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Folder Title: Health Services Integration Project - Colombia - Loan 2611 - P006794 - Staff Appraisal Report [SAR]

Folder ID: 30349480

Project ID: P006794

Dates: 6/18/1985 - 6/18/1985

Fonds: Records of the Latin America and Caribbean Regional Vice Presidency

ISAD Reference Code: WB IBRD/IDA LAC

Digitized: 10/24/2018

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M THE WORLD BANK Washington, D.C.

@ International Bank for Reconstruction and Development / International Development Association or The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org LOAN/CREDIT No. 2611-CO COLOMBIA - HEALTH SER INTEG I MIS TASK No. CLMPAI13 D-6 Staff Appraisal Report (SAR)

AraivS 30349480 R1995-279 Other# 3 Box #105265B DECLASSIFIED Health Services Integration Project - Colombia - Loan 2611 - P006794 - Stal WBG Archives Appraisal Report [SARI Document of The World Bank

FOR OFFICIAL USE ONLY

DECLASSIFIED Report No. 5532-CO WBG Archives

STAFF APPRAISAL REPORT

REPUBLIC OF COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

June 18, 1985

Population, Health and Nutrition Department Division III

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 authorization. CURRENCY EQUIVALENTS

Currency Unit - Peso Colombiano (Col$) US$1.0 - Col.$135 (May 15, 1985 Actual)

WEIGHTS AND MEASURES

Metric System

FISCAL YEAR

January 1 to December 31

PRINCIPAL ACRONYMS USED

CEADS - Centro de Adiestramiento en Salud (Center for Health Training) CI - Comit6 Interseccional (Zonal/Departmental Coordinating Units) DNP - Departamento Nacional de Planeaci6n (National Planning Department) DSBR = Division de Saneamiento Bfsico Rural (Division of Basic Rural Sanitation) FNH = Fondo Nacional Hospitalario (National Hospital Fund) ICBF = Instituto Colombiano de Bienestar Familiar (Colombian Institute of Family Welfare) INS - Instituto Nacional de Salud (National Institute of Health) INSFOPAL = Instituto Nacional de Fomento Municipal (Institute for Municipal Development) ISS = Instituto de Seguros Sociales (Social Security Institute) MOH = Ministerio de Salud (Ministry of Health) SBR = Saneamiento Basico Rural (Basic Rural Sanitation) SSS = Servicio Seccional de Salud (Departmental Health Services) UPA = Unidad Primaria de Atencion (Primary Care Unit) UR = Unidad Regional (Health Region) FOR OFFICIAL USE ONLY COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

STAFF APPRAISAL REPORT

Table of Contents

Page Number

SELECTED SOCIAL INDICATORS...... iii

GLOSSARY OF TERMS ...... iv

LOAN AND PROJECT SUMMARY...... v

I. Introduction...... 1

II. Sector Status...... 1

A. Population...... 1 B. Health-...... 3 C. Nutrition...... 4 D. The Health Care System...... 5 E. Health Care Financing...... 8 F. Health Manpower...... 10 G. Health Information Systems...... 12 H. Research...... 12

III. Key Sector Issues...... 13

A. Lack of Coverage...... 13 B. Sector Deficiencies...... 14 C. Management Weaknesses...... 14

IV. The Bank's Role...... 15

V. The Project...... 16

A. Project Summary...... 16 B. Summary Project Composition...... 18 C. Detailed Project Description...... 19

This report is based on the findings of an appraisal and a post appraisal mission that visited Colombia from June 18 to July 6, 1984, and from November 26 to December 7, 1984, respectively. The mission members were Messrs. W. De Geyndt (Mission Leader), L. Vassiliou (Economist), B. Hubert (Architect), W. Stottman (Engineer), Mrs. P. Kleysteuber (Operations Assistant), and Consultants G. Herrera (Physician) and F. Unda (Engineer).

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 authorization. (ii)

Page Number

VI. Project Cost and Financing Plan...... 27

A. Project Cost Estimate...... 27 B. Financing Plan...... o...... 29 C. Procurement...... o..30 D. Disbursements ...... #...... 33 E. Retroactive Financing...... 34 F. Accounts and Auditing...... 34

VII. Project Implementation...... 34

A. Project Management Arrangements...... 34 B. Project Monitoring and Evaluation...... 36

VIII. Project Justification and Risks...... 37

A. Project Justification...... 37 B. Project Risks...... 38

IX. Agreements and Recommendations...... *.39

ANNEXES

1. Sector Data, Project Data, Project Cost Estimate Tables...... 41

2. Rural Water Supply Subcomponent...... 73

3. Selected Documents and Data Available in Project Files 85

CHARTS

1. Project Implementation Schedule...... 86 2. Organizational Chart - MOH...... 87 3. Organizational Chart - INS...... 88

MAPS

General Project Area: IBRD 18785

Project Department: IBRD 18600 Narino IBRD 18606 Santander IBRD 18602 Cauca IBRD 18604 Cordoba IBRD 18603 Valle del Cauca IBRD 18605 Antioquia IBRD 18601 Amazonas IBRD 18599 Choco IBRD 18607 Putumayo (iii)

Rm-2s SMOSCINIGOTm PNDr lJWr

Selected Social ITdieam

O" Assme Middle Estimate Inpm Item 1960 1970 (1912-) IxG

E Per Capita (W) 270 440 1460 Adit 2109 Liteacy late (1) 62.5 SD.Ba 81.0 79.5 bIaaim & vital Statistics:

Pb1elt, Mid-yar ('ow) 15754 2126 26865 im 1 atim m at motab 48 60 65 67 Pqedatm PROjectiua Plp. in Yer 2O (mil.) 37.5 Sttamy Pop. (,dll.) 61J7 19ou1atie Dummity: Per sq. WA. 13.8 18.7 23.2 35.J PON Sq. m. ic. Ind 45 60.7 82. 92.4 Puatic GmOeth Rate ): Total 3.1 3.0 2.0 2.4 Uzbh 5.7 5.2 2.7 3.6 Oasd Birth Rate (Pm '000) 47.2 33.8 28.9 31.3 Cnue Duth Rate (Per 'OO) 17.4 9.7 7.4 8.1 ko"a Reliroe-tia- &ate 3.3 2.3 1.8 2.0 2otal Fartily late * 3.60 Phoily Pbusming: Aepatr, hmaal ('O0) 115.4 192.8 users (IZOf rie Wawa) 49.0 40.3 *=zried Wim Cil&aaring Age Uiiu Catraceptio ) * 49* Fbod mod Hatritimn:

Per Capita Supply of: Calorima of eynimemt) 96 87 108 In1 PrOtein. ((km per Day) 54 46 55 67 of iiii Ai & pal" 28 24 25(b) 34 HPmlth

Ufe apect. at Birth(yearu) 53.1 58.9 63.7 Infeut mortal. 64.7 Rate(er'000) 93.4 70.6 53.9 60.6 Child (ae 1-4) Dftth rate 11.2 6.0 4.0 5.7 Po'1mAcm Per Physicim 2640 2330 1710(e} 1918 Pbp. Pm 3xsiqt Prm 422D 730 0(c) Admisio 816 Per Hospital Bed 22.9 29.8 27.3 Pop. Per Hospital Bed: Total 360 450 580c) 367 mcbm 380 490f) 411 Rmual 2636 Access to Safe Water Pop): Total 30 63 64(d} Urm 65 55 88 73(d) 7X sal 7 28 46(d} 46 kcme Rmreta Disposal(Vop): Total 47 441d) 53 75 60(d 67 8 14(d). 25 Some: lHrld Awk Social Inicatore , Jam 1984. * Scet imrld Deselopmant Report 1964, Ma IWd1 1m (a}1973. 0}1977. c}1978. d01976. (iv)

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

GLOSSARY OF TERMS

Adult Literacy Rate: The percentage of persons aged 15 and over who can read and write.

Child Mortality Rate: Annual deaths of children 1-4 years per 1,000 children in the same age group.

Contraceptive Prevalence The percentage of married women of reproductive Rate: age who are using a modern method of contraception at any time.

Crude Birth Rate: Number of live births per year per 1,000 people.

Crude Death Rate: Number of deaths per year per 1,000 people.

Incidence Rate: The number of persons contracting a disease as a proportion of the population at risk, per unit of time: usually expressed per 1,000 persons per year.

Infant Mortality Rate: Annual deaths of infants under 1 year per 1,000 live births during the same year.

Life Expectancy at The number of years a newborn child would Birth: live if subject to the age-specific mortality rates prevailing at time of birth.

Maternal Mortality Number of maternal deaths per 1,000 births Rate: in a given year attributable to pregnancy, childbirth or postpartum.

Morbidity: The frequency of disease and illness in a population.

Mortality: The incidence of death in the population in a given period.

Neonatal Mortality The number of deaths of infants under 28 Rate: days of age in a given year per 1,000 live births in that year.

Prevalence Rate: The number of persons having a particular disease at a given point in time per population at risk, usually expressed per 1,000 persons per year.

Rate of Natural Difference between crude birth and crude Increase: death rates, expressed as a percentage.

Total Fertility Rate: The average number of children a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of average number of children per family. (v)

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

STAFF APPRAISAL REPORT

LOAN AND PROJECT SUMMARY

BORROWER: Republic of Colombia

EXECUTING AGENCY: Ministry of Health

LOAN AMOUNT: US$36.5 million equivalent.

TERMS: 17 years, including 4-1/2 years grace, at the standard variable interest rate.

PROJECT DESCRIPTION: The objectives of the project consist of: (i) providing basic health services including family planning for 3.7 million Colombians living in the poorest areas along the Pacific Coast; (ii) assisting 250 communities with access to piped water supply and to waste disposal; (iii) strengthening the rural water supply subsector through technical assistance to INS, and the preparation of a National Rural Water Supply Plan; (iv) introducing systemic changes in the organization and provision of health services through decentralization of service delivery and integration of all health activities at the lowest level; and (v) providing a cost-effective service delivery model covering 14% of the population which would be replicable to the entire sector. Achievement of these objectives would be supported by: (i) the construction and expansion of health care facilities, water systems and latrines; (ii) a training program; (iii) the implementation of timely information systems on service statistics and cost data; and (iv) a set of policy and research studies. The project is expected to reduce mortality and morbidity of women of childbearing age, infants and children, to increase contraceptive prevalence and to make significant changes in the way the health sector is organized and provides services. The project faces the risk inherent in the need for cooperation between several agencies that provide health, population and nutrition services, water supply, construction services, and equipment maintenance. This risk is being minimized through the strengthening of the regional management capacity, through technical cooperation by more developed to less developed health regions, by organizing the project into four geographic areas, each one headed by a coordinator, and by interagency cooperation agreements. (vi)

Smw OF PIuM (Nir ESMrOM

US$ (million)

% FRELI %TOIAL LOCAL FOREIG 1UTAL &SE BAE COSTS

A. PERSOEAL IEAL'IM CARE

Health Service Delivery 21.9 7.4 29.3 25 45 cammity Education 1.3 0.1 1.5 9 2 Pkintenance 0.6 0.8 1.3 59 2

Sub-Total PERSOAL HEALTI CARE 23.8 8.3 32.1 26 50

B. MIlWMDIN" L HA~LT SEMICES

Rural Water Supply Services 6.9 4.4 11.3 39 18 Vector Control 4.4 0.5 4.9 10 8 National Rural Water Supply Plan 1.4 1.1 2.5 43 4

Sub-Total ENVIVKE4!NTAL !EALIH S CVIES 12.7 6.0 18.7 32 29

C. IrrIrmaL DEVEMHENT

Sector Managment 3.7 0.8 4.5 18 7 Laboratory Support 1.0 3.2 4.2 77 6 Infoziution System 0.8 0.5 1.3 36 2 Research 3.6 0.1 3.7 2 6

Sub-Total I1STITUIMAI DEVEIPiM'r 9.1 4.6 13.7 33 21

Total MBSLINE COSTS 45.5 18.9 64.4 29 100 Physical Contingencies 1.5 1.6 3.1 53 5 Price Cctingncies 5.0 3.3 8.3 40 13

TOTAL PROJECT COSTS 52.0 23.8 75.8 31 118

Financing Plan

LCAL FOE1IG TUAL %OF (U -000) TUIAL

Organizations: World Bank 21.7 14.8 36.5 4&% Government 20.2 - 20.2 27%

Other: Supplier Credit - 9.0 9.0 } ISS 5.1 - 5.1) 25% User Fees 5.0 - 5.0}

TUTAL 52.0 23.8 75.8 100% (vii)

Estimated Disbursements

Fiscal Year

1986 1987 1988 1989 1990 1991 1992 ------(US$'000)------

Annual 2.0 3.3 5.1 7.1 8.2 7.0 3.8 Cumulative 2.0 5.3 10.4 17.5 25.7 32.7 36.5

Rate of Return: Not Applicable. COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

STAFF APPRAISAL REPORT

I. INTRODUCTION

1.01 A World Bank mission carried out a review of the health sector in Colombia and prepared a Health Sector Review (Report No. 4141-CO) issued on December 15, 1982. The sector issues identified concerned the equity, the efficiency and the effectiveness of organizing and delivering health care services. Equity referred to the wide disparity in health status across the country partly due to lack of coverage of primary health care and sanitation services. Efficiency and effectiveness could be increased through better use of existing resources, cooperation between MOR and ISS, decentralization of service delivery, improved maintenance of plant and equipment, and more emphasis on and support for preventive public health measures, such as potable water and environmental sanitation.

1.02 The Government agreed with the major conclusions of the report and prepared a health project to be considered for World Bank financing. The proposed project would be the first World Bank lending operation in Colombia which would be managed by the Ministry of Health. It would expand primary health care coverage to underserved areas along the Pacific coast and would benefit approximately 3.7 million peri-urban and rural poor. It would decentralize the planning, organizing, delivery and evaluation of services and involve the community. The Social Security Institute (ISS) would for the first time invest in health infrastructure to be owned and operated by MOH. The proposed project would enlarge maintenance workshops in regional hospitals, train staff for specific tasks, strengthen the rural water supply subsector, expand coverage of environmental sanitation to prevent water borne and fecally related diseases, strengthen the national laboratory network, and carry out a set of policy studies.

II. SECTOR STATUS

A. Population

2.01 Current and Projected Population. Colombia is Latin America's fourth most populous country. Its mid-1984 population is estimated at 28 million and by 2000 it is projected to have 37 million inhabitants. During the 1950s and 1960s it had one of the fastest growing populations in the world, with an average annual growth rate of 3.0%. However, declines in both fertility and mortality during the 1970s resulted in a present growth rate of approximately 1.9%, which is below the 2.3% average for Latin American countries and for upper-middle-income countries (Table 1 - Annex 1). -2-

2.02 Fertility. The total fertility rate (TFR) declined by 44% between 1960 and 1978, and was estimated to be 3.6 in 1983 for the total country and 4.3 for the proposed project area. Expected fertility differentials are observed: (i) fertility is much higher in rural than in urban areas, by a factor of over two to one (TFR = 6.0 versus 2.9); (ii) fertility is also higher among less-educated women and those in low-income households; (iii) the TFR is more than three times as high in the poorest as in the richest income groups (TFR about 6.0 versus 1.9); and (iv) the higher fertility among poorer women is accompanied by shorter birth intervals, higher infant mortality, and generally poorer health among mothers and children. Thus, there are still major segments of the population that are not experiencing fertility declines.

2.03 Contraceptive Prevalence. Although the percentage of women remaining single rose in the 1970s, changes in contraceptive prevalence affected fertility rates more than other proximate determinants of fertility. The 1969 National Fertility Survey found that 21% of women surveyed aged 15-49 who were married or in union were active users of contraceptives. In 1976, the Colombian National Fertility Survey found that the percentage of active users had risen to 48%. Since then the rate seems to have plateaued, as the 1980 National Contraceptive Prevalence Survey results showed 49% of women in union were using a family planning method (54% urban and 37% rural). Much of the increase in prevalence is credited to the subsidized family planning services for the poor provided by the Maternal and Child Health Program of the Ministry of Health and by PROFAMILIA, a private family planning association. The proposed project includes financing of a new National Contraceptive Prevalence Survey which would update the 1980 figures.

2.04 Mortality. As in most developing countries, Colombia's vital registration system lacks reliability. Table 2 in Annex 1 provides recent estimates of the crude death rate from 1970 to 1982 based primarily on the 1982 National Health Survey which suggest that the crude death rate fell below 7 per 1000 soon after 1978. In general, these estimates are somewhat lower than those of the National Statistical Office (DANE) and the World Bank. Variations among departments range from 9.5 (Guajira) to 4.5 (Atlantico). Similarly, the distribution of infant mortality rates range from 46 per 1,000 (Bogota) to 198 per 1,000 (Choco) live births. These geographic disparities are of special concern to national policy makers.

2.05 Age Structure. Declines in fertility and increases in life expectancy over the last 20 years have changed the age structure. The dependency burden (population below age 15 and above age 64) peaked in the early 1960s. In the late 1970s the proportion of children under 15 fell from 46.6% to 41.4% and is expected to fall to approximately 39% during the 1980-84 period. At present, life expectancy at birth is approximately 65 years for women and 62 years for men, up from the low 50s in the mid-1960s. -3-

2.06 Spatial Distribution. High rates of rural-urban migration have doubled the share of the population living in cities with 2,500 or more inhabitants from 30.9% in 1938 to over 60% currently. During the period from 1964 through 1973, the urban population grew at an average annual rate of 4.2%, whereas the rural population only grew by approximately 1% per year. The four largest cities (Bogota, Cali, Medellin and Barranquilla), each have more than one million inhabitants and together they account for one fourth of the total population.

2.07 Migration. Recent Bank estimates of net international migration indicate that emigrants exceed immigrants by approximately 260,000 annually, less than 1% of the total population. Immigrants tend to come from the Caribbean and Central America, and oil-rich Venezuela is the major recipient country for expatriate Colombians.

B. Health

2.08 Health conditions in Colombia show great inequalities between departments. Mortality and morbidity rates are extremely high in the poorest areas and are caused by limited or no access to basic health services and unsanitary environmental conditions.

2.09 Environmental Health. Although 60% of the population in Colombia has access to piped water, and 48% has sewerage connections, access to safe water in the proposed project area is limited to 10% for the dispersed rural population and only 15% have an adequate system for excreta disposal. These very poor environmental conditions cause high rates of water-borne and fecally-related diseases. Mortality rates for infants and children can be reduced substantially through removing environmental health hazards, especially provision of safe water, excreta disposal, liquid and solid waste management, and vector control. A major emphasis of the proposed project is on environmental health.

2.10 Mortality. Table 3 in Annex 1 presents primary causes of death for 1973, 1977 and 1981. Cancer, heart disease, strokes and homicides were the primary causes of death in 1981 for the population as a whole. For children under the age of one (Table 4 in Annex 1) the principal causes of death in 1981 were perinatal diseases, gastro-intestinal infections, acute respiratory infections, respiratory failure and nutritional deficiencies. Neonatal deaths (occurring within 28 days of birth) accounted for 47% of all deaths under age one in 1976, and a substantial proportion of these deaths could have been prevented by improved maternal health and nutritional status, better obstetrical care and child-spacing. The major causes of death for children ages 1 to 4 are gastro-intestinal, acute respiratory infections, and malnutrition (Table 5 in Annex 1). Mortality is lowest in the 5-14 age group where accidents are the leading cause of death. -4-

2.11 The leading causes of death among adults aged 15-44 are accidents and homicide. Mortality statistics for those over 45 indicate Colombia's transition towards a morbidity and mortality profile of a developed country. Tuberculosis and other infectious diseases have been eliminated from the five leading causes of death. Chronic degenerative diseases, principally heart disease, cancer and stroke, are now making increasingly heavy demands on the health system.

2.12 Morbidity. Gastro-intestinal infections and acute respiratory infections are the leading causes of disease in infants and children seen in ambulatory clinics (Table 6 - Annex 1). Morbidity data by geographic area are not available to demonstrate the different epidemiologic patterns that occur in the cooler highland and lower tropical and coastal regions, and the within-city differences. Some data are available however; malaria remains high at 390 cases per 100,000 inhabitants in 1983, and threatens 18% of the population. Yellow fever and dengue are significant problems in endemic areas, and hookworm is prevalent in tropical areas. The proposed project includes a vector control program and research on malaria.

2.13 Abortion is a major public health problem for women in their childbearing years. Illegal induced abortion remains prevalent, especially in the cities, and accounts for perhaps a quarter of maternal mortality. This practice led to the pioneering efforts in family planning delivery to the poor by PROFAMILIA, and by the Colombian Association of Medical Schools (ASCOFAME) in the 1960s and the subsequent MOR involvement with family planning. The persistent high rate of illegal induced abortion illustrates the unmet demand for family planning services in the lower income groups.

C. Nutrition

2.14 The nutritional status of the Colombian population has improved significantly since the mid-1960s. Anthropometry (measurement of weight and height classified by age) was used to characterize the nutritional status of children in representative sample surveys conducted in 1965-1966 and 1977-1980. The risk of morbidity and mortality increases significantly among children classified as severely malnourished by any of several anthropometric criteria. In 1965, below normal average height for age was documented and corresponding substandard weight for age. Average height for age had increased significantly by 1980 and there was a corresponding increase in weight for age. There was a significant reduction in the prevalence of malnutrition as defined by three commonly used criteria. Moderate and severe protein/calorie malnutrition, according to Gomez Classification, had declined by half among children under five and by a third among those between five and ten. -5-

2.15 The reduction has been more marked for moderate than for severe malnutrition. In 1965, 1.7% of children under five were severely malnourished, and this was still the case in 1980 in two of five regions of the survey, the Pacific and Eastern areas. This finding suggests that in 1980 there was still a subset of the population with severe nutritional deficiencies. Nutritional status has improved since 1965 with the exception of a small but significant group of seriously malnourished children. This secular trend reflects improved diet and living standards, the declining incidence of infectious disease, vaccinations, and better health care. However, in the proposed project area, about the poorest in the country, about 2% of children under five are severely malnourished, and 19.4% have some degree of malnutrition.

D. The Health Care System

2.16 Physical Infrastructure. Colombia's health sector is divided into three major parts: (i) the public health sub-sector; (ii) the social insurance sub-sector, including the Social Security Institute (ISS) for private employees, CAJANAL for public employees, and some funds targeted for specific areas and groups; and (iii) the private sector. Currently, 77% of the population has some access to health services, and 23%, or 6.2 million people, are estimated to lack coverage. Of the 77% with coverage, the public sector accounts for 52%, the social insurance subsector for 15%, and the private sector for 10%.

2.17 The public health subsector has by far the largest service network of health facilities with 638 hospitals containing about 30,000 beds and around 3000 health centers and posts. The bed/population ratio for the health regions in the proposed project is 0.66 per 1,000 (Table 7 - Annex 1) which is one third of the national average of 1.7. More than half of the health centers and posts require remodeling and expansion.

2.18 ISS owns 37 hospitals with 4,200 beds, but contracts beds in 155 MOH and private-sector hospitals, and has a network of about 50 basic care centers (CABS). Eighty-five percent of ISS beneficiaries are in the four largest cities, but only 10% of families have all their members covered. ISS has recently embarked on a program to extend full health coverage to spouses and children up to 18 years of age and to rural agricultural workers. About one out of ten families served by ISS now has full coverage.

2.19 The private sector consists of 190 small hospitals with a total of about 9,000 beds, of private office practices, and of laboratory and radiology centers. Approximately 10% of the population can afford the cost of private services. -6-

2.20 Maintenance of Buildings, Equipment, and Vehicles. Difficulties in attracting and retaining trained technicians, reductions in operating budgets, and the large variations in makes have impeded preventive and corrective maintenance. A substantial proportion of the medical equipment -- bought on credit or received as donations from bilateral sources -- is not being used because it has not been installed, it cannot be repaired, it lacks technicians to operate, or spare parts are not available. The project would assist in correcting this situation.

2.21 National Network of Laboratories. MOR established the national network of laboratories in 1977 in order to integrate all public health laboratories into a coherent system. It was envisaged that at the central level a national reference laboratory would set standards, train specialized staff and provide technical assistance to departmental and regional laboratories in the areas of clinical diagnosis, environmental health, food and drug control and communicable disease control. Some progress has been made in the first seven years of its existence towards the goal of an integrated network. Major constraints are: shortage of trained staff, lack of equipment, materials and supplies, and of equipment maintenance; the uneven quality and development of departmental laboratories; and the lack of a well-organized central level. These weaknesses result in poor quality diagnostic work, inability to perform basic tests at the lower levels with attendant unnecessary and expensive referrals to higher levels, lack of supervision and control of standards, and importation of some medical supplies that could be produced in the country. The proposed project would address these issues and seek to improve the efficiency and the quality of the laboratories.

