footnotes on next page. 39 D. Disbsrsements 5.17 The proposed Bank loan of US$94.0 million would be disbursed over a period of about six yeare (Table 5.5), based on the implementation schedule and a combination of relevant standard IBRD disburement profiles for PHN projects Ln the LAC regLon. The dLsbursmwnt proflle reflects the fact that works, equlpment and vehicles would be procured in the early stages of project implementation and that constructLon materials, drugs and pestLcLdes would be procured throughout project implementation. The Project Completlon Date will be December 31, 1997 and the Project Closing Date will be June 30, 1998. Tablo 5 t DISBURSEWENT FORECAST IBRD Fiscal Disburements Year and Semester Cumula$ve . sema.tkr 1993 2nd (Jan 93-Jun 93) 6.0 6.0 7.0 2 1994 lt (Jul 93-Dec 93) 7.5 13.5 14.0 3 2nd (Jan 94-Jun 94) 10.5 24.0 26.0 4 1995 lt (Jul 94-Doc 94) 10.0 34.0 36.0 5 2nd (Jan 95-Jun 95) 10.0 44.0 47.0 6 1996 1ot (Jul 95-Dec 95) 10.0 54.0 57.0 7 2nd (Jan 96-Jun 96) 9.0 63.0 67.0 8 1997 lt (Jul 96-Doc 96) 9.0 72.0 77.0 9 2nd (Jan 97-Jun 97) 8.0 80.0 85.0 10 1998 1ot (Jul 97-Dec 97) 7.5 87.5 93.0 11 2nd (Jan 98-Jun 98) 6.5 94.0 100.0 12 Clocing Date: June 30, 1998 Notes to Table 5.4: Totats represent total estimted costs per category including prfec ad physical contingencies. Nuers between brackets reflect Bank financing. N.1.F.: Not lank-Financed. Op. Rsrch.: Operat1onal Rearch a/ force account; b/ Local shopping on the bests of quotations from at least three suppLfers or contractors; c/ International shopping on the basis of quotations frm at least three suppiters frm at Leat two couttrfes, up to USS0.9 millon; locat shopping per bl, up to USS0.1 ftilion.; dV tlmited International bidding, up to USS8.0 mlion; direct purchase, up to U11.1 miLlion; .s ICc with prAlfficatfon, accptble to the lank; fi contractin of consultants, studies and auditors In accordeance ith nk guidelines (Augst 1981); gf reafmursement of expnditures for training including travel and per diems; hi refabursmnt of project managers nd technician urder fixed-term contracts; f/ retaburent of expnditures on a declining basis. 40 5.18 The proceeds of the IDRD loan will be disbursed as followst - Civil workes bulldlngs, 50% of total expendltures, renovatlon of laboratorles, 100% of total expenditures; - Goods (excludLng constructLon materials, vehiLles and chemLcals), 100% of C.I.F. cost of forelgn expendLtures; 100% of ex-factory costs of locally manufactured goods; and 90% of local expendlture for other items procured locally; - Construction materials (excluding constructLon materials for rura housing improvements), 50% of total expenditures; - Vehicles, 100% of C.I.F. cost of forelgn expendLtures; 100% of ex factory costs of locally manufactured goods; and 90% of local expendltures; - Chemlcals (Drugs and PesticLdes), 100% of C.I.F cost of forelgn expenditures; 100% of ex-factory costs of locally manufactured goodsl and 90% of local expendltures; - Consultants servlces (operatLonal research, technlcal assistance tralnlng and project management), 100% of total expenditures; and - Supervision and maintenance, 60% untll the amount diebureed under thLs category shall have reached the aggregate of US$6.0 mllion and 40% thereafter. 5.19 Documentation of 3xwendLtures. Wlthdrawal applicatlons for the following would be supported by full documentation: (a) works with a contraci value of US$500,000 or more; (b) goods wlth a contract value of US$200,000 or more; (c) the fLrst two contracts each project year for goods procured under LCB with a contract value of US$100,000 or more; (d) vehlcles and pestlcides- regardless of value; (e) drugs with a contract value of US$100,000 or more; (f) consultants services wlth a contract value of US$25,000 or more; and (g) all research projects. Contracts valued at below the aforementloned limits and other disbursements againet actlvltLes not undertaken by contract would be made on the basLi of Statements of Expendlture (SOB), for which supportlng documents would be malntalned by DGSSSA and IB and would be made avallable for Bank staff review. Selectlve revlew of SOB documentation, coverLng at leart 20% of contracts dLsbursed under these procedures, would be undertaken by visLtLng Bank mssLons. 5.20 As condltlons of dLsbursement: (l) no wlthdrawals shall be made for expendLtures under the project unless the expenditures are included in an annual action plan approved by the Bank; (ii) no withdrawals shall be made for expendltures for pestLcLdes unless they are lncluded ln an agreed pesticide llet; and (lll) no wlthdrawals shall be made for expenditures for drugs unless a procurement servlc-e agreement, acceptable to the Bank, has been elgned with a procurement agent (para. 7.2). Z. Accounts and Audits 5.21 A Special Account ln US dollars would be opened at the Central Bank, with an Lnltial deposit of US$6.0 million equivalent. In addition, the executLng agencies of NSAS (DGSSSA and ID) will keep separate project accounts 41 for project expendLtures in accordance with internationally accepted accountLng procedures. The accounts would show exp nditures for each project component, subdlvlded by expenditures flnanced by the Bank and the GOV. 5.22 All project accounts, the Speclal Account and all dLsbursements agaLnst 80S3 would be audlted annually by an lndopendent auditor acceptable to the Bank ln accordance wLth the Bank's audltLng guldelines. The executlng agencies would submlt to the Bank the audlt roports of expendltures within olx months of the closure of each fLsocal year. The audlt reports would certify that funds were used for the purposes for which they were provided. Assurances were obtalned at negotiations that the executing agencles will follow Bank rules in auditlng of project accounts and procurement and submLt audits wlthln six months of the end of each fiscal year (para. 7.2c). 42 VI. PROJECT BEEFITS AND RISKS A. Environmental Imgact 6.1 Although the project will use DDT and other peuticides for vector control operations, no negative environmental impact is foreseen. The Bank supports the banning of DDT for agricultural use. However, DDT remains the pesticide of choice recommunded by the World Health Organization for malaria control. In public health campaigns, DDT is sprayed only on interior walls of houses and only where the mosquito vector has shown no resistance to it. Used in this way, no serious impact on surrounding flora and fauna has been observed. Under the project, DDT will not be used for fogging or aerial spraying. other pesticides such as pyrethroids, which are commonly used in agriculture, will be used when chemical measures are applied out of doors. Malaria transmission in Venezuela, and thus the use of DDT for its control, is largely concentrated in a few Eocal areas, specifically, gold and diamond mining camps, new agricultural settlements, and some urban peripheries. Venezuela, and other countries, are nonetheless exploring alternative pesticides for use in these indispensable public health campaigns. 6.2 Procedures to assure the safe management of pesticides, including regular testing of spraymen, have long been in place as an integral part of DGSSSA disease control programs. The project will further strengthen DGSSSA efforts to provide adequate environmental and worker safeguards through the support of continuous training of spraymen in the appropriate and safe use of pesticides. Assurances were obtained at negotiations that the Government will follow standards and procedures for the selection and use of pesticides under the project which are consistent with WHO standards and procedures and, taking into account the results of comprehensive studies,. discuss and agree with the Dank on any changes in such standards and procedures (para. 7.1f). B. Proiect Benefitg 6.3 The principal beneficiaries of this project will be low income populations in rural and peri-urban areas throughout Venezuela where endemic diseases are an important cause of morbidity and the threat of their further spread is high. These populations will benefit directly through decreased risk of disease and improved health status, and indirectly through improved productivity. Reducing malaria, in particular, has a positive economic impact in agricultural areas where peak malaria transmission tends to coincide with peak labor demand. In addition, school-age children will benefit from reduced incidence of intestinal parasites which can have an important impact on learning. The benefits of controlling diseases which have the potential for rapid dispersion, especially malaria, dengue and cholera, are especially great (the externalities are high). Early intervention to halt major epidemics is much less costly than attempting to reduce disease transmission that is already widespread. The impact of the project will be gender neutral. In addition, the institutions responsible for endemic disease control will benefit from improved management and technical capacity. In particular, the project will help the ID and DGSSSA to improve the design and evaluation of control strategies and the cost-effectiveness of disease control interventions. Finally, the project will begin to reverse the decline in 43 *ndemlc dLiease control financing am part of a wider commitment by the Government to support a shift ln spendlng away from curatlve, hospLtal-based care and towards preventlve health actLon.. C. Risks 6.4 Labor strLkes due to delays in payment of M8AS flild workors pose a *lgnlficant rlsk to project Lmplmentatlon. In 1990 and 1991, DGSSSA operatlons were sorLously lpaired by such strlkes. successful and sustalnablo dLsease control depends on the timely and conasitent application of approprlate control measuresp work stoppages reduce the impact of control programs and have partLcularly affacted malaria control. MOAB official. view the problem as a consequene of LnouffLiLent control over existing funds for payment of workers (under the "Laborers' Collectlve Contract"). The situatlor would likely Lmprove lf the executing agencies had greater control of the resources budgeted for the Laborers" Collectlve Contract. Assurances were obtained at negotlatlons that the Government will maintaLn a mechanism, satLsfactory to the Bank, provLding for the management by DGWSSA of all funds for payment of DOSSWA's field workers (para. 7.1j). 6.5 There are also rlsks of delays ln project implementatlon due to the Dorrowers lack of experience wlth Bank-financed projects. The project launch seminar la therefore of special lmportance to adequately prepare all of the LnstitutLons Lnvolved with regard to Bank procedures. 6.6 The sustainabilLty of adequate flnancing for endemle dieease control programs beyond the llfe of the project Ls also a concern, given the fact that theme important programs have suffered a serious doeline in fLnaneLng over the last decade. However, the Government clearly recognizes that thli project helps to bring severely underfinanced programs back to an adequate level of funding and that adequate levels of fundlng must be maintaLned in order to maLntaLn gains achioved. The Government also recognizes that maLntainLng adequate spending on endemic disease control is part of an important and necessary shift in resource allocation in the health sector away from ouratlve care and towards wore cost-effective preventive health actlons. In addltlon, project sustainabllity is strengthened by the f .-t that more than 85% of incremental recurrent costs will be financed by the Government. Also, the number of new personnel supported by the project is small and, with the exceptlon of project management, salaries will be financed entirely out of counterpart funds (furthermore, hiring of new personnel is thlnly spread among the 28 states, oach of which will create three or four new pouLtLons to support expanded IB programs). Lastly, the future costs of disease control will declne to the extent thatt (i) the project investments successfully reduce dliease transmission; and (Li) the project helps develop more cost-effectlve interventions through improved understanding of disease situations and strategli optlons. 