Document of The World Bank
Report No. 12768-ALB
STAFF APPRAISAL REPORT
ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
NOVEMBER 8, 1994
Human Resources Sector Operations Division Central and Southern Europe Departments Europe and Central Asia Region CURRENCY EOUIVALENTS
Currency Unit - Lek US$1.00 = Lek 101 (September 1994)
WEIGHTS AND MEASURES
Metric System
FISCAL YEAR
January 1 - December 31
ABBREVIATIONS AND ACRONYMS
CEE Central and Eastem Europe CY Calendar Year DEcon Department of Economics DHC District Health Committee DHosp Department of Hospitals DHR Department of Human Resources DHT District Health Team DPH Department of Public Health DPT District Project Implementation Team DPharm Department of Pharmacy EU European Union EME Established Market Economies FUFARMA Public Sector Drug Distribution Agency FY Fiscal Year HSRP Health Services Rehabilitation Project ICB Intemational Competitive Bidding IS Intemational Shopping IDA Intemational Development Association LCB Local Competitive Bidding LS Local Shopping MOH Ministry of Health MOF Ministry of Finance and Economy OECD Organization for Economic Cooperation and Development PCU Project Coordination Unit PHC Primary Health Center PIP Project Implementation Plan POM Project Operational Manual SOE Statement of Expenditure TA Technical Assistance TOR Terms of Reference SAR Staff Appraisal Report TSD Technical Services Department ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
STAFF APPRAISAL REPORT
Table of Contents
Credit and Project Summary ...... i
I. HEALTH STATUS AND SERVICES IN ALBANIA .
A. Health Status of the Population .1 B. Health Services in Transition .3 C. Issues for Health System Reform .3 C. Government Strategy in the Health Sector .7 E. Role of the International Donor Community .9 F. Rationale for IDA Involvement .10 G. Previous IDA Involvement .11
II. THE PROJECT ...... 12
A. Project Objectives ...... 12 B. Project Description ...... 12 C. Environmental Impacts ...... 19 m. PROJECT COSTS, FINANCING AND IMPLEMENTATION ...... 20
A. Project Costs ...... 20 B. Project Financing ...... 23 C. Project Management and Implementation ...... 24 D. Project Procurement Arrangements ...... 29 E. Disbursements ...... 32 F. Status of Preparation ...... 33
IV. BENEFITS AND RISKS ...... 35
A. Benefits ...... 35 B. Risks ...... 35
V. AGREEMENTS TO BE REACHED AND RECOMMENDATION .. 36 Table of Contents (continued)
TEXT TABLES
Table 1: Demographic and Health Indicators, 1991 ...... 2 Table 2: Project Cost Summary by Component ...... 20 Table 3: Project Cost Summary by Category of Expenditure ...... 21 Table 4: Cost Summary by Component &Source of Financing ...... 23 Table 5: Summary by Expenditure Category & Financing ...... 24 Table 6: Project Procurement Arrangements ...... 29
ANNEXES
Annex 1: Basic Country Data ...... 38 Annex 2: Project Implementation Plan ...... 39 Annex 3: Detailed Cost Tables ...... 72 Annex 4: Supervision Plan ...... 86 Annex 5: Procurement Plan ...... 87
MAP: IBRD No. 25813 (Albania country map showing prefectures, districts, location of health Centers and hospitals)
This report is based on findingsof an appraisalmission which visited Albaniain February 1994. The missioncomprised: Ellen Goldstein,Task Manager, EC1/2HR;Leonardo M. Concepcion,Senior ImplementationSpecialist, EC1/2HR; James Stevens, OperationsOfficer, EC1/2HR;and consultantsThiery Tuxen, HospitalSpecialist; and Pierre Fournier, HealthOrganization and ManagementSpecialist. The mission's work was supportedby Elim Sakiqi,Liaison Officer, EC2AL. This report incorporates earlier work by Teresa Ho, Task Manager for the initialstages of project preparation, EC2HU; and consultantsJean-Marc Guimnier,Pharmaceutical Specialist and Gilles des Rochers, Health FinanceSpecialist. The Peer Reviewersare: Denis Broun, PHN and Philip Musgrove,PHN. AndrewRogerson, EC2HU, ManagerCentral EuropeanServices and RalphW. Harbison, Chief, EC1/2HR are the supervisingmanagers. Kemal Dervis, EC2DR is the Country Director. ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
Credit and Project Summary
BORROWER: Albania
BENEFICIARY: Ministry of Health (MOH)
AMOUNT: SDR8.6 million (US$12.4million equivalent)
TERMS: Standard IDA, with 40 years maturity
PROJECT OBJECTIVES: The Project will help prevent deterioration in health status during the economic transition by improvingthe qualityof basic preventiveand curativehealth services. This will be accomplished by upgrading primary and secondary facilities to minimum sanitary and physical standards, improving treatment skills of hospital physicians and nurses (to complement skill-training programs for primary care personnel supportedby other donors) and buildingcapacity at the central and district levels to manage health resources and implementsectoral reforms. PROJECT DESCRIPTION: The Project consists of a main componentto rehabilitate primary and secondary health services, and a complementarycomponent to build institutionalcapacity at the district and central levels. The Project will be implementedover a five-yearperiod by line Departmentsof the MOH, with implementationactivities coordinated by a Project CoordinatingUnit.
Health Services Rehabilitation(US$10.9 million base cost). This componentwill support: i) rehabilitation and upgrading of 100 primary health centers out of an initial network of 200 in six pilot districts (with an aggregatepopulation of around 600,000); ii) rehabilitation and upgrading of two secondary referral hospitals (Shkoder and Vlore) serving these districts and surrounding areas; and iii) strengthenedcapacity to plan and implementa comprehensivepublic health facilities maintenance program (buildings and equipment) through development of maintenancenorms/procedures and staff training.
Capacity Building (US$3.2 base cost million). This component will provide assistanceto: i) improve managementof basic health services at the district level; ii) provide in-service training for hospital physicians and nurses; and iii) build institutionalcapacity at the central level to improve sector planning, health financing and drug distribution. A portion of the proposed IDA Credit (US$0.5 million)will also be set aside to cover the costs of project coordination. - ii -
BENEFlT: The Project will help prevent increasesin prematureand preventablemorbidity and mortalityduring the economictransition by improvingthe quality of basic primary and secondary health services. Specifically, it will begin rehabilitation of a streamlinedprimary care network and its secondaryreferral hospitals. It will also update the skills of medical personnel and improve managementof health services at the district level. By buildinginstitutional capacity at the central level in the areas of sector planning, health finance and drug distribution, the Project will begin to improve resource managementand incentive structures in the health sector.
RISKS: The complexity of procurement for rehabilitation of primary health centers and regional hospitals is a risk. This will be particularlydifficult for a Ministrywith no previous experiencein Bank lendingand procurementprocedures. To facilitatecivil works procurement,the Project will follow a simplifiedlocal procurementprocedure developedfor the IDA-fundedHousing Project. In addition,the Project will provide training in procurement and contracting in both the Project CoordinationUnit and the TechnicalServices Department of the MOH. Another Project risk is the almost completelack of familiaritywith decentralizeddecision-making and managementin Albania, and the decision by Governmentto build local capacityfor managementof health resourceswithout extensive recourse to technicalassistance. To addressthis, the Project will focus on buildinga core team of trainers at the national level which can transfer managementskills and introduce managementsystems at the district level. A twinning arrangement with an academic institution will provide limited technical support to the national team. Estimated Project Costs Lal Foreign Tota1 ------US$ Million
A. Health Services Rehabilitation
1. Rehabilitationof Primary Health Centers 2.1 1.1 3.2 2. Rehabilitationof Regional Hospitals 2.5 4.8 7.3 3. Health Facilities Maintenance DA1 0Q1 02
Sub-total 4.7 6.0 10.9
B. CapacityBuilding
1. Managementof Basic Health Services 0.1 0.4 0.5 2. Hospital Staff Retraining 0.3 0.6 0.9 3. Sector Policy and Planning 0.3 1.0 1.3 4. Project CoordinationUnit O.1 0Q4 0 5
Sub-total 0.8 2.4 3.2
Total Base Costs 5.5 8.6 14.1
Physical Contingencies 0.5 0.6 1.1 Price Contingencies 0 5 Q40 1
Total Project Costs 642
Financing Plan
Governmentof Albania 2.2 1.4 3.6 IDA 4.2 8.2 12.4
Total Financing Requirements 6.4 9.6 16.0
Estimated Disbursements (US$ million)
IDA FY FY94 FY95 FY96 FY97 FY98 FY99
Annual 0.8 2.7 3.9 3.3 1.5 0.2 Cumulative 0.8 3.5 7.4 10.7 12.2 12.4 Cumulativeas % of total 6.4 27.8 58.8 84.9 98.4 100.0
1/ Figures may not total exactly due to rounding. 21 Includes local taxes and duties estimatedat US$0.7 million.
ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
I. HEALTH STATUS AND SERVICES IN ALBANIA 1.1 Forty years of isolationand extreme communistrule, followedby a destructiveperiod of political transition in 1990 and 1991, have left Albania at a level of poverty and underdevelopmentunmatched anywherein Europe. With a per capita incomeof about US$300 in 1993, and a highly agrarian labor force, the Albanian economy is more characteristic of low-income developing countries than of neighboring countries in Central and Eastern Europe (CEE). Between 1990 and 1992, civil unrest, disruption of production, destruction of infrastructure and the financial collapse of inefficient state enterprisesled to a 35 percentdecline in real incomes. Risingunemployment, impoverishment and ethnic tensionsalso threatenthe fragilepolitical stability which has been maintainedsince 1992when democratic electionsbrought the current Governmentto power. However, with a reboundin agriculturalproduction and the expansion of informal sector trade and services in 1993, the Albanian population is seeing the first signs of renewed growth in a more market-orientedeconomy. This has strengthenedthe political commitmentto carry out far-reachingreforms in both the economicand social spheres.
A. Health Status of the Population
1.2 Albaniansenjoy a life expectancyof nearly 73 years, far surpassinglife expectancyin developing countries at similar income levels (Table 1). This equals or exceeds life expectancy in CEE countries having anywherefrom three to ten times Albania's income level, although the determinants are quite different. Infant and maternal mortality in Albania remain two to four times higher than in other Europeancountries (other Centraland Eastern European--CEE--countries,and particularlythe established market economies--EMEs),while premature adult mortalitydue to chronic diseases is much lower than the European norm.
1.3 Albania exhibitsthe high fertility/highinfant mortalitypattern more typically seen in developing countries. The populationhas the youngestage structure in Europe, and the highest age-specificfertility rates. As a result, the country has a high crude birth rate and rapid population growth which will continue well into the next century. Infant mortality is, however, lower than in other developing countries at similar income levels--reflectingthe relatively high level of educationalattainment among women,the extensiveand accessibleprimary care networkand the successof past immunizationprograms whichachieved coverage rates of more than 95 percent. Nonetheless,at 32 per 1,000 live births in 1993, the infant mortalityrate in Albania is nearly double the CEE average, and its downwardtrend stagnated in the mid-1980s, and reversed in the past two years. - 2 -
Table 1: DEMOGRAPHIC AND HEALTH INDICATORS, 1991
Albania EME 1/ CEE 1/ Weighted Weighted Kenya India China Average Average
Per capita income (USS) 300 21,183 1,390 340 330 370 Crude birth rate 25 13 11 45 30 22 Cnde death rate 6 9 9 11 10 7
Crude rate of natural increase 19 4 2 34 20 15
Life expectancy (male) 70 73 67 57 60 67 Life expectancy (female) 76 80 75 61 60 71 Total fertility rate 3.1 1.7 2.1 6.5 3.9 2.4
Infant mortality rate 30.8 8 17 67 90 38
Maternal mortality ratio 2/ 50 7 29 Estimated 200-600 115
1/ The countries of the CEE are Albania, Bulgaria, Croatia, the Czech Republic, Former Yugoslav Republic of Macedonia, Hungary, Poland, Romania, Slovenia and Yugoslavia. The weighted average given here excludes Albania. The EME countries include: Australia, Austria, Belgium, Canada, Denmark, Finland, Germany, Greece, Ireland, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, the United Kingdom and the United States.
2/ Data are for various years, 1988-92.
Source: World Development Report. 1993, World Bank. 1992 Annual World Health Statistics World Health Organization.
1.4 The crude death rate of the Albanian population is very low, reflecting both the young age structure of the population, and low death rates among adults age 15-65. Relative to the rest of Europe, Albania has less premature adult mortalitydue to cerebro- and cardio-vasculardiseases, lung, stomach and breast cancers, cirrhosis and other chronic diseases which tend to be associatedwith lifestylesand occupationalhazards in industrializedcountries. A more active, agrarian lifestyle, a lower-fat diet and less abuse of alcohol and cigarettes contributeto adult longevityin Albania. However, mortalityrates above age 65 tend to be higher than in other European countries because the health system cannot offer the high-quality,high-tech chronic care for the elderly typically found in wealthier countries. - 3 -
B. Health Services in Transition
1.5 Under the former communistregime, the Albanianpopulation had universal entitlementto a full range of medical and dental services, providedthrough a public sector monopolyon service deliveryand drug supply. Resourceallocation within the public healthsystem was centrallyplanned, and based largely on historic levels and/or physical inputs (e.g. number of beds or staff), rather than on capacityutilization or services rendered. Managementdecisions were also highly centralized, and the system offered few financial or administrativeincentives to improve the qualityof care, increaseefficiency or control costs. The regime took pride in its network of facilities, favoring construction of new infrastructure at the expense of less-visiblemaintenance and operatingexpenditures. As Albania grew increasinglyisolated, medicalpersonnel were cut off from global advancesin medical technologyand pharmacology,while the local drug industry became locked into outmoded production lines and processes. Deterioration of facilitiesand equipment,inadequate recurrent expenditures, obsolete drug therapies and outdatedmedical skills resulted in low-quality care and inefficientuse of resources. By 1989, with 1.0 primary care facility and 5.3 hospitalbeds per 1,000 inhabitants,the physical infrastructurehad becomeunsustainable given Albania's limitedresources. Medical staffinglevels (1.4 physiciansper 1,000 populationand 2.5 nurses per physician) approachedEuropean standards, adding to the heavy fiscal burden. Capacity utilizationin the sprawlingnetwork was low, while fiscal and foreign exchangeconstraints further limited critical recurrent expenditures, depriving the system of drugs, medical supplies, spare parts and maintenance.
1.6 The violenceof the politicaltransition dealt another blow to the ailinghealth system. Civil unrest led to widespreadlooting, destructionand expropriationof social infrastructureassociated with the former regime. Health personnel deserted facilities, especially in rural areas. In addition, the economic transition intensifiedfiscal pressure and disrupted centrally-plannedsupply mechanisms,leading to the virtual collapseof the public health system by 1991. Governmentrevenues declinedby 35 percent in real terms between 1990 and 1992. Efforts were made to protect public spending in the health sector, which registered a decline of 14 percent in real terms during the same period, rising as a share of GDP from 3.3 to 4.5 percent. However, the prolongedfiscal crisis led to a real decline of 10 percent in public spending for health in 1993 which totaled only 3.9 percent of GDP. The prospect of negative or negligible real growth in budgetary resources in the next few years has provided additional impetusto increasethe efficiencyof resource use in the health sector. To achievethis, Governmentneeds to define policies that will reshape and restructure the health sector over the medium term, while struggling to restore basic health services during the economictransition. This difficult task falls to a new Ministry of Health (MOH), establishedonly in 1991.
C. Issues for Health System Reform
Premature and preventable death, disability and disease
1.7 In comparison with countries at similar income levels, Albania has done remarkably well in reducing infant, child and maternal mortality. Health status has even surpassed that of China, another low-incomecountry noted for its progress in improving health indicators. Building on this strong foundation, Albania now aspires to a health status for women and children which is more in line with wealthier, neighboringCEE countries. At the same time, the near collapse of the public health system is jeopardizing progress to date. To maintain or improvehealth status, Albania will have to combatthe familiar determinants of infant, child and maternal mortality in the developing world: poverty, poor sanitation, malnutrition, high-risk pregnancies, unsafe abortions and inadequate preventive health programs. The impact of these factors in Albania is reflected in the available statistics: nearly one- quarter of all infant death is due to prematurity and low birth weight. Respiratory infections and diarrheal disease are the leading causes of death among post-neonatalinfants and children. From 50 to 75 percent of drinking water sources in both urban and rural areas are contaminated,contributing to a prevalence of parasitic infections which is far higher than in other CEE countries. Although past immunizationcoverage rates approached 100 percent, vaccine effectivenessin recent years has been spotty, leaving only 40-50 percent of children adequatelyprotected.
1.8 A reductionin premature and preventabledeath and disease among women of reproductiveage and their childrenwill have the greatest positiveimpact on the overall burden of disease in Albania. This will require more effective maternal and child health (MCH) interventions in areas such as family planning, prenatal care, growth monitoring,nutrition education,household sanitation, immunizationand treatmentof commonchildhood diseases (e.g. diarrhealdisease and respiratory infections). Someof these interventions,such as family planning and growth monitoring, were previously unknown in Albania. However, strengtheninghealth promotionand preventiveservices will be particularlychallenging due to continued public suspicion of Government-sponsoredhealth education efforts, which were tainted by political ideology and propagandain the past.
Breakdownof basic health services and supply networks
1.9 Social unrest and fiscal constraints have taken a toll on the health system, exacerbatinglong- standingstructural weaknesses and inefficiencies. The primary care networkhas been decimated,the cold chain has broken down, hospitals lack basic sanitary systems and supply bottlenecks impede drug distribution. A survey of the primary care network undertakenin 1993 found an excessivenumber of facilities(967 health centers, 2,312 rural health posts, or ambulancas)partially or completelyinoperable due to damage, deterioration, expropriationor insufficient initial investment. Twenty-fourpercent of health centers and 65 percent of health posts were found to be completelydestroyed or occupied by squatters. The majority of operating health centers are damaged, and while 80 percent have electric lighting, only 60 percent have any source of heating (mostly wood), 55 percent have toilet facilities,40 percenthave running water and 14 percenthave basic laboratoryequipment. In many cases, healthcenter equipmentconsists of a stethoscope, some syringes and a cooking pot for sterilization.
1.10 Less than 40 percent of rural health centers have an officialpharmaceutical outlet, entitlingthem to a minimal allocation of drugs--often nothing more than aspirin and outdated parenteral solutions. Otherwise, rural patients must travel to public pharmacies in urban areas to buy drugs--oftenseveral hours away. Fufarma, a public enterprise, is responsiblefor almost all distributionof drugs in Albania, with little or no accountabilityfor inventory and financial flows, and a poor record for efficiency. Due to fiscal constraints, Albania's drug supply for the past two years has been financedalmost entirely from humanitarianassistance, a temporarysource of funding which is now tapering off. Many vaccineshave also been suppliedthrough humanitarianassistance, but the breakdownof the cold chain has undermined the effectivenessof the immunizationprogram. With the primary care network in shambles, basic curative care has become largely hospital-based. Shortages of essential drugs and medical supplies, coupled with unacceptablesanitary conditions,limit the benefit of both outpatientand inpatient hospital care. -5- Low-qualityhealth services
1.11 Today, health personnelin Albaniaremain isolated, and lack in-servicetraining to upgrade skills. At the same time, they are often over-specializedfor the type of family medicine needed, particularlyin rural areas. The curricula for general practice physicians and nurses needs to be updated and strengthened. The average age of functioning medical equipment in Albanian hospitals is 25 years, comparedto 7 years in Western Europe. Some equipment,dating back more than 40 years, can properly be classifiedas museum pieces. Drug productionfacilities are also obsolete, and quality control is weak due to a lack of modem laboratory equipment. Profarma, the parastatal responsible for local drug production, is locked into production lines which are both outdated and economically inefficient. Substandardequipment and procedurespose a serious threat to the safety of the national blood supply, as well. The lack of basic drugs and equipment at all levels of the system undermines the value of investmentsin facilities and staff. Rehabilitationand reequipmentof a streamnlinednetwork of public health facilities, coupled with retraining of medical staff, are essentialto improve the quality of health care.
Weak sectoral planning and resource allocation
1.12 The Ministry of Health has no locus for sectoral planning and policy analysis, and the managementtools and informationsystems needed to informthe planningprocess are largely nonexistent. Until very recently, the MOH had no department to manage human resource development. Financial accountingat all levels of the health system is extremelyweak and fragmented, and plays little role in budgeting. A share of the central Government health budget is disbursed directly to districts, and expendituredata at this level are not adequatelyrecorded or synthesizedfor sectoral planning purposes.
1.13 Investment programming also needs to be strengthened, and little effort is made to take into account associated recurrent costs. This is particularly worrisome given the influx of aid-financed investments. Resource allocationwithin the sector needs to be based on a better assessmentof the cost- effectivenessof alternativehealth interventions,as measured by their impact on the health status of the population. Resourcesshould then be shifted towards interventionswhich have the greatestpotential for reducingmorbidity, disabilityand premature mortalitywithin the population. In Albania, this will shift resources towards health promotion, primary and secondary prevention programs, public health and sanitationmeasures and basic clinicalservices. However, to make appropriatedecisions, the MOH needs to strengthen its capacity to analyze policy options and assess alternative investmentstrategies.
Excessive public health infrastructure
1.14 An excessive public health infrastructure spreads resources too thinly and creates an unmanageablefiscal burden. In Albania, catchmentareas for public health facilitiesvary greatly,but tend to be too small for efficient use of resources. Each primary health center (PHC) serves an average of only 3,700 inhabitantsand each district hospital-ostensiblythe entry point for secondarycare-serves an averageof 89,000 inhabitants. If fully functional,the primary care network (health centers plus lower- level health posts) would provide one access point for every 950 inhabitants. Currently, the average health center has six rooms, many of which may be nonfunctionaldue to lack of basic utilities, equipment and drugs. Staffing levels are also fairly high in primary care, with an average of seven staff members per rural health center. This often includesunnecessary specialists, laboratory technicians and nonmedical staff (drivers, clerks, etc.). Such an extensiveprimary and secondarycare network is neither necessary nor financiallysustainable. - 6 - 1.15 Governmentneeds to streamlinethe network of primary care facilities, concentrating resources on the rehabilitationof a reduced number of PHCs, restricted in size. There is also scope for reduction and redeploymentof medical staff at all levels of the system, although such changeswarrant study, and are sure to face opposition from the profession. Hospitals, particularlythose offering secondary care, have low occupancyrates coupledwith long average-lengths-of-stay(ALOS), indicating excess capacity. Larger catchmentareas need to be establishedfor a restricted group of hospitals offering comprehensive secondary care, rather than trying to develop comprehensivecare in 35 smaller, district hospitals. The administrationof tertiary care facilities also needs to be rationalized, to prevent duplication and/or underutilizationof specializedequipment and services.
Lack of decentralizedmanagerial capacity
1.16 After forty years of centralplanning, Albania is moving toward more decentralizedmanagement and financing of public services. The Local Government Law of 1993 transfers financial and administrativeresponsibility for many public servicesto the district and municipallevels. Educationand health services are included, although it is recognizedthat an immediatetransfer of these social services is not feasiblefrom either a fiscal or administrativestandpoint. Such a transfer would jeopardize basic social services at a time of severe social dislocationassociated with the economictransition. However, the law does envisionthe eventualtransfer of public health services to local government. In the interim, a share of the central governmentbudget is set aside for district health services, as distinct from the local budget (still financed largely by central tax revenues) for public services which have been fully transferredto local responsibility. Regardlessof whetherhealth financingis ever fully transferred to the local governmentbudget, the efficiencyand responsivenessof health services must be improvedthrough more decentralizedand autonomousmanagement.
1.17 Govermmenthas chosento retain 35 administrativedistricts, each with a District Health Officer and a District Health Councilwhich will overseeprimary and secondaryhealth facilities and other health services within the district. It is recognized that efficiency in the health system could be improved through the establishmentof catchment areas for secondary health facilities which are larger than the existingdistricts. For this reason, a decisionhas been made to downgrademost district hospitals, so that they offer only the most basic inpatientcare, while a small group would be upgradedto regionalhospitals offeringcomprehensive secondary care to larger, multi-districtcatchment areas. Althoughthis new health hierarchy has been adopted, it will take time and commitmentto define, develop and test the training programs, managementtools, information systems, supervisory arrangementsand incentive structures needed for effective district-levelmanagement of health services.