2.22 Organizational Structure. The public sector (MS/SSS) has three levels: national (MOH and its five decentralized institutes), departamento equivalent to a state or province (SSS), and regional or health region. (See Chart 2.) The national level consists of the Ministry of Health in Bogota and its five decentralized institutes: (i) the National Institute of Health (INS) which is responsible for water supply and sewerage in towns with up to 2,500 inhabitants, for production and control of vaccines, for laboratory quality control, and for special research studies (See Chart 3); (ii) the National Municipal Development Institute (INSFOPAL) which handles water supply and sewerage for larger towns; (iii) the National Hospital Fund (FNH) which allocates funds for, and approves and supervises, hospital investments and maintenance; (iv) the Family Welfare Institute (ICBF) which is responsible for a national pre-school nutrition program, child-care facilities, and for the protection of minors; and (v) the Cancer Institute. INS, INSFOPAL, and FNH budgets are approved by the Minister of Health, but the agencies are managed autonomously without formal coordination with MOH staff or line units. The lack of coordination between INS, INSFOPAL and other sections in the Ministry results in less joint planning of primary health care and water and sanitation improvements than desirable. ICBF is the most autonomous of the five decentralized agencies. -7-

2.23 Water supply and sanitation in Colombia is under the responsibility of MOH, which in coordination with the National Planning Department formulates national sector policies. In the larger cities, autonomous municipal companies plan, build and operate water and sewerage systems. In most small and medium-sized towns and cities, water services are administered by sanitary works companies which operate on a department-wide level. These companies are owned and, in conjunction with departmental authorities, controlled by INSFOPAL. In rural areas, INS through its Division of Basic Rural Sanitation has the responsibility and legal mandate to promote, plan and execute water supply systems in communities with less than 2,500 people. In the economically stronger departments (e.g., Valle, Cauca, and Antioquia) the functions of INS with respect to rural water supply have been delegated by contract to Departmental Health Services (SSS) which are responsible for health service delivery, water and sanitation. At the national MOH level, the Directorate of Environmental Sanitation assumes responsibility for providing safe water and sanitation services to dispersed rural populations and native Indians. There are other public and private institutions involved in the water sector development. Among these are, most notably, the National Coffee Growers Committee and departmental governments and development corporations. In the past, these organizations have accounted for about 20% of total sector investments. They are dominant in some areas, e.g. the Coffee Growers Committee in the coffee producing regions. The presence of many organizations in the water sector causes jurisdictional, technical and budgetary disputes. The competition between the Basic Rural Sanitation Division of INS and the Environmental Sanitation Division of MOH has been harmful to rural sector development in the past. The proposed project would strengthen INS and its Division of Basic Rural Sanitation charged with rural water supply development, and would be the basis for a national development of the subsector.

2.24 The provincial level comprises 33 departments (SSS), which implement the national health policies. At this level, overall policy is vested in a departmental health board, the members of which include the governor, health-related agency representatives and citizens. Policy matters and overall internal management are the responsibilities of the SSS director, appointed by the governor and supported in day-to-day management by a technical coordinator who is generally a career officer. The three operational units are for medical care, environmental sanitation and administration. A similar structure operates at the regional and local levels, which are managed respectively by regional and local hospitals designated as headquarters. There are 107 health regions in Colombia. The health regions supervise and coordinate the activities of 97 regional hospitals, 470 local hospitals and around 3,000 health centers and posts.

2.25 The social insurance sector consists of over 100 social insurance institutions which provide health care for salaried employees of private and public sector enterprises that are sufficiently large and formally organized to permit regular payroll deductions and employer contributions. The Social Security Institute (ISS) is the largest and is part of the -8-

Ministry of Labor. It covers 10% of the population and is financed by the employer and the employee who together contribute 7% of the payroll. All other social insurance schemes, such as those for the police and military, cover 5% of the population.

Organizatioo of the

National Health System

COLOMBIA

inistry of Health

33 Departmental Health Services (Seccionalee)

107 Health Regions (Regionals)

470 Local Hospitals

3,000 Health Centers and Health Poets

E. Health Care Financing

2.26 Total public and private spending for health accounted for 4.9% of GDP in 1981. MOH shows the sources of institutional financing of the total Colombian health sector to be as follows:

Sources of Health Sector Financing, 1983

Employer/Employee Contributions 21.6% National Budget 22.9 Departmental Budgets 9.6 Municipal Budget 0.9 Sale of Services 18.5 Other Sources 26.5 TOTAL 100.0% mum=== M= -9-

2.27 Income from beer and liquor taxes, and from lotteries are included in the department and municipal sources. Sale of services are primarily derived from the beneficiaries of the multitude of "caias" or social insurance schemes and from the private sector. One sixth of the user fees are collected in the public sector. Other sources include returns on investments, leasing of property, donations, endowments, external credit, and other miscellaneous sources.

2.28 The amounts allocated to each subsector do not equal the expenditures of that subsector because subsectors purchase services from each other. This is mostly the case with social security schemes which lack specific services in their own system and, therefore, buy these services for their beneficiaries from other providers. The table below shows that the public sector is allocated 32.7% of the total health sector budget but spends 40.9% because it sells services to the social insurance programs. The Social Security Institute, on the other hand, receives 29.0% but spends only 24.4% on its own service delivery systems. The difference of 4.6% is spent on the purchase of services from the public and private sectors. These intra-sector purchasing arrangements are efficient because they minimize duplication of equipment, facilities and personnel. The proposed project encourages these practices and strengthens them through investment by ISS in MOH facilities, and through ISS increases in the amounts of purchased services.

Share of the Health Sector Budget Allocated to and Used by Each Subsector, 1981

Allocation Use

Public Sector 32.7% 40.9% Social Insurance Schemes Social Security Institute 29.0 24.4 Other Insurance Schemes 28.8 23.9 Private Sector 4.9 6.2 Other Ministries 4.4 4.5

TOTAL 100.0% 100.0%

2.29 Per capita expenditures for health care in 1981 were US$31 for the population covered by the public sector. Average health expenditures per person for the population covered by social insurance schemes were roughly four times that amount, (US$ 120). Differences in the range of services provided by the two sectors make strict comparisons impossible. However, they indicate inequity in the distribution of health care resources. -10-

F. Health Manpower

2.30 Physicians. In 1984, there were over 23,000 physicians practicing. This is triple the figure in 1966, and the country may not be able to absorb the 1,500 physicians graduating each year. This is evidenced by a shortage of places for the internship year; increased competition in private practice a growing scarcity of positions in ISS and the SSS, which together provide the bulk of physician employment; and underemployment and unemployment in large cities. Quantity is not synonymous with equity however, as close to 70% of physicians practice in cities and departmental capitals, where approximately 40% of the population resides.

2.31 Colombian schools of medicine have tended to emulate the medical curricula of industrialized countries, notably France and USA. Physicians are trained to provide sophisticated care to individual patients. The graduates are generally capable clinicians, but their skills do not match the needs of rural communities where major health problems result from poor nutrition and faulty public health practices, where human and material resources are scarce, and the demand for service exceeds the availability of physicians as health care providers on an individual basis. A policy study in the proposed project would analyze the demand and supply of physicians, and would review the appropriateness of the medical curriculum.

2.32 Professional Nurses. Nurses with a degree or licenciate (which is obtained after four years of university) have never been numerous in Colombia. In 1982, only 5,000 nurses, or one per 5,500 inhabitants, were believed to be practicing and they prefer to work in cities. Training emphasizes clinical care, though few are trained in midwifery, and most occupy administrative positions in large hospitals.

2.33 Auxiliary Nurses and Nursing Aides. In 1982 there were approximately 17,000 auxiliary nurses and 15,000 nursing aides. The number of auxiliary nurses more than doubled since 1970. Auxiliary nurses have been for many years the backbone of services provided in rural health posts and centers. Because of the severe nursing shortage, auxiliary nurses fulfill most of the nursing needs in local, regional and university hospitals. After 18 months of professional training, they carry out the following tasks: (i) instruct, supervise and evaluate the health promoters in their units; (ii) evaluate pregnant women, refer high-risk cases, attend deliveries; (iii) monitor growth and development of children under 5; (iv) administer vaccinations; (v) solve simple medical problems, e.g., diarrhea, respiratory infections, intestinal parasites, skin rashes, cough, fever, etc.; and (vi) teach the community about health subjects such as family planning, vaccination, environmental sanitation, etc. Experience in several departments (Caldas, Valle, Antioquia) has shown that they are able to carry out these tasks satisfactorily. The auxiliary nurse would be an important health resource to implement the proposed project and, 160 would be recruited for the project area or an increase of 10%. -11-

2.34 An estimated 15,000 nursing aides with no formal training have acquired a variety of nursing skills, including deliveries, and become increasingly valuable with experience and in-service training. A small proportion eventually become auxiliary nurses.

2.35 Health Promoters. Health promoters are women trained for three months, assigned to villages surrounding their homes, and supervised by auxiliary nurses. There were about 5,000 practicing health promoters in 1982. They perform the following tasks: (i) evaluate pregnant women and refer high-risk cases; (ii) attend normal deliveries; (iii) inform couples about family planning; (iv) nutritional surveillance of pregnant and lactating women and children under five; (v) solve simple medical problems; (vi) obtain blood samples to detect malaria and sputum samples to detect tuberculosis; and (vii) coordinate with the sanitation promoter to expand utilization of latrines, provision of potable water, and appropriate disposal of wastes to combat water borne and fecally-related diseases. As a member of the community she serves, the health promoter takes the service to the people, involves the community in health actions, and is the most important preventive health care provider. Experience in several departments has been positive and shown that the health promoter is capable of carrying out these tasks. GOC's policy is to extend the use of the health promoter. The proposed project would double the number of health promoters in the project area.

2.36 The Sanitation Promoter. In 1981 there were about 1,800 sanitation promoters. These are males who follow a six month theoretical training program, followed by field work, and an additional three month formal training program. They are based at the health region and visit communities to perform the following tasks under the supervision of sanitation technicians or sanitary engineers: (i) organize the community, in coordination with the health promoter, to improve environmental health conditions; (ii) supervise maintenance of water supplies and control of quality of water; (iii) control sanitary disposition of excreta to arrest fecal contamination of water, food and soil through installation of latrines; (iv) control liquid and solid waste disposal facilities to avoid water contamination; (v) control the safety of food, water and milk through sampling and testing; (vi) control zoonoses through catching and/or vaccinating suspected biting animals; and (vii) control insects and rodents to reduce vector-borne diseases. Sanitation promoters as community members play a crucial role in organizing the population for a cleaner environment through their own efforts. However, their insufficient number and the absence of consistent supervision have limited the full realization of their potential benefit. The proposed project would increase the number of sanitation promoters in the project area from 240 to 360, train supervisors and allocate vehicles for supervision and for promoter transportation.

2.37 A major objective of the Government's program is to decentralize the health system and encourage self-help and community-oriented approaches to health care delivery. The auxiliary nurses, and the health and sanitation -12-

promoters are crucial to the achievement of the program. The proposed of health workers project reinforces that program and these three types are three-fourths of the proposed project's additional staffing.

G. Health Information Systems

data 2.38 The public health sector collects a large amount of detailed on numerous forms. Data collected are not converted into useful and timely information and are not checked for reliability and consistency. management the Data are aggregated at the departmental level which does not benefit support the establishment regional decision-maker. The proposed project would of a management information system which would first serve the planning and control needs of the local and regional level, add financial indicators, and aggregate data at that level before passing it on to the next higher level.

H. Research

2.39 The highest research authority in the country is the National Council for Science and Technology (CNCT) chaired by the President. The CNCT includes a Health Committee chaired by the Minister of Health; (INS). its Secretary is the Director of the National Institute of Health The Research Division within INS coordinates all Government financed health research and liases with non-governmental research institutions. services Colombia is one of the leading Latin American countries in health research research which is mostly carried out in academic institutions and the institutes. The economic crisis has decreased research support in last five years and research output has fallen dramatically. For example, in national fertility and contraceptive use surveys were carried out 1987, and would 1976, 1978, and 1980, but the next one is planned for efficiency be partly financed through the proposed project. Studies on the hospitals were and productivity of university hospitals and regional carried out in the late 1970s but this line of research has not been eradication continued. Research on malaria would better focus the malaria campaigns. The proposed project supports work on key policy topics, such as health care financing, contraceptive prevalence, and sector efficiency. -13-

III. KEY SECTOR ISSUES

A. Lack of Coverage

3.01 About 6.2 million Colombians are estimated to lack access to basic health services, including family planning, and to safe water and sanitation services. The absence of basic health care in parts of Colombia (especially the Pacific Coast and the National Territories) is reflected in these regions' high mortality, morbidity, and fertility rates. Primary causes of excessive death and disease in infants and children are related to poor environmental conditions, especially absence of safe water, excreta disposal, liquid and solid waste management, and'vector control. Immunization rates are low and malnutrition affects one out of five children. Total fertility rate of the peri-urban, the rural, the dispersed rural and the native Indians is well above the national average for lack of service availability.

3.02 The Government wishes to eliminate the inequity in access to basic services for the poor and has already launched a number of programs to reduce and, ultimately, to eliminate the regional disparities and inequities. In 1982, it selected the Pacific Coast area and the border zones for accelerated multisectoral economic and social development. In 1984 it completed a national vaccination campaign and immunized almost one million children against five diseases: measles, polio, diptheria, whooping cough and tetanus. The mass campaign is now being evaluated. With some additional assistance, these diseases can be substantially reduced as a public health problem. In June, 1984, a Ministerial decree established an advisory group to coordinate all primary health care activities and assigned specific responsibilities for expanding primary health care to the whole country. A national program for child survival was launched in late 1984, and contains an innovative strategy consisting of organizing the nation's youth to assist in high priority infant health programs. A youth task force of health sentinels, principally high school students, is being created, and will educate families in the prevention of the leading childhood diseases.

3.03 Government has taken a number of initiatives to increase coverage to the underserved and unserved segment of the population. Faced with the massive tasks of reducing mortality, morbidity and fertility to acceptable levels within 10 to 15 years, it has requested external assistance to meet its goals. The proposed project would concentrate on the Government's designated priority areas. It would assist the Government in expanding coverage of maternal and child health care, immunizations, family planning, oral rehydration, and malaria control to the lowest income groups in- those areas. -14-

B. Sector Deficiencies

3.04 The major sector deficiencies are: (i) a highly centralized decision-making process and service delivery system; (ii) the duplication of health actions between ISS and MOR; (iii) the neglect in the maintenance of plant and equipment; (iv) the absence of a coordinated effort to develop and maintain rural water supply systems and sanitation services; and (v) the lack of cost information and cost control.

3.05 In the Government's 1983-86 National Health Plan the health region is designated as the key organizational unit responsible for planning, organizing, delivering and evaluating primary health care services; therefore, the Plan would decentralize decision-making on type and contents of programs, and on service delivery to the lowest administrative level, and at the same time maximizing the potential for community involvement. A 1984 Presidential decree created a "Technical Committee of Coordination and Integration between ISS and MOH" and task forces have already provided the Committee with programmatic and geographic areas where integration and/or coordination of health interventions are feasible. A change in management at the National Hospital Fund (FNH) responsible for plant and equipment maintenance, and a planned strengthening of its human and technical resources has started the process of protecting the country's large investment in equipment and facilities. INS and MOH have signed a letter of agreement specifying their respective responsibilities in the provision of water and sanitation services, and cooperative mechanisms have already been created.

3.06 To put these sectoral changes into effect will be a gradual and slow process. The requested external assistance would act as a catalyst for more rapid change. The proposed project would assist the Government in strengthening and carrying out its plans for reducing these sector deficiencies.

C. Management Weaknesses

3.07 A partial cause of the lack of coverage and a major contributor to sectoral inefficiencies are poor management structures and practices. Weak logistical support systems disrupt the flows of drugs and supplies, and of spare parts. Defective maintenance of vehicles decreases the frequency of supervision. The lack of cost data and late information on service statistics severely limit planning and control of service programs. The appointment of clinical specialists, without management training, does not provide the health region with capable managers. Health services research must be operationally oriented in order to guide decisions on programs, activities, and tasks. A major flaw in primary health care in Colombia is the managerial weakness of the health -15-

region in terms of leadership, supervision, management information, train- ing of the right mix of staff, cost accounting, and means of transportation.

3.08 Government has diagnosed management weaknesses as a serious constraint to sector development. It has started a program based on the fact that good management needs trained managers, effective management systems, timely information, good communication, and regular supervision. Managers of health regions must now be physicians with a graduate degree in public health, which includes management training. Government's policy is to promote self-help at the health region level with direct participation of the departments and health regions involved. It proposes to implement this policy through stronger departments and health regions helping the weaker ones. For the proposed project, it has appointed four managers to manage four nuclei of about five health regions each and has identified in each nucleus a lead health region to assist the institutional development of the other health regions. Government has requested technical assistance and support of training programs to implement these policies. The necessary expertise is not available in the country and no other donor agency has indicated interest or willingness to assist.

3.09 The decentralization of service delivery authority to the health region level and the strengthening of management systems and practices at that level would overcome a major management weakness. The proposed project emphasizes institution building through the provision of technical assistance and specialist services, the establishment of cost accounting systems at the service delivery level, training of lower level staff, a program of research studies, and the strengthening of information systems.

IV. THE BANK'S ROLE

4.01 Bank assistance strategy in Colombia includes a broad-based effort to support agriculture, industry, infrastructure, power, and selected social projects. The latter include support for education, water supply and sewerage, nutrition, and health services at least cost.

4.02 Past Bank Assistance. Health components were included in the Integrated Nutrition Improvement Project (Ln. 1487-CO) and the two Rural Development projects (Ln. 1352-CO and Ln. 2174-CO). All three projects assisted in the introduction, consolidation or expansion of primary health care in rural areas previously underserved. A network of primary care units (UPAs) brought preventive and simple curative care to a significant number of rural poor. The Nutrition Project made the largest contribution through the building or remodeling and staffing of about 550 UPAs serving approximately 350,000 rural poor. The data collected were insufficient to quantify costs or benefits in terms of reduction in mortality and morbidity. The rapid expansion of UPAs outstripped the development of an effective management system to monitor progress, identify problems, -16-

conduct quality control and oversee the training and continued education of professionals and paraprofessionals. The key organizational flaw was the absence of delegated authority at the health region level.

4.03 Rationale for Future Bank Involvement. The proposed project would be the first Bank-supported health project in Colombia. There are several justifications for Bank involvement in the health sector. First, the project is in line with the overall strategy of World Bank assistance to Colombia. Second, there are serious health problems in Colombia which need to be addressed as a matter of high priority. Third, the shared concern of the Bank and Government for more equitable, efficient and effective provision of health services led the Government to request the Bank to carry out the health sector review and to the development of the proposed project. Fourth, the Bank has discussed sector strategy with MOB extensively during sector work and project preparation, and the Bank believes that the MOH approach to addressing its most important sectoral issues is a reasonable one. It is focused on extending coverage through decentralized and integrated health services delivery and on addressing sector-wide problems of efficiency. Finally, no other external assistance agencies are prepared to assist Colombia in financing a project which would take a comprehensive approach to improving sector efficiency. The proposed project reflects the findings of the sector review, the Government's health strategy, and the lessons learned from past Bank assistance. It aims to provide in selected underserved geographic areas: access to basic preventive and curative care, improved environmental health conditions, decentralized health care delivery, and more efficient use of existing financial, physical and human resources. In addition, the proposed project responds to GOC's desire to set the pattern for changes which can be replicated nationally and, thereby, have a long term impact on the health sector.

V. THE PROJECT

A. Project Summary

5.01 Project Goals. The goals of the project are: (i) expansion of coverage: to increase access to basic medical care and preventive health services including family planning, and to satisfy basic needs in water and sanitation for the disadvantaged in the project area; (ii) increasing sector efficiency: to decentralize programmatic decision-making and service delivery to the health region level; to increase intrasectoral coordination; to protect the investment in plant and equipment through proper maintenance; and to install cost-control procedures; and (iii) strengthening sector management: to effect changes in how health care is planned, organized, delivered and evaluated; to establish management systems to contain costs and decrease service unit cost; to train managers. and to improve supervision. -17-

5.02 Project Objectives. The goals stated above would be reached through: (i) strengthening 19 of the country's 107 health regions through improved management, infrastructure,-better trained staff and greater community participation in geographic areas where access to primary health care services is minimal or non-existent; (ii) expanding rural water supply coverage; (iii) increasing service delivery efficiency through improved cooperation between ISS, MOB, ICBF, INS and other entities active in the sector; (iv) improving the maintenance of plant and equipment; (v) developing information systems to support planning and control functions; (vi) reinforcing the national laboratory network; and (vii) conducting research studies relevant to operational problem solving and expected to have an impact on national population, health and nutrition policies.

5.03 Project Beneficiaries. Basic health services and access would be improved for approximately 3.7 million poor (13.6% of the population). Thirty percent of the target population would be peri-urban and 70% would be rural, dispersed rural and native Indian. Highest priority would be given to children under five and women in the reproductive age group. Forty percent of the population in the project area is 15 years of age or younger and approximately one third of this subset represents children under five. It is estimated that 80% of the project area population depends on the public subsector for health care while 10% avails itself of services from the Social Security Institute and 10% from the private sector.

5.04 Project Geographic Area. The seven selected departments (out of 33) and the two national territories form a continuous geographic area and are part of a disadvantaged area which has been targeted by GOC for accelerated multisectoral economic and social development. The project area, therefore, falls within the national priority plans. Four departments (Choco, Valle, Cauca, Narifo) encompass all the country's Pacific region and two abutting national territories (Putumayo, Amazonas) extend the area selected into the Amazon River basin. Two departments, Antioquia and Cordoba, border on the Caribbean, and one health region in Santander forms a logical extension of the Antioquia service area. Within these seven departments and two national territories a total of 19 health regions (out of 45) make up the project's geographic scope. They are the poorest and least developed areas and cover 396,000 square kilometers, approximately 34% of Colombia's total area. An additional four low-income health regions in four other departments and two health regions in the poor department of La Guajira will be provided with technical cooperation and training but no physical investments. These six extension points will be a stepping stone to the next phase of Colombia's integration of health services at the health region level.

5.05 Project Population Impact. It is estimated that the project would reduce the total fertility rate in the project area from 4.3 to 4.0. In order to achieve that target the contraceptive prevalence rate would be increased from about 37% currently to about 50% at the end of the project implementation period, or an increase of 35%. A monitoring -18-

system would be established to evaluate progress towards the stated target. The project would also finance the fertility component of the 1985 National Health Survey and the 1987 National Contraceptive Prevalence Survey.

B. Summary Project Composition

5.06 The project covers a proposed six-year implementation period between mid-1985 and mid-1991 with an additional 12 months for loan closing by June 30, 1992.

Component A : Organization and Delivery of Low-Cost Basic Health Care Services.

(i) The construction and equipping of 3 local hospitals, 7 health centers and 53 health posts;

(ii) The remodeling and upgrading of 8 regional hospitals, 29 local hospitals, 19 maintenance workshops, 27 health centers, and 53 health posts;

(iii) The provision of vehicles for health care services delivery and supervision;

(iv) The training of about 1200 health workers, mostly at the auxiliary nurse and health promoter levels; and

(v) Support through training for the community education/participation program.

Component B: Organization and Delivery of Basic Environmental Health Services.

(i) Construction, expansion or rehabilitation of piped water supply systems, including watershed protection and rehabilitation, and of school sanitary installations for about 250 communities;

(ii) Institutional strengthening of the Division of Basic Rural Sanitation in INS through the provision of equipment, technical assistance and training;

(iii) Preparation of a national rural water supply development plan;

(iv) Provision of vehicles, equipment and materials for installation of latrines, for the control of food and water, and for the control of zoonosis and vector borne diseases; and -19-

(v) Continuing education for sanitary engineers and training of sanitation promoters.

Component C: Institutional Development.

(i) Sector Management: strengthen organization and management of health sector institutions;

(ii) Research: carry out a set of project-related policy research studies;

(iii) Management Information Systems: establish and implement data systems to generate information for management decision making;

(iv) Laboratory Support: reinforce the national network of laboratories to increase the local diagnostic capability.

C. Detailed Project Description

Component A: Organization and Delivery of Low-Cost Basic Health Care Services.

5.07 Content of Basic Health Care Services. The project is intended to develop in each of the nineteen health regions the capacity for assessing its own health needs, and for planning, execution and evaluation of appropriate preventive and curative health programs. Basic health care would include the following programs in all project areas: (i) immunization; (ii) oral rehydration; (iii) maternal and child health care and promotion of breastfeeding; (iv) preschool nutrition and primary health care; (v) preventive and curative dental care; (vi) family planning; (vii) hypertension control; (viii) malaria control; (ix) simplified surgery; and (x) tuberculosis detection and control. (See Table 8 - Annex 1 for description of the 10 programs). The relative emphasis on each one of the above 10 programs would differ according to the specific health needs of the health region.

5.08 Construction and Equipment. In order to achieve the objective of delivering services to underserved areas, the project would support the cnstruction of 3 local hospitals for a totil of 70 beds at about 50 m per bed, 7 2health centers of about 180 m each and 53 health posts of about 80 m each. The designs for these facilities are ready and have been approved. It would also support the expansion and upgrading of 8 regional hospitals, 29 local hospitals, 27 health centers and 53 health posts. (Table 9 - Annex 1 presents a civil works schedule of health care facilities by location and site acquisition status.) Construction for health and sanitation represents about 26% of the total investment cost of which 66% is for new construction and 34% is for upgrading existing -20-

facilities and for site supervision. The construction and renovation of the health facilities would be accompanied by the upgrading of diagnostic and therapeutic tools. About 39% of total investment cost would be allocated to equipment, and equipment lists have been prepared. Construction and equipment decisions were guided by the efficiency criteria of maximizing the use of existing facilities and emphasizing simple and appropriate technology easy to use and maintain.

5.09 Maintenance of Buildings, Equipment and Vehicles. The maintenance capability would be strengthened at two levels, the national level (FNH) and the health region where the regional hospital's workshops would serve the needs of the health region. The project would: (i) carry out corrective maintenance of buildings and equipment as part of its upgrading program; (ii) require funds to be earmarked for preventive maintenance; (iii) train maintenance technicians through an agreement with SENA, the national training institute; (iv) enlarge and equip the maintenance workshops at 19 regional hospitals and assign staff to it; and (v) strengthen the institutional capability of the National Hospital Fund (FNH) through staff training and changes in the procurement process. A draft agreement between MOH and SENA for training of technicians was reviewed during negotiations and a signed agreement would be a condition of loan effectiveness.