44 VIZ. wARzMzzENTaEDHzAN MECOMMEBDAT.IQA AgCoem2nts Reacihad 7.1 At negotiation., assurances were obtained that the Borrower will: (a) by March 1 of each year (i) submit a report to the Bank, for its review and comments, on progress in implementation of all project components and any proposals for adjustments in project implementation; and (Li) submit to the Bank, for its review and approval, a proposed annual investment program providing for the activities, implementation schedule and targets, and proposed project budget for the then upcoming year, based on the implementation schedule in Annex 5 (para. 4.37); (b) participate in annual reviews (by March 30 of each year), jointly with the Bank, focusing ons (i) evaluation of progress in project execution and achievement of projnct objectives, based on the implementation schedule and agreed monitoring indicators (see Annexes 5 and 6)t (ii) review of proposed annual budgets for the project and for endemic disease control programs for the subsequent year; (iii) any changes in project design and implementation that may be necessary (including the possible effects of decentralization in the health sector); and (iv) the mechanism providing for the management by DGSSSA of all funds for payment of DG8SSA's field workers. Upon the Bank's recommendation, any required adjustments would be made in project implementation in order to attain the agreed objectives (para. 4.35); (c) follow Bank rules in auditing of project accounts and procurement and submit audits within six months of the end of each fiscal year (para. 5.22)t (d) implement the operational research subcomponent in accordance with the Operational Research Regulations (para. 4.36); (e) maintain the Project Implementation Units, Project Steering Committee, Procurement Committee and Research Steering Committee throughout the execution of the project (para. 4.34); (f) follow standards and procedures for the selection and use of pesticides under the project which are consistent with WHO standards and procedures and, taking into account the results of comprehensive studies, discuss and agree with the Bank on any changes in such standards and procedures (para. 6.2); (g) through the DGSSSAt (i) carry out a management study, not later than March 31, 1993, to review the organization and management structure of DGSSSA and make recommendations to improve such structure; (ii) not later than June 30, 1993, based on the management study and the Bank's comments thereon, present an action plan, satisfactory to the 45 Bank; and (iii) thereafter implement such action plan in a manner under a timetable satisfactory to the Bank (para 4.23), (h) carry out studies, not later than March 1, 1993, to develop appropriate indLcators of the lmpact of institutLonal development actf.vLtLes supported under the project (paras. 4.23 and 4.30); (i) ln respect of endemlc dLsease control programs: (i) durlng the lasi quarter of each flcal year, exchange vlews wlth the Bank, through the executlng agencLes, on budgetary needs; (LL) ln each fiscal yea furnLih evldence oatisfactory to the Bank showing that the final proposed NBAS budget Lncludes adequate allocatlons ln the opLnion c the Bank, not later than 15 days after the MLnLitry of Flnance has received the respectlve flnal proposed budget of MSAS8 (ii1) not later than May 31 ln each fiscal year, furnieh evldence satLsfactox to the Bank of the flnal proposed budget for endemlc dieease contrc programs for the then following fiscal year, submltted by the Borrower's Executlve Branch to the Borrower's Congress; and (Lv) nc later than March I ln each fLical year, furnlsh evidence satlsfactc to the Bank showlng the amount of expenditures incurred for endemlc dLsease control programs ln the then prevLous flscal year (para. 4.38); and (j) malntaln a mechanism, satLsfactory to the Bank, provLding for the management by DGSSSA of all funds for payment of DGSSSA's fleld workers (para 6.4). 7.2 As conditions of disbursements (L) no withdrawals shall be made for expenditures under the project unless the expenditures are lncluded in an annual actlon plan approved by the Bank; (ii) no withdrawals shall be made for expenditures for pestlcldes unless they are lncluded ln an agreed postlcide list; and (LLL) no wlthdrawals shall be made for expendltures for drugs unless a procurement servlces agreement, acceptable to the Bank, has been signed with a procurement agent (para. 5.20). Recommendatlon 7.3 Subject to the above condLtLons, the proposed project would constltute a sultable basis for a Bank loan of US$94.0 million equivalent to the Government of Venezuela, repayable in 15 years, lncluding a five-year grace period, at the Bank's standard variable lnterest rate. ~~- -' ' ~ ~~~~~~~~ Venezuela'> ' Endmic Disease control Project Project Coapanents by Tear lass Costs total ,.................................. .............................................-.---... 1993 19N1994 99 1996 199T IS Us A. Disease Control 1. serlena Centrol 642853.2 410253.2 410253.2 410253.2 410253.2 22836".0 33986.1 2. Dengue Control 369565.2 190845.2 190455.2 190455.2 190455.2 1151776.0 17139.5 3. Chagas Control 8936.2 41734.2 41344.2 41344.2 41344.2 255303.G 3799.2 4. NIVICA Rural House Iwprov 2S3004.0 249012.0 249012.0 249012.0 249012.0 124902.0 18587.1 5. Schistosomiass control 64273.7 44713.7 44115.7 43516.7 42990.3 239610.1 3S65.6 6. Intestinal Par'ptes 100908.0 65440.0 65440.0 65440.0 6S440.0 36246.0 5396.6 7. Yellow fever 38993.2 28977.2 28977.2 28917.2 28977.2 1S4902.0 2305.1 8. Cholera 22S370.8 108161.2 108161.2 108161.2 108161.2 65501S.7 9791.9 9. Other Netaxenic Diseases 24533.6 9861.6 9861.6 9861.6 9861.6 63980.0 952.1 10. Lelshm_niasis Control 41855.6 2811S.6 28175.6 4S307.2 31627.2 175141.2 2606.3 11. Leprosy Centrol 78S47.0 22894.2 22894.2 30946.2 1601.2 171299.9 2549.1 12. Onchocerclasis Centrol 40559.9 23373.2 23373.2 42662.0 26022.0 1519.3 2351.0 13. Leish/locho Entemlogy S345.0 2744.7 2744.7 5604.7 3108.7 19S48.0 290.9 14. 8S-Info, Edhc* Comm. 46627.6 37797.9 3U97.9 43432.7 38480.7 204345.2 3040.9 15. DCSSSA - Info.Eehc,tCe. 71936.4 30168.4 30168.4 30168.4 30168.4 192610.0 2566.2 ................ ...................................................................... Sub-total 2114109.6 1294152.4 1292774.4 1345142.6 1293926.3 7340107.3 109227.8 B. Institutional Development 1. OGSSSA - Trafning 91277.0 53223.0 53223.0 53223.0 53223.0 304169.0 4526.3 2. DGSSSA- Str.fgmt. 14700.0 14700.0 14700.0 14700.0 14700.0 73500.0 1093.7 3. DGSSSA Information System 120284.2 11512.0 11512.0 11S12.0 11512.0 166332.2 2475.2 4. DGSSSA Operation Research 73330.1 73330.1 73330.1 73330.1 73330.1 366650.5 5456.1 5. DCSSSA Infrastructure 445630.6 477172.2 . 489850.6 11M0.o 119050.0 1650753.4 24564.8 6. IS-TraIning 15070.0 11870.0 6938.0 1098.0 1098.0 36074.0 536.8 7. le- Strengthening Nmt. 7996.0 7996.0 7996.0 7996.0 7996.0 39980.0 594.9 8. 18-Operational Research 46000.1 46000.1 46000.1 46000.1 46000.1 230000.4 3422 6 9. 1-Infrastrutnure 26472.0 4403.2 S96.8 596.8 596.8 34665.6 515.9 10. ls6informtlon System 4227S.0 36810.3 29310.3 29310.3 29310.3 167016.0 2485.4 Sub-total 68034.9 737016.8 733456.8 356816.2 356816.2 3069141.1 45671.7 Total DASEIlNE COSTS 2999144.5 2031169.3 2026231.3 1701956.9 16so744.6 10409248.5 is4899.5 Physical contingencies 87447.1 72555.0 72863.2 555s5.5 55630.8 344047.6 5119.8 Price Contingencies 395276.7 666913.7 1065500.1 1226741.5 1578047.6 4932484.7 27986.9 Total PROJECT COSTS 3481868.3 270642.9 3164594.5 2984251.9 3284423.0 15685780.7 18006.1 eo Taxes 0.0 0.0 0.0 0.0 0.0 0.0 0.0 - foreign Exchag 2035323.6 1155256.0 1264628.2 1207436.2 1250122.1 6912966.1 839.1 t Values Scaled by 1000.0 6/17T1/ 15:17 Venezuela Endbmic Dise a Control Project Projects CaWponents bV ear Totals Including Contingencles I ~~~~~~~~~~......................................................................... 1993 1994 1995 1996 1997 lotal A. Olsease Control 1. alosriaControl 10065.2 6981.1 7367.0 7 .0 8195.2 40407U. 2. Dengug Control S989.2 3293.0 3S69.1 3831.3 4114.3 20796.9 3. Chgas Control 1385.0 709.1 745.2 786.) 829.6 4454.9 4. NIVICA Rural _owse 4prov 3984.7 4402.4 4781.8 5133.7. S513.4 23616.0 S. Schisto soiulos Control 1004.2 767.3 807.2 843.9 884.4 4307.1 6. Intestinra Parasitos 1576.3 1129.4 1207.7 1211.9 1361.3 6SS6.6 7. Yellow fevr 607.8 493.7 S25.3 SSS. S58.? 2769.8 B. holerx . 3493.7 1916.2 2095.9 2261.5 2440.7 12206.0 9. Other netaxenle Is as 383.3 16S.2 in.2 181.1 139.S 1092.3 10. Iels isam.is Control 643.8 48S.6 524.7 878.3 618.9 3203.3 11. Ieprsy Control 1226.2 404.4 442.4 S87.9 35S.9 3016.7 12. (Mdeeerlais Ccntrol 619.S 405.8 443.8 829.7 622.2 291.0 13. idshandwho Entooologr 82.7 49.4 S4.1 109.2 71.4 366.9 14. 1lU*nfo. Edu. Com 716.3 6S4.0 714.8 67.6 646.9 3302.6 1S. OCSSS*- Info*EidactCom. 1106.6 S26.3 s5.8 617.7 465.1 3489.4 ..........:...........i....................................... ........w.... Su-rTotal 32814.4 23.0 24046.0 26539.5 2735 I.2 133209.1 *. InstitutloFt l Ovel k n 1. In SSSi - tra ning 1394.7 902.4 97S.6 1044.2 1117.8 5434.9 2. DGSSSA Str."gSt. 222.4 246.? 266.4 284.7 304.4 1324.6 3. DGSSSA Informatlon System 1909.7 195.6 210.3 224.0 238.0 2778.3 4. DGSSSA operation Research 1109.9 1216.9 1304.9 1357.8 1476b 6496.2 S. OCSSSA Infrastructure 7056.3 8366.9 9270.1 2440.6 2614.5 29748.0 6. 1I-Tralhing 228.7 195.1 119.9 20.9 22.1 586.8 3. IB- Strkigthening Ngt. 121.2 137.9 150.9 162.9 175. 748.8 8. lB-Operational Research 696.3 763.4 816.5 870.6 926.3 4075.1 9. 1I-infrastructure 449.9 7.2 11.1 11.8 12.5 562.6 10. I0-InformatIon Systems 663.1 630.7 544.8 581.8 621.S 3041.8 Sub-Total 13852.1 12732.9 13672.6 7029.2 7510.2 S4797.1 ............ .................................................. ............................... ,, IV> Totsi PROJECTS COSTS 46736.5 35115.9 3718.6 33568.6 34866.s 188006.1o ........................................................................ ;...............................................................................w Values Scaled by 1000.0 6/17/19P 15t. 0 48 ANNX 1 Page 3 of 3 * t~~~~Vnzuela Endmic Disese Control Project Susry Accomts by rear Totals Including Contingencies I ~~~~~~~~........................................................................ 1993 1994 1995 1996 1997 Total I. INVESTMENT COSTS .................... A. Civil Norks 5414.1 6056.0 6660.3 0.0 0.0 10132.4 B. Construct.Hater.Outhsumes 1587.9 1m.? 1925.3 2064.3 2214.2 9567.4 C. NIVICA Construc.ejteriats 3334.5 3726.9 4043.1 4335.1 4649.9 20091.5 D. 7quf punt 5210.? 205.1 0.0 0.0 0.0 5415.8 0 Vehicles 9996.2 2J 0.0 917.6 0.0 10913.7 F OrIns 1682.5 1751.4 181S.3 1873.6 1935.0 9057.7 0 Pesticide 4737.5 4922.3 511.7 5306.0 5507.6 25585.0 I. Technical Assistane 650.8 830.4 869.6 451.7 480.7 348U.3 I Operatfonal Re eorch 1806.2 1980.3 2123.4 2258.4 2403.0 10571.3 J Training 751.9 715.1 677.7 614.3 653.7 3412.7 K. Instruct1a:nl Natw-fls 199.7 224.3 243.7 261.7T. 281.2 1210.6 L. Project Management 375.0 428.4 470.0 508.1 549.5 2330.9 ................................................................. Total IMNESTMENT COSTS 35946.8 22619.8 23940.0 18590.7 18674.8 1197M7.2 It. RECURRENT COSTS ................... A. Supervision 1859.3 2124.2 2330.2 2519.5 2724.5 11557.7 B. Maintenance 124.9 1054.6 1235.5 145S.1 1590.6 5480.7 C. Operating Costs 8805.5 9317.2 10193.0 11003.3 11876.6 51195.5 ........................................................................ Total RECURRENT COSTS 10789.7 12496.0 13778.7 14977.9 16191.7 68234.0 TotaL PROJECT COSTS 46736.5 3511S .9 37718.6 33566.6 34866.5 18006.1 ........................................................................................................ . ausSae y10. /7I 51 49 Page 1 of 1 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT FINANCING PLAN BY YEAR Total Including Contingencies US$ millions I1993 1994 1995 1996 ? ITOTAL INVESTMENT COSTS IBD -28.6 1 14.9 15.6 3.2 12.9 6 8.1 GOVERNMENT 7.4 7.7 ? 