Undefinedrole and regulatoryframework for private health services
1.18 Since November 1992, Albania has had no legal barriers to private sector health services. However, the role of private health services within a mixed public/privatesystem is still being defined, and the necessarylegal and regulatoryframework is not in place to guide private sector entry and activity in health care markets. The Governmentis looking toward greater private sector involvementin health services, under the assumptionthat well-functioningprivate markets will create the incentivesnecessary for efficient allocation and use of resources in the health sector. However, efforts to create these incentives must take into account well-recognizedimperfections and failures in the health care and pharmaceuticalmarkets. In particular, these markets are characterizedby asymmetry of information between the buyer and the seller. Efficient markets require perfect information, but health care consumersrely heavily on health care providers and pharmaciststo supply information on alternative treatmentsand drugs. If providers' income is linked to consumers' choiceof treatment, informationmay be distorted, resulting in excessive, inappropriateor unnecessarilyexpensive treatment. 1.19 Overcomingmarket failure requires an active role for Governmentin the regulation of private health services. This includes, inter alia the licensing of providers and pharmacists, accreditationand inspectionof facilities, registrationand qualitycontrol of drugs, establishmentof reporting requirements and the development of pricing policies for ambulatory and inpatient care, as well as pharmaceutical products. In the absence of appropriatelegal and regulatoryframeworks, clandestine private services- public sector staff and equipment 'moonlighting" in the private sector and collectingunreported fees- have flourished, while overt private sector initiatives have been limited. Several dozen private pharmacieshave been established,mostly selling highly-subsidized drugs purchased from Fufarma. Some private dentistry has also been established,although most dentists have begun to operate in a modified public sector scheme which introduces performance-basedfinancial incentives.
Undiversifiedsources of revenue and underdevelopedDayment mechanisms
1.20 The public health systemin Albania-as in most low-incomecountries-is financedalmost entirely from general budgetary revenues. Indeed, generalbudgetary revenuesare likely to remain the dominant source of health financingin Albania for many years to come. However, additionalrevenues could be generatedfor the health sector by diversifyingfinancing sources to includemodest payroll contributions and a wider range of out-of-pocketuser fees. On the expenditureside, payments to health facilitiesand pharmaciesfor drugs and services are in the form of budgetary allocationswhich provide no incentives for efficientuse of resources, cost containmentor improved quality of care. Under the existingsystem, public fundingof health services cannot be separatedfrom public delivery of health services, which acts as a brake on developmentof private sector care. In the medium-term,Albania needs to introducenew payment mechanisms which create appropriate financial incentives for health care consumers and providers, and remuneratepublic and private sector providers equallyfor equivalentservices. Both the diversificationof revenue sources and the introductionof new paymentmechanisms will require a more complexhealth financingadministration than is currently in place.
D. Government Strategy in the Health Sector
1.21 Improvementof health status in Albania depends most heavily on reduction in morbidity and mortalityfor childrenand women of child-bearingage. This will depend, in part, on the availabilityand quality of primary health care. The Governmentis strongly committedto the objectiveslaid out in the United Nation's Health For All by the Year 2000 strategy. With respect to maternal and child health, the Albanian Governmentand populace are determined to achieve standards found in other European countries at much higher income levels.
1.22 In a strategy documentpresented to the donor communityin April 1993, Governmentarticulated its overriding objective in the health sector: to maintain access to basic health services during the transition, and increasethe emphasison comprehensiveprimary care as the most cost-effectivemeans of improvinghealth status. To this end, the MOH -- through its Directionof Maternal and Child Heath - has drafted a proposed NationalPrimary Health Care Plan, which will be finalized in the coming year. The plan calls for decentralizedmanagement of health services at the district level, to better respond to the needs of local populations. It envisions facilities, termed "Family Health Centers", offering comprehensiveprimary care 24 hours a day. This would include preventive services and health promotion (including health education, nutrition, immunization, maternal and child health, family planning and prevention of sexually-transmitteddiseases), environmentalprotection (clean water and sanitation, endemic diseasecontrol) and curativecare (treatmentof commondiseases such as respiratory infectionsand diarrheal disease, availabilityof essential drugs, first aid for emergencies). - 8 - 1.23 To increase efficiency in the health system, and maximize the impact of limited resources, Governmentwill concentrateits efforts on maintaininga reduced number of primary health centers in a fully operationalstate. Adequateaccess to services will be maintained,while eliminatingmany partially or completelynonfunctional facilities throughout the public system. Pre-service and in-servicetraining programs will be developedfor general practitioners, nurse practitioners and midwives at the primary level. While the Primary Health Care Plan has not yet been finalized, it is largely reflected in the Government's broader strategy document, entitled "A New Policy for Health". To ensure access to comprehensiveprimary care, rationalize delivery of secondary and tertiary care, increase efficiency, control costs and improve the quality of care at all levels, Governmentintends to implementa medium- term strategy of:
a. streamliningthe network of public health facilities, through an approximate50 percent reduction in the number of health posts and primary health centers, and a 35 percent reduction in the number of hospital beds;
b. progressivelyrehabilitating and reequippingthis streamlinednetwork of public facilities;
c. retrainingand redeployingexisting medical personnel, and improvingpre-service training in the areas of family medicine and basic inpatient specialties;
d. decentralizingplanning and managementof health services to the district level;
e. eliminatingbottlenecks in the supplyof critical inputs, especially drugs;
f. developingnew financingmechanisms which will provide incentivesfor cost containment and quality of care;
g. encouragingthe developmentof private sector providers and pharmaceuticalsuppliers;
h. building institutionalcapacity for policy analysis and planning at all levels of the health sector;
L. enhancingthe Ministry of Health's capacity for regulation and quality control of drugs and health services.
1.24 In the past 18 months, measures have been taken to begin implementingthis strategy. The administrativestructure of the public health system has been redefined, and guidelines and procedures have been developedfor a decentralizedhealth mapping exerciseto streamline the hierarchy of public facilities. Many small, rural hospitals have been closed, reducing total inpatient capacity from 16,000 to 11,000beds. Further reductionto a total of 10,000 beds is envisaged. Certain district hospitalshave been selectedfor upgradinginto regionalhospitals offering comprehensivesecondary care to sufficiently large catchmentareas (300,000-350,000people). The remainingdistrict hospitals will be scaled back to offer only the most basic inpatient services. Recruitmentof medical and nursing students has been reduced in line with future needs. Profarma has been granted greater financial and administrative autonomy in the production of drugs, and private sector pharmaciesand dentists have been authorized. Family planning activities-previouslyillegal--have been authorizednationwide. A medium-termpublic investment program for rehabilitation of facilities and retraining of personnel has been defined, and Government has successfully sought external support for its health policy and associated investment program. - 9 - 1.25 Governmenthas also taken the first steps to accomplishmore complextasks such as development of the legal and regulatory frameworks for health services and drug supply, restructuring of public enterprises in the pharmaceuticalsector and strengtheninghealth financing and financial management. These efforts will need to be intensifiedin coming years. Governmentintends to generate additional resourcesfor healththrough the introductionof earmarkedpayroll contributionsand a wider range of user fees. At the same time, Government is planning to develop new pricing policies and payment mechanismsfor pharmacies,outpatient care and hospitalizationin order to: i) create financial incentives for increasedefficiency, cost containmentand improved quality of care; and ii) facilitate private sector developmentby remuneratingpublic and private providers equally, on the basis of services rendered. Governmenthas requested financial and technicalassistance from IDA for reform in these areas, which it hopes to pursue through the medium-termdevelopment of a national health insurance system.
E. Role of the International Donor Community
1.26 In the aftermath of political upheaval and social unrest, the international donor community respondedto the emergingcrisis in the health sector by providing humanitarianassistance--a portion of which is still arriving today. Bilateraldonors such as Italy, Greece, Switzerlandand the U.S., along with many charitable and/or non-governmentalorganizations provided aid, mostly in the form of drugs, vaccines and medical supplies. The European Union (EU) also launchedan emergencyprogram which is still underway,providing drugs and raw materials for drug production(ECU 7.0 million), emergency repairs and basic equipmentfor five regional hospitals (ECU 2.4 billion), equipment kits for primary care facilities and repairs of the cold chain (ECU 4.9 million).
1.27 Humanitarianand emergencyassistance from abroad mitigatedsupply constraints in the health sector in 1992 and 1993, all the while creating new logistics challengesfor Government. At the same time, Governmentbegan to elucidatea strategy for an effectiveand financiallysustainable health system in Albania(IDA assistedthis effort with technicalsupport). Throughthe preparationof an initialstrategy document and the organization of several donors' meetings, Government has elicited and coordinated donor support for this strategy. At the primary care level, in additionto providing basic equipmentto all primary care facilities, the EU will rehabilitate selectedprimary health centers, and retrain primary care personnel(general practitioners, nurse practitionersand midwives)in family medicineunder a health sector restructuringproject (ECU 6 million). UNICEF, UNFPA and WHO will support cost effective interventions at the primary level, including training and supplies for immunization, micronutrient supplementation,nutrition education, diarrheal disease control, treatmentof respiratory infections,family planningand AIDS prevention(approximately US$4.0 million). At the secondaryand tertiary care levels, in addition to emergency repairs of regional hospitals by the EC, a number of bilateral and non- governmental donors are supporting hospital rehabilitation, predominantly in tertiary care facilities. Switzerland,France and the EC are also strengtheninghospital management through trainingand twinning programs.
1.28 In the pharmaceuticalsector, Governmentintends to reduce its dependenceon humanitarianaid and emergencydistribution systems (e.g. distributionby Italian military forces) through the adjustment of drug policies and developmentof supplymechanisms which are reliable and financiallyviable. Donors have coordinatedtheir assistancein this area: the EC is strengtheningdrug inspectionand quality control; WHO is providing support for improved drug selectionand registration, and for rational drug use; IDA has made a commitmentto support developmentof pricing andprivatization policies in the pharmaceutical sector-as well as improved managementof public sector distribution systems. At the central level, a number of donors have provided technical assistance and logistical support to the newly established Ministry of Health to strengthenplanning and managementin the sector. - 10- F. Rationale for IDA Involvernent
1.29 Maintainingbasic social services as part of a broader social safety net is a high priority for IDA/IBRDin countriesundergoing the difficult transitionto a market economy. This is particularly so in a low-incomecountry like Albania, whererising unemploymenthas pushed many familiesinto absolute poverty, and a lack of resources has brought the public health system to the brink of collapse. The Bank's country assistancestrategy (CAS) for Albania reflectsthis priority, emphasizinghuman resource development,poverty alleviationand strengtheningof the social safety net during the transition. For the past two years, the donor community has provided humanitarian assistance in order to maintain a minimum supply of drugs and vaccinesin the country, and prevent a resurgence of infectiousdiseases which would further augmentAlbania's elevated infant mortalityrate. Now, Governmenthas begun to articulate a strategy for moving beyond the crisis phase to develop a more effective and financially sustainablehealth system,drawing on both the public andprivate sectors. External investmentresources and technicalsupport will be necessaryto implementthis strategy over the medium-term. In providing assistance, IDA can draw on its experience with health system reform in other Central and Eastern European countries, as well as in countries with income levels and health status similar to those in Albania.
1.30 Governmenthas requestedIDA assistanceto facilitatea transitionin the health sector in keeping with the broader economictransition. Throughthe Health ServicesRehabilitation Project (HSRP),IDA will provide support for cost-effectivehealth interventionsin areas where Albanian resourcesand donor funding are lacking or insufficient. IDA has worked in close collaborationwith the donor community to coordinateareas of intervention. In particular, IDA will not provide support for medical equipment and training in familymedicine at the primary care level, because availableexternal resources are deemed sufficientrelative to the country's absorptive capacityover the next few years. Financinggaps have been identified, however, in the following areas: i) rehabilitation of primary and secondary care facilities responsiblefor preventivecare and basic clinicalservices; ii) strengtheningof managementat the district level to improve the quality of basic health services; iii) in-service training of hospital staff; and iv) capacity-buildingat the central levelto improvesector planning, policy reform and resourcemanagement. The methodologyfor streamliningand rehabilitatingthe public health networkwhich is being developed for six pilot districts under this project would be replicated nationwide over the medium-term,with existing parallel financing from other donors (e.g. EU/PHARE, Italy), as well as follow-onprojects supportedby IDA. This first project would also support initial steps in longer-terminstitution-building and policy reform. A proposed IDA-fundedHealth Financing and RestructuringProject would provide more extensive support for institution-building,resource managementand implementationof health financingreforms.
G. Previous IDA Involvement
1.31 This will be the first IDA-supportedproject in the health sector in Albania. However, emergencyassistance for health has been provided through the IDA Critical Imports Project, which has suppliedessential drugs and trucks for drug distribution. In addition, preparationof the Health Services RehabilitationProject was supported by a Japanese Policy and Human ResourcesDevelopment Grant whichpermitted, inter alia, necessarysector work to assesspriority health issues, and help Government to articulate a strategy for primary health care during the transition.'
See Albania: Health Sector Reform during the Transition, World Bank Report No. 10362-ALB,World Bank, March 1992; and Albanie: Le Secteur des Soins de Sante Primaires, Consultants' Report,World Bank, March 1993. - 11 -
1.32 Althoughthe HSRP will be IDA's first interventionin the health sector, IDA has an portfolio of on-going human resources projects in Albania, including the Labor Market DevelopmentProject (LMDP), the Social Safety Net DevelopmentProject (SSNDP),the Rural Poverty AlleviationProject (RPAP)and the upcomingSchool Rehabilitationand CapacityBuilding Project (SRCBP). The HSRP will benefitfrom lessons learnedunder these projects, particularlythe need to keep projectdesign simple, relying, to the maximumextent possible, on local capacityfor implementationand technicalsupport--in order to improve implementationperformance and strengthen ownership of the project. Indeed, the Project Coordinating Unit for the HSRP has successfully drawn on the experience of the LMDP and SSNDPproject units to become fully operationalwithout reliance on external support. An arrangement is now being finalized to share the services of a one external Project Advisor among three or four human resources projects, includingthe HSRP.
1.33 Experienceunder another project, the Albania Housing Project, resulted in developmentof an adapted procedure and standardizedbidding documents for local contracting for civil works. These procedures and documents will be followed under the HSRP, along with other IDA-fundedprojects. The HSRP will also make use of experienceunder the RPAP in supervisinghighly decentralizedcivil works, and will make use of RPAP's community-basedcivil works to actually carry out rehabilitationof primary health centers in select rural areas. - 12 -
II. THE PROJECT
A. Project Objectives
2.1 The HSRP would help prevent deteriorationin health status during the economictransition by improvingthe quality of basic preventive and curative health services. This would be accomplishedby upgrading primary and secondary facilities to minimum sanitary and physical standards, improving treatmnentskills of hospitalphysicians and nurses (to complementskill-training programs for primary care personnel supported by other donors) and building capacity at the central and district levels to manage health resources and implement sectoral reforms. The HSRP would lay the groundwork for more intensive institution-buildingand implementationof sectoral reforms, with support from IDA-funded follow-onprojeAs.
B. ProjectDescription
2.2 The HSRP consists of two components:Health Services Rehabilitationand CapacityBuilding. Tley are describedbelow, with implementationarrangements and institutionalresponsibilities described in Chapter III: Project Costs, Financing and Implementation. Project implementationis expectedto be completed over a five-year period (November 1994 through September 1999). The project implementationplan is describedin Annex 2. Total projectcosts includingcontingencies, taxes and duties are estimated at US$16.0 million equivalent (US$14.1 million base cost). Detailed costs of each componentare shown in Annex 3. The Project would finance civil works for hospitaland health center rehabilitationand upgrading,as well as equipment,external and local training and specialistservices, and incrementaloperational costs generatedby the investments.
ComponentA: Health Services Rehabilitation(US$10.9 million base cost)
2.3 The HSRP would initiate the long-term task of rehabilitatingand consolidatingthe network of public healthfacilities in Albania, in order to develop an appropriatedistrict-level health pyramidoffering basic clinical services at the primary and secondary level. It would provide assistance for: i) the rehabilitation and upgrading of about 100 primary health centers (PHC) in six pilot districts; ii) rehabilitationand upgrading of two secondaryreferral hospitals serving these districts and surrounding areas; and iii) strengtheningof health facilitiesmaintenance capacity in the sector. Each of these elements is outlined below and described in more detail in Annex 2.
A.1 PrimaryHealth Centers (US$3.2 millionbase cost)
2.4 Considering the magnitude of the health facilities rehabilitation program, and constraints on resources and local implementationcapacity, six pilot districts in two regions (Shkoder, Puke, Malesie Madhe in the north, and Vlore, Saranda, Delvina in the south) were chosen for project coverage. In 1993, the Governmentcarried out a nationwidephysical inventoryof existingPHCs (functioningand non- - 13 - functioning)and plotted health facilities maps for the six districts. The MOH Departments of Public Health (DPH) and Technical Services (TSD) collaboratedin formulating an improved set of national standardsfor establishingPHCs, taking into accountcriteria 2 agreed with IDA. On the basis of additional detailed engineeringdata gathered in March 1994 to complementthe health maps, and the applicationof the revised standards, the 200 existing primary care facilities in the six districts would be consolidated into a smaller network of 100 PHCs3 capable of providing adequate quality primary health care to the aggregatepopulation of around 600,000. About 90 of the 100 PHCs are in existingpremises, the rest are to be located in new sites4 more accessibleto the majority populationwithin the catchmentarea of the PHC. Based on the engineeringassessments, 40 of the 100 PHCs would be provided entirely new buildings either because existing facilities are too deterioratedto rehabilitateeconomically and need to be completelyreplaced, or because of relocation. The rest would necessitate varying degrees of repair and/or upgrading of existing structures. All rehabilitated PHCs would be staffed accordingto norms agreed with IDA (Annex 2, Table B). The twenty six PHCs which have been selectedfor rehabilitation during the first year of project implementationare also listed in Annex 2, along with the implementation scheduleof this component. PHCs to be built or rehabilitatedduring succeedingyears would be specified at the annual joint reviews of the health sector budget.
2.5 Existing PHCs which were not selected for inclusion in the consolidatednetwork, would be phased out of operation during the project implementationperiod, with redeployment/reductionof staff as appropriate. The consolidationof these facilities would be linked to the entry into operation of the rehabilitatedPHCs nearby. The conditionsof closure, in terms of staff redeploymentand redirectionof all expendituresassociated with the PHCs (supplies, maintenance, etc.) are described in the Project OperationsManual (POM). During negotiations, the Government agreed that it would: (i) consolidate the PHC network in the six pilot districts in accordance with an implementation plan agreed with IDA; and fii) staff the PHC facilities rehabilitated under the project according to norms agreed with IDA.
2.6 For the Primary Health Centers subcomponent,the HSRP would financethe costs related to the rehabilitation of about 100 PHCs including: i) services of local architects/engineersto prepare the prototype designs and detailed engineering plans, and to supervise construction, ii) civil works and provisionof basic utilities; and iii) essentialbuilding equipment (heaters and washers) and furniture. The Project would also provide medical suppliesfor cost-effectiveprimary care interventions,to complement medical equipmentbeing provided to the 100 PHCs by EU/PHARE under an ongoing parallel project.
A.2 Regional Hospitals (US$7.5 million base cost).
2.7 Governmenthas selectedthe largest districthospitals for upgrading to regional referral hospitals whichoffer comprehensivesecondary care to a sufficientlylarge catchmentpopulation (300,000-350,000
2 Thesecriteria include,among others, sizesof catchmentpopulation, proximity to hospital services,staffing needs, staffing, facilities design prototypesutilizing appropriate building technology and incorporating provisions for the appropriatedisposal of medical and other wastes, etc. The Rural DevelopmentFund which is responsiblefor implementingthe Rural Poverty AlleviationPilot Project (Credit2461-ALB) (RPAP) has agreedto coordinateits programof rehabilitatingrural health facilitieswith the HSRP,and clear the proposedlocations of the RPAPhealth facilitiesrehabilitation projects with the MOH in order to avoid duplicationof investmentsand conformwith the PHC consolidationobjectives of the HSRP. These new sites are Governmentproperty with road access and ready for new construction - 14 - inhabitants). Within the six pilot districts where PHCs are to be rehabilitated,two of the five existing district hospitals have been designatedas regional hospitals- Shkoder (620 beds) and Vlore (500 beds). Servicesprovided by these two regionalhospitals would complete the pyramid of health servicesextended by the consolidated network of PHCs and the other three hospitals. Governmentagreed during negotiationsthat the district hospitals in Puke, Sarandaand Delvina, which were not selected for upgradingto regionalhospitals, will be streamlinedto offer only four basic inpatientspecialties, and have theirstaff adjustedaccordingly, in accordancewith a scheduleagreed with IDA. Government also agreed that the two regionalhospitals rehabilitated under the projectwill be staffed according to norms agreed with IDA.
2.8 The HSRP would rehabilitate/upgradethe building facilities and equipment of the regional hospitals of Shkoder and Vlore. The scope of the rehabilitation/upgradingwork would be based upon a set of functionaldevelopment plans to be prepared by a hospitalplanning specialist for each regional hospital complex. These functional development plans would outline the medium- to long-term developmentand investmentpriorities, and describe, inter alia, the: i) range of medical services to be provided; ii) operationaland organizationalrestructuring which may be needed to deliver secondarylevel medical services efficiently;and iii) staff development(and recruitment)needs. The hospitalplanning specialist would assist two local architectural/engineeringfirms selected in accordancewith procedures agreed with IDA, prepare the detailed designs and constructionplans for rehabilitationand upgrading works identified in the functional development plans as the highest priority investments. A medical equipmentspecialist would assist TSD prepare priority equipmentlists, relevanttechnical specifications and bidding documents. The building investmentpriorities, which would be agreed with IDA before detailed engineering plans are prepared, may include, inter alia: i) rearrangement of functional spaces aimed at consolidatingexpensive medical facilities and services, such as, operating theaters, radiology facilities, intensivecare units, kitchen, laundry, sterilizationservices, etc; ii) provision and/or upgrading of utility systems-electrical, mechanical, communications,appropriate disposal of medical, solid and other wastes; and iii) critical generalbuilding repairs. Priority medicalequipment would be acquiredor replaced as appropriate. The reconfiguration/consolidationof hospital services and facilitiesmay also require changes in the current operational and managementpractices of the two regional hospitals, for which training of selectedpersonnel would be needed and provided for under the project.
2.9 For the Regional Hospitalssubcomponent, the HSRP would finance: i) the professionalservices (6 person-months)of a hospital planning specialist to prepare the functional developmentplans and assist/collaboratewith ii) two local architectural/engineeringfirms which would prepare the detailed architectural and engineeringconstruction plans and bid documents for priority works; iii) services (4 person-months)of a medical equipmentspecialist; iv) civil works covering the most urgent repair and upgrading needs; v) priority hospital/medicaland related equipment; and vi) study visits (6 person- months) for selected officers of the two hospitals and MOH to observe/acquire training on modern hospital operationalpractices.
A.3 Public Health Facilities Maintenance(US$0.2 millionbase cost)
2.10 The HSRPwould strengthencapacity in the health sector, in particular, within the TSD, to plan and implement an effective public health facilities (buildings and equipment) maintenanceprogram. Buildingthis capacitywould include: i) developingappropriate preventive and appliedmaintenance norms and procedures with due attention to environmentalconsiderations; and ii) developingcapacity to plan equipmentinvestments, particularly with respect to equipmentstandardization, spare parts management, and disseminationof technical informationto the health services network. For this subcomponent,the HSRP would finance the services of a hospital maintenancespecialist (3 person-months)to assist TSD - 15 - formulatea comprehensivemaintenance program, and train its staff in core practices. The TSD would then be responsible for managingthe national program and for assisting/trainingdistrict personnel in maintenanceplanning, practices and budgeting. The Project would also finance a study tour (2 person- months) for select MOH staff to observe hospital maintenance practices abroad; training and demonstration equipment and software; and the publication and dissemination of maintenance manuals/instructionsto public health officers nationwide.
Component B: Capacity Building (US$3.2 million base cost)
2.11 The HSRP would improvetreatment skills of hospitalphysicians and nurses (to complementskill- trainingprograms for primary care personnelsupported by other donors) and build capacityat the central and district levels to managehealth resourcesand implementsectoral reforms. The projectwould support four areas: (i) managementof basic health services; (ii) retraining hospital staff; (iii) health policy and planning; and (iv) project coordination. These subcomponentsare outlined below; implementation responsibilitiesand evaluationcriteria are described in Chapter III and in Annex 2.