5.10 Staffing. To expand the scope and the quality of low-cost basic health care services, about 1200 additional personnel would be recruited over five years. Half of this personnel would be health promoters and 13% are auxiliary nurses. Together with the other auxiliary personnel, they represent 85% of staff to be recruited (See Table 10 - Annex 1). This additional staff represents an increase of about 1.6% over the current total MOH staff and would redress the imbalance in availability of health manpower in the project health regions (See Table 11 - Annex 1).

5.11 Staff Training. The project would support: (i) management training, primarily for regional managers, physicians and supervisors; (ii) upgrading of professional skills at all levels; (iii) in-service training of primary health workers; and (iv) training/retraining and continuous education for maintenance workers. About 13% of total investment cost would be allocated to this category. (See Table 12 - Annex 1 for details of staff to be trained.)

5.12 Technical Cooperation. Trainers and consultants from academic institutions and from professional skills training institutes (e.g. SENA, CEADS) would provide assistance in the design of training programs and of in-service training for specific technical skills. Technical cooperation for training would be provided by Colombian universities and training institutes through agreements with MOB. Agreements already exist with the Universities of Valle, Antioquia, Nacional and Javeriana. Technical training agreements exist with SENA; and CEADS is part of MOR. -21-

5.13 Relationships with Other Service Providers.

A. Social Security Institute (ISS). Cooperation between MOB and ISS has been minimal, although slightly improving in recent years. The project would increase cooperation significantly in the project area, setting the pattern for actions at the national level. It would do so by: (i) ISS making a US$5 million contribution to constructing and equipping local hospitals; (ii) ISS agreeing to increase its purchases of inpatient care from MOB in the project area; (iii) ISS agreeing not to construct hospitals in the project area unless MOB shall otherwise agree; and (iv) improving coordination of preventive and promotive care in the project area. A draft agreement to that effect was reviewed.

B. Family Welfare Institute (ICBF). The ICBF is structurally part of MOB but financially independent of it. Its two major responsibilities are social protection of minors and nutrition. MOB and ICBF have been working to a large extent independently of each other. The project would initiate a process of collaboration between two organizations in the project area with a view to extending joint activities to the whole country. MOH and ICBF's methods of nutritional surveillance would be standardized and applied to all children under seven years of age. ICBF's regional office nutritionists (already trained in nutritional surveillance) would assist in training health promoters and auxiliary nurses in the utilization of growth charts as a tool to detect malnutrition and monitor child health. In addition, assignment of health promoters to ICBF preschool centers would establish an operational link between the MOB and ICBF. An immediate benefit would be the application of uniform techniques and the standardization of nutrition education materials.

Component B: Organization and Delivery of Basic Environmental Health Services.

5.14 Reduction of environmental health hazards complimented by health education to change behavior would contribute significantly to a decrease in mortality and morbidity in the project area. The project would stress the integration of a set of interventions to be carried out by MOR and INS in the same communities and with their active participation:

- the installation, expansion or rehabilitation of piped water supply systems in about 250 rural communities with current populations varying from 100 to 2,500 people; and the purchase of equipment such as vehicles, trucks, mobile promotion vans, and communication and audio-visual apparatus. These systems would be built by the Division of Basic Rural Sanitation (DSBR) of the National Institute of Health (INS), in the eight health regions where it is represented, and by SSS in the other eleven health regions, under the technical supervision of INS; -22-

- the preparation of a National Rural Water Supply Plan which would formulate strategies for accelerated sector development;

- the sanitary disposal of excreta through the construction of individual latrines and sanitary facilities in rural schools, and of liquid and solid waste through the availability of community disposal facilities;

- the bacteriological control of food and water by sanitary engineers and sanitation promoters;

- the surveillance and control of zoonoses, and vector-borne diseases by sanitation promoters and the communities; and

- environmental health education as part of community education in the basic health care services component.

5.15 On the average 40% of the project area's population now has access to safe water and sanitary excreta disposal. The figure is as low as 10% for the rural dispersed population. The rural water supply subcomponent would provide safe water to about 175,000 people who live in small rural communities throughout the project area. The project would support community initiatives through the provision of materials, supplies and technical assistance to promote self-help interventions to meet basic needs in safe water, waste disposal and control of insects and rodents. The sanitation promoters would be provided with basic equipment and vehicles to carry out their tasks and supervise community efforts. For rural water supply, INS has developed an effective system of promoting, executing and maintaining rural systems, using community participation in the initial construction and recovering part of the cost through user fees. In close collaboration with the MOH health regions concerned, INS would be responsible for finalizing: (i) the list of individual interventions; (ii) feasibility studies and designs; (iii) detailed cost estimates; and (iv) implementation timetables. The project would also finance a technical assistance program to, strengthen INS' institutional and operational capabilities and to prepare a National Rural Water Supply Development Plan. (Details of the rural water supply subcomponent are contained in the implementation volume and in Annex 2.)

5.16 INS would be responsible for implementing the rural water supply subcomponent under an agreement between MOH and INS, and would: i) apply the principles and procedures of the basic rural sanitation program; (ii) apply reduced design standards (design horizons, per capita consumption) and establish mechanisms for increasing the degree of cost recovery; (iii) upon completion of a water work, transfer the responsibility to the sanitation promoters for assisting the local water committees in the administration, maintenance, and operation of systems; (iv) carry out work that meets preestablished selection criteria of per capita costs, health needs, community participation and equity considerations. For subprojects exceeding US$100 per capita cost (mid-1985 prices) INS -23-

would present a special justification to the Bank; (v) start work on projects for which designs have been completed, community participation has been assured, and local counterpart financing has been secured; and (vi) give the Bank the opportunity to comment on its overall annual investment program for the following calendar year. GOC provided assurances during negotiations that it would comply with the above points.

5.17 The rural water supply subcomponent provides a vehicle for promoting the strengthening of INS capacity, for promoting greater reliance on local resources for water sector investments, and for preparing a national rural water development plan. It is an important first step for accelerated water sector development in the future. It also combines the technical expertise of INS with the local resources of the health regions such as logistical support, supervision of sanitation promoters, environmental health education, community participation, quality control of water, and maintenance of water supply systems.

5.18 INS would assist in training and retraining sanitary engineers and promoters, and provide technical assistance to the health regions' Divisions of Environmental Health for supervising construction, operation and maintenance of the project financed rural water supply systems. In the 19 project health regions, and over the eight-year period, the number of positions for sanitary engineers would be increased by 14 and that of sanitary promoters by 120 based on a needs analysis of each health region. Operation and maintenance of water supply systems will be the responsibility of the community in collaboration with sanitary engineers and promoters. INS would provide training to sanitary promoters in water system maintenance and operation and the sanitary promoters in turn would train the community.

5.19 Other environmental health actions mainly to be carried out by the sanitation promoter would be: (i) promoting the construction of latrines; (ii) in collaboration with the malaria eradication service (SEM) conduct home visits and participate in community education regarding vector control programs and, in certain areas, conducting spraying of public buildings and individual homes; (iii) inspecting the sanitation facilities and practices in schools, prisons, food establishments, and slaughterhouses; and (iv) educating the community on rodent control, distributing appropriate rodenticides and vaccinating domestic animals against rabies.

5.20 The Bank reviewed and found satisfactory INS'.detailed proposal including: (i) a list of equipment to be purchased and draft terms of reference for the technical assistance and research program and the National Rural Water Supply Plan; (ii) project implementation schedule; and (iii) detailed cost estimates and a financing plan. Also, assurances were obtained that GOC would: (i) by no later than September 30 of each year, present a rural water supply investment and project implementation program for the following calendar year; (ii) discuss the findings and recommendations of the technical assistance program and the national -24-

rural water supply study with the Bank; and (iii) meet agreed upon selection criteria for all water supply subprojects. GOC would also assemble and maintain for periodic review by Bank missions a file for each rural water supply subproject containing relevant subproject information.

Component C: Institutional Development.

5.21 This component includes four interventions designed to support the sector's institutional development and to contribute to the successful implementation of the two service delivery components described above. Strengthening sector management and research capability, and introducing an effective management information system would also have an impact beyond the project and affect national policies in health, population and nutrition. Similarly, the reinforcement of the national network of laboratories would increase the local problem-solving capability of the health regions and support one of the central project themes of greater local self-sufficiency. Implementation of these four sub-components calls for an effort in terms of training of national staff, either locally or abroad, and specialized technical assistance.

5.22 Sector Management. An important objective of the project is to strengthen the organization and management of the health sector with changes in the areas of strategic management, financial control, cost containment, improvement of the quality of health care services, and monitoring and evaluation. Three sets of training activities would take place during the life of the project and would be targeted to different audiences. One-week courses on management decision making would be organized for 216 upper-level executives of the MOH, its five decentralized institutes (INS, FNH, INSFOPAL, ICBF, Cancer Institute) and the Social Security Institute (ISS). Two-week courses on efficient resource management would be offered to 478 middle-level managers of the same institutions. Resource management would also be the topic of intensive seminars of six-weeks duration each, for 146 professional and technical staff of the same institutions. In addition to imparting specific knowledge and skills, these three types of courses would act as catalyst and facilitator to achieve greater collaboration among the many institutes making up the National Health System. The courses would be taught by universities and private firms experienced in working with other GOC ministries.

5.23 Planning and control systems would be created and implemented in the project area and the experience would be applied to other parts of the Ministry of Health, and, specifically, to the planning, finance, and information divisions. Technical assistance would be provided by consulting firms and universities and it is estimated that about 45 manmonths of local and 17 manmonths of international assistance would be required. Assurances were given that terms- of-reference for the proposed technical assistance would be submitted to the Bank for approval.

5.24 Research. The Directorate of Research of the Ministry of Health coordinates the execution of all Government-financed health research -25-

and liaises with non-governmental research institutions. Final approval of project- financed research topics, allocation of resources, control of execution, and evaluation of results would be under the authority of the project's General Coordinator advised by the project's Advisory Committee. Execution of the research component which accounts for 5% of project cost would be the responsibility of MOR in cooperation with INS, academic and non-academic research institutes, and would benefit the sector at large. The scope of the research effort would be national, departmental, or regional depending on the specific research study. Each major research project would have a technical review committee, with representatives from MOH, SSS, ISS and the Universities. Assurances were obtained that terms-of-reference including method of selecting consultants, timetable and fees, for all research proposals exceeding US$75,000 would be submitted to the Bank for approval, and that the research program would be reviewed on an annual basis.

5.25 Three research areas would be covered under the project, i.e. sector efficiency, population, and evaluation. (Detailed research proposals are in project files.) The priority topics agreed upon include:

- six studies related to sector efficiency: health care financing; pharmaceuticals policy; development of appropriate technologies in PHC; training and managing health professionals; equipment maintenance; and operational research at the regional health area level;

- two studies on population: the fertility component of the 1985 National Health Survey; and a national contraceptive prevalence survey;

- four evaluation studies: implementation of decentralized approach to health care delivery as being implemented; health status changes in project beneficiaries; incidence and prevalence of malaria on the Pacific Coast; and planning and control systems at the regional health area level.

5.26 Seminars and courses would be organized to upgrade staff skills in planning, management and implementation of research programs. These would include: three four-week courses on research methodology for a total of 60 persons; ten two-week workshops on research methodology and administration for a total of 200 persons; and eight one-week workshops on measurement, sampling, data collection and processing, and statistical analysis for a total of 160 persons. Technical assistance needs have been estimated at 36 staff-months and would be provided mostly by national sources; international technical cooperation would be limited to specific research topics such as health care financing and pharmaceuticals. -26-

5.27 Management Information Systems. Information for the National Health System is generated by the Ministry of Health's Information Division. Under the project the present Health Information System (SIS) would be strengthened to' serve the planning and control purposes of the project managers and about 2% of project cost has been allocated to this subcomponent. At the level of the health region, an Information Unit would be created to collect and aggregate data for local decision making. Regional information would be consolidated at the departmental level. The four departmental coordinators (CI) would receive copies of the departmental statistical reports which would be forwarded to the project's General Coordinator (see paras. 7.01 and 7.04). Regional MIS units would generate weekly reports for the regional managers, monthly reports for the departmental managers and departmental committees, and quarterly progress reports for the project's General Coordinator and the project director at the national level.

5.28 The project would provide for the training of 27 data input operators, 17 programmers and 36 systems analysts, through short courses organized at the central and regional levels. Thirty-seven manmonths of national and 8 manmonths of international technical assistance would also be required for: (i) analysis and design of the information system (6 m/m); (ii) design of the data bases (2 m/m); (iii) design of the communication network (2 m/m); (iv) definition of hardware and software needs (2 m/m); (v) analysis, coding, testing and execution of computer programs (30 m/m); and (vi) evaluation and maintenance of the information system (3 m/m). While national assistance would be secured from universities or the private industry, it is expected that external technical assistance would be obtained from WHO/PAHO or private consulting firms. The Government submitted terms of reference and technical cooperation sources for the 45 staff-months earmarked for technical assistance.

5.29 Laboratory Support. The National Laboratory Network of the National Institute of Health (INS) is responsible for the control of food (meat, milk) and drug quality, of environmental contamination (water, soil, air) and occupational health, and for the setting and the enforcement of national standards for clinical laboratories. The National Laboratory Network would provide effective support to all levels of the National Health System and would contribute to the strengthening of the diagnostic capability of the 19 health regions in the project area. This would increase efficiency through minimizing referrals to the departmental level and providing quicker diagnostic feedback. About 6% of project cost has been allocated for laboratory support.

5.30 During the first year of this subcomponent, priority would be given to strengthening the organizational structure, training operational and maintenance personnel, producing preventive maintenance manuals, establishing functional relationships between the national, departmental and regional levels, purchasing a minimum list of urgently needed equipment, and finalizing the detailed lists of equipment to be procured under the project. INS would appoint a full-time senior official to manage -27-

the first year's activities and supervise the preparation and implementation of the investment program of subsequent years. This manager would also be responsible for assessing future manpower requirements and preparing budget estimates to cover operating costs of the National Laboratory network. Six months of foreign and six months of local technical assistance would be provided during the first year of implementation. Project files contain a complete proposal for the total investment program.

5.31 This subcomponent would include 167 months for overseas training and about 250 staff would be trained locally. Duration and place of training would vary according to organizational level and the degree of specialization required. Training for the central level in Bogota would be longer, and some of it would be outside the country. Training at the departmental and regional levels would be typically of short duration (one week to one month), take place in the country, and be task-oriented. A detailed training plan has been prepared and is available in project files.

5.32 Technical Assistance and Fellowships. Specialist services would be provided largely by national consultants, and a limited amount from elsewhere for the establishment of the management information system, for specific research studies, for the organization of the national laboratory network, and for the development and the execution of training programs, and for strengthening the management of the project and MOR. About 178 manmonths of technical assistance would be required.

5.33 The project would finance overseas fellowships for training in the areas of health planning, health economics, emergency medical services, health information systems, hospital and health services administration, and medical education. A draft of selection criteria for overseas training, and a list of substantive training areas and the countries for project-financed fellowships was reviewed. The Government gave assurances that it would submit to the Bank by December 31 of each year during implementation, a list of proposed fellows and their training programs for the subsequent academic year.

VI. PROJECT COST AND FINANCING PLAN

A. Project Cost Estimates

6.01 The total cost of the proposed 6-year project, to be completed by June 30, 1991, is estimated at US$75.8 million equivalent, (including identifiable taxes and duties). Base costs are calculated at US$64.4 million equivalent and contingencies at US$11.4 million equivalent; the project's base costs with price contingencies on base costs amount to US$72.3 million. Overall, physical contingencies represent US$3.1 million; price contingencies, including the projected devaluation assumptions of the Colombian currency -28-

amount to US$8.3 million. The foreign exchange component (including contingencies) is estimated at US$23.8 million, or 31% of total project cost. The first component ("Basic Health Care") would comprise 50% of base costs, the second ("Environmental Health Services") 29%; and the third ("Institutional Development"), 21%. As regards the main categories of expenditure, civil works amount to US$14.2 million, or 19% of total project costs including contingencies; furniture, equipment, materials and vehicles represent US$23.8 million (31%), technical assistance, training and research studies, US$12.9 million (17%), and project administration US$3.2 million (4%); incremental recurrent costs generated by project imple- mentation over a 6-year period were estimated at US$21.7 million (29%). Detailed project costs are shown in Annex I and are summarized in the following table.

P Cor S-MW

Colombia Pes (Million) US$ (million)

2 TOTAL Z TOTAL 2 1054 uSE %FOEIG MSE ECAL 1YOMIt TVIAL MSE COS WCAL FOREIG TOTAL MSE COS A. PERSIAL IALM CARE

11alth Service Delivery 2,951.1 997.8 3,948.9 25 45 21.9 7.4 29.3 25 45 Cmaity Education 181.4 19.0 200.4 9 2 1.3 0.1 1.5 9 2 Maintmance 74.9 107.1 182.0 59 2 0.6 0.8 1.3 59 2

Sub-Total PEMVL SEAIM CAE 3,207.4 1,123.9 4,331.3 26 50 23.8 8.3 32.1 26 50 B. EIIU3qrA HEALT SEVICES

hural Water Supply Services 926.7 596.3 1,523.0 39 18 6.9 4.4 11.3 39 18 Vector Cotrol 589.8 62.4 652.2 10 8 4.4 0.5 4.8 10 8 National Rural *ter Supply Plan 194.7 148.2 343.0 43 4 1.4 1.1 2.5 43 4

Sub-Total ERVIEKA WA12H SMV1CZS 1,711.2 57.0 2,518.2 32 29 12.7 6.0 18.6 32 29 C. IlSITUTImL DEu r

Sector rAnnament 505.1 112.9 618.0 18 7 3.7 0.8 4.6 18 7 Laboratory SuPPort 130.5 433.8 564.2 77 6 1.0 3.2 4.2 77 6 Infommation Systes 112.7 62.5 175.2 36 2 0.8 0.5 1.3 36 2 pledsrch 478.8 7.7 486.5 2 6 3.6 0.1 3.6 2 6

Sub-Total flUlTUTICILm Ius 1,227.1 616.9 1,844.0 33 21 9.1 4.6 13.7 33 21

Total MU =13 6,145.7 2,547.8 8,693.5 29 100 45.6 18.9 64.4 29 100

Physical Contingencies 198.7 220.1 418.9 53 5 1.5 1.6 3.1 53 5 Price CrativEncies 4,754.4 1,849.9 6,604.4 28 76 5.0 3.3 8.3 40 13

1OML PKUE= OSTS 11,098.8 4,617.8 15,716.8 29 181 52.0 23.8 75.8 31 118

6.02 Basis of Cost Estimates. The costs of civil works are derived from current contracts for similar constructions in the project departments. Costs of equipment, vehicles, furniture and supplies are based on CIF unit prices or local market prices, adjusted to include installation (local transportation is provided by MOH vehicles). Costs of training, -29-

applied research, local and international consultants, overseas training fellowships and other services, reflect local or international rates as applicable.

6.03 Contingency allowance. Physical contingencies are estimated at 10% for civil works, equipment, furniture, and vehicles; overall they represent US$3.1 million, i.e. 5% of baseline costs or 4% of total costs. Price contingencies from 1985 to 1991 are calculated as follows: (i) local costs 20% in 1985, and 18% for subsequent years; (ii) foreign costs 5% in 1985, 7.5% in 1986, 8% from 1987 to 1990, and 5% thereafter; and (iii) moreover, a variable exchange rate has been used for each subsequent project year. The resulting amount for price contingencies is estimated at US$8.3 million, i.e. 13% of baseline costs or 11% of total project costs.

6.04 Foreign Exchange Component. The estimated foreign exchange component is US$23.8 million, i.e. 31% of total project costs. It is based on the expectation that: (i) all civil works contracts would be awarded to local firms, with an indirect foreign exchange of approximately 38%; (ii) most vehicles and equipment contracts would be awarded through ICB with an average foreign exchange of 75%; (iii) most of the furniture would be of local origin; (iv) a training component with direct and indirect foreign exchange of about 16%; and (v) that about 20% of technical assistance would be provided by foreign consultants.

6.05 Incremental recurrent costs generated by the project would gradually increase at constant prices from Col. Pesos 158 million (US$1.2 million equivalent) during the first year of implementation, to Col. Pesos 560 million (US$4.1 million equivalent) during the 6th and last year. In 1984, total public health sector recurrent expenditures were estimated at Col. Pesos 56,775 million (US$561.9 million). The above incremental recurrent expenditure generated by the project represents only 0.3% of that budget, and would grow to 0.9% by the last year assuming budgetary allocations for recurrent public health sector expenditures remain unchanged in real terms. These costs are small considering the relatively large increase in coverage to the underserved population which would benefit from access to improved services through the project -- the expense represents US$1.11 equivalent per capita at constant prices by the last project year. Assurances were sought that the Government would allocate the necessary incremental recurrent costs for the project.

B. Financing Plan

6.06 The proposed loan of US$36.5 million equivalent would finance about 62% of the foreign exchange component (US$14.8 million equivalent), and 42% of local costs (US$ 21.7 million equivalent). Foreign suppliers' credit would finance the remaining 38% of foreign exchange (US$9.0 million equivalent). The Bank loan represents about 50% of total project cost, -30-

net of taxes and duties. The Government would provide 27% of total cost including taxes, and 25% is anticipated to come from other sources shown below. A number of foreign equipment suppliers have already expressed interest in providing the necessary export finance. An agreement has already been reached between MOR and the Social Security Institute, and a legal instrument is being prepared on the latter's financial contribution to the project. For the project's water supply subcomponent, community participation and user fees will be important financing sources for capital and recurrent costs. It is estimated that cost recovery currently averages 60% of project cost for water supply investments. The degree of community participation and cost recovery would depend on the socio-economic capabilities of the beneficiaries which are generally very low in project areas. Assurances were obtained that GOC would require each beneficiary community to contribute on average 25% of total cost in the form of labor, materials, or land. In addition, each beneficiary community would pay on the average 50% of the remaining cost through a loan; however, the adequacy of such a cost recovery would be adjusted in order to improve cost recovery.

Financing Plan

ILEAL FPEGN TTAL %CF (US$'000) 1UTAL

Organizations: Wrld Bank 21.7 14.8 36.5 48% Government 20.2 - 20.2 27%

Other: Supplier Credit - 9.0 9.0 } ISS 5.1 - 5.1} 25% User Fees 5.0 - 5.0}

TUIAL 52.0 23.8 75.8 100%

C. Procurement

6.07 Procurement arrangements would be administered by FNH with the exception of the rural water supply subcomponent where procurement will be done by INS. The table below summarizes procurement arrangements: -31-

PROJECT

CGAEC3 ICB CB MiM (US$M)

I. CIVIL WDEKS

Health Service Delivery -- 5.3 2.1 7.4 (4.2 (1.7) (5.9)

5.2 6.8 ter Systems (1.4) (2.4) (3.8)

II. VECIES 1.8 0.5 0.2 2.5 (a) (0.2)' (0.2) (-) (0.4)

III. FLNITRE, EJIUER &MATERIAIS

Health Service Delivery 9.7 2.7 0.7 13.1 (a) (29), (2.4) -- (5.3) ater Systems 3.3 4.0 0.9 8.2 (2.7).' (2.6) - (5.3)

IV. RESFARCH SIDES - - 3.2 3.2. (3.2),/ (3.2)

V. TEXIICAL ASSISTAE -- - 2.6 2.6 (2.6) (2.6Y

VI. TRAINMl - - 7.1 7.1 (6.8)1 (6.8)

VII. AILIINISIATICK- 3. 3.2 S(.2)/ (3.2)

VIII. RBCTRR r COS -- -- 21.7 21.7 ______(-) (-)

MVTAL PDJ=r OOSI! 75.8

(Bank Financing) (36.5)

Note: Figures in parentheses are the respective amounts financed by the Bank loan. */ To be financed by suppliers credit for vehicles (US$2M) and equipment (US$7); such bid proposals would include finance arrangemEnts.

6.08 Civil Works. Most civil works are scattered in remote places of project areas and are too small to attract foreign contractors. Therefore, civil works contracts amounting to US$6.9 million equivalent, including contingencies, would be awarded following local competitive bidding provided that: (i) foreign contractors would have the opportunity to participate; (ii) bids would be opened in public; and (iii) there would be no restriction for the importation of building material. The balance of civil works estimated to cost about US$7.3 million for the construction and remodeling of small health facilities, maintenance facilities and of some water supply systems and sanitary school units -32-

in remote areas of difficult physical access where no contractor is interested in bidding at a reasonable price would be carried out by force account with community participation. A provision of US$0.2 million is also included for the supervision of civil works.

6.09 Goods. Vehicles and equipment estimated to cost US$14.8 million equivalent would be procured through international competitive bidding (US$5.8 million) in accordance with Bank guidelines and US$9.0 million would be financed through supplier's credits (bids would be presented with finance terms) as explained in para. 6.10 below. Qualifying domestic manufacturers would be given a margin of preference in bid evaluation of 15% or the applicable import duty, whichever is the lower. Out of the total for goods, equipment, furniture and medical supplies for small health facilities estimated to cost about US$1.5 million equivalent would be procured through UNICEF. Equipment, furniture and medical supplies which could not be grouped in packages of more than US$50,000 but totalling less than US$2.0 million would be procured through local competitive bidding to the extent that such procedures are satisfactory to the Bank. Contracts for miscellaneous goods amounting to US$10,000 equivalent or less, but not exceeding US$250,000 equivalent in total would be procured through prudent shopping (at least three price quotations).