8.4 6.4 6.8 34.7 ___ITAL 35.9 22.6 24.0 lq16 j 18.7 _________ _1A RECURRENT COSTS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ IBRD 1.2 1.9 2.2 1.9 1 1.? C .9 GOVERNMENT 9.6 1 10.6 11.6 13.0 14.6 69.3 'TOTAL 10.8 12.5 13.6 14.9 1.2 .2 TOTAL PROJECT COSTS IBRD 29.7 16.8 17.8 16.1 14.0 94.0 GOVERNMENT 17.0 18.3 20.0 16.4 20.3 94.0 TOTAL 40.7 35.1 37.8 33.6 34.9 166-i Note: The Inflation rates used in the calculation of projoct costs were: 1992 - 67.2; 1993 - 74.5; 1994 - 78.9; 1995 - 83.9; 1996 - 88.9; 1997 - 94.2; 1998 - 99.8. The Financing Plan for 1993 - 1998 which was Included in the text of the Public Credit Law was as followst 1993 1994 1995 1996 1997 1998 Total World Bank 28 16 16 14 13 7 94 GovernMent 16 17 18 18 18 7 94 Total 44 33 34 32 31 14 166 so ANNls Page 1 of 2 ENDEMIC DISEASE CONTROL PROJECT DXS3URSMNM CATEGo-RIES AND PERCENTAOES (Us$ millions) Disbursement Cateaorr Amount Percentage 1. Civil Works 8.3 (a) Laboratory Renovation 0.3 100% of total expenditures for operational research (b) Other civil works 8.0 50% of total expenditures 2. goods 8.5 100% of C.I.F. cost of foreig expenditures; 100% of ex-fact (a) goods for operational 2.8 costs of locally manufactured research goods; and 90% of local expenditures for other (b) Other goods 5.7 items procured locally 3. Construction Materials 4.5 50% of total expendltures 4. Vehicles 11.0 100% of C.!.1. cost of foreig expenditures; 100% of (a) Vehicles for operational 0.4 ex-factory costs of research locally manufacturod goods; and 90% of local expenditures (b) Other vehicles 10.6 5. Drugs and Pesticides 32.0 100% of C.!.?. cost of foreigp expenditures; 100% of ex-factA costs of locally manufactured goods; and 90% of local expenditures 6. Consultants' Services 14.5 100% of total expenditures (a) Operational research 6.5 (b) Other technical 8.0 assistance including training and services under the Procurement Services Agreement 51 Page 2 of 2 Disbursement C^tS9W=y Amount Percentage 7. Supervision and Maintenance 8.2 60% until the amount of the loan proceeds disbursed under this category shall have reached the aggregate of US$6.0 million and 40% thereafter. S. Unallocated 7 0 Total 94.0 52 Page 1 o ENDEMIC DISEASE CONTROL PROJECT PROCUREMENT METHODS AND PRIOR REVIEW THRESHOLDS (Us$ '000) TYPE OF PRIOR REVIEW CONTRACT AGGRCG2 CATEGORY PBOCVReMN THRESHOLD VALU Linzl Civil Works ICa >500 >3000 V.A. LCB >500 <3000 10100 Force Account N.A. (100 1000 Local Shopping N.A, < 25 300 a/ Goods ICa >200 >200 V.A. LCB >100 <200 1500 b/ Local Shopping N.A* < 25 11800 c/ International Shopping N.A. <200 900 d/ Drugs LID >100 >200 8000 Direct Purchase >100 N.A. 1100 Pesticides ICB e/ >200 >200 V.A. Consultants' Services --- > 25 > 25 NVA. V.A.: Not applicable. a/Renovation of facilities under operational research component. b/Includes US$500,000 for vehicles under operational research component. c/Includes US5100,000 for basic equipment under operational research component. d/Laboratory equipment under operational research component. */ICB with prequalification. 53 ANNZX5 Page 1 of 8 ENDEMIC DISEASE CONTROL PROJECT 1XP-LEMGNATSON SCHtDULE DOSSA Disease Control C@gmonent tPart A.1 - A.41 Annual Targets (0O0s) Activity 1993 1994 1995 1996 1997 Total UALARIA (Part A.1A Rouses to visit 2900.0 2755.0 2617.2 2486.3 2362.0 13120.7 Houses to spray 650.0 618.0 587.0 558.0 530.0 2943.0 Houses to fog 3600.0 2850.0 2710.0 2575.0 2450.0 13585.0 Malaria treatments to positive cases 30.0 24.0 19.0 15.0 12.0 100.0 Preventive malaria treatments 120.0 96.0 77.0 61.0 49.0 403.0 Blood slides examined 270.0 300.0 285.0 270.0 257.0 1382.0 DENGUE (Part A.21 Rouses to visit 160.0 130.0 125.0 120.0 120.0 655.0 Houses to spray 800.0 750.0 720.0 715.0 715.0 3700.0 Rouses to fog 1500.0 1250.0 1200.0 1150.0 1100.0 6200.0 CAGAS (Part A.31 House to visit 132.0 130.0 125.0 120.0 115.0 622.0 Houses to spray 35.4 33.6 31.9 30.3 28.8 160.1 CIBSTOSOMIASIX (Part A.41 Schistosomiasis treatments 1.0 1.5 2.0 2.5 3.0 10.0 Inspections of water courses (meters) 10000.0 12000.0 13000.0 14000.0 15000.0 64000.0 Nollusciciding (meters) 1000.0 900.0 800.0 750.0 -700.0 4150.0 Charlas Sanitarias 2.5 2.8 3.1 3.5 4.0 15.9 54 ANNS 5 Page 2 of 8 ENpENIC DISEASE CONTROL PROJECT IMPLWRMI=TTION SCHEDULE DOS_SA Disease Control Comnonent (Part A.S - A.8 and A.12bi Annual Taraots (000O'* Activity 1993 1994 1995 1996 1997 Total INTESTINAL PARASITS iyMart P.51 Rouses to visit 120.0 120.0 120.0 120.0 120.0 600.0 Latrine, to build 10.0 10.0 10.0 10.0 10.0 50.0 Latrine inspectLons 36.1 36.1 36.1 36.1 36.1 180.5 Cbarlas Sanltarias 11.2 11.2 11.2 11.2 11.2 56.0 Antibelminthic treatments 5000.0 5000.0 5000.0 5000.0 5000.0 25000.0 YELLW FEE MM OTR DIBEASES (Part A.6 and A.81 Houses to spray 35.0 40.0 32.0 30.0 25.0 162.0 Houses to fog 900.0 910.0 900.0 900.0 950.0 4610.0 Yellow Fever VaccLnes to administer 800.0 800.0 800.0 800.0 800.0 4000.0 CHOLERA (Part A.71 Aqueduct inspections 29.0 29.0 29.0 29.0 29.0 145.0 Residual water treatment inspections 1.9 1.9 1.9 1.9 1.9 9.5 Solid waste inspections and disposal 1.4 1.4 1.4 1.4 1.4 7.0 Recreational water inspections 2.5 2.5 2.5 2.5 2.5 12.5 ChemLcal-Bacteriological examinations 4.5 4.5 4.5 4.5 4.5 22.5 Chlorine treatments (kgs) 135.0 135.0 135.0 135.0 135.0 675.0 WOSSSA Information. Education. Communication (Part A.12a) Household visits made 50.0 60.0 72.0 86.4 103.0 372.0 Comunlty meetings held 1.0 1.2 1.4 1.7 2.0 7.4 County aeetings held 1.0 .9 .8 .7 .6 4.0 speeches given 1.3 1.5 1.9 2.2 2.7 9.8 Wovies shown 1.4 1.6 2.0 2.4 2.9 10.4 55 ANNEX S Page 3 a VENEZ,UELA ENDEMIC DISEASE CONTROL PROJECT INPLEMENTATION SCHEDUIE IB Disease Control Comionent IParts A.9. A.10. and A.12b1 Annual Taroets Activity 1993 1994 1995 1996 1997 Tota LEPROSY (Part A.91 Multidrug Treatments a/ 704 1196 912 812 827 44! Supervision Visits central to regional 46 46 46 46 46 2 regional to local 64 82 70 84 66 31 IMISMHANIASIS (Part A.101 Glucantime Treatments 520 480 420 400 400 22S Asfotericin B Treatments 50 50 40 40 35 2] Immunotherapy Treatments 4500 4500 4500 4500 4500 225C Supervision Visits central to regional 46 46 46 46 46 23 regional to local 64 82 70 84 66 35 gNCHOCERCIASIS (Part A.1l) Visits to villages b/ 752 1652 1652 1652 1652 73 Diagnostic Tests 16000 16000 1600 1600 1600 368 Iversectin Treatments 20300 31200 31200 31200 31200 1450 IS INFORMATION, EDUCATION. -OMMUNICAT_ONS (IEC! (Part A.12b) Specialists to Hirs:c/ sociologists 4 Social Promoters 60 6 Educators 2 Supervision Visits: central to regional 40 40 40 40 40 201 regional to local 100 100 100 100 100 501 aY Multidrug treatment MNIDT) is a two-year drug therapy course; the expected number of new patients to begi MDT in eah pwqeet year is: 704 In 1993,492 in 1994,420 in 1995,392 in 1996, and 435 i 1997. b A tol of 1,652 vilages wil be visited and surveyed. Village visits, diagnostc testing through sikda-ips, and ivemei treat-ent wil begi In 93 in the states of Sucre, Amnoategui and Monagen. 'Me sane activities wvi begin in 1994 In the sates of Arag, Cojedes, Guarko, Carabobo, Falcon and Yaracuy. Ivenuectin treatments must be adminisered yearly for a perod of about 12 to 14 yeas. c/ These are expected to be hired an a pernanent basis during the first year of the project and will be paid out of counterpart projed funds. 56 Page 4 of 8 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT XMPLEMENTATION SCHEDULE Institutional Develooment Comoonent DOSSSA and la Training Suboomoonents (Part B.la and 8.2al Annual Targets Activity 1993 1994 1995 1996 1997 Total DOSSOA Trainina (Part B.1a) Management Training (number of students) 3 3 3 3 0 12 Foreign Fellowships (number of students) 2 2 2 2 0 8 Domestic Fellowships (number of students) 4 4 4 4 4 20 Entomology Course (number of courses) 1 1 1 1 1 5 Consultants to hire (months) 2 2 2 2 2 10 DGSSSA In-Service Training (Part B.1a) Continuing Education (number of courses) 35 35 35 35 35 175 Professional Specialization (number of courses) 2 2 2 2 2 10 Masters Level (number of courses) 2 2 2 2 2 10 Technical Specialization (number of courses) 3 3 3 3 3 15 Actualization Courses (number of courses) 20 20 20 20 20 100 ID Trainina (Part B.2a) Physicians' Course (student months) 33 33 66 Health Auxiliary Course (student months) 600 400 200 1200 Health Promoter Course (student months) 100 100 200 Foreign Fellowships (number of students) 1 1 1 3 57 Page 5 of 8 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT IMPLEMENTATION SCHEDULE Institutional DeveloRment Comoonent DaSS8A and IS Information Systemg subcomponents (Part B.lc and 8.2b% Annual Taraets Activity 1993 1994 1995 1996 1997 Total DOSSSgA Information Systems (Part B.1c) DGSSSA Information Systems Training (number of courses) 20 20 20 20 20 100 DGSSSA Info Systems Consultants to hire (consultant months)* 8 8 8 8 8 40 DGSSA Purchase and installation of equipment (% completed) 100% 100% 1B Information Systems (Part a.2b)- ID Information Systems Training (number of students) 30 30 30 30 30 150 IS Info Systems Consultants to hire (consultant months)* 4 4 4 4 4 20 IB Purchase and installation of equipment (% completed) 50% 100% 100% …___________________________ *based on approximate cost of US$10,000 per consultant month. 58 Page 6 of a ENDEMIC D18EASE CONTROL PROJECT IMPLEMENTATION SCHEDULE Institutional Develooment Component DWSSSA and lB Administration and Magagement Subcomponents (Part B.lb and B.20 Annual Targets Activity 1993 1994 1995 1996 1997 Total DWSSSA Admilnstration and Magaaement (Part a.1b) DGSSSA Management study (% completed) 100% 100% DGSSSA Plan to Implement Management Study Recommendations (% completed) 100% 100% DGSSSA Management Consultants to hire (consultant months) 14 14 14 14 14 70 XI Administration and Manaaement (Varft B 29L IS Management Course* for Central Level Managers (number of students) 2 2 2 2 2 10 IB Management Course for Regional Level Managers (number of students) 5 5 5 5 5 25 59 ANNEX 5 Page 7 of 8 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT 1MPLEMENTATION SCEEDULE Institutional Development Comgonent W S8SA and IB Infrastructure subcomponents -Part B.le and B.2e) Annual Targets Activity 1993 1994 1995 1996 1997 Total DOSSSA Infrastructure (Part B.Ie) DWSSSA Central Headquarters in Maracay (% completed) 33% 66% 100% 100% EZSA Research Center Expansion (% completed) 100l 100% DGSSSA Information Systems Installations (% completed) 100% 100% Latrines for Intestinal Parasite Control Program (see Part A.5) (number of latrines) 10000 10000 10000 10000 10000 50000 DGSSSA Regional Headquarters (number of headquarters) 3 3 3 9 DGSSSA Operational Bases (number of bases) 7 8 10 25 DGSSSA Field Training Bases (number of bases) 3 3 In Infrastructure (Part B2.e) IB Operational Bases (number of bases) 26 15 41 IS Training Centers (number of centers) 5 5 60 Page 8 of 8 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT IMPLEMENTATION SCHEDULE YEARLY TARGETS BY CATEGORY OF EXPENDITURE (percent of costs in category) PROJECT YEAR AND TARGET CATEGORY 1993 1994 1995 1996 1997 Civil Works 33 33 34 0 0 Latrine Construction 20 20 20 20 20 Housing Improvements 20 20 20 20 20 Vehicles 92 0 0 8 0 Equipment 96 4 0 0 0 Drugs 20 20 20 20 20 Pesticides 20 20 20 20 20 Operational Research 20 20 20 20 20 Technical Assistance 27 25 24 12 12 Training 25 22 19 17 17 Instructional Materials 20 20 20 20 20 Project Management 20 20 20 20 20 61 ANNEX 6 Page 1 of 2 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT KEY PROJECT INDICATORS 1. Two sets of indicators will be used to monitor project implementation and assess project impact: monitoring or "intermediate outnut" indicators and final outcome indicators. 