B.1 Management of Basic Health Services (US$0.5 million base cost)
2.12 This subcomponentwould provide planning and managementtraining to district health teams in support of more decentralizeddecision-making and resourcemanagement within the public health system. The training of district managers in planning and managementtechniques would be carried out by the MOH's Department of Public Health (DPH) and Institute of Public Health. External technicalsupport would be provided by the University of Montreal which has an ongoing relationshipwith MOH/sector staff and knowledgeand familiaritywith the local working environment. The sustainabilityof improved managementtechniques would be enhancedthrough developmentof a permanentcapacity for management training and advising, through a core team of trainers drawn from the Institute and the DPH. Members of this core team would benefit from short- and long-term external fellowships in health planning and management,many of which are underwayas part of project preparation. In addition,the Institute-with support provided through the Universityof Montreal--willorganize two seminars designed to introduce the team of trainers to pedagogictechniques which should help them to develop and conduct training seminars more effectively.
2.13 The strategy for district-leveltraining which has been defined by the MOH entails two training phases:
(i) A first phase of training, to be carried out during the first two project years, is designed to introducedistrict managers in all 36 districts, as well as select staff from the central level, to general concepts and techniques of health management and program development. A total of approximately160 persons would be trained in a series of two- week training seminars developedand conductedby the Instituteof Public Health, with external technicalsupport. This initiative is designed to help the MOH consolidateits new management structure which consists of District Health Teams (DHTs) and emphasizesdistrict-level decision making.
(ii) A second phase of training, to be carried out during project years three and four, would offer more intensivetraining in specificmanagement and planning techniquesto district health officers and key central level staff (about 46 persons). Training would be - 16 - organized in six modules correspondingto disciplines such as health planning, health information systems, financial management,program evaluation, etc. The training modules would be developed and conducted by the Institute's core team of trainers. External trainers would assist in conductingthe first round of training modules--each would be delivered at least twice under the HSRP--andin carrying out an evaluationof each module following its first delivery.
2.14 For the Management of Basic Health Services subcomponent, the HSRP would finance the technicalassistance contract with the University of Montreal under a twinning arrangementwith MOH which consistsof about 16 person-monthsof specialistservices. The project will also finance about 39 person-monthsof external fellowshipsin health servicesmanagement and planning; the costs (including materials and per diem) of organizinglocal training seminars for about 200 members of the 36 District Health Teams and central support personnel; and office equipmentand one computerworkstation 5 with appropriate software for the Institute of Public Health.
B.2 Retraining Hospital Staff (US$0.9 million base cost)
2.15 This subcomponentwould support developmentand implementationof the Government'sprogram to retrain (i) hospital physiciansand (ii) nurses. It complements retraining programs for primary care personnel (generalpractitioners, nurses and midwives)being supportedby EU/PHARE and UNICEF, as well as an ongoing hospital nurses' training program being supported by the Swiss Government through a Swiss Nursing School, Ecole le Bon Secours. Given its focus on improving the skills of doctors and nurses currently working in district and regionalhospitals, it should result in an immediate improvementin the quality of health service delivery at the secondarylevel.
(i) Hospital Physicians Retraining (US$0.6 million base cost). Retraining of hospital physicianswould be carried out through: a) preparation of a needs assessmentby MOH; and b) subsequentdesign and implementationof retraining activitiesto be financedby a Retraining Fund. The most urgent needs include the improvementof routine hospital practices (e.g. hospitalhygiene, sterilizationprocedures) and upgrading of curricula for basic inpatientspecialties. Once retraining needs have been systematicallyassessed, the Dean of the Faculty of Medicinewill be responsible for commissioningthe preparation of retraining programsby interested facultyand medical personnel. Proposed programs would be submittedto a small committeeof MOH directors for review and approval in accordancewith priority retraining needs agreed with IDA. Funds would be provided under the HSRP as a Retraining Fund (US$0.5 million) managed by the Dean of the Faculty of Medicine and the Project CoordinatingUnit.. The Fund would support the participationof foreign lecturersand trainingspecialists, the preparationof documentation and the costs of organizing seminars. In addition, the HSRP would finance office equipmentand workstationsfor training coordinatorsat the Faculty of Medicine, as well as a study visit to examinesimilar retraining efforts in other countries. The preparation of an acceptableRetraining Needs Assessmentdefining priority retraining needs would be a condition for disbursementof the RetrainingFund.
5 Workstationincludes a personal computer, printer, computer accessories and standard software, and office furniture for one person. - 17 -
(ii) Hospital Nurses Retraining (US$0.3 million base cost). Project support for nurses retraining would complement a program which is currendy funded by the Swiss Government to revise curricula and training techniques in Albania's Nursing Schools. The project would not fund training seminars directly, but would supply pedagogic equipment,supplies, furniture, office equipmentand limited facilitiesrepair whichwould allow the MOH and the faculty of the nursing schools to better prepare and deliver in- service training programs in hospitals as well as at the nursing schools. Nursing school staff would be assisted in preparation and delivery of these retraining seminars and courses by the staff of the Ecole le Bon Secours, with which the MOH has an ongoing twinning arrangement.
B3 Health Policy and Planning (US$13 millionbase cost)
2.16 The HSRP would assist the recendy-establishedMOH to build capacity at the central level for policy development, sector planning and resource management. As a first interventionin the health sector, the HSRP would supportonly the initialsteps in a longer-termprocess of institution-buildingand implementationof relativelycomplex sectoral reforms. These initial steps would permit more intensive institution-buildingand policy reform in the health sector over the mediumterm, to be supportedby IDA- funded follow-onprojects. Under this first Project, support would be provided in two areas: i) Health Planning and Financing; and ii) Drug Policy and Distribution.
(i) Health Planning and Financing. The HSRP would support training, study visits, technical assistance, policy studies and associated office equipment and supplies to strengthen planning and financing. This would include support for improved resource management (infrastructure planning, staffing, etc), budgeting and investment programmingin the Departmentof Economics(DEcon). The Health FinancingUnit in the DEcon would be supported in its first phase of introducingnew pricing policies and cost reimbursementmechanisms for health services and essential drugs. As a highest priority, Governmentwill seekto reduce subsidy rates on drugs and eliminatelump-sum subsidiesto Fufarma, the inefficientparastatal which formerly had a monopolyon drug distribution. It woulddo so through developmentof a pricing policy and reimbursement mechanism for drugs which: a) increases cost-sharing through introduction of copayments;b) channelsdrug subsidiesfor essentialdrugs to the pharmacy level; and c) remuneratespublic and private sector pharmaciesequally for similar products. A Drug Pricing and ReimbursementStudy would help Governmentto define this pricing policy and an administrativemechanism for cost-sharing. The HSRP would alsosupport a study and follow-up actions to develop a capitation payment system for reimbursementof routine primary care. The HSRP would also assist the MOH in national program developmentfor cost-effectivehealth interventionsat the primary level, to improve the quality of maternal and child health.
(ii) Drug Policy and Distribution. IDA has joined with the EU and the WHO in making a commitmentto support both the formulationof a coherentpharmaceutical policy and the improvedefficiency and reliability of drug distributionmechanisms in Albania. This will require fundamental restructuring of the pharmaceuticalsector over the medium term. In this Project, IDA would support training, study visits, technical assistance, policy studies and associatedequipment and supplies needed to carry out only the first steps in this mediumterm process. With input from an audit report completedas part of Project preparation(with fundingfrom a Japanesegrant), the MOH decidedto support - 18 - privatizationof Fufarma and developmentof an alternativepublic sectorprocurement and distribution capacity which would rely on private sector contracting to improve efficiency. The HSRP would providesupport to studythis proposal (the results of which can only be implemented in the medium term) and strengthen logistics management capacity in the MOH Departmentof Pharmacy (DPharm).
2.17 Duringnegotiations, Government provided assurances that: (i) a sector-widestafring survey will be completed and discussed with IDA by mid-term review (March 31, 1997), and recommendationswill be implementedthereafter as agreedwith IDA; (ii) a rollingthree-year public health investmentprogram and the draft health sector budget (recurrentand investmentbudgets) will be preparedannually by MOH and MOF and reviewedjointly with IDA by November30 of each projectyear. During the annualhealth sector budget review, IDA and the MOH would agree on rehabilitationand consolidationobjectives for the coming year under the IDA project. In addition, the results of the Drug Pricing and ReimbursementStudy would be discussedwith IDA by April 30, 1995, and implementedthereafter as agreed with IDA.
2.18 For the Health Policy and Planning subcomponent,the HSRP would finance 44 person-months of specialist services, 52 person-monthsof external training and short-term study tours, local training seminars and workshops, and office equipment aid computers for the Departmentsof Economicsand Pharmacy.
B.4 Project Coordination(US$0.5 rillion base cost).
2.19 For the project to be implementedsmoothly and efficiently,the Project's multifacetedactivities have to be coordinatedand monitored effectively,communications and linkages between implementing institutions maintained, and resources made available to implementingunits in a timely and effective manner. For this purpose, the MOH has establisheda Project CoordinationUnit (PCU) in the Officeof the Planning Advisor, under the general direction of the Minister of Health, to oversee and coordinate project-related implementationactivities. The PCU consists of full-time qualified staff headed by a Project Director, assisted by a ProcurementOfficer, a Financial Officer, and a bilingual secretary. An appropriatenumber of support personnelwould be recruited as needed for the PCU. The responsibilities, staff functions and resource requirements of the PCU are described in detail in Chapter HI. Close collaborationbetween the PCU and the TechnicalServices Department(TSD), in particular, would be needed in the area of procurement of works and goods (equipment, materials, furniture). During negotiations,Government provided assurances that it wouldmaintain the Project CoordinationUnit throughoutthe projectimplementation period with staMng, functionsand authoritiesacceptable to IDA.
2.20 For the Project Coordinationsubcomponent, the HSRP would finance: i) 12 person-monthsof assistanceby a Project Adviser who will advise PCU, as well as conduct the local training of PCU/TSD staff on project implementation,coordination and procurement processes; ii) three person-monthsof external training (on procurement, project administration) for key PCU and TSD personnel; iii) computers, office equipmentand three vehicles deployed for project supervisionuse by the PCU and TSD; iv) salaries of contractualPCU staff; and iv) operationalcosts for project coordinationduring the project implementationperiod. - 19 -
C. EnvironmentalImpact
2.21 This is a Category C project--No AppreciableEnvironmental Impact. The HSRP has positive environmentalfeatures brought about by the improvementof sanitation facilities for the disposal of infectiouswastes and other solid wastes in the rehabilitatedhealth centers and hospitals (footnote2, para. 2.4 and para. 2.8). Environmentalconsiderations concerning the use of materials availablelocally for health center and hospitalrehabilitation and maintenance(para. 2.10), would be factored into definitions of buildingquality and maintenancestandards, and in specificationof building materials. - 20 - III. PROJECT COSTS, FINANCING AND IMPLEMENTATION
A. Project Costs
3.1 Summaryof Project Costs. Total project cost is estimated at SDR8.6 million (about US$12.4 million equivalent) including contingencies,local taxes and duties. Total contingencies(physical and price) amount to US$1.9 million which represent 13 percent of total base cost (US$14.1 million). The project cost includes the rehabilitation of facilities, furniture, equipment and materials, vehicles, consultingservices, fellowshipsand training and incrementaloperating costs generatedby the investmnents duringthe implementationperiod. Base cost estimateswere calculatedin US dollar equivalentand reflect costs at the time of negotiationsin August 1994. The estimated project costs are summarizedin Tables 2 and 3 below and shown in detail in Annex 3 .
Table 2: PROJECT COST SUMMARYBY COMPONENT (US$thousand)
(US$ (Lek '0001 '000) Foreign Base Locai Foreign Total Local Foreign Total Exch. Costs
A. Health Services Rehabilitation PrimaryHealth Centers 214,557 111,081 325,638 2,146 1,111 3,256 34 23 RegionalHospitals 248,120 495,000 743,120 2,481 4,950 7,431 67 53 Health Facilities Maintenance 4,963 8,625 13,588 50 86 136 63 1 Subtotal 467,639 614,706 1,082,34 4,676 6,147 10,824 57 77 B. Capacity Building Managementof Basic Health Services 10,867 42,375 53,242 109 424 532 80 4 RetrainingHospital Staff 33,879 56,345 90,224 339 563 902 62 6 Health Policy and Planning 28,762 99,278 128,040 288 993 1,280 78 9 Project Coordination 9,131 44,125 53,256 91 441 533 83 4 Subtotal 82,639 242,123 324,762 826 2,421 3,248 75 23 Total BASELINECOSTS 550,279 856,829 1,407,10 5,503 8,568 14,071 61 100 PhysicalContingencies 52,217 55,293 107,510 522 553 1,075 51 8 Price Contingencies 44,127 41,717 85,844 441 417 858 49 6 Total PROJECTCOSTS 646,623 953,622 1,600,46 6,466 9,538 16,005 60 114 - 21 -
Table 3: PROJECTCOST SUMMARYBY CATEGORYOF EXPENDITURE (US$thousand)
(US$ (Lek '000) '000) Foreign Base Local Foreign Total Local Foreign Total Exch. Costs
1. Investment Costs A. Civil Works - Hospitals 141,751 187,000 328,751 1,418 1,870 3,288 57 23 B. Civil Works - Health Centers 181,982 84,573 266,555 1,820 846 2,666 32 19 C. Civil Works - Other facilities 4,140 0 4,140 41 0 41 0 0 D. Equipment, Vehicles and Spares 24,862 327,109 351,971 249 3,271 3,520 93 25 E. Furniture 11,088 11,870 22,958 111 119 230 52 2 F. Architectural & Engineering Fees 25,205 16,419 42,623 252 164 416 39 3 G. Specialist Services 3,312 121,975 125,287 33 1,220 1,253 97 9 H. External Training 0 36,150 36,150 0 362 362 100 3 I. Local Training 58,063 32,608 90,671 581 326 907 36 6 J. Materials and Supplies 5,316 39,125 44,441 53 391 444 88 3 Total Investment Costs 455,718 856,829 1,312,54 4,557 8,568 13,126 65 93 I. Recurrent Costs A. Staff Salaries 0 0 0 0 0 0 0 0 B. Vehicle 0 & M 3,450 0 3,450 35 0 35 0 0 C. Equipment 0 & M 70,329 0 70,329 703 0 703 0 5 D. Building 0 & M 20,781 0 20,781 208 0 208 0 1 Total Recurrent Costs 94,560 0 94,560 946 0 946 0 7 Total BASELINE COSTS 550,279 856,829 1,407,10 5,503 8,568 14,071 61 100 Physical Contingencies 52,217 55,293 107,510 522 553 1,075 51 8 Price Contingencies 44,127 41,717 85,844 441 417 858 49 6 Total PROJECT COSTS 646,623 953,840 1,600,46 6,466 9,538 16,005 60 114
3.2 Basis of Cost Estimates. Project costs were estimatedon the following basis:
(a) Base Costs. All project costs were estimated in US dollars because inflation of the Lek over the life of the Project is difficult to predict. Costs shown in Lek are the result of converting dollar estimates at the official rate of 101 Lek/US$1.00 (September1994). The average costs of consultingservices are based on recent contractsfor comparable services in other IDA-financedprojects in Albania, i.e.: i) local consultants at US$100 per month; and ii) foreign specialist services at US$16,000 per month. This unit cost includes fees, relocation/recruitmentcosts, housing and subsistence, and overheads. Short-term fellowshipsand study visits are estimated to cost US$7,000 per staff month on the average. Price estimates for medical equipment are based on current catalogue - 22 - prices provided by a hospitalequipment consultant. Furniturecosts are based on itemized lists and current market prices in Albania. Information on PHC building costs were gathered from consultations with private building contractors, these average about US$120per square meter for refurbishingand US$230 per sq.m. for new construction. Hospital rehabilitation costs would average about US$200 per square meter. Remunerationsof local staff are based on current public service salary scales.
(b) ContingencyAllowances. Project costs include a contingencyallowance for unforeseen physical variations(US$1.1 million), equal to five percent of the estimated base cost of consultingservices, fellowshipsand staff salaries, and ten percent for all other project items. Because of the significantdifferential between local and foreign price escalation rates, the overall price increasesfor the Project (US$0.9million equivalent)are based on estimatedannual foreign price increasesat the rate of 2.8 percent appliedto both foreign and local costs for the duration of the HSRP. This approach is justified on the assumptionthat the Governmentwill continuethe policy of adjustingthe Lek exchange rate to reflect the inflationdifferential between Albania and its trading partners.
(c) Foreign Exchange Component. The foreign exchange component was estimated as follows: i) buildingrefurbishment - 55 percent for hospitalrehabilitation, and 30 percent for PHCs and other minor facilities; ii) office and medical furniture and equipment, materials and software - 95 percent; iii) expatriate consultingservices, fellowshipsand studies - 100 percent; iv) local consultants,local training, local staff salaries - 0 percent; and v) maintenance costs - 0 percent. The resulting foreign exchange component, including contingencies, is estimated at US$9.6 million, or about 60 percent of total project cost.
(d) Taxes. Project costs include an estimated US$0.7 million equivalent in taxes on locally procured works, goods and services. In January 1994, the Government issued an exemptionon the payment of duties and taxes on goods (equipmentand materials) and services imported directly in connection with foreign-financedprojects such as the proposed HSRP.
3.3 Recurrent Costs. Recurrent cost estimates included in the total project cost are only the incremental operating costs generated by project investments. These recurrent costs arise from: i) maintenanceof new equipmentand vehicles; ii) maintenanceof rehabilitatedfacilities; and iii) salaries of several PCU staff. These costs are included in total project costs only to ensure that these amounts are budgeted as Government counterpartfunds on an annual basis. They represent approximately0.5 percent of the MOH's recurrent budget, and are thus deemedsustainable, particularly given the broader fiscal impact of the project, which takes into accountrecurrent cost savings resulting from streamlining of the public health network (see below).
3.4 Project Sustainability. Investmentsin rehabilitationunder the HSRP would be linked to the downsizingof facilities and consolidationof the public health network, as well as to improved planning and budgeting for maintenanceactivities. The norms and procedures for downsizingand consolidation which have been developedfor the project's six pilot zones would be applied nationwide,enhancing the financialsustainability of the system as a whole. Overall, the consolidationof the infrastructurenetwork would be budget neutral, with savings generatedby eliminationof redundant facilities and staff serving to increase the operating and maintenancebudgets for the rehabilitated network. While some staff reductionis envisionedin the pilot areas, the full extent of staff redundancyon a nationwidebasis--and, - 23 - hence, the full extent of savings to be generatedover time-would only be Inown followinga survey of staffing patterns to be supportedby the HSRP.
3.5 Financial sustainabilityof the health system would also be enhanced by capacity building activities at the central level which are supported under the HSRP. These activities would focus on improvingsector planning and budgetingand developingfinancing mechanisms for health services which create incentives for greater efficiency, cost recovery and cost containment. Thus, increased Governmentspending on non-wage operating costs--particularlyessential drugs, medical supplies and maintenance--wouldbe sustainablein coming years due to: i) consolidationof physical infrastructure;ii) rationalizationof healthpersonnel; iii) eliminationof unnecessarylump-sum drug subsidies;iv) generation of additional revenues for recurrent expendituresthrough introductionof a payroll contribution;and v) cost recovery on drugs through introductionof out-of-pocketcopayments.
B. ProjectFinancing
3.6 The proposed IDA Credit of SDR8.6million (US$12.4million equivalent) would finance78 percent of the total project cost, or 86 percent of the foreign exchangecomponent and 74 percent of local costs net of taxes. Governmentwould financethe remaining 14 percent of foreign exchangecosts, 26 percent of local costs and all taxes and duties, for a total of US$3.6 million equivalent. On the Government's request, IDA has approved a Project PreparationFacility (PPF) with a Project Preparation Advanceof US$775,000equivalent to completeproject preparationactivities including staff training and equipment and vehiclesfor the PCU and TSD for project coordinationactivities. The project financingplan is shown in Tables 4 and 5 below.
Table 4: COST SUMMARYBY COMPONENT& SOURCEOF FINANCING (US$ thousand)
Duties Govt. IDA Total For. (ExcL & Amount % Amount % Amount % Exch. Taxes) Taxes
A. Health Services Rebabilitation Primary Health Centers 618 16 3,232 84 3,850 24 1,302 2,317 230 RegionalHospitals 2,698 32 5,652 68 8,350 52 5,448 2,518 384 Health FacilitiesMaintenance 3 2 150 98 153 1 96 54 3 Subtotal Health Services Rehabilitation 3,318 27 9,035 73 12,353 77 6,847 4,889 617 B. CapacityBuilding Managementof Basic Health Services 4 1 595 99 599 4 471 125 3 RetrainingHospital Staff 74 7 954 93 1,028 6 637 388 3 Health Policy and Planning 98 7 1,345 93 1,443 9 1,107 282 53 Project Coordination 63 11 518 89 581 4 476 105 0 Total Disbursement 3,557 22 12,447 78 16,005 100 9,538 5,790 676 - 24 -
Table 5: SUMMARYBY EXPENDITURECATEGORY & FINANCING (US$ thousand)
Local Duties Govt. IDA Total For. (Excl. & Amount % Amount % Amount % Exch. Taxes) Taxes
I. Investment Costs A. Civil Works - Hospitals 250 7 3,732 94 3,991 25 2,264 1,487 240 B. Civil Works - Health Centers 474 15 2,686 85 3,160 20 997 1,973 190 C. Civil Works - Other facilities 7 15 39 85 46 0 0 43 3 D. Equipment,Vehicles and Spares 1,583 42 2,161 58 3,744 23 3,484 107 153 E. Furniture 41 15 231 85 272 2 140 91 41 F. Architectural & EngineeringFees 0 0 473 100 473 3 185 288 0 G. Specialist Services 0 0 1,366 100 1,366 9 1,329 37 0 H. ExternalTraining 0 0 394 100 394 2 394 0 0 I. Local Training 0 0 1,049 100 1,049 7 376 674 0 J. Materials and Supplies 62 12 454 88 516 3 453 4 59 Total Investment Costs 2,416 16 12,584 84 15,009 93 9,621 4,704 685 II. RecurfentCosts A. Staff Salaries 0 0 0 0 0 0 0 0 0 B. Vehicle O & M 41 100 0 0 41 0 0 41 0 C. Equipment0 & M 848 100 0 0 848 5 0 848 0 D. Building O & M 25 100 0 0 258 2 0 258 0 Total Recuffent Costs 1,147 100 0 0 1,147 7 0 1,147 0 Total Disbursement 3,572 22 12,584 78 16,156 100 9,621 5,851 685
C. ProjectManagement and Implementation
3.7 The Minister of Health would exercise final authority over the implementationof the HSRP. In keepingwith the Project's capacity-buildingobjectives, MOH line departmentsand units will implementthe project components, assisted by qualified specialists as necessary. To ensure that project objectives, performance targets and schedules are met successfully,the Project CoordinationUnit establishedin the Officeof the PlanningAdvisor under the generaldirection of the Minister (para. 2.16), would be responsible for coordinating all project-related tasks. Key personnel of the PCU include the Project Director, ProcurementOfficer, Financial Officer, and secretary, all of whom are proficient in English. Support staff would be recruited as necessary as the workload moves towards peak stages. The PCU would be strengthenedby an external Project Adviser (para. 2.16)
3.8 Project Coordination. MOH will maintainPCU as a compact, well-equippedunit with direct access to decision-makingauthority in the Ministry and other agenciesinvolved in the HSRP. The PCU would have - 25 - three sets of main responsibilities:coordination and monitoringof project-relatedimplementation activities; administrationof procurement action; and managementof project funds. In all three areas, the PCU will channelas appropriateany implementationproblems/issues which require the attentionof MOH management and/or IDA. The PCU's specific responsibilitiesare:
(i) Coordinationand monitoring. The PCU will be the principal liaisonwith other institutions outside the MOH, includingIDA and other donors, for project administrationand supervision purposes. It will ensure that all resourcesutilized under the HSRP (financial,physical, staff, etc.) are in accordance with the Project's priorities and objectives. To this end, the PCU will a) maintain up-to-date, detailed implementationschedules of each component/sub- component; b) monitor compliance by the institutions concerned, with Project/Credit covenants and with agreed performance indicators; and c) monitor the placement and performanceof staff undertakingexternal training, and of consultants contracted under the HSRP. The PCU will prepare and distribute consolidatedsemi-annual progress reports on project implementation;and annual financial audit reports.