6.10 Goods Procured through Supplier's Credit. MOR will organize detailed package lists of medical equipment and vehicles in an effort to attract cofinanciers. The Government, with Bank assistance as requested, would seek the broadest possible competition for supplier's credit and consider financing terms in bid evaluation. There is manufacturer and bilateral interest for the proposed type of goods. Presently, it is estimated that US$9.0 million equivalent would be financed through supplier's credits.

6.11 Invitations to bid would explain procedures for bid evaluation, including consideration for credit terms. The prices of all responsive bids, including credit terms, would be reduced to present value, using a preselected and announced discount rate. The contracts would be awarded to the lowest evaluated bid in terms of its present value. Contracts for which there would be supplier's credit would be totally financed by the supplier and the Government. The Bank would review, including instances where supplier's credit is being sought, notices of invitations to prequalify and to bid, bidding documents, bid evaluations and award recommendation, and proposed contracts. To ensure the timely availability of goods to be procured through supplier's credit, Bank supervision missions would review procurement packaging, considering economy, efficiency, quality, and timely availability of goods.

6.12 Services. The appointment of consultants and advisers would be done following procedures that are satisfactory to the Bank and in accordance with Bank guidelines. Terms of reference and conditions of employment of consultants and advisers as well as their qualifications would be satisfactory to the Bank. The selection of courses and candidates -33-

for the fellowship program would be submitted periodically to the Bank for prior review.

6.13 Bank review requirements. Bidding documents and contracts for the construction of the health facilities and maintenance workshops in excess of US$200,000 equivalent and all bidding documents and contracts for furniture, equipment, vehicles in excess of US$50,000 equivalent would be subject to the Bank's prior review of procurement documentation. This would amount to about 85% of the total estimated value of civil works, furniture, equipment and vehicles. Other contracts would be subject to post review by the Bank after contract award.

D. Disbursements

6.14 The project's closing date would be June 30, 1992, and would be disbursed in 7 years. It was agreed during negotiations that because of the advanced stage of project preparation, the implementation period would be six years, and disbursements in seven years. The Government intends to expedite the time frame for disbursements through the use of a revolving fund. It was also'agreed during negotiations that a special account would be opened for the project, with an initial deposit of US$2.0 million in Bank loan funds as well as a revolving fund in local currency equivalent to US$1 million by effectiveness. The Government would deposit an additional US$1 million equivalent in pesos by June 30, 1986. All expenditures financed under the loan would be channeled through the account. Meanwhile, standard Bank disbursement procedures would be followed. The Disbursement Schedule is presented in Table 15 - Annex 1. The proceeds of the loan would be applied as follows:

- 80% for civil works, including site supervision;

- 60% for civil works in water supply;

- 100% of foreign expenditures for directly imported equipment, vehicles, and materials;

- 80% of local expenditures for equipment, vehicles and materials;

- 100% of foreign expenditures of training abroad;

- 80% of local expenditures for training;

- 100% of expenditures for foreign and 80% of local technical assistance; and

- 100% of salaries and operating expenses for project administration. -34-

Disbursements for civil works carried out by force account, civil works for which contract values are less than US$50,000 equivalent, local training expenditures and salaries and operational expenses for project administration, would be made on the basis of statements of expenditures. Documentation for these expenditures would not be forwarded to the Bank but would be retained by the project unit and be subject to periodic review by the Bank. All other expenditures would be fully documented.

E. Retroactive Financing

6.15 The proposed project would emphasize institution building aspects in the public health sector and its success would depend to a large extent, on adequate manpower training. Consequently, to launch the project successfully and without delays, the Ministry started early in January 1985 with the appointment of the Departmental Coordinators, and some training and fellowships. Implementation plans for these activities were reviewed by the post-appraisal mission and were found satisfactory. Thus, it was agreed that retroactive financing would be provided up to a limit of US$3.0 million for expenditures made after January 1, 1985 for technical cooperation, training and fellowships, and for launching the project management unit.

F. Accounts and Auditing

6.16 The project coordinating office would establish and maintain separate accounts for the project in accordance with internationally accepted accounting procedures. The project cost includes salaries for 5 coordinators, 5 accountants, one at the central level, and 4 at the nucleus level located in the four project implementation areas. Technical assistance would be provided to establish the mechanism to monitor accounts at the regional and central levels. The accounting office would maintain separate accounts for project related activities, and prepare disbursement requests for the Bank. Accounts would be audited by the GOC Contraloria General and copies of the audit reports would be made available to the Bank within six months of the end of the fiscal year.

VII. PROJECT IMPLEMENTATION

A. Project Management

7.01 The MOH would be responsible for all project components. The Director General of the project would be the Minister of Health who would delegate project responsibility to the MOH Secretary General -35-

who is the highest level of technical authority within MOH. The Secretary General would be assisted in his tasks of Project General Coordinator by four regional coordinators (see para. 7.04). One of the regional coordinators is located in Bogota and would assume initially the additional responsibilities of assisting the Project General Coordinator. Project experience would show if there is a need to create a separate position for an Assistant General Coordinator. One accountant, two bookkeepers, a secretary and a driver would provide support services to the General Coordinator.

7.02 The MOH would delegate authority to the National Institute of Health (INS) for execution of two sub-components: (i) rural water supply; and (ii) laboratory support. For rural water supply, an agreement would be signed between INS and MOH whereby INS will be responsible for the planning, design and construction of water systems and sanitary school units and MOH will be responsible, through its local sanitary engineers and sanitation promoters, for operation and maintenance of the systems. The addition of sanitary engineers and the increase in the number of trained sanitation promoters would strengthen the maintenance capability at the health region level. Technical support would be provided by the departmental INS office. Additional details of the execution of the rural water supply subcomponent are contained in the implementation volume.

7.03 The National Hospital Fund (FNH) would be strengthened and would be responsible for the construction and equipping of health care facilities and maintenance workshops. Construction is mostly carried out by private contractors under FNH supervision, or by force account. FNH would ensure: (i) the timely preparation of all necessary bidding documents; (ii) the scheduling and organization of the bidding operation in coordination with local authorities; and (iii) the supervision of construction. FNH will also assist MOH in the commissioning of health facilities. Assurances were obtained that the required site supervisors and accounting personnel would be hired. Only 40% of the construction cost is for new health care facilities and the balance for upgrading existing ones. All new construction will take place in rural areas. Most sites have been identified and land donated by the community, and many sites are in the process of being legally transferred to the Ministry.

7.04 The project geographic area has been divided into four implementation units, called Comit4s Interseccionales (CI). The MOH would appoint a coordinator for each CI for the duration of the project who would report to the project's General Coordinator. The CI coordinator would be responsible for coordinating all project activities in his area. CI coordinators would be supported by an accountant, a secretary and a driver. The purpose of each nucleus is to provide horizontal technical cooperation among the health regions. To achieve that purpose, the selection of health regions within a nucleus assured the presence of the most developed and the least developed health regions. The more advanced health regions will serve as models and training grounds. -36-

This process has already been formalized by naming one of the health regions in each nucleus as a model. Provisions have been made in project cost to cover the travel and related expenses associated with this type of dynamic interaction among health regions.

7.05 Two advisory committees would be established: (i) at the Ministries' level to ensure coordination among MOB work units, INS, FNH, ICBF, ISS, INSFOPAL and DNP; and (ii) at the CI coordinator level to coordinate CI activities of participating departments.

7.06 Each of the 19 health regions has a director who is responsible for the management of all health activities in the health region. Training courses would be designed to strengthen the management skills of the health region manager and technical cooperation would be provided by national and departmental levels, and by more developed health regions to weaker health regions. Consultancy agreements already exist with major universities and training institutes. Under these agreements courses will be designed and offered, and technical cooperation provided.

7.07 Draft legal agreements between MOB and INS, and SENA were reviewed prior to negotiations. Presentation of these agreements in final form would be conditions of loan effectiveness.

B. Project Monitoring and Evaluation

7.08 Monitoring the progress of project implementation according to the project time schedule would be a main responsibility of the four nucleus coordinators who would consult with the regional managers and report to the General Coordinator. Evaluating the effectiveness of the project in achieving its objectives would be coordinated by the MOB Evaluation Unit in the MOB Planning Department supported by the evaluation research studies programmed under the research component.

7.09 The MOB Information Unit uses an unwieldy list of 164 indicators specifying their frequency of reporting and whom should be informed (Document in project file). This lengthy list has been reduced to a manageable number of 23 tracer indicators shown in Table 16 - Annex 1. The structure and process variables of these tracer indicators would be used to monitor project progress and physical implementation.

7.10 Two research studies have been specifically designed to measure project effectiveness. One study would monitor and evaluate the results of decentralized management in the 19 regional health areas with investment versus six regional health areas without additional human, financial and physical resources. The other study would measure health status changes in project beneficiaries in terms of prevalence and incidence of specific diseases. This study would also draw upon the Primary Health Care evaluation study financed under nutrition Loan 1487-CO and to -37-

be carried out by MOH in 1985. The outcome variables in the list of tracer indicators are another source of project evaluation.

7.11 The Project Director would be responsible for submitting semi-annual progress reports to the Bank and also for conducting an evaluation of the project after one and a half and three years of operation. Technical cooperation would be secured from outside the MOH. Assurances were sought during negotiations that GOC would submit semi-annual progress reports to the Bank and that the periodic evaluation would be conducted under terms of reference satisfactory to the Bank.

7.12 Targets for specific critical activities have been established and are listed in Tables 17 and 18 - Annex 1. Population targets in terms of women using family planning services by health regions are shown in Table 19 - Annex 1. These targets are based on the Government's quantified objective of reducing total fertility rate (TFR) from 4.3 to 4.0. The figures imply an increase in the contraceptive prevalence rate (CPR) from about 37% to about 50%. Other project targets are: (i) a 47% reduction in morbidity from gastro-intestinal infections in children less than one year and 54% in children between the ages of one and four; (ii) a 25% reduction in nutritional deficiencies in children less than one year and a 33% reduction for children between the ages of one and four; (iii) raising the immunization rates for measles, polio, DPT and tuberculosis to about 90% of susceptible children under the age of four; and (iv) decreasing the number of malnourished children between the ages of 0 to 4 by 23%. These health actions together with the improvement of the environment (potable water, waste disposal, vector control) would cause the infant mortality rates to drop sharply from the 70-90 range to about 40 deaths per 1,000 live births. Data collection forms to monitor the targets already exist and the information system subcomponent would strengthen the collection and reporting process.

VIII. PROJECT JUSTIFICATION AND RISKS

A. Project Justification

8.01 The ultimate outcome of the project would be to improve the health and nutrition status of 14% of Colombia's population with limited or no access to health services through a reduction of morbidity and mortality and an increase in contraceptive prevalence. A carefully planned system would be installed in 19 of the 45 regional health areas of 7 departments and 2 National Territories to improve efficiency and effectiveness in health services delivery and to extend responsibility for health to the community as well as the individual consumer of services. This model would then be introduced gradually to the rest of the country. -38-

8.02 Specific actions to increase efficiency are: (i) the decentralized system would give more authority and responsibility to the health regions in order to integrate their actions against all causes of morbidity and mortality; (ii) for the first time, parts of large cities -- starting with Medellin and Cali -- which have always had their own independent health services, would be integrated into the departmental delivery structure and process; and (iii) for the first time also, joint investments would be achieved between the Social Security Institute (ISS) and the Ministry of Health. ISS would finance the construction of health care facilities in exchange for services to be provided by MOH to its beneficiaries. More generally, the expected increase in the volume and value of services purchased by ISS would improve utilization rates of MOR hospital capacity.

8.03 The project would also be instrumental in collecting cost data through improvement of accounting systems and procedures at the regional health area level, strengthening the national laboratory network, and improving corrective and preventive maintenance of facilities and equipment.

B. Project Risks

8.04 The proposed health project would be the first project where overall responsibility rests with MOH, although this ministry was involved in the implementation of the primary health care and water and sanitation components of the Nutrition Project (Ln. 1487-CO). During implementation of that project, the MOH and INS accounts and auditing were not adequate, and insufficient supervision slowed down the civil works program and corresponding disbursements. These problems would be addressed in the proposed project through improved supervision and financial reporting, and an information component designed to strengthen project monitoring. For supervision of civil works, the project would provide 36.5 man years and 16 vehicles for site supervision. To improve accounting reporting, the project would hire five accountants and two bookkeepers for the duration of the project.

8.05 The risk inherent in decentralizing and integrating health services at the local level was reduced by limiting the number of health regions to be covered under the project. Moreover, the principal concepts have already been thoroughly tested, and have actually been implemented in the departments of Valle, Caldas, and Antioquia. Valle and Antioquia would provide leadership and technical support to less developed departments through the Technical Cooperation Nuclei.

8.06 A stepped-up program to expand coverage of basic health services, including family planning, could run the risk of meeting some resistance from rural and indigenous populations for cultural and social reasons. To counter this potential obstacle, half of the additional staff to be recruited during project implementation would be health promoters which must culturally and socially be part of the communities they serve.

8.07 The project also faces the risk inherent in the need for cooperation between several relatively autonomous agencies (MOH, INS, ISS, ICBF) and many -39- health regions. This risk is being minimized through the strengthening of regional management capacity, through horizontal technical cooperation within the four operational nuclei, and through technical assistance contracts with local universities, research institutions and specialized consultants.

8.08 Finally, the project would generate incremental operating costs arising largely from the extension of health services coverage to underserved and unserved areas. These incremental operating costs are small in relation to current budgets and were considered as acceptable by the Ministry of Finance, especially in view of the major benefits expected from the decentralized delivery model and the emphasis on efficiency as a model for the rest of the sector.

IX. AGREEMENTS AND RECOMMENDATIONS

9.01 The following were reviewed and agreed upon prior to or during negotiations:

(i) Draft agreements between MOH and SENA for training of technicians [para. 5.091;

(ii) Water Supply Subcomponent: list of equipment to be purchased, draft terms of reference for technical assistance, a project implementation schedule, detailed cost estimates, and a financing plan [para. 5.20];

(iii) Information Systems Subcomponent: terms of reference and technical cooperation sources for 45 staff-months earmarked for technical assistance [para. 5.28].

(iv) Training Subcomponent: selection criteria for overseas training, the list of substantive training areas and the countries for project-financed fellowships [para. 5.33]; and

(v) Draft agreement for cooperation between MOH and ISS (para. 5.13), and between MOH and INS, [para. 7.07].

9.02 During negotiations, assurances were obtained from the Government that:

(i) INS would employ reduced design parameters and would adopt and apply a more stringent cost recovery policy [5.16 (ii)];

(ii) INS would apply the agreed upon subproject selection criteria (priority, per capita cost) and not initiate the construction of subprojects without assured community participation and local financial support [para. 5.16 (iv) and (v)];

(iii) INS would give the Bank the opportunity to comment on its overall annual investment program [para 5.16 (vi)]; -40-

(iv) INS would, by no later than September 30 of each year, and beginning September 30, 1985, present an investment and project imple- mentation program for the following calendar year [para. 5.20 (i)];

(v) INS would discuss with the Bank the findings and recommendations regarding the technical assistance program and the National Rural Water Supply Plan [para. 5.20 (ii)];

(vi) GOC, through INS, would assemble and maintain for periodic review by Bank missions a file for each subproject containing relevant subproject information [para. 5.20];

(vii) it would submit for Bank approval terms-of-reference for technical assistance in sector management [para. 5.23];

(viii) it would submit for Bank approval terms-of-reference of all research proposals exceeding US$75,000 and review the research program annually with the Bank [para. 5.241;

(ix) it would submit for Bank approval a list of proposed fellows and their training programs for the following academic year by December 31 of each year during implementation [para. 5.33];

(x) it would allocate the necessary incremental recurrent costs [para. 6.05];

(xi) required site supervisors and accounting personnel would be hired [para. 7.03];

(xii) it would conduct periodic evaluations under terms of reference satisfactory to the Bank and submit semi-annual progress reports to the Bank [para. 7.11].

9.03 Conditions of loan effectiveness would be Bank approval of formal agreements between MOH and INS, and SENA, for implementation of project activities and establishment of project accounts [paras. 6.14, and 7.07].

9.04 Subject to the above assurances and conditions, the project constitutes a suitable basis for a Bank loan of US$36.5 million equivalent with repayment over 17 years, including 4-1/2 years of grace, to the Republic of Colombia. - 41 -

ANNEX 1

Sector Data

Table 1 Demographic Projections, 1980-2010 Table 2 Crude Death Rates, 1970-1982 Table 3 Primary Causes of Death in Colombia in 1973, 1977, and 1981 Table 4 Ten Most Important Causes of Infant Mortality in Colombia (1977-1981) Table 5 Ten Most Important Causes of Mortality in Children 1 - 4 Years in Colombia (1977-1981) Table 6 Most Important Diseases in Infants, Children, and Total Population Diagnosed in Outpatient Care, 1981-1982

Project Data

Table 7 Physical Infrastructure by Health Regions (1983) Table 8 Outline of Health Programs to be Organized in Project Area According to Local Priorities Table 9 Civil Works Schedule of Health Facilities and Site Acquisition Status Table 10 Additional Staff to be Recruited During Project Implementation Table 11 Health Manpower Resources by Region (1983) Table 12 Number of Health Services Providers to be Trained by Type and Length of Training

Project Cost Estimates

Table 13 Summary Accounts Cost Summary Table 14 Summary Accounts by Project- Component Table 15 Schedule of Disbursements

Project Monitoring and Evaluation Indicators

Table 16 Tracer Indicators for Monitoring and Evaluation Table 17 Provisional Service Delivery Targets Table 18 Targets for Project Area After 5 Years of Service Delivery Table 19 Women Age 15 - 44 at Risk of Unplanned Pregnancy and Number of Women using Family Planning Services at the Beginning and the End of the Project Table 20 Number of Children to be Vaccinated Annually in Project Health Area (In Thousands) Table 21 Number of Primary Care Units (UPAs) and Health Promoters Before and After Project Implementation in Project Health Area -42- ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 1: DEMOGRAPHIC PROJECTIONS, 1980-2010

1980 1990 2000 2010

Total Population 25,892 31,525 37,457 42,703

Labor Force Age (15-64) 14,775 19,138 23,915 28,994 11,746 Women of Reproductive Age (15-49) 6,339 8,285 10,190

1980-85 1990-95 2000-05 2010-15

17.3 Birth Rate per 1,000 Population 28.9 25.5 20.3 5.8 5.9 Death Rate per 1,000 Population 7.4 6.4 1.45 1.14 Rate of Natural Increase (Z) 2.15 1.91 1.41 1.11 Growth Rate (%) 1.96 1.82

SOURCE: World Bank, PUN Policy and Research Division, 1984 - 43 - ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 2: CRUDE DEATH RATES, 1970 - 1982

REGIONS 1970 1975 1980 1982

ATLANTICO

Atlantico 7.1 5.8 4.9 4.5 Bolivar 10.9 8.8 7.0 6.4 Cesar 11.4 9.1 7.3 6.6 Cordoba 12.5 9.9 7.7 6.8 La Guajira 19.3 14.7 10.8 9.5 Magdalena 11.5 9.2 7.0 6.1 Sucre 12.1 9.6 7.1 6.1 ANTIOQUIA

Antioquia 8.5 7.4 6.2 5.8 Caldas 9.9 8.0 6.6 5.8 Quindio 9.6 7.8 6.6 6.0 Risaralda 8.8 7.3 6.1 5.6 ORIENTAL

Norte Santander 10.8 7.8 5.8 5.0 Santander 10.3 7.7 5.7 5.0 CENTRO-ORIENTAL

Bogota 6.4 5.5 5.0 4.8 Boyaca 11.0 8.6 6.2 5.2 Cundinamarca 10.6 8.4 6.5 5.7 11.7 9.5 7.7 7.1 CENTRO-OCCIDENTAL

Huila 10.7 8.8 7.3 6.7 Tolima 11.0 7.8 6.1 5.4 PACIFICO

Cauca 12.9 10.2 7.8 6.9 Choco 19.3 14.7 10.5 8.9 Narino 10.7 8.7 6.7 6.0 Valle 9.1 7.4 6.1 5.7

Intend. y Comis 26.0 19.5 - -

TOTAL 10.1 8.1 6.4 5.8

;OURCE: National Health Survey and Alberto Bayona and Marda Ruiz, "La Mortalidad en Colombia: 1970 - 1982", 1982. - 44 - ANNEX 1

HEAM SERIIC IN1ATI4 FmmJT

TANE 3: PRIhAi CAUSES OF JEBI IN CaLOM A IN 1973, 1977 AD 1981

1973 1977 1981

RATE X RATE X RATE X % DIMG(MIS RANK MIMIL Z RAN M-LCK % RAK NILIMC

340 5.35 Intestinal infections lo. 991 11.3 10. 673 9.1 7o. 650 10.25 Cancer 30. 577 6.6 2o. 619 8.4 lo. 350 5.57 Acute respiratory infections 2o. 750 8.6 30. 533 7.2 6o. 480 7.53 Other heart diseases 40. 518 5.9 4o. 480 6.5 2o. 430 6.81 Ischemic heart diseases So. 448 5.1 5o. 475 6.5 30. 370 5.83 Cerebrovascular 6o. 398 4.5 6o. 423 5.7 4o. 290 4.5w Other accidents 8o. 336 3.8 7o. 289 3.9 8o. 370 5.81 Homocide - - - 80. 281 3.8 So. 250 3.4 - - - Chronic respiratory infections 7o. 394 4.5 90. 220 3.39 Other perinatal 100. 254 2.9 100. 213 2.9 90.

Nutritional deficiency 90. 323 3.7 - - - - 210 3.31 Hypertension - - - - 100.