2. Monitorina (Intermediate Outputi Indicators. The first set of indicators mneasure the physical execution of project activities. Specifically, they compare action taken against actions programmed or pre- determined targets. These monitoring indicators can be used for both the disease coatrol component and the institutional strengthening component. Since they are inherent in the project implementation schedule, which specifies the targets for all project activities, they are not listed here in their entirety. Looking at any activity in the implementation schedule, the intermediate output indicator can be readily conceptualized as the ratio of what was actually undertaken in a given year over what target was set for the same year. A few examples are listed below: Comoonent A. Disease Control D number of houses sprayed for malaria control over the target number of houses to be sprayed * number of houses treated with pesticides for Aedes aeag jti control over the number of houses programmed for treatment * number of meteos of water courses treated with molluscicide for schistosomiasis control over the number of meters of water courses programmed for treatment - number of house visits for inspection (for the Chagas bug) and health education for Chagas control undertaken over the number of house visits programmed * number of latrines constructed for intestinal parasite control over the number of latrine constructions programmed * number of aqueduct inspections undertaken (for cholera control) over the number of aqueduct inspections programmed * number of villages visited to undertake epidemiological surveillance and treatment/immunoprophylaxis activities for leprosy control over the number of villages programmed to be visited * number of villages visited to undertake epidemiological surveillance and treatment/immunoprophylaxis activities for leishmaniasis control over the number of villages programmed to be visited * number of villages visited to undertake epidemiological surveillance and treatment activities for onchocerciasis over number of villages programmed to be visited 62 ANNEX 6 Page 2 of 2 -Component S. Institutional-Strengthening ag o * number of field bases completed over number of field bases programmed for construction * number of regional headquarters completed over number of regional headquarters programed for construction * snumber of computer training courses completed over number of courses programmed * number of fellowships granted (and in progress) over number of fellowships programed * number of in-service training courses completed over number of such courses programmed * percentage of operational research funds utilized over percentage of funds programmed to be utilized * percentage of technical assistance fundz utilized over percentage of funds programmed to be utilized 3. Final Outcome Indicators. The second set of indicators measure the "final outcome" of the project in terms of impact on health and disease transmission. A few of these indicators are listed below. The disease situation described in Annex 7 will serve as a baseline for assessing improvement of the endemic disease situation over time. Component A. Disease Control * Malaria: number of new cases by municipality and state (incidence) and number of new cases per year per 1000 population (annual parasitic incidence) * Dengue and Dengue Hemorraghic Fevert number of new cases per year per thousand population (annual parasitic incidence) and number of new foci of transmission - Chagass total number of cases per thousand population (prevalence) and number of new cases diagnosed per year per thousand population (annual parasitic incidence) * Schistosomiasis: number of new cases per year per thousand population (annual parasitic incidence) and number of new transmission foci discovered a Intestinal Parasites: number of cases per thousand population (prevalence) * Leishmaniasis (LTA)s number of new cases of LTA per year per thousand population (annual parasitic incidence) and number of new transmission foci discovered * Leprosy: number of cases of leprosy per 1000 population (prevalence) and number of new cases identified in a given year (incidence) * Onchocerciasiss community microfilarial load (CMFL) which is a combined measure of the percentage of a community infected and the overall intensity of that infection) Component B. Institutional Strengthening 4. The executing agencies will complete studies during the first year of the project to develop appropriate indicators to monitor the impact of institutional strengthening activities. These indicators will assess, inter alia the impact of training, information systems development, research recommendations, and new or upgraded infrastructure on the coverage, quality and costs of disease control operations. 63 ANX 7 Page 1 of 17 ENDEMIC DISEASES IN VENEZUEL1 Malaria 1. Disease Situation. Malaria incidence has rLsen explosively in recent years from 4,269 reported cases in 1982 to nearly 47,000 reported cases in 1990 (see Table 1), the highest number of cases ever recorded in Venezuela. Malaria is caused = E#47, by a parasite transmitted by the bite of infected 1,754 nosquitou. In Venezuela, both the Plasmodium falcioarum and Pjasmodum vivax species of the : : e 84 malaria parasite are found. The principal vectors E of malaria in Venezuela are the mosquito species ET Anopheles A. nuneztovari,A.albimanu, and A. aauagalis. Malaria is an acute, debilitating illness that begins with flu-like symptoms including fever, chills, and drenching sweats that can often 197t come in cycles. The malaria parasite attacks and m6 destroys the red blood cells. Untreated, malaria is can be fatal, particularly infections caused by P. i9 fariclarum. Persona with no previous exposure to 197 ii304 the disease are especially vulnerable. Death may 4 - occur, in particular, when infected red blood cellos block blood vessels in the brain (this is known as i .. cerebral malaria). Malaria mortality, however, is 8,4 low in Venezuela -- about 52 malaria deaths were reported in 1990. X 2. Since the 1960e malaria incidence has fluctuated in response to changes in the level of control efforts undertaken and to the appearance of x colonization or mining activities in highly ,sM* a oreceptiv e areas where the conditions are favorable to malaria transmission. During the 19605, colonization in rainforest areas of Tachira, Barin- as, and Sulia states, where the vector was already present, was accompanied by a significant increase in malaria transmission. Later, between 1970 and 1973, there was a sharp increase in malaria in the tThe following report was prepared for the Venezuela Health Sector Study in April/May 1991 by John Wilson (consultant). 2Dlfferent anopheline ve:tors in different areas have been shown to have speciflc behavioral characteristics. Some, for example, including A. aCuaPaisj, A. darLAnaL and A. nuneatovari have been known to feed and rest out of doors, thus evadlng the effects of intradomiciliary spraying. 64 ANlNEX 7 Page 2 of 17 state of Bolivar following the discovery of a major diamond depasit and the rapid inmigration of miners and others. The vector, h.. darli-ngi, was already present and the arrival of infected migrants from other areas quickly led to an epidemic. A similar situation occurred in Bolivar in early 1983 with the discovery of new gold deposits in the municipality of E1 Dorado. Again there was a massive inmigration of miners from other parts of the country, as well as from other countries such as Brazil, Guyana, and the Dominican Republic. By the late 1980., there were an estimated 80,000 persons in the gold mining areas of Bolivar. Table 2 illustrates the associated rise in malaria. 3. These gold miners are a highly mobile, almost nomadic, group and tend to stay in the mining camps for brief periods of 3 to 6 weeks, after which they return to their home communities. Malaria is thereby exported to other parts of the country including areas which may be highly susceptible to renewed transmission, given the presence of the vector and non-immune populations. The mining camps of Bolivar state have thus had a tremendous impact on the malaria situation in the coastal state of Sucre. The frequent migration of miners to Sucre led rather quickly to the emergence of renewed malaria transmission in an area which had been free of malaria for 15 years (see Table 2). Controlling the vector and eliminating malaria transmission in Sucre was achieved earlier, but with great difficulty, due to the fact that L. giaualis, the vector in this coastal zone, is highly exophilic and exophagic (prefering to rest and feed outdoors). A. a has thus been little affected by tradtional intradomiciliary spraying. Control efforts were largely based on aerial fogging. The mining camps of Bolivar have thus been responsible for the reinfection of over 100,000 km2 in the states of Bolivar, Sucre, and Monagas. More recently, gold and diamond mining activity has been growing in the Federal Territory of Amazonas, where malaria cases doubled from 1,305 in 1988 to 2,896 in 1989. 4. Malaria transmission in the mining areas has specific characteristicst (i) it is highly focalized (ii) it is difficult to control with traditional measures such as house spraying due to the lack of sprayable surfaces, or with mass . -*.. .i. chemotherapy because of the nomadic habits of the miners; (iii) it is difficult to control by use of aerial fogging because the mines are often located in the middle of dense forest where the vector can easily seek shelter; (iv) ga ga the chloroquine resistant P. falcioarumf strains of the parasite are common; and (v) it tends to spread quickly to other areas, where . the ecological conditions for renewed 195 SOS S transmission are favorable, through the 1A6 5 E n migration of miners. >6 3a- 5. Malaria transmission has also risen in recent years, though loe dramatically, in the western part of the country in the states of 'fB & " *M Apure, Tachira, and Barinae. TransmiseLon in ;. this area is primnarily associated with new 65 AMX 7 Page 3 of 17 colonization activities in Apure state and is also affected by the importation of cases from Bolivar. Malaria transmiusion in Apure state is focalized in the new settlement areas. Living conditions there are precarious and difficult physical access and guerilla activity (by Colombian rebels) have also complicated control efforts. Fortunately, local transmission appears to be limited to P vivax, which (unlike P. falcioarum) has not presented problems of resistance to anti-malarial drugs. 6. The DGSSSA in Tachira state reported 1,280 cases of malaria in 1990 and has identified several problems: (i) the malaria situation is strongly affected by imported malaria, especially from Apure state; (ii) malaria is easily diffused throughout the state because of its good roads; (iii) climatic conditLons are hlghly favorable to mosquito breeding; and (iv) there is a high density of the vector A. nuneztovari which is less souseptible to intradomiciliary spraying because of its outdoor feeding and resting habits. Although malaria in Tachira averaged around 1,000 to 1,500 cases per year since 1985, local officials are concerned that the number of known local (autocthonous) transmission sites increased from 21 in 1989 to 54 in 1990. If the number of local transmission sites continues to grow in this way, malaria incidence is also likely to grow. At the same time, control program activities have fallen far short of objectives: house spraying and fogging activities reached only 60% and 40%, respectively, of planned coverage in 1990, largely due to labor strikes and to lack of vehicles, fuel, and supplies. 