(ii) Procurement.The PCU would have overall responsibilityfor ensuringthat all procurement activities under the HSRP are undertaken in accordance with the procedures and documentationagreed with IDA. To this effect, PCU will clear all standard procurement documentationfor works, goods, and services after obtaining IDA's prior approval where required. The PCU will ensurethat the StandardBidding Documents (SBD) prepared by the Bank for IDA-financedoperations in Albania, are appropriately modified to suit project requirements, and used consistently. The PCU will not itself conduct the procurementof works and equipmentcontracts, but will review/clearbid award recommendationsfor major works and equipment contracts undertaken by TSD (para. 3.8). PCU will forward the relevant bid documentsto IDA for prior review and/or no objections,and will be responsible for obtaining and/or following up on Government/MOH action respective of IDA's procurementaction. The procurementof fellowshipsand technicalassistance (TA) contracts will be implemented by the PCU, with assistance as appropriate, from the relevant implementingdepartments/units in finalizingproposal documents and evaluatingTA proposals received (para. 3.9a). The matrix of procurementresponsibilities under the Project is shown in Annex 5.
(iii) Managementof Project funds. The PCU will take measures to facilitate the flow of resourcesto MOH agenciesto enablesuccessful implementation of their project-relatedtasks. The PCU will administerthe SpecialAccount (para. 3.25) establishedfor the HSRP, process disbursement applications,and monitorthe use of Credit funds. PCU will maintain up-to- date accountsand records (contracts,purchase orders, guarantees,etc.) of all project-related expenditure (investmentand recurrent, IDA and Government counterpart funds), and keep updated estimatesof the total costs involvedto completethe Project. The PCU will monitor and take appropriate steps to obtain adequate Governmentcounterpart funds to finance the planned project activities. In this connection, the PCU will consolidate the estimates, prepared by each implementingDepartment/unit, of the financialand resource needs of their respectivecomponents for the succeedingimplementation year. Theseconsolidated budgetary estimates would be discussedwith IDA during the annual project performancereviews, but sufficientlyin advanceof the Government'sannual budgetary presentation/approval processes to accommodateappropriate changes. - 26 - 3.9 Project ImplementationResponsibilities. The implementationof each project subcomponentwould be carried out by the respectiveMOH technicaldepartments/units, as describedbelow. The procurementand contract payment responsibilitiesare outlined in Annex 5:
ComponentA: Health Services Rehabilitation
Facilities Rehabilitation and Maintenance. The Department of Public Health (DPH) will have overallresponsibility for PHC rehabilitation. The Departmentof Hospitals(DHosp) will have overall responsibilityfor hospitalrehabilitation. TSD will exerciseoverall technicalresponsibility over the implementationof all rehabilitation and upgrading works, and be responsible for implementingthe Facilities Maintenancesubcomponent by developinga strategy for the maintenanceof all physical assets (buildingsand equipment)in the public health system. A DistrictProject Team (DPT) in each pilot district will have primary responsibilityfor implementingthe rehabilitation and furnishing of PHCs within their respective districts. The Directors of the Shkoder and Vlore Hospitals will have primary responsibility for the rehabilitation of their respective hospitals. The TSD will: i) collaboratewith DPH and DHosp to ensure that MOH standardsfor PHCs and hospitalsare met; ii) supervise the work of architectural/engineeringconsultants; iii) prepare bid packages and bidding documentsfor major works and equipment;and iv) in collaborationwith PCU, conduct and evaluate bids, award contracts, and supervise the performanceof contractors' and suppliers' contracts. The Department of Pharmacy (DPharm) will be responsible for the procurement and distribution of medical supplies for primary care to be delivered to PHCs. Implementationresponsibilities for facilities rehabilitationare described further in Annex 2.
ComponentB: CapacityBuilding
Managrementor Basic Health Services. Implementationof this sub-componentwill be under the responsibilityof the DPH. DPH will collaborateclosely with the Institute of Public Health and Departmentof Human Resources (DHR)for training activities. The training componentwould be implementedin two phases: Phase 1, general training workshopsfor district and central level staff in health managementand program development, will be prepared and executed by the DPH in collaborationwith DHR, with external supportthrough the twinningarrangement. Phase 2, modular training programsfor specifichealth managementand programmingdisciplines, will be prepared and implementedby the Institute of Public Health with the collaborationof the DPH and DHR, with limited external support through the twinning arrangement. A staff member from the Institute of Public Health, who would benefitfrom a long term fellowshipat the twinninginstitution, will assume responsibilityupon his return for preparation and implementationof the training modules.
RetrainingHospital Staff
Needs Assessment:The assessmentof retrainingneeds for physicianswill be carried out by the DHR in close collaborationwith the Director of Hospitals for Physicians Training. The DHR will be responsiblefor: i) ensuring close cooperationwith the Faculty of Medicineand Nursing School; ii) communicatingthe results of the assessmentsto Faculty of Medicinestaff; iii) elicitingfeedback on the assessmentfindings from teaching staff; and iv) developingconsensus on retraining needs.
Program Design and Implementationfor Physicians Retraining: An institutional framework for retraininghas been designed with the close collaborationof the DHR, the Faculty of Medicine, and districthospital administrations. The PhysiciansRetraining Fund will be managedby the Vice Dean for Post-GraduateTraining who wouldbe responsiblefor organizingand coordinating the preparation - 27 - of training seminar proposals by the staff of the Faculty of Medicine. Regionaland district hospital staff, who currently serve as correspondentsto the Faculty of Medicine for the practical training of student doctors, would be responsiblefor facilitatingthe delivery of seminars held in regional and district hospitals. The Director of Hospitals for Physicians Training will be responsible for approving specific training seminar proposals once they are developed by the schools and for developinga methodology,in cooperationwith the PCU, for evaluating results.
Nurses Retraining:The DHR will be responsiblefor approvingretraining programs developed by the Tirana Nursing School with the support of a Swiss Nurses' Training Institution, Le Bon Secours. MOH has an existing and successfultwinning arrangement with Le Bon Secours. The TSD will procure the equipment(with PCU clearance)and materials to support the Tirana Nursing School.
Health Policy and Planning.
Health Planning and Financing. The MOH Departmentof Economics (DEcon)will have primary responsibility for all project activities related to annual budgeting, investment programming and strengtheningof the health financingadministration. DEcon will be assisted in these tasks by an external Financial Planning Consultant. Responsibilityfor investmentprogramming will also lie with the MOH Office of the Planning Advisor and Committeefor Health Planning (a committeeof all MOH senior managers), which will have overall responsibility for sector planning and donor coordination. The staffing survey and recommendedstaffing plan will be the joint responsibilityof the Office of the Planning Advisor and the Department of Human Resources. National program developmentfor cost-effectivematernal and child health interventionsat the primary level will be the responsibilityof the Departmentof Public Health.
Drug Policy and Distribution. The MOH Department of Pharmacy (DPharm) will be primarily responsiblefor Project activitiesaimed at developingdrug policy and building capacity for logistics management. DPharm will take joint responsibility with the Department of Economics for completing the Drug Pricing and Reimbursement Study and implementingits recommendations. Training and technicalsupport for logistics managementwill be managedby DPharm.
3.10 Each implementingtechnical department/unitwould ensure that its respectiveproject activitiesare carried out in accordance with agreed project objectives and performancetargets. A Project Operational Manual will be compiledby the PCU from documents developedduring project preparation and appraisal. The POM would constitute the implementationguidelines for each component/sub-component,and will include, for each project component,detailed TORs for consultingservices, base implementationschedules and procedures, performance targets and monitoring indicators, detailed cost estimates, and technical background as appropriate. Specific tasks, assigned in the POM, for which the implementing departments/unitswould typically be responsibleinclude:
(a) in collaboration with the PCU: i) finalizing TORs for the specialist services, feasibility studies, and training required in their respective parts of the Project; ii) assigning bid evaluation committees; iii) evaluating proposals received for consulting services; and iv) authorizingthe award of contracts;
(b) defining the conditions of closure in terms of redeploymentof staff and redirection of all expenditures(supplies, maintenance, etc.) associatedwith PHCs; - 28 - (c) monitoringthe implementationof local training and seminars; and identifying and tapping local expertise to assist in activitiessuch as preparation of detailed procedures and updating implementationschedules;
(d) preparing periodic reports on the implementationprogress of their respective components, and submitting these to the PCU for inclusion in the semi-annual report on project performance;
(e) preparing physical and financial forecasts of future activities required to implement their component(s)of the Project, and forwarding these estimates to the PCU for inclusion in budgetary proposals for the succeedingimplementation year (para. 3.6c).
3.11 The preparationof a POM in form and substance acceptableto IDA, would be a conditionof credit effectiveness.
3.12 Monitoring and Reporting. The PCU would be responsible for project monitoring. The Project ImplementationPlan outlinedin Annex 2 includes a frameworkfor systematicmonitoring and evaluationof progress in project implementation. It identifies a set of performance indicators to be used in project supervision. A detailed outline for routine progress reporting would be includedin the POM. This outline would be designed in such a way as to encourage regular monitoring of project activities and resource availabilities. On a semi-annualbasis, the PCU would submit to IDA a consolidatedreport on the status of project implementation,covering each component,its objectivesand activities,and including:i) current status and issues; ii) deviations,if any, from the implementationplan and project targets; iii) recommendationsfor actions and forward planning; and iv) actual and planned expenditures. Duringnegotiations, Government providedassurances that MOH will prepareand submitto IDA by March 31 and September30 of each project year, reports on the progress achieved in Project implementationaccording to performance indicatorsagreed with IDA.
3.13 Mid-TermReview and Evaluation. By March 31, 1997 (or about two and one-half years after Credit Effectiveness), the PCU would undertake jointly with IDA a mid-term review of progress in project implementationto determine whether: i) the HSRP's intendedobjectives remain valid; ii) implementationis advancingsatisfactorily to justify its continued implementation;and iii) any adjustmentsto, or significant restructuringof, the Project are necessary to improveits effectiveness. The Project OperationalManual will be updated followingthe mid-term review and the annual work program for the followingyear would reflect the recommendationsmade. During negotiations,the Governmentprovided assurances that a mid-term project review would be conductedby March 31, 1997, accordingto terms of reference agreed with IDA.
3.14 Project Completion and Evaluation. Project completion is expectedby September30, 1999. The PCU would be responsiblefor preparing a Project ImplementationCompletion Report.
3.15 IDA Supervision. Becausethis is the first project in the health sector in Albania, the HSRP would require intensivesupervision, especiallyin the first year of implementation. Project monitoringreports and indicators,the POM, and a careful review of project expendituresand availabilityof project resourceswould form the basis for the supervision missions. Staffing for supervision missions would need to include, in additionto the task manager and project implementationspecialist, periodic visits by specialists in health planning, pharmaceuticalpolicy and health finance. The SupervisionPlan is shown in Annex 4. - 29 - D. Project Procurement Arrangements
3.16 Project procurement arrangementsare summarizedin Table 6. Standard Bidding Documentshave been developedby IDA for Albania and would be utilized for the procurementof IDA-financedworks, goods, and related services. Expendituresfinanced entirely with Governmentfunds are shown under the N.B.F. (Non-BankFinanced) column. A ProcurementPlan (bid packaging, estimated costs, timing) is provided in Annex 5.
Table 6: PROCUREMENT ARRANGEMENTS I/ (US$ million)
Category of Expenditure ICB Other N.B.F b/ Total
1. Civil works 3.9 3.1_l 7.0 (3.7) (2.6) (6.3)
2. Equipment, vehicles, furniture materials 1.7 1.4 di 1.5 _/ 4.6 (1.6) (1.2) (2.8)
3. Technical assistance, fellowships 3.3 f/ 3.3 and training (3.3) (3.3)
4. Incrementalrecurrent costs 1.1 g/ 1.1 (0.0)
Total 5.6 7.8 2.6 16.0 (5.3) (7.1) (0.0) (12.4)
Note: Figures in parenthes are the respective amounts fuianced by IDA. «I Figures may not addup exactly due to rounding. k/ N.B.F. - Non-Bank Fmanced expenditure. pI Civil works (aggregate US$2.6 million equivalent) for primary health care facilities (US$2,000 - USS100,000) to be awarded through local competitive procedures for snmallworks in accordance with procedures anddocumentation agreed withDA. g/ InterationaI shopping (aggregate US$890,000) packages estimated between US$10,000 and US$100,000 per contrct; Local shopping (aggregate US$310,000) packages estimated at less than US$10,000 per contract; and Direct contraeting (aggregate US$40,000) proprietary items such as jounals and computer software. e/ Hospil equipment financed by Government. / Services of consultants/institutions (advisors, experts, fellowships/training) to be enaged in accordance with IDA Guidelins for the Use of Consultanu. g/ Itema of recurrent expenditure financed entirely by the Government and procured in accordance with regular Govermnt procedure. - 30 -
3.17 The PCU would have overall responsibilityfor procurementactivities under the project (para. 3.8(ii)). Specificprocurement responsibilities under the HSRP are provided in Annex 5.
3.18 Procurementprocedures under the Project would be as follows:
(i) Procurement of Goods. Goods procured under the HSRP would consist of medical equipment, medical supplies, office equipment and supplies (including computers and related-equipment,software, photocopy machines, facsimile machines), vehicles, training materials and furniture. To the extentfeasible, invitationsfor bids on equipmentwould be grouped into sizablebid packages in order to promote competitionand benefit from economiesof scale in bid prices. Contracts for goods estimated to cost the equivalent of US$100,000or more would be procured followinginternational competitive bidding (ICB) procedures in accordancewith the Guidelines - Procurementunder IBRD Loans and IDA Credits (May 1992). Goods procured through ICB would constituteabout 55 percent of the total cost of IDA-financedgoods. The remaining 45 percent of IDA financedgoods would be in minor packages suitablefor procurementmethods other than ICB as follows: (a) contracts for goods estimated to cost between US$10,000 and US$100,000 per package (aggregate IDA US$890,000), may be procured through internationalshopping (IS) on the basis at least three price quotationsfrom suppliers from three eligible source countries;(b) contractsfor goods (aggregateIDA US$310,000) estimated to cost less than the equivalent of US$10,000 per contract, including (i) essentialPHC furniture which are of simplemanufacture, bulky, and limited in quantity as procurement is timed with completionof PHC works contracts, and (ii) off-the-shelf items such as office and training supplies and small equipment, may be purchased through local shopping (IS) on the basis of a minimum of three price quotations obtained from qualified suppliers; and (c) contracts for goods which IDA agrees are of a proprietary nature, e.g. computer software and medical journals/referencematerials, etc. (aggregateUS$40,000 IDA financing),may be acquiredthrough direct procurement from proprietors and/or copyright holders, in accordancewith procedures acceptableto IDA. Other hospital equipment (aggregatevalue US$1.5 million) would be financed entirely by the Government.
(ii) Procurementof Works. Civil works contracts include the rehabilitationand upgrading of 100 primary health centers in six districts, and the rehabilitation of two regional hospitals. Civil works contracts for the two regional hospitals would be procured following ICB proceduresin accordance with IDA Procurement Guidelines. Local contractors competing for works contracts under ICB, would be given a margin of preferenceof sevenand one-halfpercent (7.5%) in bid evaluationover competingforeign bids, in accordance with relevant provisions in the IDA Procurement Guidelines. Contracts for the rehabilitationof the 100 PHCs are dispersed and of small value, with contractsestimated to range betweenUS$2,000 and US$100,000(aggregate IDA US$2.6 million). It is not feasibleto create large enoughpackages for these contractsto attract foreign bidders, so works contracts for the PHCs would be awarded following local competitive bidding procedures for small works, in accordancewith the proceduresand documentationagreed with IDA. - 31 - (iii) Procurement of Consulting Services. Consultants for specialized and professional services financedunder the HSRP would be selected in accordancewith the Guidelines for the Use of Consultantsby WorldBank Borrowersand by the WorldBank as Executing Agency (August 1981). Specializedservices includefive consultingpackages (aggregate IDA US$1.0 million) which could be provided by qualified consulting firms or institutions: detailed architectural/engineeringservices for rehabilitating two regional hospitals, managementof basic health services, developmentof drug policy, and district managementtraining. The technicalassistance package for district managementtraining (US$250,000 over three years) would be awarded on a sole source basis to the Universityof Montreal whichhas establishedclose working relationshipswith the MOH. IDA has found the qualificationsand performance of this institution satisfactory, and retaining the services of this institution will not disrupt the ongoing programs. The HSRP also includes specialized services (aggregate IDA US$0.5 million) more appropriatelyawarded to individualspecialists selected from a short list becausethe fields of expertiseare unrelated, or in the case of constructionsupervision-services are needed concurrently in different geographic locations. To the extent feasible, external fellowshipsand training programs (aggregate US$1.5 million IDA financing) shall be included as part of the technicalassistance packages procured from consultingfirms and training institutions. Local training would be carried out at MOH headquarters and at local MOH offices, with the assistance of above specialists. The list of consulting services and training needs supportedby the HSRP is shown in Annex 2.
(iv) IncrementalOperating Costs. Buildingand equipmentmaintenance services, staff salaries (except PCU contractualstaff which are financedby IDA) and other incremental non- salary recurrent costs would be financed entirely by the Government and would be procured in accordancewith current Governmentprocedures.
3.19 Contract Review. The procurementdocumentation to be submitted for prior review by IDA includes:invitations for bid, instructionsto bidders, bidding documents,bid evaluationreports, and draft contracts. It is estimatedthat prior review would cover about 58 percent of the value of all contractsfor civil works, goods and consultingservices. The remainingcontracts would be subject to selective post- award reviews by IDA. A detailed list of procurementpackages under the HSRP is provided in Annex 5. Prior review by IDA would be required for all ICB contracts, as well as the followingcontracts.
(i) Civil works: the first PHC works contract awarded using local competitive bidding procedures in each of the six districts;
(ii) Technical Assistance: (a) contracts above US$50,000 equivalent-all procurement documentation(budgets, TORs, selection procedures, short lists, letters of invitation, evaluationreport, draft contracts);(b) single-sourceconsultant contracts and assignments of a critical nature, as reasonablydetermined by IDA- all procurement documentation (see above); (c) contracts below US$50,000 equivalent-TORs; and (d) amendmentsto the employmentof consultantsraising the contractvalue to more than US$50,000-TORs;
(iii) Fellowshipsand Training: TORs or external fellowshipsand study visits.
3.20 ProcurementInformation to be Providedby the Borrower. The PCU wouldpromptly inform IDA of contractawards and procurementissues, and would includethe followingprocurement informationin periodic progress reports: - 32 - (i) revised cost estimates for individual contracts and the total project, including best estimatesof allowancesfor physical and price contingencies;
(ii) revisedtiming of procurementactions, includingadvertising, bidding, contractaward and completiontime for individual contract; and
(iii) status of aggregatelimits on specifiedmethods of procurement.
E. Disbursements
3.21 The HSRP is among the first IDA operations in the human resources sector in Albania, and therefore, the country disbursement profile is speculative. The HSRP has been designed within the capacityof MOH to executeover a five-yearperiod, and credit funds are expectedto be fully disbursed within twenty-two(22) quarters of BoardApproval (by March 31, 2000). Disbursementswould be made as follows:
(i) Goods (equipment, furniture, medical supplies, materials and proprietary items): 100 percent of foreign expenditure; 100 percent of ex-factorycost of locally-manufactured items; and 85 percent of the cost of locally procured items;
(ii) Civil works: 100 percent of foreign expenditureand 85 percent of local expenditure;
(iii) Technicalassistance, studies, fellowships,and (localand external)training: 100percent.
3.22 MOH staff salaries, operation and maintenancecosts of facilities (buildingand equipment)and other non-salaryoperational cost would not be funded out of the IDA credit.
3.23 All withdrawalapplications will be fully documentedexcept that contracts for goods and works under US$100,000 equivalent and contracts for technical assistance, studies, fellowshipsand training under US$50,000 will be supportedby Statementsof Expenditure (SOE) certified by the PCU Project Director. The required supportingdocumentation would be retained by the PCU for at least one year after receipt by IDA of the audit report for the year in which the last disbursement was made. This documentationwould be made available for review by the auditors and by visiting IDA staff upon request. The processing, disbursement and monitoring of the allocationsof the proceeds of the IDA Credit and Government counterpart financing would be managed by the PCU in coordination and consultationwith the MOF.
3.24 Secial Accont. To facilitate timely project implementation,the Governmentwould establish, maintain and operate, under terms and conditionsacceptable to IDA, a Special Account for the PCU, denominated in US Dollars in a bank acceptableto IDA. Payments of eligible expenditure (works, goods, furniture, specialistservices, training) may be made by the PCU out of the SpecialAccount. The Special Account may be establishedin US Dollars, with a total authorized allocationof US$600,000. The initial deposit into the SpecialAccount will be $300,00, until the aggregateamount of withdrawals from the Credit account shall be equal to or exceed the equivalent of SDR 1,00,000. The Special Accountwould be replenishedon a monthlybasis or when the undisbursedbalance falls below an amount equal to 50 percent or less of the initial deposit. In addition, monthlybank statements of the Special Account which have been reconciled by the Borrower would accompanyall replenishmentrequests.
_ ~~ ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ------_------33 - 3.25 The Ministry of Finance has introduced new procedures to be carried out by the Treasury Departmentto monitorthe flow of funds depositedin special accountsestablished for public institutions, such as the Special Account in the Bank of Albania opened by the Treasury Department for the PCU under the proposed project. The MOF assigns a code number identifyingeach Special Account, as well as an item code number for different categories of eligible expenditure. To inform the Treasury of expendituresunder the Special Account, the PCU would submit a monthly statement indicating the amount and category (as defined by the Treasury) of each payment.
3.26 Paymentsof works and furniture contractsadministered by the DPT would also be subject to the MOF requirements. The PCU issues to the District Health Officerheading the DPT an authorizationto spend the funds for project-related works and furniture contracts in the district. The District Health Officer would verify the amount and purpose of payment stated in the invoice submittedby the local contractor or furniture supplier, and forward the invoice with its certification to the PCU. The PCU would, in turn, issue instructionsto effect payment out of the Special Account. Responsibilitiesfor processing contract payments under the Project are shown in Annex 5.
3.27 Project Account and Audits. Separateproject accounts would be maintainedby the PCU. The project accounts, includingthe PCU accounts and the Special Account, would be audited in accordance with the Guidelinesfor FinancialReporting and Auditing of ProjectsFinanced by the WorldBank (March 1982). Within six months of the end of Government'sfiscal year, IDA would be provided with an audit report of such scope and detail as IDA may reasonably request, including a separate opinion by an independentauditor acceptableto IDA, on disbursementsagainst certified SOEs. The separate opinion should mention whether the SOEs submitted during the fiscal year, together with the procedures and internal controls involved in their preparation, can be relied upon to support the related withdrawal applications.
F. Status of Preparation
3.28 Project preparationundertaken thus far would permit timely implementationof project activities. MOH has establisheda SpecialAccount for the PCU. A Project PreparationAdvance (US$775,000) has been authorized and is disbursing. The PCU is fully operational, the Project Director, Procurement Officer, Financial Officer and bilingual secretary have been appointed and are in place. A Project Adviser to the PCU has been contracted on TOR satisfactoryto IDA. MOH has completeda detailed district mapping exerciseand has selected all 100 sites for PHCs to be rehabilitatedunder the HSRP, as well as the 26 PHCsto be rehabilitatedduring the first project year. IDA has approveddesign prototypes for three types of PHC facilities. PCU and TSD staff have received initial procurement training in Tirana, organizedby IDA, and the PCU ProcurementOfficer has already completedthe intensivecourse on procurementconducted by ILO/Turin. Three MOH staff selectedfor short-term fellowshipsin health planning and managementare already in place at the training institutions(Harvard and Boston Schools of Public Health). Coordinationand implementationresponsibilities of the PCU and the implementing departments/agencieshave been established, and detailed first-year implementation plans for each subcomponenthave been developedby each implementingunit/department with assistance from IDA. The PCU has drawn on the experienceof other IDA Project Units in Tiranato initiateproject preparation activities without the benefit of external technical assistance, demonstrating a growing capacity to implementthe HSRP. - 34 - IV. BENEFITS AND RISKS
A. Benefits
4.1 The HSRP would help prevent further deteriorationin health status (i.e. increases in premature and preventablemorbidity and mortality)during the economictransition by improvingthe qualityof basic primary and secondary health services. Specifically, it would begin rehabilitation of a streamlined primary care network and its secondary referral hospitals. It would also update the skills of medical personnel and improve managementof health services at the district level. By building institutional capacity at the central level in the areas of sector planning, health finance and drug distribution, the HSRP would begin to improve resource managementand incentive structures in the health sector.