SOCE: Coloubia - 1984 Health Diagnosis, W4I/PAH) and HE COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 4: TEN MOST IMPORTANT CAUSES OF INFANT MORTALITY IN COLOMBIA (1977 - 1981)

1977 1981

RATE X RATE X DIAGNOSIS RANK MILLION % RANK MILLION Z

Intestinal infections lo. 14.470 24.0 2o. 7.240 16.33

Acute respiratory infections 2o. 9.133 15.2 3o. 5.770 13.02

Other perinatal 3o. 7.355 12.2 lo. 7.650 17.26

Anoxia and hypoxia 4o. 5.590 9.3 4o. 5.640 12.74

Chronic respiratory infections 5o. 3.907 6.5 7o. 2.120 4.77

Avitaminosis/nutrition defic. 6o. 2.833 4.7 So. 2.500 5.64

Congenital malformation 7o. 1.906 3.2 6o. 2.150 4.86

Other bacterial infections 80. 1.603 2.7 80. 1.370 3.08

Meningitis 90. 1.383 2.3 90. 1.220 2.75

Whooping cough 100. 774.000 1.3 ------

Other metabolic diseases ------100. 780.000 1.75

SOURCE: Colombia - 1984 Health Diagnosis, WHO/PAHO and MOH COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 5: TEN MOST IMPORTANT CAUSES OF MORTALITY IN CHILDREN 1 - 4 YEARS w---w-= IN COLOMBIA (1977 - 1981)

1977 1981

RATE X RATE X DIAGNOSIS RANK MILLION 2 RANK MILLION 2

Intestinal infections lo. 1.629 23.2 lo. 840 16.84

Acute respiratory infections 2o. 1.054 15.0 2o. 730 14.80

Chronic respiratory infections 3o. 618 7.4 50. 320 6.50

Avitaminosis/nutrition defic. 4o. 454 6.5 3o. 420 8.41

Other accidents 5o. 327 4.7 4o. 390 7.87

Measles 6o. 282 4.0 6o. 270 5.37

Helminthiasis 7o. 241 3.4 100. 100 2.11

Whooping cough 8o. 181 2.6 ------

Meningitis 90. 179 1.6 7o. 150 3.11

Anemias 100. 164 2.3 ------

Other bacterial infections ------80. 120 2.50

Motor vehicle accidents ------90. 110 2.29

SOURCE: Colombia - 1984 Health Diagnosis, WHO/PAHO and MOH columA HEALTH SERVICES INnERATIO PRDJECT

TAKE 6: MUST IPUMAN DISEASES IN IMANS, CHIEREN, AND IUMAL POPULATION DIA0UED IN WFPATIENW CARE, 1981-1982

CmILDRNF < 1 YEAR (fl.E4 1 - 4 YEARS UEAL PCPUIATIG

CAUSES CAUSES CAUSES %

1. Intestinal infections 27.4 1. Acute respiratory infections 20.8 1. Other childbirth-related coplications 10.0 2. Acute respiratory infections 24.1 2. Intestinal infections 14.8 2. Acute respiratory infections 9.8 3. Skin infectis 7.5 3. Helminthiasis 9.1 3. Dental 9.7 4. Chronic respiratory codition 5.6 4. Skin infections 7.2 4. Genito-urinary disesse 9.4 5. Central nervous system 4.1 5. Chronic respiratory 6.3 5. Intestinal infections 7.0 6. Other viral infections 3.8 6. Other nervous system 4.5 6. Other wounds 5.7 7. Perinatal-related conditions 2.7 7. Other infectious disesses 4.3 7. Other nervous system 5.0 8. Other infectious diseases 2.7 8. Other wounds 4.3 8. Helminthiasis 4.9 9. Helminthiasis 2.6 9. Other viral infections 3.7 9. Skin infections 4.9 10. Digestive system 4.0

SMCER0: Colombia, 1984 Health Diagnosis, W1/AHD and NOR - 48 - ANNEX 1

HEAME SERVICES INTIEATION PROJET

TAME 7: PHYSICAL INFASIRMTRE BY HEALTH REGIONS (1983)

NUMER OF

OCCUPANCY EDS PER RATE REGIONAL IOCAL HEALI HEALTH HEALTH REGICS 1000 pop (Z) HOSPITALS HOSPITAiS CEfIES POSTS

31 NARIlU 0.43 68.2 2 2 8 0 8 12 Ipiales 0.41 62.9 1 I\znaco 0.44 72.1 1 2 - 19

CAUCA 0.42 30.9 2 2 6 32 2 13 Ocacidente 0.39 34.0 1 - Sur 0.42 30.0 1 2 4 19 92 VALLE DEL CAUCA 0.53 59.9 5 7 7 22 Buenaveatura 0.70 53.1 1 1 2 6 Cali Area 2 0.05* 40.0 1 - 4 28 Roldanillo 1.79 44.5 2 2 - 36 Tulua 1.00 75.3 1 4 1 8 AMAZCKAS 2.41 60.1 1 - 5

PLUmmY 0.76 51.0 1 3 7 22 20 SANTANDER 2.38 40.0 1 8 1 San Gil 2.38 40.0 1 8 1 20

0.78 42.7 2 5 43 80 OCDOBA 60 Lorica 0.98 27.2 1 4 32 20 Manteria 0.70 50.5 1 1 11 23 20 53 ANrIo(wIA 0.46 60.4 5 Ia Meseta 0.72 47.5 1 10 2 13 2 1 4 ftdalena Medio 1.16 53.6 1 0.73 79.7 1 3 4 15 Bajo Cauca 21 Uraba 0.76 62.2 1 6 5 - Medellin Nr-Oriental 0.11 * 67.0 1 2 8 CaxxO 1.04 44.8 - 3 4 40 4 40 Istmina 1.04 44.8 - 3 101 378 TOTAL PRJECT AREA 0.66 51.8 19 53

* Ratios reflect situation in the target area in the city. GImiEA HWMI SI(MCIM MrMrAMC Paw

TAKE 8: WnBR. O HREAL W IQMES 70 ME GaZUZED IN IRJ1 T AMEA A)U1DM T IMAL PMICMTIS PAM 1 CF 2

PBRAM WHAT IM W) ReSINZ MEBLUiAK

DMAMMA 1. Control of enviromental risk Throubout project Reginal Saitation Unit Thrcuhout commity factors (matr, latrines, implemetation and (116) TMineer Sanitation Promoter sanitatim, vector Control) beyond 2. Ihacation All arsof health tesm, B, S, C 3. oral Rehydratimi Mimn diarrhea occurs Yother guided by pro-ter, muz. airs. AIETADIAEAL 4. Clinical diagnosis If diarrhea persista Auxiliary mrse, ND HPB,1 D ASE 5. laboratory disgais Severe or persistet cases laboratory technicians In 6. Appropriate medical treatme Severe cases Promoter, asu. urse, M EP, IR 7. Dehydratim at health institutim 1ban other tratment fails Marse, auxiliary aurse HP, IN 8. Hospitalization "D I, M

CXMMICAZE 1. Commnity .oxation and motivation hrownabut project Cmmunity participation personel, promoters, etc. C, S, CAIP, B DIABI 2. Completion of the cold chain First two years of project Regional Health administratim Ia, E1, B' 3. Vaccinatim cman " Promoters, auxiliaries at XFA CS, CAIP EPARm PROGRAM 4. AMqiisition of supplies Regional Health mit aministrators Reg. Health Unit Admin. (F 5. Training of professionals Thrugout project 8, IN lIRle rIU and amdliarias implementatin 6. Imaiztion of prqeunt woman and Promoters, auxiliary nurses, other ers C, CAIP, S, B children under 5 yaws of age health tow COPT, BUD, Polio, Nmeles)

11L & 1. Idetification and early Dhrig home visit Promoters, auxiliary nurse B PRIUALn registration of prW t woman MMlAIY 2. Referral to M (if possibla) Whe prepa wmatn are Preoaters, auxiliary urse IF MA32AL A) for risk aaae- n registered amE Eawn 3. Prenstal care of high risk cases Dhring pregnancy Cbstetrician i, IB 4. Preatal care of sinma risk cases eral physicimn, auxiliary nrse. IN, E6 5. Prenatal cue of low riskases " Auxiliary nurse, praoter E6, EP, IN TANS 6. Tetans vaccination, nutritional care hrisg prensocy Auxiliary ourse, promoter B, HP, IN i iMMM 7. Training of traditional uidwifes . Throubout project Regional health uit staff, auxiliary nurse B', IH 8. Institutional delivery according On demad , auxiliary urse, prmoter U, Ia, E6, B to risk 9. Post-partu care promotion Post-portia Auxiliary aurse, promoter HP, E, H breast feading 10. Follow up wne and family plainig Post-partum PrOMIter H edication

1WUAM 1. Promotion of family plamin lcgitudinally PrONoter, Aux. murse, Cammity Part. Staff C, H P IAWr aucation 2. Clarificatio of reproductive risk Post-partua, o demand Auxiliary iurse, 1 E, Ia, 1E, ' FMfI PIAINU 3. Prescription of now-surgical Post-partus, m demand Auxiliary airse, 16 U, IN, 16, HP ontraception 4. Follow up care, vaginal cytology Anually, pp-mr Promoter, auxiliary nurse HP, B

TUNIMIJMIS 1. Detectim of ases longitudinally Promoter, auxiliary nurse C, HP, E 2. Sputum examination Upon detectim laboratory taelmcimu, prooter obtains specimen IN, U TAN rSirM 3. Prescription of trat Upon disgooia 16, m er sm circumstances auxiliaries HP, 1e, IN COMIL 4. Caitact investigation and follow up Up-u diagnosis Promoter, auxiliary aurse H, C

SDMS: C - Cmmuity E - Health Citer IN - local Hospital S - School B - HOW HP - Health Post R - Regioal Hospital m n mmOIDWA ITIRNIU 2=

TAEA 8: WGJ C MUif FIr*A 7D Z GI NID IN PMET AifA A 1=) IICAL MIaEITI P*M 2 OF 2

ImmnB( WHAT WHON 1NiERC SM WHIRE -ROGR

NaIuWr1TXW, 1. tandardizatio of child growth First t years of project ICE and XDGWf nutritionists Dgota, Reg. Health Units IMNECTIU metdlogy Lamm 2. Registration of childre ower longitudinally Promoter, auxiliary HrH, HP, CAIP POS1nnr TEIUlrMAIL 7 Yrs UIRITcUN AND RANAnnRI 3. Training of persomel cc growth First tra years of project ICW mtritionists %R.Health Units PRiEf HAU f surveillance CAME 4. Preventive and curative services Iougiatsuinally Promoter, auxiliary aurse, ND Il, E, ip for pre-school children H, CAIm 5. Referral of childre vith growth Upon detection Promoter, auxiliary nurse, CAIP staff Hf, iP, la failure for medical evaluatim and trearamst 6. Nutritional redbilitation tUon referral CAIP staff, prooter, auxiliary murse CAIP, iP, W 7. Health and nutrition -Aatim for LcxgiAinally and when CAIP staff, promoter, auxiliary aurse C, H, CAIP, iP parmts child referred 8. Develnmet of innovative pre-school longituinally ICE regieaml staff, MnAUI, Regicual Health ICEF Rgota, ICF PU care prcgrame uits, RICE

IEhL 1. Cmmity eucation Longitudinally Promoter, dantal hygieist, dentist C, S, H CAWir 2. lBxoatin of school children cu ar school wroll-t Detal hygienist S, CAlp PV3ENTIVE AND dental hygiene CRNAXW IMNISK! 3. Topical flor applicatim, referral During elementary school Dental hyginist S, CAIPs pethology preset years 4. Untal tra t utilizing Upmn referral or deman Dentist, Dentist auxiliaries HC, I0 delegatim of functionsA appropriate. Pregnant w mad children (5-14) given priority

(UPIRmINUOR1. Detectiou of persons with lmgitudinally Promoter, auxiliary nurse H, SP hypertension HYPIfUINSI 2. Referral for disgoois and treament hen detected Promoter, auxiliary mrse , HP (31TL 3. Prescriptiou of treaNt " E, auxiliary rse HP, Be, IH 4. Follow up care Longitudinally Promoter, auxiliary nurse H, HP

MA1IA 1. Cmmity educatin, cmmuity longitudinally Cmmuity participatim umit, SHN, Health staff C, H organizatron 2. Vector control logitudinally SE1 regional Sanitatian nit C, H MALARIA 3. Detectim of cases longitudinally Promoters, health tem members, SHN H, UP, W, U! 4. Iabratory diagnoeis Upon detection Laboratory technicians I, W, iP 5. Treatment prescriptin Upon diaosis ND, Auxiliary airse, SW! 1E, EC, BP 6. Follow up After dianosis Pomoters, auxiliary murse H

SE1CAL 1. Conmity education, health staff logitudinally Health staff, simplified surgery staff person C, H PFROK edacatiM SWLIFIND 2. Detectiou of cases in need of laigindivally MD, auxiliary mrse, promter H, iP, Bf, HH, in SURGRE surgical treas.t 3. Referral to simplified surgery upon detection MD, auxiliary nurse, prmoter, HP, f, 1E, UH Pmgraa 4. Training of patiet and family After referral Dimre, auxiliary nurse, prowter iP, Ei, NI, IU 5. Surgical treat..nt, day surgery After training El with special training, need not be surgeon IE, in program 6. Follow up care Post-!p Family, auxiliary nurse, prmoter H

GI Guidelines concerning the following topics are curratly iuder develoment: (a) Geriatrics; (b) Mantal Health; (c) Upper respiratory infectious, Alcohol and Dng Abuse

C C-.uity W - Health Caner in : local S - School Af - m W -ath Post In an Amioa - 51 - ANNEX 1

Cmasu MaiB MUICB nMrTrI PM=3 PAS 1 at 5

TANX 9: Civil Works Scn1and of Hawlth Facilities nd Site kquisition Stabs

mu ti armu mm sr Acasn1Tm SITES 0/8 86/87 87/88 88/89 89/90 STAX

1. R1UMD A) IIIALES

NComtruction:

P.S. Talambi - Puerres - - D - - + P.S. Coliubsa-Oachacal OD - - - - + P.S. mmoopmew - Puerres - 8 - - +

Samodeling:

C.S. POUrr" 40 - - - - NIA P.S. **flinaMa-Qzacal 40 - - - - /A P.S. Jose aria Hernaez 40 - - - - I/A Emposion:

C.S. Pupiales-Cabacera - 50, - - - N/A C.S. Cmtadearo-Cabecera 50 - - - - N/A C.S. AIdm-Cabama 50 - - - - I /A C.S. Cordobw-Cabecera 50 - - - - N/A C.S. Qmagit:.-CabdCAe - 50 - - - /A C.S. Sao Pedro Potosi-Cabsceza - 50 - - - A C.S. Ilea-Cabacera - 5 - - - N/A

B) MOME

Saw Castructiai:

P.S. Vaquaria- cO ------+ P.S. Rosario -TaO - - - - + Remodeling:

P.S. Lorente-Thco 8 - - - - N/A

2. CAXA A) OOniMz

Now Ccostruction:

P.S. Sigui-lope - 8 - - - + P.S. oiinx-Qupi - O - - - + P.S. Cmagui-'rbiqui - - so - - + + P.S.h iita.-Qmpi O - - - - Pmmdelimg:

P.S. San Jose-Qiapi 30 - - - - N/A P.S. Coxopcion-GQipi 30 - - - - N/A P.S. Chuare-Qapi 30 - - - - N/A

B) SR

Now Construction:

C.S. SBta Pa - - 18D - - + P.S. I& Hradura-Abuer - - - OD - + P.S. Son lorsUg-Belivar - - 80 - - + + P.S. Djarra-MIUVaderU OD - - - - Ramodeling:

E.L. Maercderes 120 - - - - N/A C.S. aTboa - 18D - - - N/A C.S. Axplia - 100 - - - N/A C.S. Aleguer-Patia 100 - - - - N/A C.S. Son Sebastimn - - 18D - - N/A

C.S. - SAITH CM * - Ietified R.L. - IDCAL HnFTAL + - Ir Proce U.S. - WMGIAL HSPITAL I - cqx P.S. - HUaL13 POST N/A - DDO not apply -52 -

0flwA HU1M V1E I1nEATIm synig PACE 2 CV 5

TIME 9: Civil Works Scb@&ku of Health Facilities and Site Acquisition Status

Mern O SIA SITE

SrS 85/86 86/87 87/86 88/89 09/90 Tara 3. UUZr 3L CICU

A) ONWAMNU A Now Costruction:

P.S. Zacarins 0 - - - -- + famdelig:

H.R. Univatur 400 - - - - N/A H.L. Puerto Ybrizalde 250 - - - - N/A P.S. %Ne1 40 - - -- - N/A P.S. Sao Francisco de kau 40 .-- - N/A P.S. Sabaletas 40 - - - - N/A P.S. Csbcera 40 - - - - N/A P.S. Purto aspme 40 - - - - N/A P.S. QM&Ulto 40 - - - - N/A P.S. am Jose deo Abiesya - 40 - - - N/A P.S. Punta Soldedo - 40 - - - N/A P.S. Sao Fracisco Javier - 40 - - - N/A P.S. El Pital - 40 - - - N/A P.S. Potedo - 40 - - - N/A P.S. San Isidro II - 40 - - - N/A P.S. Sm Cipriano - 40 - - - N/A P.S. Sm Ant-i de urunigUi - 40 - - - N/A

3) CALI A..wds.ivg:

.R. Josquin Pz B. - Cali 300 - - - - N/A

H.R. Josquin Paz B. - Cali 170 - - - - N/A

C) nimirii

New Cuutructim:

P.S. Santa Teresa-Bolivar ------+ P.S. cetres-aolivr SD - - - - + P.S. Belgica S - - - - + Ra3mdeliog:

.R. Roldmillo 400 400 - - - N/A I.L. Bolivar 200 300 - - - N/A D) TMA New Caurtruction:

P.S. Ia Marina - Trujillo OD - - - - + RDmodeli4:

.R. Tulua 166 - - - - N/A H.L. Basulagrande 150 - - - - N/A P.S. Frameds -Tulua 56 - - - - N/A

Bpmanmi:

C.S. uIn - ZAn Sanitaria 300 - - - - N/A

C.S. - main Cam Identif ied L.B. - IDCL 1ETAL + - In Process L.N. - INGL 1 L I - Acquired P.S. - HAW POT N/A - Does not apply - 53 - ANNEX 1

MALE amMeS WKWATON PIA PACE 3 (r 5

TAME 9: Civil WIrks Semsila of Ha1th Pacilities and Site Acquisition Status

NJ=E Or SQPE gmm SMZ

SrES 85/86 86/87 87/88 88/89 89/90 SAMU

4. AM2OAS

H.R. Ieticia 300 300 - - - N/A C.S. Aracura-aticia - 150 - - - N/A - NIA C.S. Tarapacas-eticis - 50 - - C.S. Pedrera-eticia - 50 - - - N/A C.S. la Qorreraaeticia - 150 - - - N/A P.S. Son Rafael - - 200 - - N/A C.S. Miriti - I0 - - - N/A

5. PEtUS4A3

New Cmstruction:

P.S. Mcaya 8D - - - - P.S.RinMo SD - - - - * P.S. HErendu - 8D - P.S. Cascte - - - - P.S. Puntales - - SD - - P.S.3"i - - - - P.S ctaRosa de Sucumbi - - - SD -

H.L. Colon - 2D0 - - - WA H.L. PuertoL uiano - 35 - - - N/A C.S. Villagaron - 100 - - - N/A C.S. Orito - I0 - - - N/A P.S. Puerto Ospma 8D - - - - N/A P.S. ftyoyoque 8 .- - - - NA P.S. Puerto Q nn SD - - - - N/A

6. SANMIR

A) SAN GIL Remodeling:

H.L. Son Roque-Charala - 250 - - - N/A ac!pansion:

H.R. San Gil - 40D - - - N/A H.L. Valle Son Jose - 300 - - - N/A C.S. Villameva - 100 - - - N/A

7. CXOM

A) IMLCA

New Constructio:

P.S. El law SD P.S. Candelaria - SD - - * P.S. El Porvenir-Sen Antero - 8D - - - P.S. Sitio Viejo-hiNa - - - -

Ramdeling:

H.S. San Vicente de Paul - Ioriea 1,119 1,490 627 - - N/A H.L. San Bernardo - 250 450 - - K/A P.S. 140 Sigales - 60 - - - NA P.S. Corosslito-Chiin 60 - - - - N/A xpension:

H.R. Son Vicente de Paul -Lria 432 577 243 - - N/A P.S. Paso jIevo-Sui Bernardo 30 - - - - /A

C.S. - HEALTH COI * - Idmtifie H.L. - 1OCAL N)SITUL + - In Process H.R. - wICW.L MONTAL I - Acquired P.S. - HKALTR PSe N/A - Dos not apply - 54 - ARNX1

AImI S ICES INBATIQ PynI PAM 4 C 5

TANZ 9: Civil W1bks ScA1e of Slmith Facilities and Site Acquisition Status

NLDGE C SPAE mus SIT ACQUISrTICN SrrES 85/86 86/87 87/88 88/89 89/90 STATUS

7. COMA

B) MNMERIA

New Constructinm:

C.S. Son Francisco del Rayo-ontelibano - 18 - - - X C.S. El Carmelo-Tierralta ISD - - - - * C.S. Valencia 266 334 - - - x C.S. Santa Fe - Monteri 8 - - - - * P.S. Tres Piedras 8D - - - - X P.S. Popayan-malete 9 - - - - * P.S. Snt-der de Is C. - Mminto - - D - - * P.S. Juan Jose-Puerto Libertador - - - - * P.S. Pica Pica-*ontelib-no - - - * P.S. Saize-Tierralta 8- - - * P.S. Santa Fe Ralito-Tierralta - 89 - - - * P.S. Paluira-Tierralta - - 8* P.S. Son Rafael-Mluxcia - - - * P.S. Palotal-Aympel 9 - - * P.S. El Cedro-Ayapel 8D - - - * Rmaling:

H.L. Montelib$00 - 120 - - - N/A H.L. Sam Joge-4yapel 365 727 409 - - N/A I.L. Son Nicolae-Planeta Rica 230 - - - N/A H.L. San Jose-Tierralta 575 - - - - N/A C.S. La Q ja - monteria - 60 - - - N/A C.S. Puerto Libertador - - 300 - - N/A C.S. re4bntelibmw - 100 - - - N/A P.S. Num lucia-monteria - 40 - - - N/A P.S. Cristo ey-fuerto Escondido - 120 - - - N/A Expansion:

H.L. )*ntelibsuo - 50 - - - N/A I.L. San Nicolas-Planeta Rie 156 157 157 - - N/A H.L. San Jose-Tierralta 667 667 666 - - N/A C.S. Is* nja-olnteria - 100 - - - N/A

8. MIr IA

A) IA PHEMA

New Constructim:

H.L. Ca.pm.ento 440 - - - - + P.S. El Pescado-Briceno O - - - - * P.S. Son Pablo-ome Plata - 8D - x P.S. Valle-Toledo - 8D - - * Raaeling:

H.L. Son Rafael-Carolina - 2MO - - - N/A H.L. San Jose de la Mtaun - 30 - - - N/A H.L. Son Andres dela Cmnqia - 200 - - - N/A

B) Mk fAIMfA SMIO

New Construction:

P.S. Murillo-puerto Berrio 80 - *

C) KMJ CAWA

New Construction:

.L. El nre 470 - - - - * P.S. Puerto Trims-CauMcaia - 8 - - - * P.S. El Tigre-Caucasia - - 8 - - * P.S. Qidbrama-Cmui. - - - - * P.S. Las Concham-Nschi - - - - * P.S. Ia, nmuca-Taraw 8 - - -

C.S. - HEAI Cu * - Identified R.L. - OICAL ITAL + - In Process H.S. - IMGML PITAL I - Acquired P.S. . wAnPinT N/A - Does not apply ANNEX 1 - 55

mom1HI sVo(7 nBMATMI PNiEW r PAC 5 (I 5

TAKE 9: Civil Woks Schele of Health Facilities md Site Acquisition Status

-m OF soI Nwas Sni

Srmi 85/86 86/87 87/88 88/89 89/90 8aS

B. ANTM1A D) tAlM

New Construction:

H.L. Turbo *** 1000 1500 - - - I P.S. Djero-Arboletes* - - O - - * * P.S. Trinidad-Arboletes * - - - - P.S. Nuva Antioquia-Turbo ** 0 - - - - + - * P.S. Caribia-4scocli * - --

fimdeling:

H.L. QCigorido - 250 - - - N/A H.L. San Pedro de Uraba 50 - - - - N/A C.S. Car"a - - 120 - - N/A

Espension:

H.R. Apartado WO - - - - N/A H.L. Mitata 120 - - - - N/A i.L. Chigorodo - 120 - - - N/A H.L. San Pedro de Urfba 230 - - - - N/A C.S. Carpa 50 - - - - N/A C.S. Bojira-Mitata - 50 - - - N/A

E) ECELIN N1R-ORIENTAL

New Canstruction:

C.S. El Paimal-Nedellin 18 - - - - x C.S. Villa de ouadslupeidellin 18 - - - - I C.S. Pablo VI-Madellin - 1W - - - * 9. COM

A) ISIMMA

PMBodelirg:

H.L. Eduardo Santo. - Istmina - 882 739 - - N/A H.L. Sa Jose - Coxdoto 300 - - - - N/A C.S. Noit.a 150 - - - - N/A C.S. Tado - 150 - - - N A C.S. hidAoya 120 - - - - N/A P.S. Basuru - 70 - - - N/A P.S. Prim ra - 70 - - - N/A P.S. Puerto Salazar - 70 - - - N/A P.S. - 70 - - - N/A P.S. Tarido 70 - - - - N/A P.S. Purto Pervel 70 - - - - N/A P.S. son Miguel - 70 - - - WA P.S. Certegui-Tado - - - 70 - N/A P.S. Cannlo-Tado - 70 - - - WA P.S. Las Anfine-Todo - - 70 - - N/A P.S. Playa de Oro - - 70 - - IVA P.S. Opagodo-Condoto - 70 - - - N/A P.S. SertaAm-Caodoto - - 70 - - N/A P.S. Somta Rit&-Condoto - - - - 70 N/A P.S. Pie de Pepe-fajo Baudo - 70 - - - N/A P.S. Smita Barbara-Cwsdoto - - 70 - - N/A P.S. Boca de Pepe-fajo Baido - - 70 - - N/A

hpamsion:

H.L. Eduardo Satos 242 203 - - - N/A H.L. San Jose-Coxdoto 300 168 - - - N/A P.S. Palestina iW - - - - N/A P.S. Sipi 100 - - - - NA

C.S. - HE* . - Identified R.L. - IWAL HDTPML + -In Procs H.R. - IMCIAL HOSTAL I - Acqired P.S. - SEAIl PooT N/A - Dos wt apply -56 - ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 10: ADDITIONAL STAFF TO BE RECRUITED DURING PROJECT IMPLEMENTATION

CUMULATIVE TYPE OF STAFF NO. PERCENT PERCENT

Health Promoters 626 50.4 50.4

Sanitation Promoters 120 9.7 60.1

Auxiliary Nurses 159 12.8 72.9

Dental Hygienists 53 4.3 77.2

Maintenance Assistants 45 3.6 80.8

Medical Records Assistants 35 2.8 83.6

Administrative Assistants 20 1.6 85.2

Dentists 39 3.1 88.3

Physicians 0 0 88.3

Other Professionals 144 11.6 99.9

TOTAL 1,241 100 100 57 -- ANNEX 1

mminsmCs InHM2ATICI PID3E2

TAE 11: WHIR NALWN MOrDn N REM (1983)

RATIO PIR 10,000 IHIrIANII

DUIAL PC MATICII REIM U MSI 8 TA RSE MEAU REMO ('000) pMSICIm IIIIS -m EMyOrT UAWIMI POMU PIU M AID GlUES

ARADI0 421.67 1.30 0.26 0.12 0.17 0.05 0.76 0.57 0.21 6.85 Ipiales 184.971 1.68 0.38 0.11 0.11 0.11 1.57 0.81 0.05 3.35 M 236.699 1.01 0.17 0.13 0.21 0.00 0.13 0.38 0.34 9.59

CADX 221.548 0.99 0.23 0.09 0.05 0.05 2.39 0.41 2.17 0.41 Occidmte 54.474 1.10 0.18 0.00 0.00 0.00 3.30 0.18 3.49 0.37 gur 167.074 0.% 0.24 0.12 0.06 0.06 2.09 0.48 1.74 0.42

VAUZ I& CAM 831.244 1.94 0.36 0.19 0.23 0.00 1.73 0.77 4.21 4.63 penavetura 2D7.135 2.27 0.19 0.24 0.24 0.00 1.88 0.87 6.86 5.55 Cali Are 2 * 388.85 0.72 0.33 0.15 0.13 0.00 0.08 0.18 1.67 1.26 Rolduillo 53.575 3.17 0.75 0.37 0.37 0.00 6.91 2.80 7.65 10.64 Ibla 181.684 3.80 0.50 0.17 0.39 0.00 3.58 1.32 5.61 9.03