7. Roinforcement of malaria control is urgently needed to reduce transmission, especially in the mining camps, and to halt the further reinfection of receptive areas where malaria was brought under control in the past. The problem and the costs of controlling it have grown without a concomitant increase in the DGSSSA budget. Consequently, funds have been sLphoned off from other important disease control efforts. Even so, the malaria control program has still suffered serious shortages of basic inputs such as microlancets, microscopes, microscope lLghtbulbs, spraying equipment and replacement parts, vehicles and vehicle maintenance. Furthermore, the DGSSSA programs have been seriously compromised by labor problems. In 1990 and 1991 there were frequent work stoppages as DGSSSA field workers, and other MSAS workers hired under "Collective Contract" protested long delays in payment of field allowances. In January and February 1991, for example, DGSSSA workers in Bolivar went on strike and malaria control activities were essentially halted. Fortunately, some activities were continued since part of the labor force was contracted under an agreement with the Corporacion Venezolana de Guayana (CVG), a parastatal regional development corporation, and payments to these workers were not interrupted. The DGSSSA is presently seeking dlrect control over the Collective Contract funds, now managed centrally by MSAS, in an effort to avoid the delays in payment of workers. 8. Control Activltles. Early malaria control efforts in Venezuela sought to control morbidity and transmission by eliminating breeding sites (source reduction) and through mass chemoprophylaxis, using quinine. Objectives shlfted to eradication in the early 1950. with the introduction of DDT for intradomLcLILary spraying. This method of interrupting the transmiosion cycle 66 ANNEX 7 Page 4 of 17 involvex spraying interior walls of houses and associated structures with DDT a residual action pesticide lasting for several months, in order to kill mosquitoe that land on the walls after feeding. Between 1945 and 1960, malaria transmission was eliminated from three-fourths of the originally malaria-infested area of the country. After this initial period of success, the country was stratified into "attack" phase and "maintenance" phase areas. The maintenance area is presently comprised of 536 municipalities (460,000 km2) with a population of 15 million or 76% of the total population of Venezuela (approximately 20 million in 1990). The attack area is comprised o 34 municipalities 1140,000 km2) with a population of 670,000 or 3% of the total population. However, as illustrated above, the disease situation has changed dramatically since the original stratification was made in the 1960X. In 1990, malaria incidence in the maintenance area was four times higher than in the attack area, reflecting the significant reinfection of areas where malaria was once brought under control. 9. The basic executing unit of DGSSSA programs in the field are the "demarcations" which are headed by Inspectors. The demarcations in each stat4 report to the Zone Service Chief for Endemic Diseases. Malaria control activities are carried out in the field by teams of spraymen (rociadores) and house visitors (visitadores). There are two types of spraymen teams: one which undertakes the intradomiciliary spraying and another which operates the aerial fogging machines (either truck-mounted or portable). The house visitors provide malaria treatment and collect blood samples from volunteer notification posts, which are taken to DGSSSA field laboratories (usually at the demarcation) for analysis. Visitors and spraymen are supervised by team leaders who are supervised by inspectors. 10. The principal control measures in use are: (i) intradomiciliary sprayinS with DDT and phenitrothion ({ii) aerial spraying (fogging) with malathion; (iii) treatment of confirmed casesl (iv) mass chemoprophylaxis, or suppressive treatment, in some high risk areas; (v) epidemiological surveillance through passive case detection (taking blood samples from febrile patients who seek assistance at DGSSSA laboratories, health centers, hospitals, volunteer notification posts, etc.) and in some limited areas of especially high transmission, active case detection (visiting houses to take blood samples); (vi) entomological surveillance to etudy vector distribution, density, behavior, and susceptibility to pesticides in use; and (vii) education activities to promote personal protection measures (including use of impregnated bednets) as well as to enlist community participation in the detection and elimination of vector breeding sites. 11. Ideally, the control program would select a combination of measures which are appropriate for a specific tr ismission situation. Different areas and situations pose different problems. For example, mining camps may have no 3About one third of the country is classified as "originally without malaria" and has an estimated population of 4 million or 20% of the total population. Although imported cases are found in this area (955 in 1989), known local transmission has been minimal -- only eight cases in 1989. 67 ANNEX 7 Page 5 of 17 permanent dwellings and a nomadic population, new settlements have precarious housing, coastal areas have a particularly exophilic vector (A. aqua0alis) and peri-urban malaria transmission may be most effectively reduced through drainage works to eliminate breeding sites. The measures selected must take into account the characteristics of specific vector, human and parasite populations, as well as ecological, economic and cultural factors. In practice, however, resource constraints have limited activities in most areas to intradomiciliary spraying, fogging, and passive case detection and treatment. 12. Adiugtina Malaria Control Goals and Strateoy. The DGSSSA maintains the long-term objective of eradicating malaria, although this has proven an elusive goal given current technological and economic constraints. Alternatively, the DGSSSA intends to control malaria transmission, prevent malarLa mortality, and reduce morbidity. To achieve this the DGSSSA plans to carry out a new malaria control strategy utilizing the stratification system and control measures detailed below. (a) Strata 1: Areas with Permanent Malaria Transmission (3 subareas). (i) Areas with Stable Populations. These areas have more settled populations of farmers, ranchers and merchants who live in relatively complete dwellings with sprayable interior walls. In addition to treatment of cases, the control measures to be applied in these areas are intradomiciliary spraying, aerial fogging, and elimination of breeding sites (through drainage, landfill, larvicide application, or biologlcal control of larvae). The impact of these measures on the vector population will be closely monitored. Evaluation of the parasite will be undertaken through active case detection carried out by Rural House Visitors and through passive case detection carried out by the DGSSSA, volunteer colaborators and the local general health services. (il) Areas with Indigenous (tribal) Populations. This includes a number of different ethnic groups living in the forest in dwellings of various types usually not suitable for intradomiciliary spraying. Spraying would be limited to structures with suitable surfaces. Aerial fogging will also be applied. In emergency situations, health teams will carry out mass blood surveys, on site diagnosis and treatment of cases and individuals living with them, and vector control where possible. Routine epidemiological surveys will be conducted with the particlpation of religious missions and other institutions located in the indigenous areas and trained indigenous leaders. (iii) Mining and Logging Areas. These highly mobile populations live in precarious dwellings in remote forest areas. Where possible intradomiciliary spraying will be applied. Aerial fogging will be carried out to reduce vector density. The DWSSSA will organize networks of voluntee;: anti-malarial distributors who 68 ANNX 7 Page 6 of 17 will provide radical treatment of cases, as well as prophylactic treatment of especially vulnerable groups, in order to reduce malaria mortality and morbidity. (b) Strata 2: Reinfected Areas (where malaria war earlier under control). These areas, where malaria tranomiosion has been re-established, require a comprehensive attack in order to eliminate transmission once again. They will therefore be subject to the same control strategy as (a) above. (c) Strata 3: Areas of Eradicated Malaria. In these areas the focus will be on maintaining and reinforcing epidemiological surveillance through passive case detection. Any new cases found will be given radical treatment according to established norms for specific parasite species. Any new active foci would be treated by the following measures: mass serological survey, entomological survey, intradomiciliary spraying and aerlal fogging, treatment of cases and mas anti-malarial treatment. These measures will continue until the foci is completely eliminated. Parasitological and entomological evaluations would continue for a period of at least one year beyond that time. In addition, the DGSSSA will maintain vector control and epidemiological surveillance activities in receptive and vulnerable areas contigous to areas of high malaria transmission. In all of the above Strata, health education activities and promotion of community participation will be carried out by personnel at the regional level. 13. The DGBSSA needs innovative strategies for problem areas like the mining camps of Bollvar state. These will only be found by investing in operational research and by investing in the training and deployment of qualified epidemiologists in the field. The institution has already begun to study new options for control and is rethlnking its stratification. In addition, the DGSS8A began a study in 1989 on the risk factors for malaria transmission in Bolivar state (supported by the WHO/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases). It is also conducting field experiments with pesticide impregnated bednets. Regaining control of the malaria situation in Venezuela will be largely a matter of understanding new situations in the field and developing the appropriate tools and strategies to deal with them. 14. Disease Situation. Dengue is caused by an arbovirus which is transmitted to humans by the mosquito vector edes aevoyti. This vector is amply distributed in Venezuela breeding almost exclusively in man-made containers such as flower pots, water barrels, and diocarded tires within or around the household. Since 1950, there have been several epidemic outbreaks 69 ANNX 7 Page 7 of 17 of dengue in Venezuela, the most significant occuring in 1964 (about 18,000 cases), 1966 (8,000 cases), and 1978 (1,200 cases). The most s ; recent outbreak occured between October 1989 and March 1990 and 4 V zU 19S -9- affected 70% of the area of the country. More than 12,200 cases were ; reported, and over 2,700 of these were dengue hemorrhagic fever (the first time this more violent form of the disease has been seen in l 1. 0 Venezuela). There were 73 fatalities. Table 3 shows the distribution of cases by state. 15. Contr*1 Activities. The Aedes jgey=j control program began in 19474 as an eradication program and is .7 carried out by the Vector and Reservoir Control Division of the ~ ass 31 Rural Endemic Disease Control Directorate of DGSSSA. Since the late 1970., however, the program has been in decline. In 1976, 500,000. house inspections were made and over 120,000 houses were treated. By r0 1980, only 59,000 houses were inspected and 9,700 treated. By 1989, only 11,700 houses were inspected and only 5,500 treated. Outbreaks of dengue since 1989 havea been the result of this decline in ...... epidemiological and virological surveillance which in turn is due to the allocation of scarce DGSSSA resources primarily to malaria control. 16. The DGSSSA has recognized and advocated the need to establish a National Dengue and ARdes aeayptl Control Program. Such a program would involve a number of public health institutions including the National Hygiene Institute (INH), the Venezuelan Scientific Investigation Institute (IVIC), and DGSS, all of which would have an important role in virological, serological, clinical and epidemiological surveillance. Within this program, DGSSSA would undertake A2des aeog =i control (spraying and health education). Also, to help monitor the conditions for viral transmission, the DGSSSA would be responsible for entomological surveillance and would assist other institutions in epLdemiological surveillance. 