B. Risks
4.2 The complexityof procurementfor rehabilitationof primary health centers and regionalhospitals is a risk. This will be particularly difficult for a Ministry with no previous experiencein Bank lending and procurementprocedures. To facilitatecivil works procurement, the Project will follow a simplified local procurementprocedure developedfor the IDA-fundedHousing Project. In addition,the HSRP will provide training in procurementand contractingin both the Project CoordinationUnit and the Technical Services Departmentof the MOH. Another Project risk is the almost complete lack of familiarity with decentralizeddecision-making and managementin Albania, and the decision by Government to build local capacity for managementof health resources without extensiverecourse to technical assistance. To address this, the Project will focus on building a core team of trainers at the nationallevel which can transfer management skills and introduce management systems at the district level. A twinning arrangementwith an academicinstitution will provide limited technical support to the national team. - 35 - V. AGREEMENTSREACHED AND RECOMMENDATION
AgreementsReached at Negotiations:
5.3 During negotiations,the Governmentagreed that:
(i) the PHC network in the six pilot districts would be consolidated over the project implementationperiod according to an implementationplan agreed with IDA and the PHCs rehabilitated under the project would be staffed accordingto norms agreed with IDA (para 2.5);
(ii) the district hospitals in Puke, Saranda and Delvina, which were not selected for upgrading to regional hospitals, would be streamlinedto offer only four basic inpatient specialties, and have their staff adjusted accordingly, in accordance with a schedule agreed with IDA (para 2.7);
(iii) the regionalhospitals rehabilitated under the project would be staffed accordingto norms agreed with IDA (para 2.7);
(iv) a sector-wide staffing survey will be completed and discussed with IDA by mid-term review (March 31, 1997), and recommendationsimplemented thereafter as agreed with IDA (para 2.17);
(v) a rolling three-year public health investmentprogram and the draft health sector budget (recurrent and investmentbudgets) will be prepared annually by MOH and MOF and reviewed jointly with IDA by November 30 of each project year. During the annual health sector budget review, IDA and the MOH would agree on rehabilitation and consolidationobjectives for the coming year under the IDA project. (para 2.17);
(vi) the results of the Drug Pricing and ReimbursementStudy will be discussedwith IDA by April 30, 1995, and implementedthereafter as agreed with IDA (para. 2.17);
(vii) it will maintain throughout the project a Project Coordination Unit with staffing, functions and authoritiesacceptable to IDA (para. 2.19);
(viii) that MOH will prepare and submit to IDA by March 31 and September 30 of each project year, reports on the progress achieved in Project implementationaccording to performanceindicators agreed with IDA (para. 3.12);
(ix) a mid-term project review would be conductedby March 31, 1997, accordingto terms of reference agreed with IDA (para. 3.13).
Conditionof Effectiveness
5.4 The preparationof a Project OperationalManual (POM) in form and substanceacceptable to IDA, would be a condition of credit effectiveness(para. 3.11). - 36 - Conditionof Disbursement
5.5 The preparationof an acceptableRetraining Needs Assessmentdefining priority retrainingneeds would be a conditionfor disbursementof the RetrainingFund (para. 2.15(i)).
Recommendation
5.6 Subject to the above, the proposed operationwould provide a suitablebasis for an IDA credit of SDR8.6 million (US$12.4million equivalent)to the Governmentof Albania on standard IDA terms, with 40 years maturity. - 37 -
ALBANIA
HEALTH SERVICES REHABILITATIONPROJECT
ANNEXES
TABLE OF CONTENTS
Annex 1: Basic Economic, Social and Sector Data
Annex 2: Project ImplementationPlan
Annex 3: Detailed Cost Tables
Annex 4: SupervisionPlan
Annex 5: Summary of ProcurementArrangements - 38 -
ANNEX 1 Page 1 of 1
ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
Basic Country Data
Demo&ap_hy Year' Total Population (million) 3384 1992 Density (pop./sq.km) 118 1992 Percentage of Population in Rural Areas 64 1990 Population Growth Rate (annual rate) 2 1991
Economy and Labor Force GDP (USS million) 692 1992 Annual Per Capita GDP (USD) 204 1992 Inflation (5) 237 1992 Total Labor Force (million) 1680 1992 Male (%) 48 1992 Female (%) 52 1992 Labor Force Participation Rate (% of labor force) 74 1992
Health Life Expectancy at birth (male) 70 1991 Life Expectancy at birth (female) 76 1991 Infant Mortality (per 1,000 live birth) 31 1991 Maternal Mortality Ratio (per 100,000 live births) 50 1988 Total Fertility Rate (live births/woman) 3.1 1991 Hospital beds (per 1,000 inhabitants) 4.4 1991 Physicians (per 1,000 inhabitants) 1.4 1991 Nursing personnel (per physician) 2.5 1991
Education Gross Enrollment Ratios (% of relevant age cohort) Primary 94 1992 Secondary 45 1992
Source: Albanian Ministry of Economy, Statistics Bureau, World Bank and IMF staff estimates.
l All 1991 and 1992 data are estimates. - 39 -
ANNEX 2 Page 1 of 32
ALBANIA
HEALTH SERVICESREHABILITATION PROJECT
Project Implementation Plan
1. The following Project Implementation Plan (PIP) outlines the procedures for implementing each component/subcomponent of the HSRP. The PIP describes the scope of each project component, the inputs and sources needed at each implementation stage, procedures applicable for critical tasks, the implementing units/institutions and their responsibilities, and the expected outputs/outcomes of the project interventions at Project completion. This PIP would be the basis for the Project Operational Manual (POM) to be prepared by the PCU jointly with the implementing units/institutions. The POM would describe in greater detail the elements outlined in this PIP, delineating specific targets for each project year, and the necessary resources to meet these targets. The POM would be updated during the joint MOH/IDA annual reviews of project performance.
The Project
2. The main objective of the HSRP is to help prevent deterioration in health status during the economic transition by improving.the quality of basic preventive and curative health services. This would be accomplished by upgrading primary and secondary facilities to minimum sanitary and physical standards, improving treatment skills of hospital physicians and nurses, and building capacity at the central level to manage health resources and implement sectoral reforms. The HSRP consists of two components described in more detail below: (a) Health Services Rehabilitation; and (b) Capacity Building. The Project is expected to be completed over a five-year period (November 1994 through September 1999). Total project costs including contingencies, taxes and duties are estimated at US$16.0 million equivalent of which IDA would finance US$12.6 million, and the balance by Government. Detailed costs of each project component are shown in Annex 3.
Component A: Health Services Rehabilitation
3. The HSRP initiates a national program of rehabilitating and consolidating the existing public health facilities network. The consolidated network would support the development of an appropriate district- level health pyramid offering basic clinical services at the primary and secondary level. This Project component will: (a) rehabilitate/upgrade around 100 selected primary health centers in six pilot districts; (b) rehabilitate/upgrade two secondary referral hospitals serving the pilot districts and surrounding areas; and (c) strengthen sectoral capacity to maintain the health physical infrastructure. The implementation plan and output indicators for this component are provided in Tables F and G below. - 40 -
ANNEX 2 Page 2 of 32
A.1 Primary Health Care Centers (US$3.3 million base cost)
4. Background. A nationwide survey I of primary health care facilities (PHC) gathered basic statistics for developing a national program of consolidatingthe PHC network. This data, used in conjunctionwith MOH's definition of the basic features of a PHC broadly estimated the number of facilities needed nationwideto provide an adequatelevel of primary health care. Due to constraintson availableresources and implementationcapacity, Governmentand IDA agreed to proceed with the PHC rehabilitation program on a pilot basis. Thus, the HSRP would cover two geographic regions, each comprising three contiguousdistricts. These districts (Shkoder, Puke, Malesi e Madhe in the Northern Region; and Vlore, Saranda and Delvina in the SouthernRegion) were selected as they combine a mix of economic and geographic conditionsroughly representativeof the country as a whole. They also include districts where implementationof the MOH policy of downsizingthe number of health centers has already progressed much farther and more enthusiastically. Based on detailed engineering assessmentsof existingfacilities in the six pilot districtsand applyingthe norms and designstandards (see Tables A and B below) agreed with IDA, it was determinedthat the 200 existingPHCs in the six pilot districts could be consolidatedto an efficient networkof about 100 PHCs capableof providingadequate access to primary care to an aggregate population of 600,000. These standards, together with a demonstrationof communitysupport for the Project 2 were applied in selecting the sites for PHCs that would constitute the streamlined network. The detailed engineeringassessment revealed that about 70 percentof existingPHCs need completebuilding replacements because the advancedstate of deterioration plus the inappropriateconfigurations of existingstructures make repairs and or upgrading uneconomic. The healthmapping exercisealso indicatedthe advisabilityof relocatingsome PHCs to sites more readily accessibleto the majority populationin the catchmentarea of the PHC, ten of the 100 consolidatedPHCs would be located in new sites. These sites are public property and do not pose any constraintsto early implementation.
1 A nationwide survey of PHC facilities was conducted in July/August 1993, with technical assistance extended to the MOH by EC/PHARE. The survey reveals that there exist officially 967 primary health centersin Albania(206 urbanand 762 rural). About15 percentof urbanand 24 percentof nrualhealth centersno longer functionas such, either becauseof destructionor occupationof the premisesby squatters. In addition,there also exist 2,312 ambukancas (rual health posts where a nurse or midwife provides preventivecare and first aid, and is visited by a doctor fromtime to time, but not daily), of which around 800 still function. The Project will not rehabilitate the ambulancas.
2 Communityinvolvement is non-financial in natureand comes in the formof, interalia, providing clear title of ownershipof the propertyoccupied by the PHC, ensuringsecurity arrangements to protectthe facility fromvandalism, etc, anddemonstration of readiness/capacityto sustainroutine building maintenance with localresources. - 41 -
ANNEX 2 Page 3 of 32
TABLE A: Primary Health Care Center Architectural Worksheet
I------~~i------* i Area '1Total |AttomanceGross | | Type of Accommodation I per MNo.of| Net Ifor _aLls|Building|Furnitur|Equipmt I Facility I Placelunitsl Area I and 1 Area iCost b/I Cost | .*2| 1 1 Sq.m-ICircutatnI Sq.._. USS0WO USS0 I
* TYPE1: PHC for 4000 popuLation ' f' ' | Examination/ConsuLting Room 17.3 1 1 1 17.3 S0.43O1 I ITreatment Room : 8.61 1 : 8.6 0.43 I Storage/UtiLityRoom 1 4.5 1 1 4.5 Waiting Area 118.2 1 118.2 5S0.15 Toilet :4.5 2 1 9.0 ...n .
SUBTOTALS 57.5 32.0 89.5 S1.01 $0.58 I . , ,I = = = =… = = = =,Ia I TYPE 2: PNC for 4-S8 poputation 0 * I Examination/ConsuLtingRoom 1 17.3 1 2 1 34.6 1 1 $0.86 ITreatment Room 110.8 1 1 110.81 : :50.291 Pharmacy : 8.6 1 1 1 8.61 0.29: Storage/UtiLityRoom I 4.5 1 1 1 4.5 1t1 Waiting Room :18.2 : 1 :18.2 1 $0.30: Toilets 4.5 1 2 1 9.0 1 I :. SUBTOTALS 85.6 1 42.0 1 127.6 S1.74 I 50.76
TYPE 3: PHC for 10-30000 populationI. I * j Examination/ConsultingRoom 1 17.3 I 3 1 51.8 1 1 1 S1.17 I TreatmentRoom |15.0 11 15.01 S10.39 Laboratory :10.5 1:1o0.5 :S0.34 Pharmacy :13.1 11 13.1 :50.34 Storage/UtilityRoom 1 8.6 1 1 8.6 Waiting Area 42.3 1 1 42.3 50.30S 1 Office (2 staff) 13.5 1 1 13.5 1 50.76SO IToilets :5.4 2 10.8 : I. .:- SUBTOTALS 165.7 59.0 1 224.7: S3.30 51.03
1ATERNITYNMDULE $0.63 Patients room (2 beds) 16.8 1 1 1:16.81 0.63 Labor room 5 9.0 1 1 1 9.01 1 |0.50 a DeLivery :20.2 1 1 :20.2: $0.75 Storage/UtiLity Room 1 6.0 1 1 1 6.0 Midwife :8.1: 1 1 8.1 I 10.29 ToiLet 1 3.6 1, 1: 3.6 * : SUBTOTALS 63.7 25.0 88.7a 1 52.17 : $0.27 | ------42 -
ANNEX 2 Page 4 of 32 Table B: Primary Health Care Center Staffmg Norms
Type of Facility Personnel Category Number of Staff
Type 1: PHC for 4,000 full-time physician 0 Population or full-time nurse/midwife 1-2 less
l ______visiting physician 1-2 |'Type 2: PHC for 4,000- full-time physician 2 8,000 full-time nurse/midwife 2-3
l ______visiting physician 0 Ty.pe.3 PHC for 8,000- full-time physician 1 per 2,000 population
Population full-time nurse/midwife 2 per physician
I ______visiting physician 0 Maternity module (2 beds) full-time physician 0 full-time nurse/midwife 1 visiting physician 0
5. ProjectScope. For the 100 selectedPHCs (Table C), the HSRPwill finance: (a) the rehabilitation includingselective replacement of buildings(see Table B) in the six pilot districts; (b) essentialfurniture; and (c) services of local architects/engineersto: (i) finalize designs of prototype PHC centers; (ii) complete detailed engineeringplans and bid documents; and (iii) supervisethe works contracts. The HSRP will also finance medical supplies for cost-effectiveprimary care interventionsto complement medical equipmentbeing provided to the 100 PHCs by EU/PHARE under an ongoing parallel project. The total base cost is estimated at US$3.1 million equivalent. Detailed estimatesof the cost 3 of this
3 Construction/rehabilitation costs of the PHC facilities are based on three basic prototype designs (70 sq. m., 105 sq. m., and 170 sq.m.) . The facilities include working spaces for up to three physicians and related support staff, and service facilities. A supplementary module (maternity unit) is attached to selected PHCs. The average unit construction cost of new buildings in urban/semi-urban areas is currently estimated (February 1994) at US$200 per square meter, with facilities in rural areas costing approximately 20 to 25 percent higher. Based on the survey of existing PHCs, the cost of building rehabilitation/upgrading would range between 30 to 60 percent of the cost of new structures. In addition, provisions for water supply (deep well pumps in rural areas) and external works (about ten percent of building cost) would have to be added in most cases. Engineering fees, including construction supervision costs, are estimated at about five percent - 43 -
ANNEX2 Page 5 of 32 subcomponent and the annual investments needed during the five-year project implementation period are shown in Annex 3 of this Staff Appraisal Report. The consolidation of the existing PHC network implies that the operations of a number of redundant PHCs should be phased out ' over a reasonable period in order to achieve the cost effectiveness and efficiency objectives. MOH has begun to take significant steps in this direction in not resuming the operations of non-functioning PHCs. During implementation of the HSRP, these steps would be carried further in the six project districts by phasing out PHCs excluded from the rehabilitation program, including, as necessary, implementing measures to redeploy personnel and/or terminate the services of redundant staff, all in accordance with the schedule agreed with IDA during negotiations.
of civil works costs. The indirect foreign exchange cost of civil works for PHC facilities is estimated at about 30 percent of total cost.
4 The plan and timetable for this phase-outoperation would indicate, among others: (i) the number PHCs to be closed in each district annually; (ii) number of staff expected to be redeployedand/or terminated;(iii) outline of the training/retrainingprograms for affected PHC staff; and (iv) annual budgetary implications of the phase-out operation. - 44 -
ANNEX 2 Page6 of 32
Table C: List of PHCs to be Rehabilitated
Location lDistric,TyWeRehab 0,BtlgArea Cost5wm2 ',construct Cost CUSSODD),Fumi,Equiip :Nedic :TotaL * ~~~of !Popula-:of'1 or ------…----' tureI imintiSuppLyl Cost/ * ~~~PHC ; tion IPNC :RepLace:Existl Add 'Rehab, Add Rehab -Ad Totat Cost Cost Cost IPHC
lilNarte 17836 T2 IRehab 122 -- 150 : 18.3: 0.O 18.31 1.51 0.81 0.4:1 21.3: 2 Shushice 7533 T2 IRehab 263:--: 701 18.41 0.0: 18.4: 1.81 0.8: 0.4: 21.4: 3 1Vilahin :9962 :T2 I Rehab 757 a50 a :37.9: 0.0: 37.9: l.8 O.8~ 0.41 40.91 14 4at Poro* 4827: T2 IRehab 130 - 100 113.0 0.0: 13.0 1.8: 0.8: 0.41 16.01 Mat orikumn 8909 T2 IRehab 277 -- 81: 22.4 0.0:22.4:1.8:0.8 0.4 25.4: 66Novosele 159251T2 RepLace:--- :1128: : 200:1 o.o: 25.6: 25.6: 1.81 0.81 0.4: 28.61 17 :Sheriste 18996 T2 IRehab1a :8 40 : 100 1 200 1 8.8 : 8.0 116.8 :1.8 :0.8 I0.4 119.8 8 KaLtarat 43341 T2 :Replace:,--- 1281 200: 0.0: 25.61 25.6: 1.8: 0.8: 0.4: 28.6: 9 Raanice :4139 :T2 I Rehab I 140 80 : 11.2 : 0.0 :11.2 11.8 10.8 I0.4 I14.2 I 10 1IBrataj 4650 1 T2 IRehab 1 300 --- 50 1 1 15.0 1 0.0 1 15.0 I1.8 : 0.8 I 0.4 : 18.0 111I Sevaster** 6341 1T2 I Rehab 1300 1 --- I100 I 1 30.0 : 0.0 1 30.0 1.8 1 0.8 : 0.4 33.01 1l2 Kote 1 8408 1T21Reptacel 184 1--- I50: : 9.2:10.0:19.2 : 1.8 10.8:10.4 112.2 : 1131Dhermni 1 1575 1 T2 :RepLace:--- : 128 : 1 220 : 0.0 28.2 1 28.2 1 1.8 1 0.8 I 0.4 1 31.2 1 1141Kuc : 1800:1T2 IRepLacel -- 1 128 :1 :220 o.0 : 28.2 : 28.2 1 1.8 : 0.8 : 0.4 1 31.2 1 115 Tre VeLtazer** 4530 1 T2 :RepLacel--- :128 1 1 220 : 0.0 1 28.2 1 28.2 : 1.8 0.8 0.4 1 31.2 116:Selenice * 1 14313 : 3 IRepLace:--- 225 : : 200 : 0.0 : 45.0 : 45.0 '3.3 1.0 10.5 1 49.8 117 Himare I9300 T2 IRepLacel- 1 128: 1 200 1 0.0 1 25.6 1 25.6 1.81 0.8 10.4 1 28.5 1181Vtore HC 1 1800001 T3 IReptacel-- 1 225 1 1 200 1 0.0 45.0 1 45.0 3.3 1 1.0 0.5 49.8 119IVLore CH2 :T3 :Rehab1300 1--150 I 1 15.0 0.0 : 15.0 1 3.3 I 1.0 0.5 119.81 :20 VLoreHC3 1T3 Rehab 280 -- 50 1 1 14.01 0.0:1 14.0:13.3 1 1.0 :0.51 18.8: MaternityUnits Inumber>1 5 1 Add I - 1 445 1 I 200I 0.0 1 89.0 1 89.0 I 11.0 1 1.5: 1 101.5 1201SUSToTAL VLORE 11933781 1 1 1 1 01213.2 1 348.3 1 561.5 1 53.0: 18.3: 8.4 641.21 I ISARAND a a g aaa I 1 1KonispoL* 3348 :T3 Rehab :249 1- :152 : :37.8 1 0.0 137.8 :3.3 :1.0 10.5 142.6 22Memoraq 3100 Tl Rehab 164:- ~75 12.31 0.01 12.3: 1.11 0.61 0.3: 14.31 13 1Markat 13140 :Til Rehab :49 1- 1100 : 4.9 1 0.0 1 4.9 11.1 :0.6 :0.3 16.9 4 Lukove 14510 :Ti: Rehab 12481- 175 I 118.6 0.0 :18.6 1.1 10.6 10.3 120.61 5 1Grave 134791Ti Rehab III - 172 1 18.0 1 0.0 1 8.0 11.1 10.6 10.3 110.0 I6 1 Livadhja** 15240 T2 IRehab 1198I- :150 1 29.7 1 0.0 129.7 11.8 10.8 10.4 132.71 :7 Partizani* :3456 T2 RehabI326 -- 74: 24.1: 0.0: 24.1: 1.8:0.8 0.4:27.1: 18 Borsh* 13400 T2 Rehab 252 -- 1431 36.0: 0.01 36.0: 1.81 0.81 0.4: 39.0: 9 Mursi 15840 1T2IRehab 344 - 75 125.8 0.0 25.8 11.8 :0.8 10.4 28.8 110 KsamniL 3107 1T2 IRehab248 - 172 1 117.9 0.0 117.911.8 0.8 :0.4 120.9 fli SarandaNC 1 1256001T3 IRepLacel--- : 225: :1200:1 0.0:1 45.0:1 45.0:1 3.3 1 1.0 1 0.5:1 49.8 1 112 SarandaHC 2 1 1 12 IRepLace:--- 1 128 1 1 200 1 0.0 : 25.6 1 25.6 1 1.8 1 0.8 1 0.4 1 28.6 1 IMaternityUnits Inumbter>14 AddI --- 356 1 1 200 1 0.0 1 71.2 1 71.2 1 8.8 1 1.2 1 1 81.2 I121SUBTOTAL SARAliDA642201 : - . 215.2 141.81357.0 30.6 10.4: 4.61402.6: ------I- ----.------45 -
ANNEX 2 Page 7 of 32