AM2IUIA 37.698 4.24 1.59 1.59 0.80 0.00 10.35 1.86 13.26 20.43

227.69 1.01 0.44 0.35 0.31 0.00 3.16 0.44 2.77 9.44

156.099 2.75 0.% 0.70 0.58 0.00 3.33 0.90 6.28 21.65 Smi Gil 156.099 2.75 0.96 0.70 0.58 0.00 3.33 0.90 6.28 21.65

COMME 620.656 2.34 0.42 0.52 0.23 0.00 1.93 0.93 5.25 10.62 lorica 164.511 1.95 0.30 0.43 0.24 0.00 3.10 1.15 4.98 10.88 bmiteria 456.145 2.48 0.46 0.55 0.22 0.00 1.51 0.85 5.35 10.52

ANnlOQDIA 1056.921 1.25 0.44 0.86 0.19 0.03 1.30 0.46 2.86 7.56 Ia Meseta 174.988 1.66 0.80 0.06 0.23 0.06 2.17 1.03 4.06 28.29 Mgdalema Redio 56.83 1.76 0.35 7.74 0.35 0.00 2.29 0.70 4.05 3.70 3ajo Caca 99.69 1.50 0.50 0.70 0.30 0.10 3.21 0.70 3.91 8.83 Uraba 220.724 1.72 0.32 1.09 0.32 0.05 2.45 0.68 4.26 4.58 Ydaellin Rcr-Orimtal * 504.689 0.79 0.36 0.30 0.08 0.00 0.00 0.10 1.49 1.86

Cmw 108.028 1.11 0.37 0.46 0.28 0.00 4.26 0.00 0.93 15.09 IstminA 108.028 1.11 0.37 0.46 0.28 0.00 4.26 0.00 0.93 15.09

TUAL PDJT ARIEA 3681.554 609 153 176 83 6 695 235 1256 2934

Ratio per 10,000 - 1.65 0.42 0.48 0.23 0.02 1.89 0.64 3.41 7.97 populatio

(1) Reliable data not available. * Ratios reflect situation in the target area in the city. -58 - ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 12: NUMBER OF HEALTH SERVICES PROVIDERS TO BE TRAINED -===== BY TYPE AND LENGTH OF TRAINING

LENGTH NUMBER OF TO BE TYPE OF TRAINING TRAINING TRAINED

FORMAL TRAINING

Public Health 12 - 18 months 81 Sanitation Promoter 12 months 109 Health Promoter 3 months 746 Dental Hygienist 3 months 59 Maintenance Technicians 6 months 14 Maintenance Perito 4 months 17 Maintenance Auxiliary 2 months 49

TECHNICAL COURSES

Management 3 months 224 Resource Management 45 days 1,104 High Level Management Seminars 1 week 92

WORKSHOPS

Professionals/Technicians 2 weeks 1,509 Continuing Education Promoter/Auxiliary 1 week 1,308 Community Leaders I week 700

TOTAL 6,012 mum== -59- ANNEX 1

FALTH SERVICES DMTIM PRWECT Page 1 of 6 TAEE 13: SENT AgC~ S @

(US$'000) _ _ rT_ (Including Contingencies) I. INVESRCOSTS MIT 85/86 86/87 87/88 88/89 89/90 90/91 TUAL FREQNI OCAL TOTAL

A. CIVIL WS

1. NEW CVmEnItM

local Hospitals Facility 0.8 2.2 - - - - 3 429.3 459.7 889.0 Health Center " 3 2 2 - - - 7 145.2 154.2 299.4 Health Post " 22 15 12 4 - - 53 448.8 476.9 925.7 Sub-Total NEW CM n CTIC 1,023.3 1,090.8 2,114.1

2. SITE DEVEOiIEWT Value * ** - - 186.2 235.1 421.3 3. RENDVATIOS

Regional Hospitals Facility 2 2.5 0.5 - - - 5 246.7 263.0 509.7 local Hospitals " 6.1 6.8 2.1 2 - - 17 461.4 486.0 947.4 Health Centers " 3 3 4 1 - - 11 104.9 111.1 216.0 Health Posts " 9 16 8 5 4 - 42 138.3 144.1 282.4 Sub-Total RENOVATIONS 951.3 1,004.2 1,955.5 4. EMPANSIONS

Regional Hospitals Facility 1.5 1.5 - - - - 3 268.5 291.7 560.2 Local Hospitals " 2.1 6.8 2.5 - - 12 590.3 626.9 1,217.2 Health Centers " 3 4 4 5 - - 16 149.8 156.2 306.0 Health Posts " 5 3 3 - - - 11 126.7 133.9 260.6 Sub-Total EXPANSIONS 1,135.3 1,208.7 2,344.0 5. SUPERVISION OF CIVIL WRKS

Site Supervisors /Y 10 15 9 2.5 - - 37 - 124.0 124.0 Travel Expenses Days 1,560 2,340 1,404 390 - - 5,694 - 47.9 47.9 Sub-Total SUPERVISION OF CIVIL WRS - 171.9 171.9

6. IURAL WATER SUPPIY *

Water Systes & School Tits Value *** ** *** *** * - - 1,918.9 4,858.3 6,777.2 -M -

B. MAIl ENANE WRKSHS 5 6 8 - - - 19 211.5 222.6 434.1

SLUIOAL CIVIL WOES 5,426.5 8,791.6 14,218.1

* = Cost estimate includes equipimit and pipes. - Value ammut in respective years WY - Ykn-Year - 60 - ANNEX 1

C0010BIA HEALTH SERVICS InrM ATIct PROJECT Page 2 of 6

TABLE 13: SIMNAR ACOxxJs COST SIMR

(US$'000) Contingencies) q"ITTfY (Including TOTAL 87/88 88/89 89/90 90/91 IUAL FORKEIN IDCAL 1. EMwsMi COSTS UiT 85/86 86/87

B. EQJIPMENT/ATERAIS

1. HEALTH SERVICE DELIVERY 624.8 1,862.1 4 10 - - - 15 1,237.3 Rgional Hospitals Package 1 - - 44 2,047.2 1,055.3 3,102.5 Local Hospitals tk 5 39 - - - - 35 173.1 90.0 263.1 Health Centers " 21 13 1 - 63 32 4 - 228 432.0 219.7 651.7 Health Posts " 55 74 8 - - 92 789.6 404.3 1,193.9 hinteance Equipment " 30 30 24 4,679.2 2,394.1 7,073.3 Sub-Total HEALTH SERVICE DELIVERY

2. RURAL WATER SFIPLY - 4,075.8 3,393.4 7,469.2 Water System*/Pipes Value 781.7 INS Development Program Value - 514.5 267.2 4,590.3 3,660.6 8,250.9 Sub-Total RURAL WATER SULIY

114.2 - - 19 73.7 40.5 3Set 19 - -- -

4. ENVIR4ENIAL HEALTH 426.3 1,805 1,805 - - 7,220 184.1 242.2 latrines Each 1,805 1,805 9 - - 121 45.6 23.9 69.5 Sanitation Promoters Tool Sets 45 48 19 - - -- 17 17.8 9.8 27.6 Sanitary Engineer Tool Sets 17- - - 90.8 Zoonosis Control Kit/Set 144 - - - - 144 58.6 32.2 - 167.3 167.3 Trash Collection Set/Comanities 48 72 62 49 231 306.1 475.4 781.5 Sub-Total EMRONV1 E AL HEALTH

239.0 673.8 5. INORMION SYSTEM Value-434.8

11.5 32.4 6. RESEARC ACTIVITIES Value-20.9

7. LABORAT1R ACIVITIES

. Training Equipment 89.6 Laboratory Activities Value -- -- ,357.8 31.8 3,332.4 78.0 4,112.4 Technical laboratory Equipment Value 3,390.2 811.8 4,202.0 Sub-Total LAB0RATORY ACIVITIES

8. I lTI QIMAL DEVEIMMN

Administration of Integration 99.6 54.8 154.4 of Services Value 99.6 54.8 154. Sub-Total fnlTI(1ONAL DEVELUMENE

13,594.8 7,687.7 21,282.5 SUBTUTAL EQIPMENr/MATERIAIS *

included in civil works. * = Total does not include equipment for the water works which are * Value amount in respective years - 61 - ANNEX 1

aE(LpIA REALMH SER8VICES INDERATION PRKWlET Page 3 of 6 TAXM 13: SU0AN ACUMU!S OST StM

(US$'000) QMNiTTY (Including Contingencies)

I. mvEnem COSTS twT 85/86 86/87 87/88 88/89 89/90 90/91 TOTAL FOREIN LOCAL TIOAL C. VEHICLS

1. Health Service Delivery: 4-Wheel Drive 51 - - - - - 51 411.9 140.2 552.1 Truck 2 - - - - - 2 21.8 7.4 29.2 Ambulance 48 ------48 658.2 224.0 882.2 Boat 30 - - - - - 30 151.3 51.5 202.8 Spare Mtors 46 - - - - - 46 92.5 31.5 124.0 Horses 50 61 10 - - - 121 - 51.0 51.0 Motorcyles 25 - - - - - 25 22.1 7.3 29.4 Bicycles " 26 - -- - -26 4.1 1.4 5.5

Sub-Total HI2H SERVICE DELIVER 1,361.9 514.3 1,876.2

2. Civil Wrks Supervision Each 18 - - - - - 18 162.9 55.1 218.0

3. Mainteamnce Activities Each 1 - - - - - 1 20.2 6.9 27.1

4. Enviromental Health: 4-heel Drive Each 17 - - - - -17 137.3 46.7 184.0 Boat 8 - - - - - 8 28.4 9.7 38.1 Motorcycle " 47 33 3 83 50.1 16.5 66.6 Bicycle 14 - - - - -14 1.7 0.6 2.3

Sub-Total !ERVINN2?AL HEALIH 217.5 73.5 291.0

5. Adninistratin/4 %eel Drive Each 5 - - - - - 5 40.4 13.7 54.1

Sub-Total VEHICLES 1,S92.9 663.5 2,466.4

D. RESFARC PROGAM

Research Publications Copies 4,300 4,000 4,300 4,000 4,000 - 20,600 16.1 15.4 31.5 Research Studies Each 2 3 3 2 1 1 12 - 3,194.9 3,194.9

Sub-Total BSEARCH PROGRAM 16.1 3,210.3 3,226.4

E. TEHNICAL ASSISIIJE

Sector Management MIM 30 27 32 5 - - 94 216.6 131.3 347.9 Research Studies 8 8 10 10 - - 36 - 64.7 64.7 Infonatim Network " 6 16 15 8 - - 45 88.7 66.4 155.1 Laboratory Network " 12 - - - - - 12 12.5 10.2 22.7 Rural Water Supply value *** **- - - - 226.1 173.3 399.4 Consulting Services K8WP Value * * - - - 502.2 1040.9 1,543.1

Sub-Total TECHNICAL ASSISTAENE 1,046.1 1,486.8 2,532.9

F. TRAINING

1. TRAINING/REATH SE!RVICES PE!RSCNEL

Public Health Part. 18 28 21 18 - - 85 34.3 294.1 328.4 Seitation Promoter " 53 48 14 - - - 115 6.5 57.0 63.5 Health Pramoter " 317 268 123 42 - - 750 28.6 250.3 278.9 Oral Hygienist Aux. " 24 26 12 2 - - 64 3.7 32.0 35.7 Mintence Tech. " 14 2 - - 16 1.1 10.2 11.3 Mintenance Peritos " 13 4 - - - - 17 1.5 13.2 14.7 Ykintenarce Aux. 27 15 6 6 - - 54 2.9 25.3 28.2 Admin./"nement 121 47 57 19 - - 244 14.0 122.9 136.9 Resource )hanament " 517 100 486 30 - - 1,133 21.9 190.9 212.8 High level Semins/Iin-ftt " 36 22 30 10 - - 98 3.6 31.5 35.1 Professionals/Teemiriae " 1,020 614 986 296 - - 2,916 210.2 1,818.1 2,028.3 Catinuing Ed. Prom./Aua " 0.7 5.8 6.5 Cmnity leaders " 176 188 208 208 - - 78D 3.9 33.7 37.6

Sub-Total TRAINIDI/HEAL SEVICES PER aMM 332.9 2,885.0 3,217.9

H/M - Ma-Manth *** - Value smount in respective years Part. - Participants - 62.- ANNEX 1

HE'AL1M SE!RVICES INTOGRATION PROJECT Page 4 of 6 TALE 13: SUMfARY A000M S0T SQ4MR

(US$'000) ANrTY (Including Contingencies)

I. INEST1Mo COSTs UNIT 85/86 86/87 87/88 88/89 89/90 90/91 TOAL FORKI LOCAL lUIAL

F. TRAINING

2. C01iiT0 !XLATION

Workshops Part. 170 146 105 104 - - 515 10.8 93.2 104.0 Food & Materials/Participants Value **- *-* .* ** - - - 158.2 1,344.7 1,502.9

Sub-Total OC4M TY EDUCATION 169.0 1,437.9 1,606.9

3. FELlWSHIPS 6 6 4 3 3 - 22 641.2 68.1 709.3

4. INSTITUTIONAL DEVELOMENT

Saminars Part. 62 62 62 62 - - 248 7.0 59.8 66.8 Wrkshops " 297 58 296 60 59 - 770 42.9 371.1 414.0 Health Mnageamt Specialization " - 262 241 261 - - 764 46.3 388.7 435 Curriculum Review Value *** *** *** *** - - - 11.2 97.5 1 Information Systen Part. 55 21 4 - - - 80 4.6 41.0 U Laboratory Specializatin " 191 30 30 - - - 251 20.9 188.1 2D9 Research Activities " 107 118 128 61 14 - 428 31.4 269.5 300.9 maintenance Activities 10 7 - - - - 17 0.7 6.6 7.3

Sub-Total DNITIUlCML DEVEILMM 165.0 1,422.3 1,587.3

SUBIAL TRAINIG 1,308.1 5,813.3 7,121.4

G. AINISRATIMN OF I)TGATION OF SERVICES

Salaries Value * * * ** * *** - 1,447.1 1,447.1 Materials/Supplies Value * *** *** *** *A* *** - 42.8 42.8 Per Diems Value * *** *** *** *** *** - 538.2 538.2

Sub-Total AMINISTRATIC OF INEGRATI1 OF SERVICES 2,028.1 2,028.1

H. TECNICAL foomETIfm - iESS DEVEIDPED RGONS Value *'* *** ** ** ** - - 112.7 1,056.1 1,168.8 EfMILLIO:' ) TOAL I]NVESDMET COSTS 13.6 15.4 12.6 7.9 3.9 0.5 54.0 23,307.0 30,737.2 54,044.2

Part. - Participants Value - Value amount in respective years - 63- ANNEX 1

HAIII SERVICES IN11MATION PRWBCT Page 5 of 6 TAN.E 13: SUNKMf ACCN1'S aOST SEHI4O

(US$'000) qlwmr (Including Contingencies)

II. R 1RR! COSTS wT 85/86 86/87 87/88 88/89 89/90 90/91 TUtAL FrRE3 IDCAL 1ULAL

A. nCROOMED AL SAAIIES

1. HEALT STAFF

Dentists /Y 1 11 23 33 39 39 146 - 1,259.2 1,259.2 Veterinarians " 3 10 11 11 11 11 57 - 586.7 586.7 Administrators " - 4 10 13 13 13 53 - 559.7 559.7 Civil &gineers " - - - 1 1 1 3 - 20.3 20.3 Nurses " 16 34 45 52 56 56 259 - 1,665.8 1,665.8 Bacteriologist - 4 8 14 15 15 56 - 349.9 349.9 Nutritionist/Dietician " - 1 4 9 9 9 32 - 199.6 199.6 Clinical lab Technician " - 4 11 16 18 18 67 - 260.2 260.2 Administrative Assistant " - 4 14 17 19 19 73 - 337.1 337.1 Health Statistician " - 3 6 6 6 6 27 - 138.6 138.6 Records Assistant 3 13 23 31 35 35 140 - 495.9 495.9 Assistant Oral Hygienist " 1 18 34 46 51 51 201 - 644.9 644.9 Health Promoter " 116 243 381 509 646 646 2,541 - 4,848.7 4,848.7 Maintenance Auxiliary " 6 23 32 42 45 45 193 - 558.9 558.9 Nurse Auxiliary " 29 82 120 137 159 159 686 - 2,127.5 2,127.5

Sub-Total HEAUM STAFF - 14,053.0 14,053.0

2. RESEARNI ACTIVITIES

National/Regional Research Infornmation Centers 6 6 6 6 6 6 36 - 254.1 254.1

Sub-Total REEAOM ACTIVITIES - 254.1 254.1

3. !NVI I NUAL HEAI1H

Engineers M/Y 1 14 14 14 14 14 71 - 502.0 502.0 Sanitary Prczwtors " 35 52 82 112 120 120 521 1,571.0 1,571.0

Sub-Total ElNVIRIOKNrAL HEALH 2,073.0 2,073.0

4. INRRI TIN SrAFF M/Y - 10 11 11 11 11 54 - 419.0 419.0

SLIMUTAL INCRD9M1NAL SAARIES 16,799.1 16,799.1

B. PEATING COSTS - ENVIRI4EN1AL HEAL12

cmicals Value *** *** * * * - 1,383.3 1,383.3 Per Diem Value *** *** **- * *** *** - 839.6 839.6

Sub-Total (PIATIN COSTS-ENVIRHtOCAL HEALH - 2,222.9 2,222.9

N/Y - Man-Year Vlue - alue amunt in respective years - 64- ANNEX 1

WLLI4BIA HE~ALTH SE!RVICES IDBGATION PROJECTPae6o6 Page 6 of 6 TANE 13: STH4AM ALCOWIS COST SINfAR!

(US$'000) q3ANrrY (Including Contingencies) TOTAL FOREIN IWCAL TTAL II. RBZURRT COSTS UNIT 85/86 86/87 87/88 88/89 89/90 90/91

C. VEHICE OPERATIG OUSTS

Envircawntal Health Value ** ** 82.2 82.2

Sub-Total VEHICLE CPERATD USTS - 82.2 82.2

D. KAINTMANCE OF HWPMUr & BUUDIMM 1,845.3 1,845.3 Health Services Facilities Value * *** ** - 1,845.3 1,845.3 Sub-Total KAINTM1WE OF BIMI & DUINGS

53.3 562.8 E. GLASSWARE AND RAELMS Value * *** *** *** *** *-* 509.3

F. OFFICE SUPPLIES 4 92.8 Information Systen Value *-* *-* *-* *-* *** *** - 92.8 Research Activities Value * * *** ** *** *A* - 48.3 48.3

Sub-Total OFFICE SUPPLIES 141.1 141.1

G. SPARE PARIS 86.3 Information System/Computing Value --- 86.3

Sub-Total SPARE PARIS - 86.3 86.3 21,739.7 Total RORE COSTS US$M 1.2 2.2 3.3 4.3 5.2 5.5 21.7 509.5 21,230.2 TOTAL PWJECT OSTS US$M 14.8 17.7 15.9 12.2 9.1 6.1 75.8 23,816.5 51,967.5 75,784.0

- Value amount in respective years OM3IA MATR SVI(CE irai IOJICT

TAKE 14: Sumary Accout by Project Camp t - (Colombimm Pesos '000 - Totals Incluling Cctingecifs) PaSe 1 of 2

POrAL MEMAL CARE mIu WAL WAIM SE UCES InSTTIlIOAL EVEMMI RW!Mi RIMAT. MmIE YICYAL SE= 1ABOI nORIATIH SEMvtE C[anT SIWFLT 1E1tf KRAL WAi 1 I. SIn r COIS I T EDXAI(3 WhNmUECE SVICESE CIT. SP PAN WiM SIFPn sum R85ZAN E ITAL

A. CIVIL WE- 1. R Construction 383,462.2 - - 383,462.2 76,389.5 2. Site Dewelopmeet 76,389.5 - - - 369,151.3 3. Rewvaticus 369,151.3 ------4. 1Rnaim 428,605.3 - - 428,605.3 32,265.2 5. Supervisio of Civil Works 32,265.2 - - - 1,438,657.6 6. Rural iter Supply - - - 1,438,657.6 -- - 82,100.5 7. Mainten-oce Worksps - 82,100.5 -- ---

2,810,631.6 Sub-Total CIVIL WM 1,289,873.5 - 82,100.5 1,438,657.6 ---

B. lqunmmr/wgmuAM 1,361,810.8 1. Health Service Delivery 1,124,186.9 237,623.9 - --- 1,729,775.5 2. Rural liter Supply - - - 1,586,895.7 - 142,879.8 3. Training 17,554.6 ------17,554.6 147,395.2 4. ariroo.gntal Health - - - 147,395.2 -- 103,601.3 - 103,601.3 5. Inforation System ------4,969.8 4,969.8 6. Research Activities - - - - - 853,706.8 7. laboratory Activities -- - - 853,706.8 8. Institutional Deveoat - - 23,737.1 - - - 23,737.1 4,242,551.1 Sub-Total NIWM ~IE/WMT5OAIs 1,141,741.5 - 237,623.9 1,586,895.7 147,395.2 142,879.8 23,737.1 853,706.8 103,601.3 4,969.8

C. M.ICU --- - 289,883.6 1. Health Service Delivery 282,726.2 - - - 7,157.4 2. Civil Wrks Supervision 34,244.2 -- - - - 34,244.2 - - 4,160.7 3. intieene Activities - - 4,160.7 - - - 45,721.7 4. Rairommenti Health - - - 45,721.7 - - - - - 8,321.4 5. Aghintration 4-4mel Drive - - -- 8,321.4 - 382,331.6 Sub-Total 9g!IQ 316,970.4 - 4,160.7 - 52,879.1 - 8,321.4 - - -

- - 666,478.2 666,478.2 D. REAK PDOA ------3,492.1 29,419.1 12,909.7 422,428.1 E. TKMCAL ASSISIAIE - - 311,200.9 65,406.3

F. TmAIN - 604,254.4 1. Training Health Service Peraml 604,254.4 ------326,482.2 2. C.mity Eucation - 326,482.2 ------43,430.8 - - 141,428.4 3. Fellowship - - - 97,997.6 58,798.2 307,179.0 4. Institutional Demlopment - - 1,228.2 - - - 205,137.8 34,464.5 7,550.3 7,550.3 58,798.2 1,379,344.0 Sub-Total 2RADiN; 604,254.4 326,482.2 1,228.2 -- - 303,135.4 77,895.3

419,012.0 - - - 446,479.1 G. A1MNISTIhMTI1ICFM&TIO - - - - 27,467.1 - OF SERVICES - - - 247,228.0 H. TmMECAL (XXWATIM WS - - - - - 247,228.0 EVEED R=CME 743,155.9 10,597,471.7 7IUAL DIIESI r COSTS 3,352,839.8 326,482.2 325,113.3 3,025,553.3 227,741.4 454,08D.7 1,066,840.2 935,094.2 140,570.7 WA12- SERVICES IMWHATIUM PF13DJCr

TAE 14: Summay Acmt by Project Component (Colombian Peso. -000 - Totals Including Contingencies) Page 2 of 2

PERSgOL M1MAM CARE !VENWE02MAL MA39 SERVICES UISVITTUTIAL DEVEIMI

HEALTH RIAL WM! NATIOEL SEiCE 0019MLSpply S1CTf MMALWATER S M UABRAIM D C4ATION TI. 1nau r COSTS MU1EM EDEATION )MINIMM E SERVICE!S OML SIpPLY PAN MANGIAG SUPPOR SYSTEM REEARCH 1OAL

A. flEUIIAEL SAIARTLR 1. Health Staff 3,364,793.9 ------3.364,793.9 2. Researhb Activities ------56,489.3 56,489.3 3. Environmental Health - - - - 488,372.7 - - - - - 488,372.7 4. Information Staff ------98,611.4 - 98,611.4

Sub-Total MMMOM SAIARI8srAL 3,364,793.9 - - - 488,372.7 - - - 98,611.4 56,489.3 4,008,267.3

B. OPElATTX COSTS EIN1INAL 8 H ------504,880.7 - - - - - 504,880.7

C. ICLEz OWRATIlNG m - - - - 18,284.4 - - - - - 18,284.4

D. YARMUENARE O E!I!Tr ANDSllDIRM 410,277.3 ------410,277.3

E. GASB M A------125,700.2 - - 125,700.2

F. IcOFSPLI ------20,943.6 10,730.6 31,674.2

G. SPARE PAS ------20,225.3 -- 0,225.3

T13AL COSTS 3,775,071.2 - - - 1,011,537.8 - - 125,700.2 139,78D.3 67,219.9 5,119,309.4

TOAL PFlKMT COSS 7,127,911.0 326,482.2 325,113.2 3,025,553.3 1,239,279.2 454,080.7 1,066,840.0 1,060,794.3 260,351.1 810,375.8 15,716,780.8 - 67 - ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 15: SCHEDULE OF DISBURSEMENTS