70 AME 7 Page 8 of 17 Chaaas Disease 17. Dissaue Situation Chagas disease is caused by , ajru which is -ab*g transmitted by two trlatomine insect vectors: Bbagniu 21ua and Triatoma miaculia f i g_a_ _ __ Rabbits, small rodents and other small mammals 4 ' can servo as reservoirs of Zcruzi.ui. L. prDliQ uo is found in 79% of the country (590 mi' u of 746 municipalities, covering 714,572 km2) and ,.X maculat in found in 7% of the national R955 8,536 territory (55 municipalities covering 63,783 5 B,.2 - i km2). The population of this area is an > 87 e estimated 14.2 million, however, the actual ; 4,Q8 population at risk is limited to low-income * 6,.:9 household'., since the vectors shelter in palm thatch used in walls and roofs, and in the b to i only) cracks of mud walls (a more precise estimate uo>--u s8 of population at risk is not available). At nlght, the triatomine bugs defecate on the ._.:_.---:.i-.__. __.__.__.E. E skin while feeding on human blood and subsequent scratching of the irritated bite introduces the insect's feces, which carries the Chagas parasite, into the human bloodstream. The early stage of infection may look like malaria, with fever and swollen lymph nodes. This acute phase is on rare occaslons fatal, but usually the patient survives and goes through a symptomless phase lasting many months or years. During this period, the parasites invade and severely damage internal organs, especially the heart. There is no cure for Chagas disease, which is usually detected only after major damage has been done. The patient becomes progressively weaker and may eventually die of heart failure. 18. In Venezuela, Chagas is found in a belt which runs across the states of Aragua, Guarico, Barinas, Falcon, Merida, Trujillo, Portuguesa, Lara, Zulia, Yaracuy, Cojedes, Carabobo, Miranda, Anzoategui and Sucre. The states known to be most affected are Lara, Portuguesa, Trujillo and Carabobo. In most of the area, the population at risk lives in small and dispersed rural settlements. Table 4 shows reported cases of Chagas disease in recent years. The apparent drop in new cases detected between 1987 and 1988 reflects the deteriorabion of Chagas surveillance, not an improvement in Chagas control. With the decline in surveillance activities in recent years, it is probable that underreporting of Chagas disease is high. 19. Control Activities. The objectives of the Chagas control program are to interrupt transmission of the disease through vector control (intradomiciliary spraying), construction and improvement of rural dwellings (to eliminate the habitat of the vector in the home), and health education. In the past, Chagas control has benefited indirectly from intradomiciliary spraying of DDT for malaria control. The first epidemiological surveys specifically for Chagas control were begun in 1961. At present the program covers 14 states. As Table 4 shows, coverage in terms of blood samples taken for epidemiological surveillance has fluctuated considerably in recent years. In a number of 71 amu Page 9 of 17 states (e.g. Monagas, Anzoategui, Guarico, Sucre, and Portuguesa), however, Chagas control is paralyzed since all resources have been allocated to malari and dengue control. Plans for control activities in six additional states exist but have not been realized due to lack of resources. 20. Chagas control activities begin with house visita to inspect for the precence of the vector. This is carried out by an inspector. If a house is found to be infested with the vector a team of spraymen treat the dwelling an associated structures on a 4 by 4 month cycle using dieldrin and other pesticides. In addition, house visitors (visitadores) will visit to take blood samples. If positive cases are found they are followed up with an EKG exam (portable EKG equipment is taken to the field) to determine if the victi has heart damage. Inspectors also are responsible for community education. They explain the disease and its transmission and the importance of eliminating thatch construction material and of sealing crevices in walls by covering mud walls with plaster. 21. Poverty plays a central role in the continued transmission of Chagas disease and for this reason the DGSSSA has sought to integrate Chagas control wLth the National Program for Housing Improvements (NIVICA), run by the Directorate for Rural Housing of DGSSSA. Housing improvement is a logical complement to vector control through residual spraying. However, the NIVICA program is very limited in scope with programs in only three states, Falcon, Portuguesa, and Lara. Although the Chagas control program does provide HIVICJ with the epidemiological information to target its activities, NIVICA tends to operate more in areas where the building materials can be readily transported. Thus, the housing needs of areas which are more remote, and usually more affected by Chagas disease, are generally unattended. 22. Resurgent malaria and the recent epidemic of dengue and dengue hemorraghic fever have had a serious impact on Chagas control activities in 1990. In the state of Portuguesa, for example, almost no vector control was carried out in 1990, since the Chagas program depends on the same spraymen and equipment that are used for malaria and dengue control. In recent years the level of activity in Chagas control has fluctuated considerably, depending on the availability of resources. On the whole, the Chagas control program is underfinanced and requires a major infusion of human and financial resources in order to achieve a reasonable level of coverage. As noted above, there are six states which are known to be areas of Chagas transmission where, for lack of sufficient funds, no control activities are being carried out. Intestinal Schistosomiasis (Bilharzia 23. Disease Situation. Intestinal schistosomiasis is caused by the parasite Bghistosoma mangoni.4 In water, the larval form of the schistosomes (cercaria) are shed from infected snails and penetrate the skin of people who enter the water to swim, wash, or fish. The snails are infected by another 4Another major form of schistosomiasis found in South America, but not in Venezuela, is urinary schistosomiasis caused by S. haematobium. 72 _ESX 7 Page 10 of 17 stage of the schLitosome (miracLdia) whlch hatch from eggs passed ln the stools of infected persons. In the human host, the adult male and female forms of the paraslte llve in the blood vessels of dLfferent organs and release eggs that are paosed out ln stools or that become lodged in the tlesues. Schietosomal dLsease progresses slowly, as a reactlon to these eggi ln the tlssues. It L characterized by progresesve enlargement of the liver and spleen and damage to the LntestLne resultLng from leslons around the eggi and hypertension of the abdomlnal blood vessels. Repeated bleedlng from thei vessels can be fatal. The data from coprologlcal exams in Venezuela show tha person. over 10 years of age are slLghtly more affected than persons under lC but recent serologLcal studies suggest that not enough is known about schistosomiasis in Venezuela to say whlch, if any, populatlon group li most affected. 24. Based on the coprological data, and on knowledge of the distrLbutLon of infected snail populations, S. mansonL is known to be endemic in Venezuela's most densely populated region, the center-north. The endemic area covers an eatimated 15,000 km2 or 1.6% of the country, and lncludes the Federal Distrlc and parts of the states of Aragua, Carabobo, Guarlco and Miranda. The population of thie area is approximately 7 milllon, of whlch an estimated 2 million people are actually at rlsk. The presently known dlitribution of the disease corresponds to the dlitribution of the snail intermedlate host, BLomDhalara alabrata. S The socLo-economLc conditions and habits of the population in the endemic area are generally amenable to the perelstence of this dieease. In some areas (e.g. Aragua and Carabobo) the problem ls aggravated by brick manufacturers who are extractlng clay and leaving behind huge water-filled pits that are soon infested by B glabrata. These flooded clay pLts are often adjacent to poor, crowded barrLos and are inevitably used by the population. Other problem areas include new low-income neighborhoods that have appeared ln low-lying peri-urban areas of the cltles of Maracay and Valencla. 25. Surveillance of schistosomLasis in Venezuela has varied greatly since 1943 when surveillance activities began. Between 1943 and 1960, DGSSSA made 87,639 feces exams of which 12,851 or 14% were positive for S. mansonlE . Between 1986 and 1989, DGSSSA made 125,062 feces exams of which 719 or 0.6% were positive. These data suggest that schistosomiasis control activities, mainly mt.,.. *aciciding, have been very effectlve over the years in reducing prevalence of the disease. However, the introduction of new serological diagnostic methods have raised some important questions. In 1989, DGSSSA collected 2,062 serological samples in Carabobo state, and found 789 or 38.7% to be positive for S...anoni. Another 1,350 blood samples were examined in 1990 of which 358 or 26.5% were positive. Thus, it seems that actual prevalence of schistosomiasis may be much higher than previously estimated. It may be that lighter infections do not show up in the coprological exams but do show up in the serological tests. The implication for control is that, 58. manPnoL has sometimes been found in two other potential anail intermediate hosts, a stramLa2a and B. havanensis, which are distributed over most of Venezuela. 73 ANNEX 7 Page 11 of 17 with the more sensitive serological diagnostic tool, the schistosomiasis control program could identify and treat a much larger percentage of infected individuals and significantly strengthen efforts to eliminate the dLsease. 26. Control Activities. Since 1943, schlstosomiasis control has used a polyvalent strategy attacking the major points in the transmisslon cycles the Lntermediate host through mollusciciding, the parasite through chemotherapy (using Oxamniquine or Praziquantel), and the human reservoir through education. Control activLties have included epidemiological surveys, hydrographic studies, malacologlcal (snail) surveillance, mollusciciding in infested waters, drainage works, construction of sidewalks, washing places (lavaderos), public baths and latrines, treatment of cases, and health education. 27. As in malarla control, each state where the schistosomiasis control program operates is divided into demarcations. The principal control activities for schistosomiasis in Venezuela underway today are snail control, epidemiological surveillance and treatment, and community education. Snail control activities are carried out by specialized teams of workers: some workers clear the underbrush along water courses so that others, following behind, can use small nets to capture snails. When infested bodies of water are found, captured snails are taken to Maracay for testing. The infested waters are treated by the same teams with molluscicide (prLmarily Baylucid, but also sodium pentachlorophenate, copper sulfate, Frescon, and sodium citrate). The worker teams are supervised by an inspector. In 1989, 10.4 million linear meters of water courses were inspected. The program planned to treat 881,000 linear meters but due to increasing costs and insufficient transport and personnel, covered only 50% of this goal (441,000 linear maters). 28. Spidemiological surveillance ia carried out by inspectors in areas where infected snails are found by collecting feces samples for diagnostic testing (mainly at the DGSSSA laboratory in Maracay). This is followed up by treatment of positive cases. There is a new plan, however, which has yet to be financed, which would train inspectors and workers to take blood samples for a new schistosomiasis surveillance system based on serological surveys. Community education is carried out by the inspectors with assistance from specialists from DGSSSA headquarters. Efforts to change the high risk behaviors of populations at risk need considerable strengthening, however. 