------!------Location 'Distric,'Typel, ------!------Rehab 1, ------!------Of 'Poputa-11of Sidg Area Cost:$/m2 POC , or 11----- 11------',Construct Cost (US$= i------i------i------I ition 1PUCiReplacelExisti, I----- 11------I------I------), Fumi',Ecpjip 11ledic ------11------Totat 1, ------Add Rehab,' Adcl Rehab 1,ture mnt I'Suppty,' ------Add Totat Cost Cost/ 11 1 1 Finiq ------Cost Cost PNC IDELVIRR 4991 T2 ------2 Krongi Rehab 316 ------3 Nesopotan 1338 TI Rehab 149 47.1 4138 235 149 0.0 47.1 1.8 4 ALiko T2 Rehab 121 35.0 0.0 0.8 0.4 50.1 2779 T2 149 35.0 1.1 5 Kalase Rehab 193 18.0 0.0 18.0 0.6 0.3 37.0 1210 TI Rehab 145 28.0 1.8 0.8 0.4 6 Vergo 4275 T2 Rehab 141 71 0.0 28.0 1.8 21.0 7 PiLake 352 159 10.0 0.0 0.8 0.4 31.0 2061 Tl 56.0 10.0 1.1 0.6 8 Delvine HC1 Rehab 128 0.8 0.3 12.0 9 DeLvine 15000 T3 Rehab 78 10.0 0.0 56.0 1.8 0.4 59.0 NC2 500 100 0.0 10.0 1.1 Maternity 1 T3 iRepLacel --- 50.0 0.0 0.6 1, 0.3 J, 12.0 Units Inumber>l 3 1224 1 1200 50.0 3.3 ------1 Add I --- 267 1 0.0 1 44.8 1 44.8 1.0 1 0.5 1 54.8 ISUBTCYFAL 1 1200 1 0.0 1 3.3 1.0 1 0.5 DELVINA1 35792 ------1 53.4 1 53.4 1 6.6 1 49.6 1 1 ------i------1 0.9 60.9 254.1 i------i------i------1 98.2 1 352.3 1 23.7 ------I Hat Vetipoie 1 7.9 1 3.5 1 387.4 2 ',SHKODERUra 1504 T2 Rehab e Shtrenite 1185 311 150 3 Rragam Ti Rehab 46.7 0.0 1215 Ti 50 _40 190 200 46.7 1.8 4 Koman** Rehab 198 9.5 8.0 17.5 0.8 0.4 49.7 5 Mat 600 T2 Rehab 150 29.7 1.1 0.6 0.3 BarbuLtush 3262 123 150 0.0 29.7 1.1 19.5 6 Hat Oblik T2 Rehab 190 18.5 0.0 0.6 0.3 2702 T2 150 18.5 1.8 31.7 7 Haimet ** Rehab 105 24 28.5 0.0 28.5 0.8 0.4 21.5 8 Grude 2041 T2 Rehab 100 10.5 1.8 0.8 0.4 e Re 2052 210 150 0.0 10.5 1.8 31.5 9 Trush T2 Rehab 133 31.5 0.0 31.5 0.8 0.4 13.5 10 Nes 2906 T2 Rehab 150 20.0 1.8 0.8 0.4 4100 200 150 0.0 20.0 1.8 34.5 11 Bushat T2 Rehab 105 30.0 0.0 0.8 0.4 23.0 8200 T2 24 50 30.0 1.8 0.8 12 Knsmac Rehab 176 5.3 0.0 5.3 0.4 33.0 13 Guri 2000 T2 Rehab 50 8.8 1.8 0.8 ZL 2000 150 50 0.0 8.8 1.8 0.4 8.3 T2 Rehab 105 7.5 0.0 0.8 0.4 11.8 14 Mat Miede 24 50 7.5 i.8 0.8 2000 T2 Rehab 142 5.3 0.0 5.3 0.4 10.5 1516 1 Vukjakaj 50 1.87.i 0.0 1.8 0.8 Drisht Gegaj**l 3000 0.0 7.11.8 1.11 8 0.8 0.4 8.3 17 Pog 1500 1 TlT2 IRehab I 2CIO 0.6 0.3 10.13.8 1, 1200 1 T2 Rehab 60 150 18 Vio MNELE IRehab 1 160 30 30 30.0 0.0 30.0 19 I 29a4 I Ti IReplacel 50 8.0 1.8 0.8 VeLipoie Plazh 1 1900 --- 1 90 1 0.0 8.0 0.4 33.0 20 Muriqan 1 T2 IReptacel --- 0,220 1, 0.0 19.8 1.8 0.8 0.4 1 1166 1 Ti 1128 1 1200 1, 19.8 1, 1.1 11.0 21 Shtoi i Ri IReptacel --- 1 90 1 0.0 1 25.6 1 25.6 0.6 0.3 21.8 22 Kish 1 1471 1 Ti IReplacel 220 1 0.0 1 1.8 1 0.8 1 Ar 1 800 --- 1 90 1 1 19.8 19.8 ' 0.4 1 28.6 1 23 Theth 1 Tl IReptacel --- 220 1 0.0 1 19.8 1.1 1, 0.6 0.3 ' 1 800 : TI 1 90 1 1220 19.8 1 1.1 1 21.8 24 Prekai :Replacel --- 1 90 1 0.0 1 19.8 1 19.8 0.6 0.3 1 21.8 25 Kir- 1 400 1 Ti IReplacel 1 220 1 0.0 1 1.1 1 0.6 1 I 800 --- 1 90 1 1 19.8 1 19.8 0.3 1 21.8 1 26 Ndrejaj-Shosh I TI :RepLacel --- 220 1 0.0 1 19.8 1.1 1 0.6 0.3 1 **I 1000 I T2 1 90 1 1220 1 1 19.8 1.1 1 21.8 1 27 Shkoder HCI IReptacel --- 1128 0.0 1 19.8 1 i9.8 0.6 0.3 1 21.8 1 28 I 80000 I T3 IRepiacel 1 220 1 0.0 I 1.1 1 0.6 0.3 Shkoder HC2 --- 1225 1 1 28.2 1 28.2 1 1.8 1 21.8 1 29 Shkoder 1 T3 IReplacel --- 200 1 0.0 1 45.0 1 0.8 1 0.4 1 31.2 HC3 1 T3 1225 1 1200 1 1 45.0 1 3.3 1 1.0 1 30 Shkoder HC4 IReptacel --- :225 0.0 1 45.0 1 45.0 0.5 1 49.8 1 Maternity 1 1 T3 iRepLacel 1 1200 1 0.0 1 3.3 1 1.0 0.5 Units Inumber>l --- 1225 1 1 45.0 1 45.0 1 3.3 1 49.8 1 ------5 1 Add I --- 1200 1 0.0 1 45.0 1 1.0 I 0.5 1 !------1445 1 200 1, 45.0 3.3 49.8 1 30 1,SU13TOTALSKKMER ------0.0 1, 89.0 1.0 0.5 49.8 li32788 1 89.0 11.0 1.5 ---- :------101.5 i------i---- i------298.5 469.4 ------767.8 64.0 24.3 ------11.4 a67.5 ------46 -
ANNEX2 Page 8 of 32
Lcation 1DIatrIc of ohr t *td Ar- t Coct:fuhzZCmutruct Ccet CS001o) IFurni,Equip lMW1c I Tota PK tint PK Rer _____-__ ------______-__ --- turo mir suppLyCcost/I PhCPplce Exi AddR Add R b Add Totetcost Cost ct PTo
2tPora ^* t 2223 T2 Rehb 200 I S 30.0 0. 30.0 1.8 0.8 0.4 33.0 2 tblle^^ 5260 T3 Rehab t323t 43t 3 t° 43.3 3 3 1.0 0.5 48.1 3 Fthe Arrez ^^ 17005 T3 Rehab 289 --- 150 ' 43.4 0°0° 43.4 3.3 I l.Oj 0.5' 48.21 |4 | Luf 6870 T2 Rehab 119 20° 101 12.0 0:0 12.0 1.81 0.8 g 0.4 15.0 1 ai 5 n| ^^7680CJeg; T3 Rehab 432 11W:000 4o.2 3.3 1.0.1 0.5 48.0 |6 | Dcrdhce.. 37841 T2. Rehh b 152 198 30.1t 1 t 30.0-3201 1.81 t7 t ocl. ^^t .I 39004 T2 Rehab 18 --- 1 0012 19.81 19.21 1.8 0.8 0.43 21.8 KrthpuL 2843 T2 Replce -- 1Z9 It 220 t0 ° 2192I 28.2 I 1.8 0.8 0.4 31.2 8 191err s qet 11200 Tl IReplace --- t 90 220 0t0 19.81 19.8 1.1 0.6 0:3 21.82 I " 0 , Ft*t t 1234 T1 optpce --- 90 t220t °- 19.a 19.a 1.1 0.6 0.3 2 1.8 11 Arat 17 I|T1 IR pt:cel --- 1 90 2 20 t °- 19.a 19.8 t11 1 0.6 003 2 1.8 12 Buglon 1457 T1 oRplctco --- 90 t 1220t °° 19-8 t19.8t1.11 0.6 t0-3 2 1.8 13 tortur 11651 TI IReptci --- go ' 220 0 .01 19.8a 19.8 1.1 0.6 0.3 21.8' 14 Berishe* .Vogel 163U T1 ORpl C .. 90 12201 0.0 1 19.81 19.81 1.1 0.6 0.3 21.8 '15 tMaeria to 1123 t T1 IR*pl&ce --- 1 90 1220' 0.0 19.8 19.8 I 1.1I 0.6 1 0.3 1 21.8 ' 5 anity Units tnuimb ro 6 t Add I 534 t 200 1 0.0 I 106.8 06.8 13.2 I 1.8 1 121.82 ! 15ISUTOTAIL -I -PUnE ---59121 I1------I- '1Z1.1I - -- I 22 273.6 -1 494.7 L-1-139.8 113.0 1 5.6-. 1.t 553.1 1 t l"ALESI"RDhE t t I ------I------i 1 toKto 4900 1 Ti I Rehab I 131 --- 1 150 1 t 19.7 0.0 19.71 1.11 0.61 0.3 221.7 1 I 2 Baiz 17000 T2 I Rehab "146t ---1 0loo 114.61 0.0 14.6 1.8 0.8 0.4 17.61 1 3 tVrake 35001 Tl Rehab 1190 --- t42 8.0 0.01 8.01 1.11 0.6 0.3' 10.01 I4 Gruemire* 5W T2 Rehab 150 --- 10O 15.0 0.01 15.01 1.81 0.8, 0.4! 18.0w I5 IVuket 221301 Ti Rehab 74 20 40 3 0 0.0 0 t 1' 0.6 0.3 5.01 I 6 Zagore ^ ; 2200 IT2 I Rehab 200 --- 30 I 6.0 0.0 6:0 1:8 0:8 0.41 9.01 I7 1J24151 Tl Rehab 80 101 30 1202.4 0.0 2:4 1.1 0.61 0313 4.4 8 Selc t1500 T1 gRqpLcce| --- 90 t 2 - 98t198t11,06 .3 28 1 9 1 KopLik ^ UW8200 T3 IReplce--- 225 t 200 0 ° 45.0 t 45.01 3.3 1 1.0 t 0.5 I 49.8 1 10 Buz1 Uj3 2500 T1 IReplace --- go 220 0.0 I 19.8 19.8 1.1 0.6 0.3 21.81 11t Breto ht 2200 t T1 topL&ct --- t 90t 220 00.t 19-a 19-a 1.1 006 0.3t 21.8| 12 Rect 2600t T1 oRpl&ceg... 90o 220 0.0 19.8 19.8 1.1 0 06 0.3t 21.8 13 Kushe Hot t 30000 Ti RepLce --- 1 90 t 1 220 0.0 19.8 | 19.8 t 1.1 ' 0 6 ' 0.3 21.8a 1141 Vermosh 1 18501 Ti Raptcel --- 190 I 220 0.0 19.8 t 19.8 1.1 0:6 0.3 21.81 I I "aternityUnits mniudmer 3 Add - 267 200 0.0 53.4 53.4 66.61 0.9 j 60.9 -- -- .... I ..... I I I...... … I -- 1 14_1 RJTOTALNALEESi 48995M ////111111/Il/I/l/I Ill/I 68.6 217.2 285.8 26.3 ' 10.3 4.7 327.1
100_ CJUUTOTAL 1534294 ill/i Il/////I 1278.6__//IIII//Il/I 11548.4 2819.0 1237.4 84.2 38.2 13178.81 ------t------|----- |------|------I------|------I--- - 47 -
ANNEX 2 Page 9 of 32
6. ImplementationResponsibilities. Implementationof the PHC subcomponentwould be the overall responsibilityof the Director of the Departmentof Public Health (DPH) which has central authorityover the operations of PHCs. The TechnicalServices Department(TSD) will provide the technical expertiseto help DPH formulatenational standards for facilities and equipment,ensure conformityof the consolidatedPHC network with these standards, and oversee the PHC construction and equipmentprogram. The Project CoordinatingUnit (PCU) will monitor overall implementation progress, and compliancewith procurementprocedures agreed with IDA. A District Project Team (DPT) will be set up in each district and will be directly responsiblefor the rehabilitationand furnishingof PHCs within their respectivejurisdictions. DPTs will keep the DPH, PCU and TSD up-to-dateon the status of implementationin the district. The District Health Officer would lead the DPT, which would also includethe district or local engineer, an accountant, and a PHC specialist. DPTs may commissionlocal architects or engineers as needed, to carry out the day-to-day supervision of construction. The responsibilitiesof the DPT comprise the following:
(a) Bidding and contract award: DPTs will implementthe civil works and furniture bidding and contractingprocesses for the PHCs in their jurisdictions. DPTs would: (i) prepare a detailed technicaldossier for each PHC describing the physical needs for rehabilitation,building plans, specifications,furniture needs, cost estimates, as well as other legal or institutionalrequirements; (ii) prepare bidding packages and documents using the standard formats prescribed by the PCU and agreed with IDA; and (iii) invite and conduct the bids. Bidding would be conductedby a district bid committee presided by the District Health Officer, the district engineer, and the district Treasury representativewith a TSD representativeas observer. Procurementprocedures are described in paras 3.17 - 3.19 of the SAR. Procurementprocedures and the matrix of procurement responsibilitiesare outlined in Annex 5.
(b) Implementationof constructionand furniture contracts. Each DPT will administer the works and furniture contracts within its jurisdiction, and will be responsiblefor monitoringcontractor performanceand quality of construction,measuring completed works/furnituredeliveries, and processingpayments to contractors/suppliers. Contract payment and disbursementprocedures administeredby the DPT would be subject to the MOF requirementsand carried out in accordancewith the matrix of responsibilitiesdescribed in Annex 5. Upon approval of contract awards, PCU issues to the District Health Officer heading the DPT an authorizationto spend the funds for project-relatedworks and furniture contracts in the district. The District Health Officer will verify the amount and purpose of payments stated in the invoice submitted by the local contractor or furniture supplier, and forward the invoicewith its certificationto the PCU. The PCU would, in turn, issue instructionsto effect payment out of the Special Account.
7. ImplementationPlan. Table D outlines the implementationtimetable and schedule of civil works procurement. Implementations would proceed in the following manner. Each DPT would
5 The followingactions have been completedas of negotiations:(a) detailedengineering data of all PHCs in the sixdistricts were compiled and PHC sites plotted on geographicmaps; (b) definition of newnational standardsfor PHCs takdng into account IDA's comments; (c) preliminary architectural designs of prototype - 48 -
ANNEX2 Page 10 of 32 commissionlocal architects/engineersto prepare detailed constructionplans and bid proposal documentsto rehabilitatethe PHCs in the designatedgrouping. The Standard Bidding Documents prescribed by IDA would be adaptedby the DPTs for this purpose, and the resulting documents cleared with the TSD before constructionbids are invited.. Concurrently,TSD will prepare the furniture standards for PHCs and the correspondingstandard procurement documents. DPTs will indicate their specific requirementson the standardfurniture bids documents, and upon clearanceby TSD proceed with procurement. Procurementof furniture packages would be timed in a manner that would synchronizefurniture deliveries with the conclusionof constructionworks in each construction group. Similarly, DPharm will prepare the procurementpackages for PHC medical suppliestiming deliveries of medical supplieswith the entry into operations of the rehabilitatedPHCs in each group. The PHCs to be includedin succeedinggroups to be rehabilitated/builtwould be identified during the joint annual review of the health sector investmentprogram and budget. The actual timing and number of PHCs included in subsequentgroups may be adjusted (advanced/increased)depending upon the District's demonstratedcapacity to implementthe project.
PHC facilities.MOH will presentthe ruialPHC prototype designs for IDA reviewat negotiations; and (d) 26 out of the 100 PHCs have been identified for implementationat the start of the Project, and designatedas Group 1. - 49 -
ANUNEX2 Page11 of 32
Table D: PHC Rehabilitation Implementation Schedule
-- D Districts
Description of Item/Activity hkQd Puke Malesi Vlore Sarand Delina
Number of PHC facilities 30 15 I4 Ja 9 of which: Replacement 13 8 7 9 2 1 Rehabilitation 17 7 7 11 10 8
Selection of PHCs (completion) 05/94 05/94 05/94 05/94 05/94 05/94
Preparation of PHC bid document packages: Group 1 (09/94-11/94) 5 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 2 (08/95-10/95) 9 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 3 (08/96-10/96) 8 phc 5 phc 4 phc 5 phc 4 phc 3 phc Group 4 (08/97-10/97) 8 phc - ---- 5 phc - -
Bidding and contract award: Group 1 (11/94-03/95) 5 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 2 (10/95-02/96) 9 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 3 (10/96-02/97) 8 phc 5 phc 4 phc 5 phc 4 phc 3 phc Group 4 (10/97-03/98) 8 phc - - 5 phc - -
Construction period and commissioning: Group 1 (04/95-03/96) 5 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 2 (03/96-02/97) 9 phc 5 phc 5 phc 5 phc 4 phc 3 phc Group 3 (03/97-02/98) 8 phc 5 phc 4 phc 5 phc 4 phc 3 phc Group 4 (03/98-12/98) 8 phc - - 5 phc - - - 50 -
ANNEX 2 Page 12 of 32
Table E: Primary Health Centers for Rehabilitation and Consolidation in Project Year 1
DISTRICT REHABILITATION CONSOLIDATION
SHKODER Oblik Velinaj Barbullush Ranxa Velipoje-Qender Rroshkull Vukjakaj-Gejaj Boksi Ndrejaj-Shosh Guci e Re
PUKE Berishe Bushat Merture Lumbardhe Porava Qerret i Siperm Bugjon Bregu Blerim Fierze
MALESI E Vermosh Zagore MADHE Bratosh Pjetroshan Koplik Sterbeg Buze-Uji Bogic-Polvar Zagor
VLORE Poro Fitore Trevllezer Bishan Sevaster Hoshtim Shushice Matogjin Selenice Risili Armen
SARANDA Livadhja Xare Borsh Meyoq Konispol Cuke
DELVINE Delvine e Re Bajke Kalase Lefterhor Aliko Stjar
A.2 Regional HosDitals (US$7.4 million base cost)
8. Background. District hospitals constitute the second tier of the district level health pyramid. In line with its regionalization plan, the Government selected a small number of district hospitals to be upgraded to regional hospitals offering referral secondary care to a sufficiently large catchment population of approximately 300,000-350,000 inhabitants. The hospitals of Shkoder (620 beds) and Vlore (500 beds) would complete the network in the project's six pilot districts wherein the rehabilitation of PHCs and training in management of basic health services would be carried out. The - 51 -
ANNEX 2 Page 13 of 32
development of an appropriate district level health pyramid offering basic clinical services at the primary and secondary level also implies rationalization of the Government investments in hospitals.
9. Since 1992, bed capacity has been reduced by 25 percent in the two regional hospitals and by 30 percent in the three district hospitals in the project zone. Government has also agreed to limit all district hospitals (i.e. those not to be upgraded to regional hospitals) to providing at most four basic inpatient specialties (internal medicine, surgery, pediatrics and obstetrics/gynecology), and adjust staffing accordingly. Reduction of the standard work week to 40 hours has increased staffing needs by nearly 20 percent, absorbing some excess labor in hospitals. However, Government has also agreed-as an interim measure until a more definitive study of staffing patterns is undertaken-to establish a norm of 1.5 staff per bed in district and regional hospitals. To achieve this norm, Government will reduce non-medical personnel in the hospital sector by six percent in 1995, including all hospitals in the project zones. During negotiations, the Government agreed that: (i) the district hospitals in Puke, Saranda and Delvine, which would not be upgraded to regional hospitals will be streamlined to offer only four basic inpatient specialties, and their staff adjusted accordingly, as agreed with IDA; and (ii) rehabilitated hospitals will be staffed according to norms agreed with 1DA. It is recognized that further staffing changes in the project zones-particularly further reduction and/or redeployment of staff from district to regional hospitals- will be necessary based on the development of functional master plans for the two regional hospitals and subsequent restructuring of hospital operations. This question will be addressed as part of the broader sector-wide staffing survey and recommended staffing plan. During negotiations, the Government agreed that a sector-wide staffing survey will be completed and discussed with IDA by mid-term review (March 31, 1997), and recommendations implemented thereafter as agreed with IDA.
10. Project Scope. The HSRP would support the most urgent and essential rehabilitation and upgrading work on the Shkoder and Vlore hospitals. 6 The rehabilitation/upgrading work would be based upon a set of functional master plans 7 laying out the medium-/long-term development and
6 The existing hospital facilities comprisevarious old structures, the most recent built in the early 1980s, which house medical servicesincluding surgery, pediatrics(with separatebuildings for prematureinfants), matemity, infectiousdiseases, and psychiatric departments,and utilities. The quality and technologyof the existing physical plant is generally well below acceptablestandards for modem hospitals. Both the Shkoder and Vlore hospital facilities have major deficiencies which include: (a) antiquated and non- functioningmedical equipmentand technology;(b) deficient/sub-standardutilities - sanitary, electrical, water,heating, medical waste disposal, laundry, kitchen, communications; (c) redundant expensive facilities such as laboratories, surgical theaters, x-ray suites, sterilization rooms; (d) poor building and space planningcharacterized by the disorderlyinternal/external circulation of patients, emergencycases, public, vehicular traffic and access to services; and (e) other major deficiencies(e.g. weak structures,inadequate radiation safeguards, poor isolation of intensive care/sterile areas, leaking roofs/plumbing, dark passages/rooms,broken fenestration,deficient access facilities for the handicapped,etc.). Moreover, the poor physicalenvironment in the two hospitalsdiscourage good medical and sanitary practices, and have negative impact on the physical and psychologicalhealth of patients, as well as on the attitudes and efficiencyof hospitalpersonnel. All these deficienciespoint out a need for a well conceivedrehabilitation and upgrading of the hospital physical plant.
7 The functionalmaster plan would outline the medium-/long-termdevelopment program of each hospital complex. The plan would be prepared in close consultationsbetween the MOH Departmentof Hospitals, - 52 -
ANNEX2 Page14 of 32 investmentpriorities for the two hospital complexes.The HSRP would finance: (a) professional services of hospital developmentplanners (6 staff months)to prepare the two functionalmaster plans; (b) professionalservices of two hospital design specialists/firms,to prepare detailed architectural and engineeringdesigns and bid documentsfor priority works; (c) services of a medical equipment specialist (4 staff months)to finalize the priority equipmentlists/specifications and bid documents and assist in equipmentbid evaluation;(d) civil works covering the most urgent/essentialrehabilitation and upgrading needs; (e) priority medical and related equipment;and (f) training in modem hospital operationalpractices for selectedofficers of the two hospitals and the MOH. The total base cost is estimated at US$7.4 million equivalent. Detailedestimates of the cost 8 of this subcomponentare shown in Annex 3 of the SAR.
11. Implementation Responsibilities. Implementationof this subcomponentwould be the overall responsibilityof the Director of the Departmentof Hospitals (DHosp), which exercises authority over the operations of hospitals in the country. The Directors of Shkoder and Vlore Regional Hospitalswill oversee the project implementationprogress in their respective hospitals and report to the DHosp Director. The TSD will provide the technicalsupport to both DHosp and the hospital directors. TSD will: (a) supervisethe work of consultantsin the preparation of hospital equipment lists and specifications,detailed hospital rehabilitationplans and bidding documents; (b) conduct the bidding processes for works and equipment;and (c) supervise the constructionand equipping of the two hospitals. The DHosp will be responsiblefor the design of the hospital staff training program which would be implementedin collaborationwith the regional hospital Directors. The PCU will closely monitor the implementationof all these activities and clear contracts before signature. Paras. 3.17 to 3.19, and Annex 5 of the SAR outline the procurementprocedures, matrix of responsibilitiesfor the procurementprocesses and paymentof contracts, respectively.
12. Implementation Plan. There are three implementationphases in this subcomponent:
Phase 1. (July through October 1994) -- PCU will recruit a hospital planning specialist to
describe, inter alia, the (i) scope/rangeof medical servicesto be providedin the hospitalcomplex; (ii) the order of priorities and timing of the hospital upgrading investments;(iii) operationaland organizational restructuring which may be needed to deliver medical services efficiently, and (iv) projected staff development(and recruitment)needs. The functionalmaster plan would be accompaniedby a schematic architecturalplan of the hospital site layingout all facilities(buildings, utilities, approachesand circulation, etc.) and indicating the planned redistribution, integration, expansion and/or demolition of buildings necessaryin order to upgradethe complex. The functionalmaster plan would form the basis for preparing the detailed architecturaland engineeringplans and bid documentsfor the priority works and equipment to be financedunder the HSRP.