CUMULATIVE UNDISBURSED DISBURSEMENTS DISBURSEMENTS BALANCE FISCAL SEMESTER ------YEAR ENDING AMOUNT % AMOUNT % AMOUNT

1986 Dec. 31, 1985 0.7 1.9 0.7 2.0 35.8 98.1 June 30, 1986 1.3 3.6 2.0 5.5 34.5 94.5

1987 Dec. 31, 1986 1. 3.6 3.3 9.0 33.2 91.0 June 30, 1987 2.0 5.5 5.3 14.5 31.2 85.5

1988 Dec. 31, 1987 2.0 5.5 7.3 20.0 29.2 80.0 June 30, 1988 3.1 8.4 10.4 28.5 26.1 71.5

1989 Dec. 31, 1988 3.5 9.6 13.9 38.0 22.6 61.9 June 30, 1989 3.6 9.8 17.5 48.0 19.0 52.1

1990 Dec. 31, 1989 4.0 11.0 21.5 59.0 15.0 41.1 June 30, 1990 4.2 11.5 25.7 70.5 10.8 29.6

1991 Dec. 31, 1990 4.2 11.5 29.9 82.0 6.6 18.1 June 30, 1991 2.8 7.7 32.7 89.5 3.8 10.4

1992 Dec. 31, 1991 2.3 6.3 35.0 96.0 1.5 4.1 June 30, 1992 1.5 4.1 36.5 100.0 0 0

TOTAL 36.5 100% - 68 - ANNEX 1

(XILIIBIA HFALTH SERVICES INXYQRATICN PROJWCT

T A B L E 16: TWACER INDICATORS FOR M0MU1IfG AND EVALUATI(N

IEVEL CF ANALYSIS FRE(qEThY

IDICA1MS FAC. R S N M Q S A

A. STIXTURE 1. Costruction a. Percent completim of new vorks X X X X b. Percent completion of expansin works X X X X c. Percent coapletim of reaxdeling X X X X d. Percent execution of costruction investment X X X X

2. Equipment a. Percent of equipment delivered to Health Center X X X X b. Percent of equipnent delivered to Promotores X X X X c. Percent execution of investment in vehicles X X X X received by auxiliary staff (Pruovtores) d. Percent execution of equipment investimt X X X X

3. Training a. Percent prxwtores trained X X X X b. Percent prootores retrained X X X X c. Percent execution of training investment X X X X

4. Institutimal Development a. Percent facilities following program execution norms X X X X

5. Preventive Maintenance a. Percent facilities carrying out preventive X X X X plant and equipment maintenance

B. PHO(ES 1. N=mber of medical visits for children < 5 years X X X X X 2. Hospital occupancy rates X X X X X 3. New family planning acceptors X X X X X 4. EET coverage in children < 1 year X X X X X 5. Coverae by health prwooter X X X X X 6. Coverage with safe water X X X X X

C. IMPACT 1. Infant Mortality X X X X 2. Incidence of Polio X X X X 3. Incidence of Tetanus X X X X 4. Incidence of Acute Diarrheal Disease X X X X

IEID: Fac. - Service Delivery Facility M = Mbnthly R - Regional Managament Q - Quarterly S - Seccional & Nucleus Mangewent S = Seni-Annually N - National Manageznt A - Annually COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 17: PROVISIONAL SERVICE DELIVERY TARGETS

m= -

PERCENT SERVICES 1984 1989 CHANGE

HOSPITAL SERVICES 1. Inpatient Care a) No. Beds/1,000 population 0.6 0.6 ---- b) No. Discharges/1,000 population 20.0 32.5 62.5 c) Occupancy Rate 52.8 62.6 18.6

AMBULATORY SERVICES 1. Number of MEDICAL VISITS 1,523,068 2,059,538 35.2 2. Number of PROMOTER VISITS 338,718 908,647 168.3 3. Number of NURSE VISITS 423,793 1,000,211 136.0

DENTAL SERVICES 1. Curative Dental Treatment a) Number of Treatments 151,053 250,000 65.5 2. Preventive Dental Treatment a) Number of Treatments 227,264 655,048 188.0

SERVICES PROVIDED BY SANITATION PROMOTER 1. Control of Public Establishments a) Number of Visits 300,209 484,626 61.4 2. Control of Schools a) Number of Visits 7,305 15,072 106.3 3. Control of Water/Sewerage Systems a) Number of Visits 16,901 26,759 58.3 4. Vaccination of Domestic Animals a) Number of Vaccinations 162,979 380,476 133.4 5. House Inspections/Vector Control a) Number of Inspections 261,701 319,639 22.1 -70- ANNEX 1

COGIBIA RFAITH SERVICES INrEGRATIX PROJET

TABLE 18: Targets for Project Area After 5 Years of Service Delivery

1983 1989 PFCENr ESTIMTES ESTD#TES IMPROlME (%) (%)

I. CAUSE-SPEIFIC M(FBIDIMY

A. Children less than 1 year 1. Perinatal conditions 32.6 20.0 38.7 2. Gastro-intestinal infections 13.1 7.0 46.6 3. Acute respiratory infections 11.8 8.0 32.2 4. Nutritional deficiencies 4.0 3.0 25.0

B. Childre ages 1 to 4 1. Acute respiratory infections 13.9 10.0 28.1 2. Gastro-intestinal infections 13.0 6.0 53.8 3. Accidents 7.8 6.0 23.1 4. Nutritional deficiencies 7.5 5.0 33.3 5. Measles 7.3 0.0 100.0

II. OUICME IlICA1RS

A. Tummization (% of susceptibles < 4 years) 1. Measles 45.0 90.1 100.2 2. Polio 32.8 89.2 172.0 3. DFT 30.3 89.2 194.4 4. BcG 56.4 90.7 60.8

B. Family Planning 1. Nunber of Users 135,090 182,554 35.1 2. Total Fertility Rate (RTh) 4.3 4.0 7.0 3. Contraceptive Prevalence Rate 37.0 50.0 35.1

C. Malnutrition (all degrees) (% of childre 0 - 4 years) 19.4 15.0 22.7 - 71 -ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 19:Wouen Age 15 - 44 at Risk of Unplanned Pregnancy and Number of Women Using Family Planning Services at the Beginning and the End of the Project

WOMEN USING FP SERVICES WOMEN * WOMEN AT RISK OF TOTAL 15 - 44 UNPLANNED 1983 1989 HEALTH REGIONS POP. AGE GROUP PREGNANCY EST. EST. (198A) (1983)

1. NARiNO (a) Ipiales 184,971 35,329 18,071 6,686 9,036 (b) Tumaco 236,699 45,210 23,125 8,556 11,563

2. CAUCA (a) Occidente 54,474 11,385 5,374 1,988 2,687 (b) Sur 167,074 34,584 14,933 5,525 7,467

3. VALLE DEL CAUCA (a) Buenaventura 207,135 50,748 20,808 7,699 10,404 (b) Cali Area 2 388,880 110,053 46,753 17,299 23,377 (c) Roldanillo 53,575 12,483 4,805 1,778 2,403 (d) Tulua 181,684 43,604 17,417 6,444 8,709

4. AMAZONAS 37,698 7,050 2,831 1,047 1,416

5. PUTUMAYO 227,690 56,992 27,726 10,259 13,863

6. SANTANDER (a) San Gil 156,099 32,156 14,772 5,466 7,386

7. CORDOBA (a) Lorica 164,511 37,838 14,335 5,304 7,168 (b) Monteria 456,145 104,931 39,746 14,706 19,873

8. ANTIOQUIA (a) La Meseta 174,988 43,747 16,642 6,158 8,321 (b) Magdalena Medio 56,830 14,208 5,424 2,007 2,712 (c) Bajo Cauca 99,690 24,992 9,470 3,504 4,735 (d) Uraba 220,724 55,181 21,042 7,786 10,521 (e) Medellin Nor-Oriental 504,689 130,210 53,999 19,980 27,000

9. CHOCO (a) Istmina 108,028 23,334 7,834 2,899 3,917

TOTAL 3,681,584 874,035 365,107 135,090 182,554

Target of Family Planning Acceptors by Year in Project Areas 1/

1983 1984 1985 1986 1987 1988 1989 TOTAL

Total Users 135,090 140,548 146,955 154,312 162,618 171,875 182,554 182,554

New Acceptors 5,458 6,407 7,357 8,306 9,257 10,679 47,464

1/ New acceptors will be monitored daily by health service delivery personnel using the official registry No. SIS-135, "Registro Diario de Usuarias Nuevas de Planificacion Familiar". between the ages * Women at risk means those women in te reproductive age span assumed of 15 and 44, discounting sterilized and pregnant women - 72 - ANNEX 1

COLOMBIA HEALTH SERVICES INTEGRATION PROJECT

TABLE 20: NUMBER OF CHILDREN TO BE VACCINATED ANNUALLY IN ======PROJECT HEALTH AREA (In Thousands)

VACCINE 1985 1986 1987 1988 1989

Measles (one dose/child) 172 168 170 174 177

Poliomyelitis (3 doses/child) 167 167 171 173 176

DPT * (3 doses/child) 193 166 169 171 173

BCG ** (1 dose/child) 139 147 145 151 151

* Diptheria, Tetanus, Pertusis ** Tuberculosis

COHDIBIA HEALTH SERVICES IlRThATI PROECT

TANE 21: N[MI OF PRIKMA CARE UNITS (UPAs) AND HEALR POIfraS =-- EEEUE AND AFTER PlFDECT IMPIMETAI IN PRWET HEAUm AREA

INCREASE

PRIMAXI CARE UNITS 1984 1989 ND. PERCENr

Nmber of functioning Priary Care Units 99 166 67 68

Nimber of Health Proxters 515 1,141 626 122

Populatcu Receiving Services frm Health Prowters * 297,900 659,700 361,800 121

* Basl on observed 1983 data of 578 beneficiaries per health proter. - 73 -

ANNEX 2

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

ENVIRONMENTAL HEALTH SERVICES COMPONENT

RURAL WATER SUPPLY SUBCOMPONENT

Objectives and Implementationi

Objectives

1. The rural water supply subcomponent would have three main objectives. The first would be to supplement the efforts under the Health Services Integration Project by providing an adequate and safe water supply to about 150,000 people who live in rural communities (average population about 500) throughout the project area. The second objective would be to enhance the absorptive capacity of the rural water supply sector through the institutional strengthening of INS and the preparation of a National Rural Water Supply Development Plan. The third is to promote better inter-institutional coordination and cooperation, particularly in the maintenance of completed water systems. These objectives are in line with the recommendations made in the Bank's subsector report to be published in the near future and have the full support of the Government.

Description

2. The proposed subcomponent project would include:

(a) the construction, expansion or rehabilitation of water supply systems, including water shed protection measures, and the construction of sanitary school units in about 250 rural communities with current populations varying between 100 and 2,500 people;

(b) the purchase of equipment including vehicles, trucks, mobile promotion vans, communication and audio-visual apparatus;

(c) technical assistance and training to the Basic Rural Sanitation Division of INS in the following areas: organization and management, low-cost technology, system design, community motivation;

1Excerpts from staff working paper for the rural water supply subcomponent prepared by LCPWS, March 1985. - 74 - ANNEX 2

(d) the preparation of a National Rural Water Supply Plan (NRWSP) which would include an inventory of water supply resources and needs, the definition of short-, medium- and long-term investment programs and the formulation of strategies for accelerated and more efficient sector development.

3. The beneficiary communities of the subcomponent would be located in the health regions covered under the Health Services Integration Project. A list of priority projects prepared jointly by INS and the Ministry of Health for each of the regions is attached to the Rural Water Supply Working Paper. With few exceptions, the system to be constructed will deliver water to customers through a house- or yard tap. As the project area covers a large portion of the Colombian territory with widely varying hydrologic and topographical characteristics, water delivery will be from springs and by gravity, through pumping from surface water sources and wells (dug and drilled), and in the rain intensive areas of Colombia's Northwest through collection of rainwater from roofs.

Project Cost

4. The total cost of the subcomponent, construction is estimated at US$ 16.9 million (Table 1). The average per capita cost for systems to be constructed under the project is estimated at US$ 70 in end of 1984 prices. Contingencies amount to US$ 3.1 million, 22% of base cost. INS is exempt from import duties but must pay value added tax of 10% on purchase of equipment and materials and a special tax on foreign consultant fees. Taxes totaling some US$ 800,000 are reflected in the local cost component of the taxed items. The cost estimates in Table 1 include estimates for the preparation of studies and designs and administration, supervision and promotion which INS expects to carry out the project with its present personnel.

Table 1. 9umazy of Subcaoqxnent Cost

local Foreign Total Total as 2 of Base U$million - Inwestyaw Prcgr Supply of eqipment/pipes 2.8 3.0 5.8 42 Civil or*s/pipe laying 2.8 0.8 3.6 26 Land 0.3 - 0.3 2 Studies/design 0.6 0.2 0.8 6 Adninistrstioa/a4prvii/ promotion 0.4 0.4 0.8 6 Subtotal 6.9 4.4 11.3 82 Sector/Institutional Development Prcgra Supply of eqiphent 0.2 0.4 0.6 4 Tecinical assistance 0.2 0.2 0.4 3 Cansulting services N3P 1.0 0.5 1.5 11 Subtotal 1.4 1.1 2.5 18

Total Base Cost 8.3 5.5 13.8 100 Contingencies 1.4 1.7 3.1 22 Total Project Cost 9.7 7.2 16.9 122 - 75 - ANNEX 2

Financing

5. The financing plan of the subcomponent is presented in Table 2. The Bank loan would finance the component's foreign exchange component (42% of total subcomponent cost), and 30% of local cost bringing total Bank financing to about 60% of component cost. The Bank loan and the government contribution would be passed on to INS through the Ministry of Health in accordance with the terms of an agreement to be negotiated between INS and the Ministry. Local contributions would qualify as counterpart effort only, if they are spent in investment programs covered under the project and approved by the Bank. The Bank loan would be serviced by the Government.

Table 2. Financing Plan

Investment Sector/Inst. Total Program Development Project Source of US$ US$ US$ Financing million % million % million %

Bank 7.7 56.4 2.4 80.0 10.1 59.8 Communities 2.7 19.4 ------2.7 16.0 Departments/lottery 1.4 10.1 ------1.4 8.3 INS ordinary budget 1.4 10.1 ------1.4 8.3 Gov't budget 0.7 5.0 0.6 20.0 1.3 7.6 TOTAL 13.9 100.0 3.0 100.0 16.9 100.0

Institutional Responsibilities and Subcomponent Management

6. INS would have the responsibility for executing the water supply component. In the departments of Valle, Cauca and Antioquia the component would be carried out by Departmental Health Services under the supervision of INS as established in the delegation contract. For all subprojects, the principles and procedures of the Basic Rural Sanitation Program (Attachment 1) with slight modifications regarding community participation and cost recovery mechanisms and design parameters will be applied. Assurances to that effect were obtained during negotiations. Within DSBR, the subcomponent would be managed by a Project Execution Unit (Unidad de Credito Externo) which already has been formed for this purpose and is staffed adequately. The promotion and execution of the works would be directed and/or monitored by INS's regional supervisors.

7. INS would coordinate its work closely with the Ministry of Health, and Departmental Health Services, especially in the identification and selection of subprojects, investment programming and maintenance and operation. The Project Management Unit in the MOH, responsible for the management of the Health Services Integration Project would be kept fully informed. INS and MOH presented to the Bank a draft agreement defining the responsibilities of both parties with respect to the execution - 76 - ANNEX 2 of the water supply subcomponent under the Health Project. The signature of the MOH-INS agreement, acceptable to the Bank, is a condition of effectiveness for the loan.

Execution

8. INS' departmental offices would promote, identify, prepare, design and supervise the construction of rural water supply projects following the procedures established under the Basic Rural Sanitation Program (Attachment 1). In case of insufficient in-house engineering capacity, INS would contract out studies and design work. Procurement of pipes and other materials would be done in bulk by Headquarters, while small amounts of materials and civil works would be procured at the departmental level. The projects would be executed partly by the members of the community under the guidance of an INS community organizer or a local skilled foreman. Works exceeding the capacity of the community would be executed by local contractors or by force account. INS would have sufficiently experienced personnel and acceptable procedures for procuring equipment and materials and to supervise and administer the project.

Programming

9. The proposed investments would be made during the years 1985 through 1991, i.e., about 42 subprojects per year. The key to the successful and timely execution of the project would be good programming and planning. The short-term programming element for the rural water supply system construction program would be an annual investment and project implementation plan which INS would prepare in coordination with MOH and departmental authorities for each of the years of project execution. This plan would be submitted to the Bank by no later than September 30 of each year for the following year and would contain the following information:

(a) a description of each subproject proposed for construction including basic information on the characteristics of the community, its priority within the departmental investment program, project cost (total and per capita) supported by at least a preliminary design based on a known water source, a financing plan outlining the participation of the community and others and an implementation schedule;

(b) bidding documents and a time table for the bulk procurement of materials and equipment for the subprojects proposed under the annual investment program; and

(c) a description of activities planned under the technical assistance program and in the preparation of the National Rural Water Supply Plan. - 77 - ANNEX 2

10. The plan should also present financial projections (sources and application of funds) which would identify all investment programs which would identify all investment programs which INS plans to undertake during the coming year. The first annual investment plan would be due September 30, 1985 and cover INS' activities through the end of 1986. Assurances were obtained from GOC at negotiations that INS would adhere to the programming procedure described above and give the Bank the opportunity to comment on its overall annual investment program.

11. The process of hiring of consultants for the technical assistance program and the preparation of the National Rural Water Supply Plan would get under way soon after negotiations. INS has already presented to the Bank draft terms of reference. Assurancis were obtained from GOC that INS would give the Bank ample opportunity to review and discuss the findings and recommendations regarding the technical assistance program and the National Rural Water Supply Plan.

Selection of Subprojects

12. Beneficiary Communities would be selected from a list of prioritized projects, which INS has prepared for each Health Region in coordination with MOB. The prioritization of project communities within each region was determined primarily on the basis of estimated per capita investment cost and present public health conditions but also took into account factors such as: community preparedness to support project; equity considerations; willingness of department to contribute to the project; importance within the Government's development programs; and development potential of community.

13. With the introduction of reduced design parameters, the average per capita cost of systems supported under the project is estimated to be about US$70 (December 1984 prices). The need to consider more than mere cost criteria in project selection would make any subproject with a per capita cost of up to US$100 or Col$10,000 (in December 1984 prices and exchange rate levels) eligible for Bank financing. Any subproject with a higher per capita cost would have to be approved by the Bank through a special justification submitted by INS. In addition to meeting selection criteria INS would initiate the construction of a project only if: (a) the community has demonstrated its willingness, by signing a contract with INS, to participate in the construction of the system and to pay back a part of the investment cost in accordance with the community participation and cost recovery requirements adopted for the project, and (b) local funds are available as required under the component's financing plan. Assurances were obtained that INS would not begin a project before the afore-mentioned criteria have been met.

Review of Subproiects

14. While the Bank would comment on proposed annual investment plans on the basis of preliminary information, disbursements for an individual subproject would be agreed to by the Bank only after review - 78 - ANNEX 2 of project documentation showing that the subproject meets all selection criteria and is being constructed following the principles and procedures of the Basic Rural Sanitation Program. Attachment 2 presents a list of information which INS should prepare for each subproject and deposit in a file for review by a Bank mission. Assurances were obtained from INS that it would follow this procedure.

Design Parameters

15. Among the design parameters which INS engineers use at present to design rural water systems, several are unjustifiably high and should be reduced to make more efficient use of the investment funds available. In particular, design period and per capita water consumption should be adjusted. For small systems (less than 1000 people) the design period would be reduced to 10 years (currently 20 years for all system components) for those system components which lend themselves to stage construction such as storage tanks, treatment plants and to some extent water mains. For larger systems INS' engineers will carry out a staging analysis of the major system components and determine the time horizon which would result in the least-cost staging of works. Per capita consumption would be reduced from the current 80 - 150 1/c/d range to the 60 - 120 1/c/d range and take into account the climatic conditions and socio-economic characteristics of the community. Assurances were obtained from INS that it would apply the reduced design standards and practices summarized above.

Community Participation and Cost Recovery

16. Under the proposed rural water supply project, cost recovery from communities is expected to increase in the future from a current average of 60% to about 70%. Table 3 compares present cost recovery rates presently used by INS in the Basic Rural Sanitation Program with those to be applied under the project.

Table 3. Cost recovery parameters

To be applied Existing under project Initial contribution, % of project cost average 21.7 25 range 10 - 15 15 - 30

% of project cost to be repaid average 60 70 range 40 - 70 40 - 80

Repayment conditions amortization period 15 10 - 15 interest rate 6% 6% - 12% - 79 - ANNEX 2

The degree of community participation and cost recovery will depend upon the socio-economic capabilities of the beneficiaries. Assurances were obtained from GOC that the cost recovery parameters in Table 3 would be applied by INS for all water supply projects carried out under the project, and would be reviewed by June, 1986.

Maintenance and Operation

17. Under the Basic Rural Sanitation Program, the community is responsible for the maintenance and operation of the water system through its water committee. The local INS promoter is responsible for assisting and supervising community water committees. In the past, INS promoters have not been able to fully support the promotion and follow-up activities related to the maintenance and operation of water systems and supplemental action such as hygiene education, promotion of sanitary excreta disposal facilities, etc. In supporting a major objective of the Health Services Integration Project, i.e., the decentralization of the health system and the encouragement of more local involvement in health care delivery, the responsibility for supervising the maintenance and operation of completed systems would be entrusted to the Sanitation Promoter of the Departmental Health Service. The draft agreement between the Ministry of Health and INS would spell out clearly the respective responsibilities between the two institutions regarding maintenance and operation responsibilities for subprojects financed under the loan.

Procurement

18. A major obstacle in INS' rural water supply operations have been cumbersome and inefficient procurement limits and procedures. For example, the authority of a regional office for contracting civil works has an upper limit of Col$450,000 (less than US$4,500). INS has presented to the Bank proposals for more efficient local procurement arrangements which would be applied during implementation.

Disbursements

19. The water supply subcomponent has a 6-year implementation period (1985-91) and would be disbursed in 7 years. For the efficient implementation of the water supply subcomponent, the establishment of a special account for the project has been arranged. This account would reduce the time interval during which INS would have to finance with its own resources the Bank's share of goods and services.

20. Disbursement of the Bank loan would be against:

(a) 100% of foreign expenditures for direct imports; 80% of local expenditures for equipment and materials;

(b) 60% of total expenditures of civil works performed under contract or force account; - 80 - ANNEX 2

(c) 100% of foreign expenditures and 80% of local expenditures for consultant fees and training.

21. For contracts, whose value is less than US$10,000 equivalent and civil works carried out by force account, disbursement would be made against certified statements of expenditure. Documentation for these expenditures would not be submitted to the Bank, but retained in INS headquarters for periodic review by the Bank. All other disbursements would be fully documented. INS would handle disbursement for the rural water supply subcomponent.

Monitoring, Reporting, and Project Supervision

22. INS would inform the Bank and MOR of progress in project execution through semi-annual progress reports. Reports would be due September 30 and March 31 of each year. The reports would summarize status of project execution distinguishing between projects under preparation, execution and already completed. They would also summarize activities and expenditures related to the technical assistance program and the preparation of the progress reports would be the comparison of targets stated in the annual implementation programs and achievements and proposals describing how delays would be made up. Assurances were sought from GOC during negotiations that INS would adhere to these reporting procedures. Since a major objective of the water supply subcomponent is to prepare INS and the rural water supply subsector for increased investment in the future, LCPWS would take on the responsibility for supervising the execution of the rural water supply subcomponent in coordination with PHN. - 81 - ANNEX 2 ATTACHMENT 1

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

Water Supply Subcomponent

Methodology for the Promotion and Construction of Rural

Water Supply Projects Under the Basic Rural Sanitation Program

Once a community has shown the desire to obtain a water system, the following five basic steps are followed by INS to satisfy the aspira- tions of the community:

Phase 1 - Study of the Community involves the preparation of a socio- economic-cultural profile of the community and its attitude towards sanita- tion to assess the communities' needs, disposition and capacity towards participation in the project. During this phase the basic technical data required for a conceptual design of the system are gathered (water source, sketch of topographical situation). This work is done by INS' promoters and involves the Regional Engineer for technical matters. This phase ends with informing the community of the general feasibility of the project and a clear exposition of INS procedures for community participation.

Phase 2 - Preparation and Approval of the Project begins, if the initial response of the community has been favorable and the prefeasibility of the project has been affirmed. It involves topographic work, the preparation of studies and designs and the establishment of a cost estimate. In doing this, INS' regional engineer, or in some cases engineering consultants, follow a clearly defined methodology and format and apply established design criteria.

Phase 3 - Motivation, Promotion and Organization of the Community uses the existence of plans and designs as tools to obtain full community support for the project. There are audio-visual presentations about sanitary prac- tices and the use of water. Community leaders are being asked to give their support to the project. There are meetings open to all community members in which the pros and cons of the project and the need for self- help are stressed. At the end of this Phase, the community, usually repre- sented by the President of the Junta de Accion Comunal, will sign an agree- ment with INS which stipulates the following major points:

a) percentage of project cost which the community is to contrib- ute to the project in labor, cash or materials; -82 - ANNEX 2 ATTACHMENT 1

b) the portion of the externally-supplied investment funds through INAS which is to be repaid and the condition for repayment;

c) the responsibility of the community to take over the care of the system once completed and the functions of the (Water Com- mittee which will be elected by the community to administer, maintain, and operate the system; and

d) the estimated amount of monthly payments which each household (cuota familiar) will have to make to meet loan amortization and operating and maintenance costs.

Phase 4 - Construction of the System begins only after the signing of the contract. The community will participate in the works by supplying materials, providing transportation, making available land and right of ways, and through labor (pipe laying) under the guidance of a local fore- man. The construction of more involved facilities (storage tank, treatment plants) is usually carried out by a local contractor hired by INS or through force account. In some cases, the community will also provide cash either collected among themselves or made available by local political authorities. INS keeps careful records of all community contributions.