29. Operational research on biological control is being carried out in collaboration with the School for Advanced Studies of the University of Perp$gnan (France) and the Guadaloupe Island Hospital Center. The objective of the project is to exa;mine the impact on B. alabrata of the introduction of a competitor snail, Thiara tuberculata. A Schistosomiasis Research Group was formed in 1984, to help orient the activities of the schistosomiasis control program, which is comprised of the head schistosomiasis control program and representatives from the Bilharzia Laboratory of the Tropical Medicine Institute of the Central University of Venezuela, the Department of Parasitology of the University of Carabobo and the SchostosomiasiL Laboratory of the Center for Microbiology and Cellular Biology of the Institute for 74 ANNLX 7 Page 12 of 17 Scientific Investigation (IVIC). The objective of the group is to work together towards improving diagnosis, treatment and control of schistosomiasis in Venezuela. 30. The schistosomiasis control program needs to reassess the epidemiological situation, based on serological surveys, and to develop a control or erradication strategy, accordingly. To do so, greater investment in schistosomiasis control will be needed since, for several years, resources for schistosomiasis control have been used to help combat resurgent malaria. In addition, schistosomiasis control suffered a major setback in 1990 due to the tranefer of its manpower to the dengue control effort. Field activities have slowed due to labor strikes and lack of funds to pay field allowances. The schistosomiasis program requires basic transport of its own to achieve adequate coverage and resources are needed to undertake small drainage works, especially in new peri-urban areas where the risk of intensified transmission is high. Coordination with etate and municipal authorities to encourage such w-orke and to maintain existing drainage canals is also needed. Laboratory space and equipment, new supplies, and re-training of personnel are urgently needed and the program would also benefit greatly from computerization of the its information system to manage the epidemiological and snail surveillance eystems. Other Intestinal Parasites 31. Disease Situation. The prevalence of helminthic ....... ...... . infections is a consequence of poor living standards and, specifically, of the inadequate disposal of human wastes. The most recent epidemiological survey of intestinal parasites in Venezuela began in 1989 after a 83 B 0 lapse of 13 years since the 5 A;z previous survey of 1976. The new > _*______m_-_:___._______:_::_._::_-_.._-_ survey, which should be completed by late 1991, adds information on parasite load and covers the same localities studied in 1976 in order to allow an analysis of the impact of control measures applied. Thus far, 33,457 samples from 15 states have been processed with the results shown In Table 5. These preliminary data appear to indicate that the anti-helminth campaign of the last 13 years has resulted in a significant decline in prevalence. 32. Control Activities. The objective of the control program for intestina' helminths is to reduce infection to a level that no longer constitutes a public health problem. The program is carried out throughout most of the country and targets the principal geo-holminths: Ascaris lumbr$coidA, Tricluris trichiura, Ancylostomida. ( K2lator americanue and Ancvlost2m& duadenalk), and Enterobius -ermLcularli. The principal activities of the control program, which are executed by the Zone Service personnel based at the state level, includes 75 ANNiX 7 Page 13 of 17 (a) Epidemiological surveillance to determine parasite indices and health/sanitation surveys of households and communities. (b) Education campaigns in the schools and in the community. (a) Latrine construction with participation of beneficiaries in construction and provision of materials. (d) Mass anti-helminth treatment through schools and communities (local health centers) with Mebendazole (single dose 500mg preceded by one day with single dose of piperazine). The program has operated best through the schools, where treatment is administered twice a year. 33. The program's budget has not kept pace with rising costs and population growth. Coverage has therefore been lower than projected: 34% for latrine construction and 74% for antihelminthic treatment (1989). The figures on latrine construction over the last two decades show a very strong declining trend: only 786 latrines were constructed in 1990 as compared to an average of 1,496 per year in the period 1985-89, 1,597 in the period 1984-88, 4,220 in the period 1979-83, and 10,376 in the period 1974-78. Until 1990, the Ministry of Health was providing funds to DGSSSA to purchase building materials for latrines for needy beneficiaries. This support has been terminated and now beneficiaries must be able to furnish all the materials. 34. At present, DGSSSA has sole responsibility for intestinal parasite control. Coverage could be easily expanded and improved through the involvement of the general health services in the control program. eprosv 35. Leprosy (also known as Hansen's dieease) is caused by a slow growlng bacterium, Mvcobacterium lecrae, which grows mainly in nerve cells and macrophage cello in the skin. The clinical cc rse of leprosy varies from asymptomatic infections to severe disfiguring Jisease. Skin lesions may appear and heal spontaneously. As the disease progreeses, usually over many years, the skin lesions may become more frequent. These lesions range from depigmented patches, usually with loss of skin sensitivity, to multiple nodules with extensive skin thickening and folding. Lose of sensitivity in the skin often results in unnoticed burns or ulcers. Lesions of the nerves can lead to muscle weakness and atrophy resulting in deformities, especially of the hands and feet. The disease leads to disfigurement an" disability due to injuries resulting from loss of nerve sensation. The mode of transmission is not clearly known but it i6 generally accepted that prolonged and intimate contact with the source of infection is necessary. The bacterium is believed to be transmitted mainly from the nasal discharge of infected people, but may also be tranomitted by skin contact. 36. In 1991, Vene&uela had 13,616 registered cases of leprosy. The number of new cases reported in the last decade is summarized in Table 6. The rise in new cases detected each year does not indicate a worsoening sltuation, but 76 ANNEX 7 Page 14 of 17 reflects improvements in surveillance . .. The IB estimates that over the last 40 ..... i ; years, the incidence of leprosy has - - o actually declined from 16/100,000 in ; * ; i 1951 to 1/100,000 in 1990. In 1981, the IB stratified the country into three areas: (i) the high prevalence area, with greater than 2 cases per 1,000 population, comprised of the states of 'f.. Merida, Tachira, Trujillo, Barinas, and - Apure; (ii) the medium prevalence area 35f with between 1/1,000 and 2/1,000, comprised of the states of Nueva U.j Esparta, the Federal District, . 4' ' Portuguesa, and Guarico; and (iii) the.19 7 438 low prevalence area with le than 49' 1/1,000, comprised of the rest of 198 41. Venezuela. 37. The principal activity in control ... of leprosy is epidemiological surveillance of patients and their contacts and supervised treatment in order to interrupt transmission by reducing incidence. This is carried out at the state level by the SDDe. The latter are, ideally, but not always, staffed with a doctor, nurse, field inspector, and social worker (all of them do have a doctor, however). In addition, the leprosy program carries out health education geared to changing attitutes about the disea-s, focusing on lts curability, low infectivity, and the benefits of immunoprophylaxLs. Rehabilitation activites are also undertaken ln some areas to reduce incapacLtatLon ln patients who lose sensitLvLty, especlally ln the hands and feet (such patlents tend to injure themselves ln routlne actLvLtLes). 38. For many years the only treatment for leprosy was dapsone, a drug whlch halts the multiplication of the bacterlum. Treatment was lengthy, sometimes life-long, there was risk of relapse, and resistance to dapsone was appearing in many areas. However, a newly developed multi-drug therapy (MDT) has been in use in Venozuela slnce 1985. MDT combLnes dapsone, rLfampLcLn and clofazimine. A total of 5,445 patLents hvee recelved MDT (a coverage of 87%) of which 1,980 cases (32%) have successfully completed treatment. MDT is implemented ln all states except Tachlra, Apure, and Merlda (where immunoprophylaxLs is being tested) and Bollvar, due to dlfflculty of access and other problems associated with such frontler reglons. The IB is also worklng on immunotherapy, using the same compound which is being tested as a vacclne, described below. So far, the IB is encouraged by the results of immunotherapy, claimLng that 90% of patients treated have responded positively. 39. Venezuela is one of several countries now working on prevention of leprosy through vacclnatlon. The objective is to reduce prevalence and incldence by protectLng high risk contacts. As areas of hlgh prevalence, 77 ANA2X 7 Page 15 of 17 Apure, Tachira, and part of Merida were selected for an immunoprophyl&xis study which is testing a vaccine made of dead M. leJrae and a compound called B.C.G. At the beginning of the study, an epidemiological survey was conducted: 2,294 cases were registered and their 64,572 contacts (people at highest risk of contracting the disease) were identified. Of these contacts, 29,116 received the vaccine. The contacts are examined annually. 6 So far, the IB is encouraged by the results and hopes to expand the program to all endemic areas in the country. 40. The Institute for Biomedicine needs to undertake a comprehensive evaluation of the leprosy control program in all states and territories. Based on such a review, surveillance and treatment activities should be strengthened in areas which are presently underserved (especially more remote areas with v'eaker health infrastructure such ts Amazonas and Bolivar). In addition, the results of the immunoprophylaxis and immunotherapy studies now underway should be evaluated as soon as possible with a view to determining whether these studies should be expanded, in order to make these alternative therapies available to leprosy patients and contacts throughout the country. Leishmaniasis 41. Leishmaniasis is caused by a - 7- parasite transmitted by infected sutX eaus and eocuta -u sandflies (genus Lutzomyia in Venezuela) which breed in moist soils, for example, in forest areas, caves or burrow of X e --98; small rodents. Several species and subspecies infect man, leading to symptoms ranging from simple self- , healing skin ulcers to life-threatening disease. Small mammals including )Bl . 