8 Cost estimatesof the priority works are based on detailed engineering assessmentsand of the existing buildingscarried out by TSDwith the assistanceof engineeringconsultants in 1993. Measurementswere taken of buildingstructural elements and utilitiesthat neededimmediate attention, and unit costs were appliedon thesequantities to arriveat the totalbudget for priorityworks. Allowancewas givento some consolidation/rearrangementof hospital servicesand utilities. The direct/indirectforeign exchangecost of civil works is estimatedat about 65 percentof total buildingcost. Professionalarchitectural/engineering services are estimatedat about 10 percent of civil works costs. Equipmentcosts were based on a list of critical hospital equipmentthat either need replacementor are not available in the existing complexes. - 53 -
ANNEX2 Page15 of 32 prepare the functionalmaster plans and site layouts of the two hospital complexesin collaborationwith TSD, DHosp, and the directors of the Shkoder and Vlore Regional Hospitals. IDA's comments/noobjections would be sought on the rehabilitationand upgrading priorities identified in the functionalmaster plans. Concurrently, TSD would prequalify and select two local architectural/engineeringfirms to prepare the detailed constructiondocuments for the priority rehabilitationworks. PCU will recruit an equipment specialist to prepare the detailed priority hospital equipmentrequirements of the two hospitals
Phase 2. (October 1994 through June 1995) -- Detailedplans and constructionbid documents based on priorities agreed with IDA would be prepared by qualified local engineeringfirms assistedby the hospital planning specialist. Specificationsfor the priority equipmentand bid documents would also be prepared. Buildingcontractors would be prequalifiedby TSD. Internationalbids would be invited after PCU has sought IDA's no objectionsto the final priority hospital rehabilitationplans, bid documentsand contractorshort list (for civil works).
Phase 3. (beginningJuly 1995) -- Tenders would be invited for civil works and equipment supply contracts. Contracts would be awarded following receipt of IDA's no objections. Constructionworks and delivery of equipmentsupply contracts would commenceduring this stage. Concurrently,DHosp would recruit specialiststo prepare the training programs on modem hospital operationalpractices for selected staff of the two hospitals and MOH. Candidatesfor external training in these areas would be selected. The training programs would be elaborated in consultationbetween DHosp and the MOH Personnel Department. The training plan would be forwardedto IDA for commentsand no objections. Staff training programs (local and external training) would take place during this phase.
A.3 Public Health Facilities Maintenance (US$ 0.14 million base cost)
13. Background. The large majority, if not all, of public health facilities in Albania are in a state of advance physical deteriorationdue to the chronic lack of financial resourcesto rehabilitate/upgradethe antiquated(and in some cases, vandalized)facilities, and the general lack of maintenance. There are heroic efforts by staff of PHCs and hospitals to clean the premises of the facilities, but these actions often fall far short, in terms of regularity, techniqueand determination, of what is necessaryto prolong the functionallife of the health infrastructure. Substantialinvestments to upgrade the quality of health facilitieswould quickly be wasted unless equal effort and commitment are invested by both MOH and local health administratorsto sustain the upkeep of the physical plant.
14. Scope. The HSRP would strengthencapacity in the health sector, in particular, within the TSD, to plan and implementan effectivepublic health facilities(buildings and equipment) maintenanceprogram. Buildingthis capacity would include: i) developingappropriate preventive and appliedmaintenance norms and procedures with due attention to environmentalconsiderations; and ii) developingcapacity to plan equipmentinvestments, particularly with respect to equipment standardization,spare parts management,and disseminationof technicalinformation to the health services network. For this subcomponent,the HSRP would financethe services of a hospital maintenancespecialist (3 person-months)to assist TSD to formulatea comprehensivemaintenance program, and train its staff in core practices. The Project would also financea study tour (2 person- months) for select MOH staff to observe hospital maintenancepractices abroad; training and demonstrationequipment and software; and the publicationand disseminationof maintenance manuals/instructionsto public health officers nationwide. -q 54 -
ANNEX 2 Page 15 of 32
prepare the functionalmaster plans and site layouts of the two hospitalcomplexes in collaborationwith TSD, DHosp, and the directors of the Shkoder and Vlore Regional Hospitals. IDA's comments/noobjections would be sought on the rehabilitationand upgrading priorities identifiedin the functionalmaster plans. Concurrently,TSD would prequalify and select two local architectural/engineeringfirms to prepare the detailed constructiondocuments for the priority rehabilitationworks. PCU will recruit an equipment specialistto prepare the detailed priority hospitalequipment requirements of the two hospitals
Phase 2. (October 1994 through June 1995) - Detailed plans and constructionbid documents based on priorities agreed with IDA would be prepared by qualified local engineeringfirms assistedby the hospital planning specialist. Specificationsfor the priority equipmentand bid documentswould also be prepared. Building contractorswould be prequalifiedby TSD. Internationalbids would be invited after PCU has sought IDA's no objectionsto the final priority hospital rehabilitationplans, bid documentsand contractor short list (for civil works).
Phase 3. (beginningJuly 1995) - Tenders would be invited for civil works and equipment supply contracts. Contracts would be awarded following receipt of IDA's no objections. Constructionworks and delivery of equipmentsupply contractswould commenceduring this stage. Concurrently,DHosp would recruit specialiststo prepare the training programs on modem hospital operationalpractices for selected staff of the two hospitals and MOH. Candidatesfor external training in these areas would be selected. The training programs would be elaborated in consultationbetween DHosp and the MOH Personnel Department. The training plan would be forwardedto IDA for commentsand no objections. Staff training programs (local and external training) would take place during this phase.
A.3 Public Health Facilities Maintenance (US$ 0.1 million base cost)
13. Background. The large majority, if not all, of public health facilities in Albania are in a state of advancephysical deteriorationdue to the chronic lack of financial resources to rehabilitate/upgradethe antiquated(and in some cases, vandalized)facilities, and the general lack of maintenance. There are heroic efforts by staff of PHCs and hospitals to clean the premises of the facilities, but these actions often fall far short, in terms of regularity, techniqueand determination,of what is necessaryto prolong the functionallife of the health infrastructure. Substantialinvestments to upgrade the qualityof health facilities would quickly be wastedunless equal effort and commitment are investedby both MOH and local health administratorsto sustain the upkeep of the physical plant.
14. Scope. The HSRP would strengthen capacityin the health sector, in particular, within the TSD, to plan and implementan effective public health facilities (buildingsand equipment) maintenanceprogram. Buildingthis capacitywould include: i) developingappropriate preventive and appliedmaintenance norms and procedures with due attention to environmentalconsiderations; and ii) developingcapacity to plan equipmentinvestments, particularly with respect to equipment standardization,spare parts management,and disseminationof technicalinformation to the health services network. For this subcomponent,the HSRP would financethe services of a hospital maintenancespecialist (3 person-months)to assist TSD to formulate a comprehensivemaintenance program, and train its staff in core practices. The Project would also finance a study tour (2 person- months) for select MOH staff to observe hospital maintenancepractices abroad; training and demonstrationequipment and software; and the publicationand disseminationof maintenance manuals/instructionsto public health officers nationwide. - 55 -
ANNEX2 Page16 of 32
15. Implementation Responsibility and Operatdonal Plan. The TSD would be responsiblefor managingthe nationalprogram and for assisting/trainingdistrict personnel in maintenanceplanning, practices and budgeting. TSD will collaboratewith the District Health Officers and the Shkoder and Vlore Hospitals, in organizingthe maintenancetraining and demonstrationprograms. Implementation of this program would begin in 1995 with the recruitmentof a maintenancespecialist by PCU. The draft maintenanceprogram would be discussed with IDA. Meanwhile,candidates for external training would be selected and fielded for training. On return of the trainees, TSD will begin implementation of the program in the pilot districts. TABLE F: Fadlities Rehabilitation Implementation Plan
__ Pct^tY _ _ _ _~~~119414 _I 1 l99 I 1996 ---- ''ll1 191 119
tg.mHea do Co--WM"" - 111 - - -11H11-t 111-1111 t 11111111111
Wm1B;g1:}1J1{f1[S dm~~~~ol
I _... _ ...... I II 1-6 0I IIIIIlIlIlI__1__III 1 :
-LA~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~' Ll~~~~~~~~6 I1IIIlII_Y...... Ye 21 ya_Yo :__IIIIa Y 5 _ lI hhl>ue_lr_W______tttAcItivity 1941 11 1 1-1 1 199 1 199 _I 197TI I I1198 IX|W04~~~~~ FnnA MJ AS0OJIF~ ~~~ AMJJAsoNr ~ i FIAA M111-1 JI A1111111S111 NI I IIIJiAS OJIMAMJJASOND1 MII gterA"FLT SEVIE 4 tttHA010241ITAT-1 1X§ -lc-.-uf.f Pk H.eC-w -Gdd- d-d.% >1 llElSlllli q-wa0- -F,jv- _N 111-1 X 1 lllllllB l, Ci -" IWk1sI| W [R lftlth Sfit .6 FM6-i . _ _1 llz 1 lzlIlllll IIIIIZ§l11Xn 1
F,p-~~~~~~~~~~~~~F- f t C ll_1 0||}}§}0{§§0+3 1*A .. 0._ %WFW l l__1IlNIIIIIII IIIIIII1 Fwii111*llllllII___11Ill1IILL ,,,,,{
PMb^IIIII.+i i* I H IIIIIIIIIII q CIVM~~~~~~ IV r-_ l ML:§I |X_1kii §||0III 00% kI III WAM I , , , ii&t8i J I IIIIIIII|I1
C-gd"p111 _ _1111 #-1dIIIIIIIl 111Iiill 1 1.mt I-----: ___1111aa_11I- t- e A12 t t t lklltllllMnIjlI_ll X 111111-1111111f1111111,1IIIII11"l!I141~~~~~~~~~~~~~~~~~U 1% Pm._._ _ 1111.I W%. _ 11* ____1 i _XLll 1bl1l_llIiinuoiiilllT Ao-4f--.----"-.f&L W,v-,d1121- 1X-_i.. 111 t llllllllllllllllel~tl owwok. I1111II101 S1t11m iS S E
_d..dIdm_4~~~~~~~~~~~~~~~~~~~~o TABLE F: FacilitiesRehabilitation Impleinentation Plan
PCowlWr_n-A ...... ty....rect I IIIIIIIIIIIIIIIIIIIII11199 1 1 1 11 1199
"A -~. 111110 ------+ ll:llllllIIIIIT II
Ic__i-_"o 11111r------s-qllllllr n nFosnel_ IIIiL r l111|I11 R.k.-Oubllllllnllllll_=Illl lp.Wo' W-* T *-Iil t tE3E M S IUiiiilllliiill |m"Prt-i _ T- ~ a L__ Itowatililli E S E 1II§IIiI§§iIIII4I4§}44s§IIIIi§084t^t~~~I 1°-t--*- I I I I I @------__ I I __ _ _ L _ _ _ I I l l _X | | | j X X X s l Z l t rl s | | I | | | | ! | 1 1 1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ , H.I.IPk1diI!1!gQi:20t
""e . f 2o I I{ { 1Mti gEonX 0 ft_-z.1111 ------X 111141111141--1 - 59 -
ANNEX 2 Page 20 of 32
Table G: Output Indicators for Facilities Rehabilitation
Component/Activity Output Target Revised Completion Target Rehabilitationof PHC 1. Rehabilitationand End second Facilities furnishing of 27 PHCs project year
2. Rehabilitationand End third furnishing of 31 PHCs project year
3. Rehabilitationand End fourth furnishingof 29 PHCs project year
4. Rehabilitationand End fifth furnishing of 13 PHCs project year Rehabilitationof 1. Shkoder and Vlore 6 months RegionalHospitals functionalmaster plans after start-up completed
2. Hospital equipmentbid 6 months documentscompleted after start-up
3. Constructionbid documents completed 1st semester of Year 2 4. Constructionbids awarded 4th quarter of Year 2 5. Hospital rehabilitation completedand equipment 4th quarter installed of Year 4
Hospital staff trained Year 3 Facilities Maintenance 1. Equipment maintenance End first Program program designed project year
2. Maintenancetraining Coterminous completedin project PHCs with PHC completion
3. Maintenancetraining for Completed .______regional hospitals in Year 3 - 60 -
ANNEX 2 Page 21 of 32
Component B: Capacity Building
First Year Implementation Plan--Capacity Building
16. Given that the Health Services Rehabilitation Project is the first IDA project in a recently-established Ministry of Health, it will be a formidable challenge to the implementation capacity of the line departments. This is particularly true in the area of capacity building, the benefits of which are less immediate and tangible than those of the rehabilitation and reequipping of facilities described above. It was viewed by the MOH and IDA during project appraisal as particularly important to carefully assign implementation responsibilities, establish timetables for completion of project activities and underscore the need for accountability in project implementation. The following matrix of activities and implementation responsibilities was prepared during appraisal as a tool to facilitate the capacity building components during the first year of project execution. They focus only on the early stages of project implementation to emphasize an orderly progression of activities, and avoid overloading the administrative capacity of the PCU and other implementing units. More detailed matrices for later project years are being developed as part of the Project Operational Manual. llhbh H: MATh OF IMZMTATION NSEMMES AND STAPMG
0 -I I Ma _ f Baue Healt Servkes
1. Dma Tal Vbkb d B Dr. SUlumd Comdpad
2. Approve Tet ViJD.pL He11_ Drs. Siai_d & Hlio CaMyed
3. Saed A_N uim V_*4 Dp PUAN NmI Dr. Sianoud A NMuDs Cazyded CA4im of NqedYim
4 Sem 4 *ai I Dt. HMel PCU Dr. Hado&&r.§Wh C bmpkuedfat 2 U_u 2 of 4 _UWinaL . EqgImm f_ I yr IDSph, 1993 S. Follw upas2 umu vho DgVL lie" PCU Dr.H .Hoft k Oclu, 1994 comupleesido2 inowA teai.4
6. CalmS dz m FHC fr UI m he_i_mIDqIL PR Dr. Niro Dmber, 1994
7. Piqie. dl BMWIh heeib/Dqe pH Dr. Marilo Fewraymq ud, 1995
3. Selue tzua *fh w Pe ci Ha* IbW*A DepL PR Dr. Mawori.cb, 1993
9. FP& Phaw Tairg H" B PR Dr. HMi.o May, 1995, _=y, 1997
10. hepaw U PIs Da b omum Dr. ShsiIdr. Nod Dederw, 1994- J_ 1995 Ml
11. Sl -_ Pds 1MW _0ub&= Dr. SImalmIDr. Nl I1996, Ww 197
12. FUdugaglsm-o w.S_9 . Pdb Dr. SlhfafmDr. Nd Si 1995,FP 19"5 4 13. _OH Pdb aub daM Dr. SimolIDi. No _i 1996 B te1.pnao pmudW by uieds o _aeed Table H MAIThX OF BDMIZME4TION RUI t ONlllLrh11 AND &AFMM
IS-pe DocLo Rd Cm__
1. Rdk N_A.IW PW_= DOpewi MmdL i,. Al* vA D. UMd. CubLam C_im _dbm he 2.mby, Dpep. ( HF-b Dr- Ka6b. C_Z_ 3
2. _qono =-smi_- a-__Fodl Dr. UKDr K* . oib 2. V m 1mdmpDr. am W. Kr C=Xd
-F_fto -&*d * o 'a MW d _y+_W hFb. Dw y pupD_ TA-hM19
S.|_miS.P F_Db_umu E.IJf _.0--i C, d"4y1*,bU -d rk~m t 1 doN Idudt bfiiMiaMdli Fmsdiy Pu.. " Dr. Ken, WrMqid D..smur.
7. Pmumc. *au-d ^ - __IF_QJ I .Wi .__ ~~~~~~~~~~~~~~~~~~~~~1994 .*I.g_ Me" Fmmb, p Dr. kaiim.Dr.Ab D.mi.
S. E -ff pmubIFa* M y Pum Dr. Kmnm,Dr. Al Dooemb-. Ds_mW 19'"4 9. Daub. at pip.n imdaSd bbaci Pum, a Dr. MS.k Dir. A%L Dr. 1 1995 ~- fSW R 4l Dupe. Zjii Dr. Kri
10. Ric_dm of _ MmIi mInby Dr. IT Puj YI 243 Table H: MATRIX OF IMPLEENTATION RESPONSIBILITIES AND STAFFING
Component: Spedacst Nurses Retraiig Component
_Ativit Agenc Responsible xan blo . F
1. Cotact 'Bon Secours" School to arrange Human R urce Dept./ Dr. Alqi with Dr. Koa Completd extension of technical support Nursing ScDool
2. Prepe equipment needs for in-service Nursing School Dr. Koka Completed training progm
3. Identify training facilities, materials nd Human Resources Dr. Alqi, Mr. Mborja Completed equipment to allow expansion of in-service Department training activities
4. Develop selection criteria and select Nursing School Dr. Koka Completed "nure trainers' from among hospital staff nurses
5. Procurementand delivery of podagogic Project CoordinationUnit Mr. Shehu January, 1995 and office equipment to the nursing school
6. Prepare nursing and maagement Nursing School Dr. Koka January, 1995 The World Bank may be asked to trining of trainer courses underwritethese ctivities
7. Review training of triner ppols Nursing School with the Dr. Koka with Dr. Alqi Febnuiry, 1995 Peronsel Dept.
8. Engage experts to train the trainers Nursing School/PCU Dr. Kokl/Mr. Shehu June, 1995
9. Execution of retraining program Nursing School Dr. Koka Project Yrs. 1- 4 5 Table H: MATREXOF IMPLEMKATION RESPONSIBILITIES AND STAFFING
Subcomponent: Health Planning and Financing
AMMIVRavosible - Mara r Roa ble D n
Enoll two cdidas for astm-te Depaitmeit of PubLicHeafth Dr. Harito Coapltd fsflowiiipa in bealh pl ud (DPan
EnroU 2 candidates for lonh-term Depa_mea of PubLicHealth Dr. Harito Conapeted London School of &eWwhip in healh pinaqg and (DPH) Hygine&h1M mapmgeient. Boe School of Public Reamt Enoll first candidate for long-mm Depanment of Economics Mr. Kadiu Coapleted London School of Hygiene fellowship in health economics. (DEcon) and Tropical Medicinc
Fmclizeeterms of referme for Proect Coordination Unit Mr. Kadiu with Mr. Conyieted Fnancial Plnning Conmktant (FPC). (PCUl) and DEcon Shehu
Recruit Fuanci PbnningCotPat. PCU and DEcon Mr. Kadiu with Mr. NovJDcc., 1994 Shehu
Appoiut second candidate for Depatment of Economics Mr. Kadiu Jamry, 1995 felovwhip in health economics as (DEcon) nationsl counterpart to FPC
Orgaiz MCH Progm Developmeit D nment of PublicHealth Dr. Harito Proect Yar I Wodbhop (DPH)
b- t4> Table H: MATREXOF IMPLEMENTATION RESPONSIBILITIES AND STAFFING
Subcomponent: Health Planning and Financing (continued)
Azitz Azenc Reonrible Manager Remoonible Comol6tion Date
Prepare anIna budget submiinion and Department of Economics Mr. Kcdiu, Mr. Haxhi November 1994 (and rolling three-year pubic inve6ment each .baequett year) program
Procure equipment Project Coordination Unit Mr. Shehu P"ject year I (PCU))
Lii
Enroll second candidate for long-term Departmnnt of Public Health Dr. Harito Prject year 2 fellowahip in health panning and mnnagement.
Enroll scond candidate for long-term Dcpartment of Economics Mr. Kxdiu Project year 2 fellwship in health economics. Table H: MATRIX OF MPLEMEINTATIONRESPONSIBLITI AND STAFFING
Component: Drug Policy and Distribution
DMr Pricing and Reinbuemenat Study
Clear terms of refereace Dept. of Pharmcy and Dr. Saliaei with Mr. Complted (TOrS) Vn prepre db Dept. of Economices Kadiu list
Launch tenders Project Coordination Mr. Shehu October, 1994 Unit Evaluate consultants' bidc aEd awarteconatsc PCU, DPharm, DEcon Mr. Shchu with Dr. November, 1994 Salicsi andMr. Kadiu
OrPil-in opHIZg traig DPharm and DEcon Technical working group November/Dec, 1994 Technical working group: session in MOH M.Gyi Mr. Gjyli, Ms.s Lugau Collhbornte with/facilitate (DPharm); Ms. Cico work of con/u litatS DPharm and DEcon Technical working group JaInuary, 1995 (DEcon), MOF representative Review draft repolt and prepare writtena omtnd DPharm and DEcon Dr. Saliasi with Mr. Februay, 1995 Kadiu, tech working grp Organiize discussion session Or draft repont DPharm and DEeon Technical working group February, 1995
Draft implmetrtion plan fr atudyreomntatn for tionrawdy reconumndatiomDPharm and DEcon ~~~~~KadiuDr. Saliasi and Mr. March, 1995
Select candidates for bort term fellowships in gitis DPhrm Dr. Slii Project yaemr1 finanial mangeme_ and drug pricing and procurement policy
Inylmekt drug pricing policy and reimbuwme-nt mechanism for aid Darm and DEon Dr. Sahasa a Mr. Prc years l-S drugs K*diu
Impmemet procrensu and ditribution O activities Pt sctor btch |uppli. DPhalm Dr. Saliao| Pojec yea 2-5 - 67 -
ANNEX2 Page28 of 32
Monitoring and Evaluation--Capacity Building
17. Three types of indicators would be used to monitor and evaluate the capacity building componentsof the project: (a) input indicatorsto measure whether capacity building inputs such as technical assistance, equipment, and staff training are delivered on time, in the right quantity and quality; (b) output indicatorsto measure whether and to what extent services or products to be delivered such as training programs and studies are actually delivered; and (c) outcome indicatorsto measure the effectivenessof the services and products delivered and the extent to which project objectives are actually attained.
18. The detailed project cost tables in Annex 3 of this SAR list project inputs in the amounts and timing proposed for project implementation;these tables would form the basis for monitoringthe flow of project capacitybuilding inputs. Quality of project inputs would be measured against specifications for services or goods to be delivered as indicated in procurement and service contracts. Capacity building outputs and outcomes and the criteria with which to measure their achievementare set out below. Table I: Output Indicators for Capacity Building
, Component/Activity Output Target Revised Completion . ______j|__ Target Managementof Basic 1. First series of general End second Health Services training seminars in health project year managementcompleted for 160 staff
2. First series of modular End third training seminars for project year specific management disciplinescompleted for 46 staff End fourth project year 3. Secondseries of modular training seminars for specific management disciplinescompleted for 46 End second staff project year
4. Pedagogic seminars completed - 68 - ANNEX 2 Page29 of 32
PhysiciansRetraining 1. Needs assessment 6 months completed after start - up
2. Equipment Delivered End first project year
3. Number of training Three programs completedper year Nurses Retraining 1. Equipment Delivered End first project year
2. Number of training Two programs completedper year Health Policy and 1. External fellowships Planning completed:
2 health planning Board approval
1 health planning End first 1 health economics project year End second 1 health planning project year 1 health economics January 1995 2. Drug Pricing and ReimbursementStudy completed November 30 of each 3. Preparationof annual project year rolling three-year public investmentprogram and standardizedannual budget Midterm submission project review 4. Staffing survey and recommendedstaffing plan June 1995 completed
5. Seminar on MCH program development, developmentof supply list for Primary Care Fund - 69 -
ANNEX2 Page 30 of 32 Outcome indicators
19. Outcomeindicators would assess whetherthe developmentobjectives of the project have been met. The key objective of the project is to help prevent deteriorationin health status during the economic transitionby improvingthe quality of basic preventiveand curative health services. For this reason, it was decidedthat outcome indicatorsshould focus on the evolutionof health status and the utilizationof health services (as a demand-side indicator of quality of care) in each of the six pilot districts, as comparedto the national average. The ability to assess the impact of project activities is hamperedby two factors: i) limited availabilityof reliable baseline and subsequentdata; and ii) the impossibiity of isolatingproject effects from exogenousfactors (e.g. economicgrowth) at the national and district level which impact on health status and utilization of health services. In addition, it is not possible to disaggregate the relative importance of improvements in physical infrastructure (rehabilitation) and improvementsin health system managementresulting from capacity-buildingactivities. Nonetheless, a limitednumber of indicatorshave been selected to assess the overall impact of the project in the pilot districts, based on the existinghealth informationsystem in Albania. These indicatorsare listed below, and would be tracked throughoutthe project implementationperiod as follows (separatetables would be prepared for each district and for the nation as a whole, as outlined in the Project OperationalManual):
Table J: Outcome Indicators
District 1993 1994 1995 1996 1997 1998 1999 Health Status
infant mortality rate | ___
under-five mortality rate n| atermalmofality rate= _ _ = = = _
Utilization of Health Services ======
TotalPHC conitatioA
PHC conultations per capita = = __ = =_
Total frstt-ime PHC visits
imnmunizationcoverage rates:
DPr polio umesles Table K. Summaryof TechnicalAssistance
1 ..... e..ti.&.evie . a.ae . . . 2 34...... l. TVTk 1. Health Services Rehabilitation
A. FacilitiesRehabilitation HospitalPlanner #1 3 2 1 1 7 Implementation EquipmentSpecialist #2 2 1 1 1 5 Implementation Arch/Engineering Services:Skodra #3 lumpsum Implementation Arch/Engineering Services:Vlora #4 lumpsum Implementation ConstructionSupervision Individuals as needed Implementation
B. FacilitiesMaintenance MaintenancePlan #5 3 3 Implementation
0 II. Capacity Building
A. Managementof Basic District Management #6 4 2 7 4 17 CapacityBuilding Health Services Training ManagementWorkshops * LocalTraining
Long -Term Fellowship 3 12 6 21 ExternalTraining Short -Term Fellowships 3 15 18 ExternalTraining
ModularTraining Seminars * LocalTraining
B. Doctors Retraining RetrainingFund Seminars * * * LocalTraining Table K. Summary of Technical Assistance (cont.)
~~~...... 4rbro.. . t~ot~
11.Capacity Building (continued)
C. Helth Planningand HealthPolky & Planning 17 3 7 6 3 19 CapactyBuilding Poky: FRnan MCi ProgramWorkshop * 11111 CapactyBuilding MCHSeminars * LocalTraini
Long-Term Fellowships Planning 12 12 24 ExternalTraining Finance 12 12 24 ExtenalTrainn Short-Term Felovwships 4 4 Exte Training StudyTours/Training * Training
D. HealthPlanni and DrugPrcing Study J8 9 8 5 3 25 CpacwyBuilding Poky: DrugPoliy 0 CapacityBuilding DrugPolicy Sem s * * Loc Trainn
E. Proet Coordnation ProjectAdvisor *9 4 4 2 1 11 Implementation PCUTechnical Staff 12 24 12 6 4 58 Impementation Short-TermFellowships 2 3 5 ExternalTraining Auditor 110 1 1 1 1 1 ...... E...