Phase 5 - Maintenance and Operation. Once inaugurated, the system becomes the property of the community which elects a water committee to administer, operate, and maintain it. The committee consists of three community members - a President, Vice-President, and a Treasurer and a fourth member who is representative of INS (usually the community motivator) who has the task of assisting the committee in administrative matters and controlling that the committee follows established procedures. The Committee is responsible for keeping the books, collecting the cuota familiar, and, if necessary, employing personnel for maintaining the system. It also decides on system extensions and new customers. -83 - ANNEX 2 ATTACHMENT 2

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT WATER SUPPLY SUBCOMPONENT

Subproject Documentation

For each subproject to be financed under the subcomponent, INS would prepare the following documentation:

(a) a technical and socio-economic project appraisal providing the following information:

(i) physical characteristics of the community and water resource conditions, including a schematic map;

(ii) assessment of socio-economic characteristics of the community and prospects for development;

(iii) assessment of sanitary conditions of the community and desc'ription of sanitary practices;

(iv) forecast of population and water consumption;

(v) description and evaluation of alternatives to supply the community with water;

(vi) calculation of the estimated cost and economic compar- ison of feasible alternatives; (vii) selection and justification of proposal solution and preparation of detailed cost estimates;

(viii) preparation of financing plan and implementation program;

(ix) projection of future maintenance and operation costs;

(x) calculation of monthly fee for family (cuota familiar) required to meet maintenance and operation costs and to pay back loaned investment funds;

(xi) plan of action for supplemental public health measures to be promoted and implemented by Regional Health Unit such as excreta disposal and hygiene education. ANNEX 2

- 84 -ATTACHMENT 2

(b) final designs and specifications;

(c) signed agreement between INS and community specifying level of costs recovery in accordance with the principles defined for the project;

(d) agreement between INS and the Departmental Health Service regarding continued assistance to the community and the pro- moticn and implementation of supplementary public health measures such as excreta disposal and hygiene education; and

(e) project financing plan with commitment by departmental authorities to make available sufficient counterpart funds.

This documentation would be kept by INS in the project file for review by Bank supervision missions. Disbursements for expenditures per- taining to an individual subproject would only be made after Bank mission has reviewed the documentation and expressed agreement to its content. - 85 - ANNEX 3

COLOMBIA

HEALTH SERVICES INTEGRATION PROJECT

Selected Documents and Data Available in Project Files

"Proyecto Consolidaci6n del Sistema Nacional de Salud", Solicitud de Credito Externo Banco Mundial, Ministry of Health, Colombia, February 1984. (Four volumes).

"Colombia, Health Services Integration Project, Water Supply Component -- Staff Working Paper", LCPWS Division, The World Bank, January 1985.

"Colombia Health Sector Review", Population, Health and Nutrition Department, The World Bank, Report No. 4141-CO, December 15, 1982.

"Analisis Financiero del Sector Salud - Nivel Institucional, 1981", Oficina de Planeaci6n, Ministry of Health, Colombia, October 1983.

"Colombia, Diagn6stico de Salud - Politicas y Estrategias", Ministry of Health, Colombia / Pan American Health Organization, Bogot&, June 1984.

"Hacia la Equidad en Salud", Plan Nacional 1983-1986, Departamento Nacional de Planeaci6n/Ministerio de Salud, Bogota, January 1983.

"Memoria al Congreso -- Ministerio de Salud 1983-1984", Jaime Arias, Bogota, 1984.

"Levels and Recent Trends in Fertility and Mortality in Colombia", Hania Zlotnik, Committee on Population and Demography, National Academy Press, Washington, D.C., 1982.

"Poblaci6n y Morbilidad General (1977-80) -- Estudio Nacional de Salud", Aurelio Pabon Rodriguez, Ministerio Salud/Instituto Nacional de Salud/ Asociaci6n Nacional de Facultades de Medicina, Bogota, December 1983.

"Bibliografia Anotada sobre Poblaci6n/Planificaci6n Familiar, Colombia", Asociaci6n Colombiana para el Estudio de la Poblaci6n/Corporaci6n Centro Regional de Poblaci6n, Bogota, March 1984. - 86 -

OaGU~ Chart 1 mw2 mwn IN MONimJ1C

Project !astati s Scheiule

--- I- II II II Il Project I IProjecti 85/86 if 86/87 it 87/8 -11 88/89 If 89/90 11 90/91 ljinbationi itL I 111... I I I I I. I I I I iii I I I III1.-(.i fl12adI3rd4tbI IlatIaiI3rdImtbI I 1991 1 Project ktivity I 1985 I1st12Id 3rdiAtbI flat2adt3rdihI f1st 12a3rdiAtbilotI2adl3rd14tl

11. Civil ierks Design aind Site Presation I I I I I11I11 I . Fin.lD...gns Hospitaws/-terstPo-ts I I I I I II 1 1 1 11 1 1 1 it I I I I I I I I i i I I I 1 1 1 1 1 1 1 1 I B. just nts to tI I IIII I A. Prqarto of Stndr Bidin Ioum t 1 1 1 1 1 11 1 1 1 1 1 1 1 1 1 1 I I I I itI I I I I I1 1111 I C. constctoPogeso I I - . + I~ 4 4 - --I I I I 12. Construction Prr:

i I I I I I I I I I I (a) Constructi/Ex ion of th Facilities i i i I I 1 1 1 1 (b) eodelir of Health Facilities I i i Ii I I i i I II 1 1 1 11 1 1 - 1 11 1 II I 111 1 11 111 11 I W) Maintenanc Arms in Regioal itals I I I I I iI I I I If I I 1 I I I I I I i i 4 11 1 1-i-1 11 41 1 1 it1 I1 I4~I-4--~IIII 131 Funiur() Rural %ter SuMy System I I I I I I I 4 i I i I () atrines I I -I I I i I i i i 4

if I 1 11 1 1 1 It I I11111I 1 11 1 1 1 I C A hiptribtim ofandntatW.in o cur 1 1 I 1 4 4-4I1+11I11I IC. Distributio and InstallatioI---4-44-4 1 1 1~ 11 1 1~ 1 11 1- 1 1 I 11 11itI111 A. .Preparation Of txlWBdigDmt11 1 44.+- -I I If I I II IC. Distruioni and Installation I 1 I I 4 4 11 1 . 44

Service Delivery Personel: A. Health I I I I I I I II I I I I I (a) Forml Trainig Progra I I i I i i 1 1 i I I I i I I I i I I (b) Technical C rse 1 i I i M i Ii 1 4 4 11 1111 1 S (.) whrkahps ad Sminars 1 4 11 11i C. Co.munity EducationI S(a) Train of Trainers I (b Continuing Education of Pronotoma I (c) W*rksb*p for C-amuiy leaders i iii SC. VAintmmnce Personnel 1)D. Sector M-esmnt |(it) Sminars for High-level aNsagers- I (b) Wrkshvpe for Division ani Zonal Chief* I (c) ResourcesAministratio IntensiveCourIsI--- I I I I II I I I II I 16 8.w .itndica i tiac I I I fI I I I I I ft I I I I I I I I I I I I I I II I I E. Fellowships I I IIIII IF. Forl Training OPriculm -evi-a- -pecialiat-4 1 1 1 1 1 1 1 I . Technical Laboratory 111 1 1 H . Research Methodology and Hiaemant 4 11 1 1 1111 11 S1. wnorsation systea

I i I I I I I I I I II I Project Adi wini trhti : I II I I i I I II I I I I (a) Establishment of Project Accounts I Wb Second Project Preparation B. Bector Manompnt I I I I II I I I I I If I I 1.C. Training:Reeah Studies I I it I Wa Rewim of Acaeo Program SD. Laboratory Fsthk,: S(a) Final Feasibility Proposal f Wb Preration of Rqippwnt Lists- 9 . IMEOMUM ln vocwk: I I I I I II I I (a) Alyis A Design of Inforation Systm i I I I I I I (b) axlk*tion of the SystII Ii I I I II I F. Research I 1Imr-*: I I I (a) alation .nd neelmdolca Of Studies~ I G. Mural Vater Supply 1 I (a) National Rural Water &wplyPlan 1,1 114-1 1111

I (a) 1985 Natioal Fertility Survy I Wb Contraceptive Prsaalmoe study 111 I I I II I I I III I I II I I (c) Efficiency of Project m m i1 I I I I I II I I I Ii I (4) Sol. BealthF.an. Services Proj. Ara I I I I I I I I I II i I I II I () a iate Tehnology for ealth Ca I I I I I I ii I Ii I I I I I I II I I II I I I I S o ources - Health sectorI I I I I I I I 111-4I4-4 - Health Sector I I 6 (&) Physical Infrastructure I II III S(h) alth Sector Fin ing Study 1 - BaItor I I II I I I I I II141 I Wi) fnoe nt Dzcicio Health 1 I (j) etiaisci of Drg S- -ply I II 1 1 1 1 1 I 1 I1 4 4 1 I 1 I Il I I () Operstial Reteh at I giIoal Level I I 1 1 I I I I I I i I 1 I I (1) olaria Incidence Trnds i- I -I I I I II i I I 1 I 1 11 I I I It I I I I I I I I 1I I I 1 if I I 1 11 1 1 1 11 1 - 87 - CART 2

COLOMBIA HEALTH SERIMCES INTEGRATION PROJECT Organlzaltonal Chart - Mininy of Health

L - -- -

VC.-Mflsto

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4rttIttA

Env1OmTE

L

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medWed B-Ank-27079 -vv.. ontw

-~i soodnis W1_ &W,27 ORGANIZATION CHART OF INSTITUTO NACIONAL DE SALUD (INS)

MTA OCECTM

DIRECCION

EOFICINAENCOORDINACKON OFICNA E P ANACO T ------""-- -- "-*""-~~~ "" ~EPIDEMIOLOGICA

OFOCINA DE ASISTENCA ~~ OFICNA URIICA ------~ ~~ 1DEDELA LA DIRECCIONDREC

JDMVSM L*8ORATOW NAX10ML DIVISION DE DIVISION DE SANEAMIENTODVSONAMNTRTA JE SAUJD-SAMPER MARTINEZ7 RVESTIGACINES ESPECIALES BASICO RURAL ST

Sackinde iagostca eccdo d P4ogranocida __ idno do - PciT -reso- h" sigacisy Rb u -Supervis y EvoSociun

Sccidn do Estudios Seccin d Presupueslo y Contobilidod - C y da do Eststicm y Constncclones

Soccida do ASlifs do Drps l d ornocin Seccion do Sor.cios Genefoles camisatorc - ~ nlm bobids

semciin do MAisi d6 .... ii do-io t

_l-SecidbraOri dSAgus -

Seccian do Supervisidn id Cadvel moivgica " y Asislncio Tecnico

SsDm liIecsmyCeato do 1 Seccionoles - Decumme"Isci I. IBRD 18785 78* 4' ' CUAA E JAMAICA, "AI~ O IA C 0 L 0 M B I A SNICAIAGU-A HEALTH SERVICESO INTEGRATION PROJECT PANAMA ohota FRGUIANA

BRAZIL PERU

BOLIVIA RIA VENEZU ELAA PAKLAGRY PA NA MA Allr ENTINA /

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RElA I

T- IT,',' R VE NEZUEL A I RBP18601

L Po ~A 1 poIeT / 9h0 FOT, Heot e G ao G Tumoco

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C) R0 *E4' C U A D 7

-MILES

0 50 10 150 200 250O KILOMETERS \ AA V,4Z 0N A S 5see I&RD 18601 B R A Z I L

[: Project Departments/ 19 Project Health Regions

@National Caitol - A SCities and Townis with Popi-lation 0,ve 40,000

MainHrgway P E R U

Deparrmei Boujnd.rie

--- - International Boundari s

7,8' 74'*1, 1\ , FEBRUARY 19"5 COLOMBIA -x NARINO El HEALTH SERVICES INTEGRATION PROJECT 4 Health Regions of lpiales and Tumaco

-7

f C A U C A Voquero mMACO //C U Vaq,,eri

A RosarroBrbca.7S

- PASTO

SELECTED ROADS omb AIRPOR TS 1 Ilel us- Aernande30,, RIVERS - - & HEALTH-.-- REGION BOUNDARIES Imd"40pSS'S . r re s - - A i R PODE P A R T ME N T B O U N D A R IE S A Mel o 7 .P. - -- INTERNATIONAL BOUNDARIES IPIALES PPPs" P U T U M A Y O EXISTING EXISTING EXISTING TO BE TO BE TO BE TO BE EXPANDED & EXISTING CONSTRUCTED EXPANDED REMODELED REMODELED REGIONAL HOSPITALS r55 may ba een prepareS by LOCAL HOSPITALS t nk'ete. I I tef y (f 1 SSSOe convenien e o b e A HEALTH CENTERS tnemaeot The Wd bank NETnd be iernaton vSFnance POSTSe dnHEALTHhnbondaressown

TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY may S FACILITYp5rt 11,S d not rl,. The efrn Wbnrln bank Theand

snternatiSea Fnance Corporabin sSdrnen Sn tbe 55 Th 3D SDany 5 sraS ]D1 2D 3 KI LOME TE RS 2 30 4D 5 * 4e0n0remntnocetanosnt Sr see tsmtoer Sr any Cr~bb-dS COLOMBIA CAUCA HEALTH SERVICES INTEGRATION PROJECT Health Regions of Guapi - Occidente and El Bordo - Sur PACIFIC OCE AN Son Pedro- de Naya V A L L E D E L CA U C A AV

Noonanmi to-

GorganaZaragoza

SnBernardo Alt Sigu SLTpeA

Sown Rosa GUAPI OCCIDENTE hanar {A 4 HRS5 GUA P \rtj S Antonfo San 9 o 0* 4 HR5 Jose r 30 M,,- GUPI 50An~n0Santa Mar a D7H,?S2 A4 HR5 Concepcion F 2 HRS Colle Largo 5 G IHRt Belon H P HRA 51 POPAYAN Naran os

H U I L A DLos Brisas

Batsi as San Alfonso 1. Fonda Piedra Sentoda T S EL - EL BORDO - Pat. If ToPopa EL BORDO - UR A I HR 0 1 - GucHcona HR 45 em 8 40m1 P /I HR - 30m C I HR Q I HR V L\a HerdI Lr Vega D 40 m" R 30 m,, H2M,, V L iaaf IH,? - 30 m , x 40 n 5rn Ltrac - /H T H?- Galodz 30mon SAlrnaguer G se Caquiond Volencio 40 Pmrn W ~Mo arras( La He .. n0 3 oSHR Min W M+5 n A\ E I ar e ua on to5" 0 10 20 30 0 Mon X 40Mo 40 50 Mercaderes' San Joaqn Son G tK Sonho M 2 HRS corenZ. El ROsOIN 7Hf3mi zombrerilJos C Milagros Arb \So n J wnT Pt/r leda A Florencia " n /- Santa Rosa .To P/to/, 1o SELECTED ROADS AIRPORTS N A R I N 0 RIVERS Sta Mario de Villoaobas Son J.. do Vlalos HEALTH REGION BOUNDARIES J --- DEPARTMENT BOUNDARIES

EXISTING EXSTING TO BE EXISTING EXISTING TO BE TO SE EXPANDED CONSTRUCTED EXPANDED REMODELED REMODELED The REGIONAL HOSPITALS ro'This te map has beennlene prepared e by LOCAL HOSPITALS Conveien a i ntfernaWonal e o the Aj A HEALTH CENTERS nanke The eona tions < used and fthe boundaies shown On this Map do not imp"y, an the - A HS -30 L PS -Part O ayjdet" of The Wartd Bank and the o n/n TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY Fon e toea tau c any na e of ay territory Or any S*endorsement or acceptance of C boundtaesC loo) COLOMBIA VALLE DEL CAUCA -

HEALTH SERVICES INTEGRATION PROJECT RIS ARALDA Health Regions of Cali Buenaventura, Roldanillo and Tulua

EXISTING EXISTING EXISTING TO BE - 7 TO BE TO BE TO BE EXPANDED & - EXISTING CONSTRUCTED EXPANDED REMODELED REMODELED .. REGIONAL HOSPITALS LOCAL HOSPITALS HEALTH CENTERS HEALTH POSTS

6 HRS dOr/ TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY

SELECTED ROADS QUINBe10 AIRPORTS ROLDANILLO RIVERS - ' Sta. Teresa HEALTH REGION BOUNDARIES 7 s 3 n BO IVAR DEPARTMENT BOUNDARIES

0 10 20 30 40 50 KILOMETERS Cristaoes .f'' Bugalaqrande -T U L U A CHCO C. Pro.S. Zona EspanaSontoria oTULUA PCo H~ 0

Pro Frazodas

BUENAVENTURA A ,C 535kacaiasSon Cipriano

Punta SoldadA ASabaletas San Jose de Anehicayd

San Francisco > El Pital

Son IsidroT0LIMA BUENAVENTURA TOLIMA CALL Joaquinaz

Veneral

P.. This map has been prepared by The World Bank s staff exclusvely for the cnosuenenc Of the Sn Antonio d Yurumangui:aes and s exclusivy for the internal use of The World Bank S A n d Y n an d the ter n a on F an c e ThedenominahonsForporation m In ti al in m> donFrancisco C C A U C A used and the boundares show > on this map do not rply, on the part of The World Bank and the International Finance Corporaton, o, e' . ~ .any udgment on the legal status of any territory or any endorsement or acceptance of such boundares Lr( L BRD 18601

COLOMBIA AMAZONAS HEALTH SERVICES INTEGRATION PROJECT Health Region of Leticia C- -V PUTUMAYO A U P E 5

-7 TR ogot ( To Puerto leguizcmo H )'

~ At rocsora

To9,o/. Puerto Alegria -

N Chorrero

P E R PERUU

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P E R U

EXISTING EXISTING EXISTING TO BE TO BE TO BE TO BE EXPANDED & EXISTING CONSTRUCTED EXPANDED REMODELED REMODELED

REGIONAL HOSPITALS LOCAL HOSPITALS A HEALTH CENTERS HEALTH POSTS

I~35te TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY

SELECTED ROADS by AIRPORTS Thoo mop has been preparnd byA RP RT ain The World boks sta eRffnxcuseRI b ...andnon ve fyOrthe RIVERS f h f TerWorld hFank HEALTH REGION BOUNDARIES nod fho I~bO~~~F ,nL 0 20 40 60 80 !Kmr Crpan The nnaDEPARTMENT BOUNDARIES KlOMETERS part f Thr a o INTERNATIONAL BOUNDARIES koteroationa Finane Corporaoion oOt oranyterrtory,an any jodgment on the opgal sofu of no0m f f Soch BondarAe.

FEBRUARY 1985 I BRD I8& NARINO -- -- COLOMBIA S13 J Condaguo * -3

oc \H SneRoque uno,8- CAC)U E TA - Sa n aedo . LG u z m a n ' Maria Vi- lorn,'n LOCALJose PJ.A - 2PtU mb 30mb-- . EXISTINGEXISTINGTOBE EXISTING v C -2H 3EXTING CONSTRU CTED EXPANDED REMODELED REMODELED Puet As E - 7 H R -HR/ REGIONALHOSPITALS PRIo CocdI Pto.G FKf --ocd7070 Hr/i 0Mt.EXS Ma yoyoque 0/ LOCALHOSPITALS - anPeroH R e 4PI - 20min A K- 30 mini - 3 mA HEALTH CENTER S Puerto Asis Z - 7HP 30m/n tv - 0 MtnHEALTH a HAT T POSTS Sto 30 iiMecay Rosa L Hormig a TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY de Sucumbios Merermig

_ _ _ _ _ S L C 5~n.MigueI Merpnou SELECTEDE ROADSO D -o D A I R P OR T S RIVERS ELC U AeD a HEALTHREGIONBOUNDARIES

REC A O O D E PA R T ME NT B OU ND AR IE S ) ~ INTERNATIONAL BOUNDARIES

This map has been prepared by The World Bank's staff exclusively N lTgu An for the convenience of the readers and is exclusively for the internal use of The World Bank P and the International Finance * E23 Corporation. The denominations 20U0405 used and the boundaries shown 0 - on this map do not imply, on the 2 E part of The World Bank and the ---- 0 International Finance Corporation, KPLOMETERS any Judgment on the legal status of any territory or any er--sement or acceptance of undaries . A O**

FEBRUARY 1985 COLOMBIA SANTANDER HEALTH SERVICES INTEGRATION PROJECT Health Region of San Gil N

0 10 20 30 40 50 C E S A R KILOMETERS

-IN ' NR TE D E BO I . SANTANDER

BO0L I V A Rtt

BUCARAMANGA

AAN T QUI AHR 8 15Mi,n 0 CHR 0 J HRS E I HR F I HR-3in 4 G 5 min H IHR - 30mr, Guane Villonuevo 1 45 mu J 7 HR / A Los Vueltos K HR -30min Bocore BARICHARA 1 2 HRS CURITI As 7 HR - 30m Cbrero SAN Gl N 1kR- 30hHmPn .. E o 1 HR - 30o in P 7HR nchote Q Js P 30 m .rR MOGOTES Padua SoarI Jose: Los Molinos

6 H SAN JOSE jRiachuelo CHRLA K Coromoro ONIZAGA ) \0 * m icl Lo Canters, N (Encino BOYACA

- - - SELECTED ROADS - -- AIRPORTS .. Z RIVERS BOYACA HEALTH REGION BOUNDARIES DEPARTMENT BOUNDARIES

EXISTING EXISTING EXISTING TO BE TO BE TO BE TO BE EXPANDED EXISTING & CONSTRUCTED EXPANDED REMODELED REMODELED REGIONAL HOSPITALS LOCAL HOSPITALS HEALTH CENTERS ins HEALTH POSTS his map nas been preparedby The World Bank's staff the readers and s exclusiey for the convenience of exclusively for the oteal use of The World Bank and the inernational HP Finance Corporation The i TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY denominations used and the boundaries shown on this map do not imply, on the part of The World Bank and the International Finance Corporation, any judgment on the legal status of any territory or any endorsement or acceptance of such boundares. c0 COLOMBIA

San Be nardo El Porvenir - CORDOBA Paso Nuevo HEALTH SERVICES INTEGRATION PROJECT Health Regions of Monteria and Lorica LORICA Cantde aria "7

.. ~ /Corozalito-

IRHI

Los enciae Popoyan de E U R

Crist RReyt

3040e20S0 0

Sart Rafael> El Coramelo EP Cedeo

Palota->P paie

A~~~ N T1 0C) TIS

K~e P~ d o REGIONA HOSPITALSp

ERR-LHEALTH -. DEAEENBANDRERGION BOUNDARIE

-~~IR Sa.-- -T RFNA.O PIAS EXIG CPELETD RODEL \c de Po it SC A HFPA L

rl RA RR- TCE - EGAIES -)kH Pro~ Aie-oo HEALTOMENERRS

------. . - . -A IH E A THRT ST

on te teot tah~ ot ny erhtry o an endrseent , aceptnce t sEXISTIrNrrG EXISING XISINGO 0

the sreaders and is nrctns ndyyter te irernat ns t Texusvy Wn o n n the o enratroa . ~I~ ~ ~IAt TRNPRAINSTEERL'-TMOFCL Fi nance C~orporatnnn The dehnminathons used and the hoondaries sheen on thrs map do not A N TIO Q UIA3 f M OTRA ORTP NTST O np~ the aJ at The Worod Bank and the tnter nt inaBO n e orpoR Sme ARBOLETE C A R / 8 PE A AJ COLOMBIA So, Joon de Urobo s L UeDANTIOQUIA

zopoto F ino.a -1 eCoN.o HEALTH SERVICES INTEGRATION PROJECT Health Regions of Medellin, Uraba, Lo Meseta oErib Bao Cauca, and Magdalena Medio N ECOC LI \Son JoseI deMu os Sto Cto.lino

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AN PEDRO DE URABA Tie edreciros' P , t PIe TURB T, S Nueno j '. Mret

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C- -zo C.-ze d. eU Beo Ars E a 50,, colonA * tEXISTING 2,0V IrsEl SolvadorA EXISTING EXISTING TO BE Ust it- Aa TO BE TO BE TO BE EXPANDED & A c .2d A '-* 1- EXISTING CONSTRUCTED EXPANDED REMODELED REMODELED .A rrdo TrN-dod -H PlnAy This ma ha b preared b REGIONAL HOSPITALS 20, PttIn,5 Tte W ~olI0k staff exctosoetym A Ah. I., vncIn ce a the 0 LOCAL HOSPITALS corA iternal Ie It The Worldan 8.sHEALTH CENTERS A , Pooldo and the internataonal FinanceC I AusedCorporatson ad the Theondare denmnations 4 d )HEALTHP HEALTH POSTS Lo *', n, 00,0 o this map dO not ,mpty. on the C ( hart Of The World hack andc te omata orn 2 HRS- 40cm TIME TO TRANSPORT PATIENTS TO REFERRAL FACILITY acy judgment on the legal status or oey tnrrtory or 1any edorsemert or acceptance of such bOOnd,0,05 COLOMBIA ( CHOCO \ HEALTH SERVICES INTEGRATION PROJECT Health Region of Istmina

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EXISTING EXISTING EXISTING TO BE TO BE TO BE TO BE EXPANDED& EXISTING CONSTRUCTED EXPANDED REMODELED REMODELED r- REGIONAL HOSPITALS LOCAL HOSPITALS A HEALTH CENTERS A n HEALTH POSTS

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KILOMETERS QUIBDO

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This map has been pinpared by The World Bank's staft exclusively tor the convenience of the Ieadersand ,secls onytr the V A L L E D E L C A U C A enternal use o he Wodld bank and the International Finance Corporation The denominations used and the boundaries shown on this map do not imply, on the SC~Plestna partotTheWorld Bank andthe >International Finance Corporation any judgment nn the legal status 01 any territory or aiiy endorsement or accer such boundaries U, ______