1, i0 rodents and dogs, serve as reservoir : -i01 hosts of infection and may play an 1,640 important part in the epidemiology of X 1$ the disease. In Venezuela, two forms of 257 leishmaniasis are found: s. teamentar 1964 A.677^ americana (also called cutaneous and 1987 2,406 mucocutaneous leishmaniasis) and _ 198. !iceral or Kala-Azar. The former is ... ; more common and its symptoms may range from simple skin ulcers to major tissue ... ... .. .... destruction, especially of the nose and mouth. Visceral leishmaniasis is a more serious form of the disease and usually fatal if untreated - its symptoms include fever, malaise, weight loss and then anemia and uwelling of spleen, liver and lymph nodes. Simple cutaneouo leishmaniasis can heal by itself without medical intervention, leaving the person immune to further infection from that particular form of the disease. However, some cases of mucocutaneous leishmaniasis (as well as 6The study is eupported by TDR, CONICIT, MSAS, and PAHO. 78 ANNEX 7 Page 16 of 17 visceral leishmaniasis) are extremely difficult to treat and may require a long course of pentavalent antimony drugs (Glucantime or Pentostam) and sometimes the antibiotic amphotericin B. 42. Cutaneous and mucocutaneous leishmaniauis have been reported in nearly all states in Venezuela with the exception of Nueva Esparta and T.F. Delta Amacuro (see Table 7). Underreporting is high and there may be as many as 10 cause unreported for every reported case. Table 7 summarizes the reported cases of cutaneous and mucocutaneous leishmaniasis in Venezuela since 19S5. The IB has classified the different states where transmission occurs into active focis Lara, Tachira, Merida, Trujillo, Barinas, Miranda, Anzoategui, Sucre, T.F. Amazonas, Zulia; and slightly active foci: Bolivar, Cojedes, Falcon, Monagas, and the Federal District. A few small foci of L. isceral have been found in five states: Lara, Guarico, Sucre, Anzoategui and the Federal District. Incidence of visceral leishmaniasis has been about 50 new cases per year. 43. The control strategy for leishmaniasis (LTA) in Venezuela involves: (i) active case detection utilizing trained community leaders and local health services (as well as development of new diagnistic techniques); (ii) register, treatment and follow up of cases (as well as study of new therapies and mmiunotherapieu)j (iii) studies of the vector, Y:eservoirs, epidemiology and imuunology of known fociij (iv) health education in high risk areas focusing on vector avoidance (use of bednets and insect repellents); and (v) training programs for local health service personnel. 44. The IS is carrying cut important studies on a vaccine for leishmaniasis which may be useful in both prevention and treatment of the disease. The Rafael Rangel National Institute of Hygiene has an agreement with the IS to assist in vaccine production. OnchocerciaeLe 45. Onchocerciasis is causee by a thread-like worm, Onchocerca volvulus, which is spread by the bite of the female blackfly (Simulium metalicum, iJulD-um ex$auum, SimuliJum Pintoi, and sijulai Guasinanguineum in Venzuela). Victims of onchocerciasis suffer severe debilitation and itching due to the proliferation of mill^one of infant worms (microfilariae) produced by adult worms (macrofilariae) located in nodules under the s.sn. Years of repeated reittection and eventual mtcrofilarial migration to the eyes will lead to severe ocular damage and blindness (hence, onchocerciasis is known as Riverblindness in Africa). In Venezuela, onclhocerciasis is found in the eastern states of Anzoategui, Monagas, and Sucre, the central states of PAragua, Miranda, Carabobo, Guarico, Cojedes, and Yaracuy, and se southern states of Bolivar and Amazonas. The IB estimates that there are approximately 80,000 cases of onchocerciasie in Venezuela. However, a complete and systematic mapping of onchocerciasis in Venezuela is still needed, including an assessment of the extent of blindness due to onchocerciasis. 46. Onchocerciasis control activities Are limited to passive surveillance and treatment of cases with ivermectin (Mectizan), an effective 79 ANNEX 7 Page 17 of 17 microfilaricide recently in use since 1987. Ivermectin treatments must be administered yearly for the lifespan of the adult parasite (11 to 14 years) sLnce ivermectLn does not klll the adult worm. In Venezuela, vector control was attempted for a short period between 1959 and 1965. The effort was halted, however, because of lts high cost and because it dld not have a slgni£fcant impact on vector density. Effectlve control of onchocerclasis L Venezuela would require an active epidemiologlcal survelllance system, as we as a program for mass Lvermectin treatment in important foci across the country. 80 Pago 1 of 1 VENEZUS ENDEMIC DISEASE CONTROL PROJECT DWSSSA Expenditures for Endemic Disease Control 1985 - 1990 (1990 US$ millions) ear MSAS/a states/b cva Ta 1985 32.1 38.0 0 70.1 1986 33.4 36.8 0 70.2 1987 27.2 28.3 0 55.5 1988 24.5 27.0 0 51.5 1989 18.8 15.4 2.9 37.1 1990 16.1 29.5 2.2 47.8 1991 25.4 39.8 3.1 68.3 CVGt Venezuelan Corporation of Guayana MSAS: Ministry of Health and Social Assistance a/ MSAS figure does not include MSAS contributions to Rural Housing, Aqueduct, and Sewers Programs of the Rural Housing Autonomous Service b/ this amount is largely in support of the Rural Housing, Sewers and Aqueducts Programs. IS Expenditures for Endemic Disease Control 1986 - 1990 (1990 us$ '000) Year MSAS /a VCV Lb Subtotal /c Rotal 1986 493 194 687 178 100 865 1987 443 199 642 121 100 864 1988 445 196 642 87 100 829 1989 369 189 558 132 100 790 1990 352 197 549 130 120 799 TDR: WHO/UNDP/World Bank Special Programme for Research and Training in Tropical Diseases; supports leishmaniasis immunoprophylaxis program (vaccine production and field expenses) a/ Personnel expenditures, all I8 disease control programs. b/ Personnel expenditures, all IB research and training programs. C/ AMERICARES: supports Leprosy Multidrug Therapy (MDT) program (drugs and field expenses). 81 Page I of I VENEZUELA ENDEMIC DISEASE CON1ROL PROJECT SELECTED BACKGROUND DOCUMENT aAILABLE IN PROECT 1 A. Reqorts and Documents Related to the Project A.1 "Proyecto Control de Enfermidades Endemicass Nalariologia y Saneamiento Ambiental". Volumes I and I. Direcion General Sectorial de Saneamiento Sanitario Ambiontal (DWSSA), Caracaa, February 1992. A.2 "Proyecto Control de Enfermedades Endemicas en Venesuela, Banco Munditi, Programas de Lepra, Leishmaniasis I Oncocercosia, Desarrollo de Infraestructura Fisica". Dio@mdiL@ne Institute, Caracas, November 1991. A.3 Action Plans for 1993 and Review of Disease COutrol Strategies. Institute of Biomedicine. June 1992. A.4 Action Plans for 1993 and Review of Disease Control Strategies. General Sectoral Directorate for Environmental Sanitation. June 1992. A.5 Venezuela Health Sector Study (yellow cover), June 1992, The World Bank, Washington, D.C. A.6 "Selection and Use of Pesticides in Bank Financed Projects's Norman Gratz and Bernhard H. Liese. The World Bank PPR Working Paper Series, Number 11, Washington, D.C., 1986. A.7 "Guidelines for tb& Selection and Use of Pestieldes in Public Health Proqrams in Bank-financed Projects". The World fank, OPF 11.04 B. Roggrts and Working Pa2ers Related to the Sub-Sector B.1 St.ff Appraisal Report - Brazil - Amazon Basin Malaria Control Project. The World Bank, Report Number 7535-BR, Washington D.C., April 21, 1989. 8.2 oryanixing and Managing Tropical Disease Control P2arms: Lesson of Success. Bernhard H. Liese, Paramjit S. Sachdeva an D. all" Cochrane. World Bank Technical Paper Number 159, 1991. 5.3 "The Onchocerciasis Control Program in West Africa# A L;ay-tern Commitment to Success". Bernhard H. Liese, John Wilson, Bruce Benton, and Douglas Karr. The World Bank, P33 Working Paper Series, Number 740, August 1991, Washington, D.C. 5.4 "Development Policies and Realths Farmers, Ooldlners and Slums in the Brazilian Amazon". John F. Wilson and A. AlLcbu9an--c1nab* The World Bank, Environment Department, DLvisional Working Paper, Number 1991-18, January 1991. 82 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT Page J ANNUAL SUPERVISION PLAN SunervisLon Skllls: Task Manager (Coordinating with Procurement, Disbursen- and Legal) Epidemiologist/Endemic Disease Control Specialist Architect Information Systems Specialist Project Implementation Monitoring Specialist Anthropologist/Sociologist Year Round Actionst Review and follow up on bidding documents, contracts, a operational research proposals. January - Fobruary: Project Launch Seminar (1993 only). Bank Participants: Manager, Procurement Officer, Disbursement Officer, Law Endemic Disease Control Specialist. Follow up. March: Review at headquarters of: Annual Project Implementatic report on previous year s activities; Proposed annual action plan and investment program for then subsequent year and the report on expenditures dur the previous fiscal year; and DGSSSA plan to implement recommendations of management (1993 only). Undertake supervision mission for, Lnter alLa Joint a review with Borrower of: (i) progress in project execut and achievement of project objectives using input and outcome indicators in Annex 6 of Staff Appraisal Report (ii) proposed annual action plan and investment program the then subsequent year; ';ii) any changes in project design and implementation that may be necessary; and (1 mechanism for DGSSSA management of all resources for pa: of DGSSSA field workers. Supervision report writing am follow up. Follow up. May a June: Review final proposed budget of the Executive Branch SSi the Congress (for the then following fiscal year) to coi that it includes adequate allocation for endemic diseass control programs and activities. Follow up. July - Auoustt Review annual audit. Follow up. 8imp- bar Supervision Mission. Review implementatlon of action p] and field operations. Supervision report writing. Fol3 up. October - Decmbert Follow up. 83 CHART I VENEZUELA ENDEMIC DISEASE CONTROL PiKOJECT Organization Chart of the General Sectoral Directorate for Environmental Santtation Ministry of Health a cialAssinc |2 DGSSSA General Sectoral Director Tgchnl Coordinain NWd 8o Orr Pbfs, Budge & -L"m wout sys m - Norms - Office - Support and Technical P gand Bg AslIstuice - Informadon Systani= Admk b7 W nPersonel o.i eWVIM Ombe X. -Admlaton - Makftbwm - AdmnstaWon b_Wmo R11 E1dm Dles San8y Eng kin AnSdo 6_ 1o HDko_la Dhocof ofeowf | _ - Fbwmk . Mam, Chaga and Ground Saniton Grdue TratM. - Rat Aq_ du t* Ocer Meutaxu - Wat Santation Resw| - Rwnl Hqj owa - Ai -Sadftfo* Tew .r r* DGSSSA State-Level Regional Services CHART2 84 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT Organization Chart of the Biomedicine Institute IMinistry of Health and Social Assistance' L-Central_University of Venezuela DWM"M b iomedicine Institute ., -Ub_I - 81*104.efel Dermato"y' Pn g8 6opkm o UwU* Cm&hgl ............................................ ................................. ........ - WHO bornating Ceneer Clieni - Graduab Couin for Ru ow.h and Tr*et knmunology in Da_Mi oy Leoroy amo TMrpr - nmulogy I - Gorat Cour" Th D_WA" HbWdm- H -WHOlPAHO Fiow*lp FldopadobBy - UndeVadtf mi - Miaroiolnd Togy WHO Cod_ , Expn - GrbduaW Go INIIe and PASO PhbyIn M _ooogy caw br tor LM; - Mlow"y 1- Graduft Th$4 - statis.i md Compton - HybomW - Genetic EngbQ - Molecuiw Boogy I mntmoclamisty - Edeolgy E ectron Microscopy -h_mmh umtly -V.eblnaryiblotrlu 85 CHART 3 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT DGSSSA PROJECT IMPLEMENTATION UNIT DGSSSA Director Project Steering Committee _- IR _ h- iProjec Manager Technical Sections W Endemic Diseases Section Health Education an ~~~~~~~~~~~~~Community Participation - |Malariai |Dengue | Dengue Hemorraghic Fever | Diseases 86 CHART 4 VENEZUELA ENDLMIC DISEASE CONTROL PROJECT IB PROJECT IMPLEMENTATION UNIT EB Director' .;.. ....... 1Prot Stng Ci - _. _............ ........ ....... .................. ........_ Project Manager' I~~~~~ Lu_gon Syptwm Secdion rAdm'nastretion Section Tcnical Section . ~~Health Education and Cmmunity Participatlon oil 1 Swdonnchoce rclssis Section Y efn - . , . ... .. | .. ............................... _1 ............. ....... ........ ..... 87 CHART5 VENEZUELA ENDEMIC DISEASE CONTROL PROJECT PROJECT COMMITTEES |Ministry of Health and Social Assistance l I § IB | . | ~~DGSSSA Prmocure n'W| Research Stering FCic Itonnte P t etCommitPee Prje Pcinprmpnt_on UnK Project Impaleominalson nO lu jARUE NETreRntA. ANTILLES C a r i b b e a n iNETH) -1 2D ' -120 o //t ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~G UA R 0 100 0 Go d V E N E Z U E L A J ENDEMIC DISEASE CONTROL PROJECT o 6}> Construction of Central Headquarters * Construction of Regional Headquarters 8 *O Oi'fields Elevations: Over 500 meters 200-500 A AZON - 0-200 Major Roods c-~ Rivers _° o Selected Cities and Towns @ State or Federal Territory Capitals 0 20 * National Capitals - State or Federal Territory Boundaries * / \ International Boundaries b 100 200 300 KILOMETERS 72 D 706 666