L~~C*~mIcalAsaIutMC1~~24 12 8 4 58.I ExtematTralntng999 SS t~~~~~~00 06 - 72 -
ANNEX 3: DETAILED COST TABLES Health Services Rehabilitation Expenditure Accounts by Components - Totals Including Contingencies (US$ '000)
Capacity Building Health Services Rehabilitation Management Primary Health of Basic Retraining Health Health Regional Facilities Health Hospital Policy and Project Centers Hospitals Maintenance Services Staff Planning Coordination Total I. Investment Costs - 3,854.9 A. Civil Works - Hospitals - 3,854.9 - - - - - 3,159.7 B. Civil Works - Health Centers 3,159.7 ------46.2 C. Civil Works - Other facilities - - - - 46.2 - D. Equipment,Vehicles and Spares 94.4 3,054.4 34.1 55.5 327.5 57.7 120.0 3,743.6 - 271.5 E. Fumiture 271.5 ------462.9 F. Architectural & Engineering Fees 179.0 283.9 - - - - 1,366.0 G. SpecialistServices - 287.5 49.0 246.5 - 426.8 356.2 393.5 H. Extemal Training - - - 152.2 - 198.8 42.5 - 1,049.4 I. Local Training - - 52.7 121.6 552.1 322.9 J. Materialsand Supplies 43.0 - 17.1 23.2 38.3 394.1 - 515.8 Total Investment Costs 3,747.6 7,480.7 153.0 598.9 964.1 1,400.3 518.7 14,863.4 II. Recurrent Costs A. Staff Salaries ------40.7 40.7 B. Vehicle 0 & M ------21.7 847.5 C. Equipment 0 & M - 719.1 - - 64.0 42.7 - 253.0 D. Building 0 & M 102.6 150.4 - - - - 1,141.2 Total Recurrent Costs 102.6 869.5 - - 64.0 42.7 62.4 Total PROJECTCOSTS 3,850.1 8,350.2 153.0 598.9 1,028.1 1,443.1 581.1 16,004.6
Taxes 230.3 384.4 2.6 3.0 2.8 53.3 - 676.4 Foreign Exchange 1,302.4 5,448.3 96.1 471.4 636.9 1,107.4 475.9 9,538.4
>E HealthServices Rehabilitaton ExpenditureAccounts Breakdown
Baw Cast ysk d Cndingaemes Ple Cofltogncles Toeb Incl. Cont O_Casb Pikl LeeMd Loced Local Locdl * Prkes Cas, ma lEad. Dwo*. & PW. (Exa Ddl" & For. (Kul. D xe£ (ExaL Duld*. Caste a Physicl PFo.Exch. Taxsl Taxs Tabtl Exch. Taxes) Taxes Total Exch. TaxesI Tax.s Totl Foe. Exch. Taxc") Taxes ToeAl Ba. L lwstnas C_ts Coss COOL AClvUWeaf.t 1qompkat 1.8700 1,219.9 197.6 3,287.5 187.0 122.0 19.8 328.8 B CwIWorksl 129.5 946 14.3 238.6 2,188.5 1,436.8 231.7 3,854.9 3,504.4 -HMO a,ds 845.7 1,659.9 159-9 2,l66.5 84.6 166.0 350.4 16.0 266.6 68.7 147.2 13.7 227.5 997.0 1,973.0 189.6 C. CivlWor-O9rhetlh - 38.9 2.5 41.4 3,159.7 2,872.4 267.2 - 3.9 0.2 41 - 06 0.0 0.6 - 43.4 0.E iip7 V hd4chSaVW eSp 3271.1 103.6 145.0 3,519.7 28 46.2 42.0 4.2 114.5 2.3 3.5 1203 98.4 1.0 42 103.6 3,483.9 EFurn*m 1187 76.4 34.4 106.9 152.7 3,743.6 3,617.9 125.7 229.6 11.9 7.6 3.4 230 9.4 68 2.8 19.0 F. ech al& Engki gFew 164.2 252.0 139.9 90.9 40.7 271.5 246.8 24.7 416.2 9.6 17.8 27.4 6.3 13.0 - 192 G.S p.ei.San4eas 1,219.8 180.1 282.8 462.9 434.2 28.7 33.1 - 1,252.9 61.0 1.7 - 62. 48.0 2.5 H E Tni,n 361.5 - 50. 1,329.7 37.3 - 1.3660 1,301.0 65.0 361.5 18.1 . - 18.1 14.0 LLoDClTrlnlg - 14.0 393.5 * - 3935 374.6 18.7 326.1 580.6 - 906.7 326 58.1 - 907 17.0 J. Mtlswid aSuppbs 35.0 52.0 375.7 673.7 - 1,049.4 954.0 95.4 3913 3.3 498 444.4 33.7 0.3 50 39.0 26.1 Tota l h _vshntCos 0.2 41 32.3 4530 3.8 589 5159 4740 41.8 8,568.3 3,967.9 589.3 13,125.5 5629 379.7 47.9 9805 417.2 301.0 39.2 757.4 9,538.4 4,648.6 676.4 14,863.4 13,821.5 1,041.9 A SoaE s5_ - - - * - - IL VhidcO& M 34.5 - 34.5 - 3.5 3.5 2.7 C.Eq*nwt40& M 2.7 40.7 40.7 37.0 3.7 703.3 703.3 70.3 - 70.3 O. 73.9 739 . 847.5 - 8475 770.5 EBad.O M -& 20 207.86 208 77.0 TotWRoeiusnt 208 244 24.4 12510 C.sla 945.6 . 945.6 253.0 230.0 230 > - 94.6 . 94.6 . 101.1 ¶01.1 TeXd 8,568.3 i-1,41.2 - 1,141.2 1,037.5 103.7 4,913.5 589.3 14.071.1 5629 474.2 47.9 1,075.1 417.2 402.1 39.2 958.4 9,538.4 5,789.8 676.4 16,0046 1459.0 1,145.7
O ZC
qp Health Services Rehabilitation Expenditure Accounts by Years -- Base Costs (USS'000)
Base Cost Foreign Exchange 94/95 95/96 96/97 97/98 98/99 Total % Amount I. Investment Costs A CMI Works - Hospitals - 986.3 1,440.7 860.6 - 3,287.5 56.9 1,870.0 B. Civil Works - HeaKhCenters - 693.0 853.0 773.0 346.5 2,665.5 31.7 845.7 C. Civil Works - Other facilities 41.4 - - - - 41.4 - - D. Equipment,Vehicles and Spares 340.6 1,667.0 1,126.8 374.3 10.9 3,519.7 92.9 3,271.1 E. Furniture - 59.7 73.5 66.6 29.8 229.6 51.7 118.7 F. Architectural& EngineeringFees 191.4 90.2 65.6 52.5 16.5 416.2 39.4 164.2 G. SpecialistServices 568.6 292.6 242.1 122.9 26.6 1,252.9 97.4 1,219.8 H. ExternalTraining 155.5 122.0 31.5 52.5 - 361.5 100.0 361.5 I. LocalTraining 130.2 379.5 303.4 93.6 - 906.7 36.0 326.1 J. Materialsand Supplies 51.4 115.3 103.7 93.6 80.5 444.4 88.0 391.3 Total Investment Costs 1,479.2 4,405.7 4,240.2 2,489.5 510.9 13,125.5 65.3 8,568.3 II. Recurrent Costs A. Staff Salaries ------B. Vehicle0 & M 6.9 6.9 6.9 6.9 6.9 34.5 - - C. EquipmentO & M 12.0 74.5 181.8 218.8 216.3 703.3 - - D. Building 0 & M - 6.9 38.8 76.4 85.8 207.8 - - Total Recurrent Costs 18.9 88.3 227.5 302.0 309.0 945.6 - Total BASELINECOSTS 1,498.0 4,494.0 4,467.7 2,791.5 819.9 14,071.1 60.9 8,568.3 PhysicalContingencies 95.7 313.9 336.3 249.5 79.7 1,075.1 51.4 552.9 Price Contingencies Inflation Local 4.1 64.0 134.7 152.6 85.8 441.3 - - Foreign 16.2 95.9 137.7 138.1 29.3 417.2 100.0 417.2 Subtotal Inflation 20.4 159.9 272.4 290.7 115.1 858.4 48.6 417.2 Devaluation ------SubtotalPrice Contingencies 20.4 159.9 272.4 290.7 115.1 858.4 48.6 417.2 Total PROJECTCOSTS 1,614.1 4,967.7 5,076.4 3,331.7 1,014.6 16,004.6 59.6 9,538.4
Taxes 3.2 217.1 246.0 164.9 45.1 676.4 - - ForeignExchange 1,314.4 3,307.6 2,971.6 1,666.9 278.0 9,538.4 - - 4 w HealthServices Rehabilitation HealthCenters Rehabiliton D_Sft C_f
amUUom Ur* Raw cos U1. Om am Si? of Om TW Cost 54U 9mU 17 711 S Tobi L vs.iMd C_ed A. PAkb.bUnte of ksU CaMbom 1. VbomP#Wwy H. Ci cows 26 32 29 13 100 - 1380 1699 1540 69.0 5309 2 Sinxd Plkw,my I Creum1w c on i'd 26 32 29 13 100 67s 108.0 97,9 43.9 337.6 3.utPukin y H*M CwOu axWhidnhl 26 32 29 13 100 - 86.6 1066 96.6 43.3 333.1 4. Ssdcw FPI -y Hudh C**m oonWlob lsb 26 32 29 13 100 188.8 232.3 210.5 94.4 726.0 s. Puk H & am a % 26 32 29 13 100 1216 149.7 136.6 60.8 467.8 6. M_eMmPuFb,inyHud w*m l % 26 32 29 13 100 70.3 86.5 78.4 35.1 270.2 8ubbi ft.hmd.u o Hamm Combus - 693.0 6530 77 346.5 2,66.5 IL Pwaulur #r PHOB 1. VkmPIkYy HIICw4U a I 26 32 29 13 1O0 13.3 10.4 14.9 6.7 61.3 21 Smmt Pbl yH W CuUu %ab 26 32 29 13 100 7.7 9.5 6.6 3.8 2s.6 3. DCW A*w_y HshMM C rucs C0.0sum % 26 32 29 13 100 6-. 7.3 6. 3.0 22.9 4.SNudr Rknwy HIdth wCuM %& 26 32 29 13 100 16.1 19.6 17.9 6.0 61.9 5. Pula PuMy IMw CbIus Fq2llnUs 26 32 29 13 100 - 10.0 12.3 11.2 5.0 38.5 6. Mds MfdhinPAF Huiny Chuw 001.plbvW% 26 32 2D 13 100 6.0 8A. 7.4 3.3 25.4 8.Ma_ F _ruim- PHC. - 59.7 73.5 8e.6 29z. 229.6 C~ E__eX" fr ric 1. VF_ Psvn Ho ceuau khw S= 4.7 5.8 5.3 2.4 18.2 2. A w PM H=m e -mn hip 2Z7 3.3 3.0 1.3 10.4 3..MwPVI -- VH=M Cwem bmw a 2.0 z5 2.3 1.0 7.9 4 SPh_dw F% my HdM -,p ban mar" 6.3 7.7 7.0 3.1 24.2 1 5. Puke PubW HMOb Cetam b mnm - 3.4 4.1 3.8 1.7 12.9 6. MaIa * Mmii. Puiwy Io Clm n - 2.7 3.3 3.0 1.3 10.3 _8 EgM _ forb - 21.6 *J.8 24.3 10.9 83.9 0. P"IC Ue_ Suppl 1. Vbp Pjuw Hha ("w kxm - 2.2 2.7 Z4 1.1 6.4 2.Sw PbPuwy lb" Owmu kwp m - 1.2 1.5 1.3 0.8 4.A 3 C* RPbiuy4mMh OCuVa w ma- 0.9 1.1 1.0 0.6 3.5 4, SNo Plh_ uu_ Ceue bm - 3.0 3.6 3.3 1.5 11.4 5. Puke Pwb,-- IHm Cuim.h kwwma - 1.5 1.6 1.6 0.7 5.6 6._ de & dhmPtkn.yab iCsru kpumW - 1.2 1.5 1.4 0.6 4.7 Soba PHO Micd Supp4e - 9.9 12.2 11 1 5.0 38.2 E _ 'N--'Bg_ _ h wk 1. DA DOign & _hubq I %o 10 100 528 26.4 19.8 19.8 13.2 131.9 2. c uu sa i n 100 - - - - 100 O.092 6.6 6.6 6.6 3.3 23.2 TOW husmo Ceob s52 617.5 991.9 90o.4 408.7 3,172.3 A.lemWAdg Coblao
1. VU PHC mog OWM wVY 0.5 2.6 5.9 7.7 16.7 2- Sww PHC Buuii OU -u 0.3 1.7 3.7 4.9 10.6 3. Dd* PHC SLw OL ww°j - 0.3 1.6 3.7 4.9 10.5 t 4 Sh,dw PgH-CBL OiL wvw - 0.7 3.6 6.0 10.6 22.9L s. Pile PHC BC q COILM evo 0.5 2.3 5.2 6.6 14.8 CD 6. Mm" PHC bI OIM WVKM - 0.3 1.3 3.0 3.9 6.5 4
ToedsTl 52.652nG.8h- 620.120. 1,005.013.1 930.629.4 447.638.9 3,256.4_64.14 HeaKthServices Rehabilitation HospitalRehabliafon Detalbd Costa
Quantle una Bne Cost Unit 94196 96f 97 S7198 989 Total Cod 94196 9619 97 37n3 9819 Totl btwsbe Cost A. Cill Weds 1. Shkoder Hisplbl Rablitation compAon V 30 40 30 100 - 609.2 812.2 609.2 2,030.5 2.VbrelHIa Rehabiitation conwlto%a 30 50 20 100 - 377.1 6285 251.4 1,257.0 subtl CiNil Wad 986.3 1,440.7 860.6 3,287.5 I Atchlbctua & Engnung Fes 1. Slhoder Hoapal DiadEnlndhErlng cmplti%s 50 30 10 10 100 86.7 32.3 24.2 16.1 - 161.3 2 Vbm Hopibl Dald d En&etrg coain%s 50 30 10 10 100 49.9 25.0 15.0 10.0 99 8 Sublotal Archltacl & Englneed Fee 138.6 57.2 39.2 26.1 261.1 C. TechnIcal Atance 1. HopialP rnwr usallmonth 3 3 1 1 8 24 72.0 72.0 24.0 24.0 - 192.0 2. EqpmertSpeaclalit dalflOh 2 1 0.5 0.5 - 4 18 36.0 18.0 9.0 9.0 - 72.0 Subtotal Technical Assistnce 108.0 90.0 33.0 33.0 - 264.0 0. Hosptal Medkl Equipnwm 1. Stdbr H l Eqipwmr comwption V. 50 25 25 100 - 500 0 250.0 250.0 1,000.0 Z Shkder Prity Hpitl Eqipnert h conmpleon V 50 50 100 450.0 450.0 - - 900.0 3. Viom Hospital Equipment cmpletbon V 50 25 25 100 - 200.0 100.0 100.0 - 400.0 4. VoaPrrf HDomEquptoentb f domplton% 50 50 100 - 3000 300.0 600.0 Subtotal Hosplal Micdkl Equipment 1,450.0 1,0 0 350.0 2 900.0 Totalnvesbnnt Costs 246.6 2,583.5 2.612.9 1,269.7 - 6,712.6 L Racurre* Costa A. Buildig Maienane Shld Hospir Ei O&U annu - 2.6 14.2 29.0 29.0 74.8 Vlore Hpa Budn O&M uil 1.6 11.5 17.9 17.9 49.0 Sublotl uliding Maintennce - 4.2 25.7 46.9 46.9 123.7 L H_ospa Equipmen 0M ShkDdr EqpLert OLM-1 annu- 16.1 36.2 64.4 64.4 181.1 Shider Equipment OLU-2 uwi - 15.8 63.0 63.0 63.0 204.8 Vlo' Equipment O&U-1 aua - 6.4 14.5 25.8 25.8 72.5 Vbr Equmenlt O&M-2 10.54nual 42.0 42.0 42.0 136.5 Totl Pat ure Costs 53.0 181.4 242.1 242.1 718.6 Toal, 246.6 2,636.5 2,794.3 1,511.7 242.1 7,431.2
%sFhincd *rm dthaneral suices, lb Fhwnd bom dUe external aouc
> CD z 0O HeafthServices RehabitPation Hefi Faeos Mak _mance
Wt UN NW gr i NM TO-l CoKM NW P78 am Totb A.I _ -rdh 3- - - 3 15 - E.Eui 40 45.0 k-0 - 239 C Iad T_bIU ku m- - 299 4.0 - . . 4.0 P. T_1_ d ndSm_Im * T_d 15.0 ... 1S.O -13.5 . 135A
0o Health Services Rehabilitation Managementfor BasicHealh Services D I Costa MsSww audEee unkt Ban coso unnit 5 496 966 397 376 99 Totl Coo UN 91 967 979 3I133 Totdl L hiveslmnui Cosh A ODbIct Plmuiandli s 1.1ST Phase- 0 Trni Tachnd Iical monb 4 - - - 4 13.5 U4.0 - - - 54.0 LavT Sw is 66 6 - 172 0.1U4 15 15.0 * . 316 M ida wid Spoe kanp 1 1 - - 2 312 4.0 4.0 - - - 6.0 S 1ST Pls.. - i TOlT73 19.8 93. 2.2ND Phs. -Madu Taing Tacl IAshun mI . 2 7 3.5 12.5 13. - 27.0 945 47. 166. FakoAlps m1iUI 3 12 9 15 39 35 10S 42.0 315 62.5 136S TrinIng Equ Dudla pdp 490. - - . 49. hU.tb idSLqspI hmipe - - 6 6 - 12 1 - 6.0 6.0 - 12.0 LocdTraniS,* p 6 6 - 12 5SS6 - 35.9 359 - 71. S_fW2ND Plie - Moadu_ Trini 60.3 69.0 167. 1416 - 43S.8 To ivewsimui Codsa 134.1 388I 167.9 141.6 532A L RPcmreui Cost Toel 134.1 60. 167.9 141. . 532A CA iC_*on.d_- dv_ I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
in Ciniipuirinh waib elda. ~w~ae eqi~musid midaidbua~
oZ HealthServoes Rehabltaon HoIpId Shif R Dockm
_____Ufa__ Um Co Urf NM3 NM 3736 TW Cam N7 T A. 5quNmud 1. CUs Eqaxnut F* odf Vb h ui 4 12.2 12.9 2. Pin" Equm,at M.& F_ol has - - 64.7 - 64.7 3. Oats EuaiMt hMONrn t12. st_ti - - - - 12.J - 3090 --- M k -m*s TPr Pmp-uw_b is hasp C. T,i 9610 1320 132.0 - 4W0D Mhi wnd8Vin Id hsso 0.5 05 Told bw 3 OS05 0.5 2.5 CsCost 96.5 23.1 132.5 L Utsarmi CoZ U3O SOS I AkEqu 0muO6M 4.2 TOW3A aditCOA 4.2 4.2 42 16.7 Totel - 42 42 42 4 te .7 3.5 267. t- i. 4T to O0t e _ubw For o DZpLo -- FOVfbw0_
~lc ato da Iig p.mq h bI - 1, hl-s. g*easau. uha*. pwssuI . Id nti uw sfor FMu i DpL of P _o= 0
IIz HealfthServices Rehabilitation HospitalStaff Retrak*i: Nines d CoB"s Js,
__ __ O __ __ Uft Bas Co UMt NM MT H7* Toal Coat 4MSSWl 97 am n ToWl L hIwn_ur Cost. A Eqs*w,uiA kmp s 1245 74.7 . - U.2 B. Ru_o at d Trinin FaMss ka_ - 41.4 - 41A C. UbL yOb apkm- 36.0 - 350 Taw hwmummiCo 20.9 74.7 - 275.6 L RmcurrutCosft A. E_m*OW i - 92 92 92 92 368 Tod R.wr et_ 92 92 92 92 36. Total 200.0 639 92 92 92 312A mPed.ug.i mu *s ed d _,1muRCa udmi a fd.t Mmh Sdis. b 0*.. wdul_u fr Sdusd
oc o HealthServios RehabII.ion Sior P m ho d Palry DO_:hpmut Fhine DL Co
Udit S6 UIW ffl3 271S _~ Tak Ced Sig _~ ISS 5A73 _ to A.Eqnoum. 1.C. ut _ _t w I - 1 I 2316 21 -- 231 STaIuUL W_moih 6 a a C. TramfhPe 1s 12 720 72A0 72 2161 l.MCH4 D0.W_ p I 1FI - 1 1s 2. MCH 8ae,*moI 16- - - 160 2. Lw4TJm Al 4.6 4.6 Hm i Fug** bn_0.0 HoW 40.0 - 60 _Fe hy 40.0 STb_ki L_Ti nFdw 40.- - O0D 4.Uh*T_ FAd*o _mw 60. U - - - ,a" S6.fJT_ F_hfbu.. 25.0 - - 25.0 S.bokiT__pum - 4SA 36.? 361 J 1227 1271 1284 3KT SJ - 301 D.TNMV WbS&4*§.ab_ h .w Tloi -uwCA 4.0 3.0 2.0 1.A 99 LRA-m,-- Comb 23&4 203A 112.7 361 - EAnT A. EqumtOM c Is1 19 19 Is 1.9 3.7 L.OtmEwmbim how_ 12 12 12 0 TowneaazdCom" - 42 0A14 5.0 5.0 50 2. 7.4 TodJ 6.9 6.9 69 4.4 1.A 2710 2403 20T 1119 41D0 19 60132 l To Y_ .W D_S lD fw oySdEmm.k_# P
__'Z 2 ANNEX 3 - 83 - Page 12 of 14
I| q q |;i S t|qQq vtI.I
j i .QQq *e qi'qqe -I-1q
** 8 e ! 8--
IA~~~~~~I
I~~~~~IIQsI. I- Xg§
ilfl i t '
IullSdC III]
"f; ".]14§I*§ a-. HaIh SrvicesRehabiblaon
P. Cor
L'hw mcosts A. WVNd _ 3 3 24. 74.7 - 74.7 B. I nEJta b hay mm 39.8 30* C. Te.dudo Asshidos 1. Pm*.A*dw . m__ a 2 1 1 12 16 12JD 320 16.0 160J 1s. 2.Am^ uf 1 1 1 1 1 5 20 20.0 200 20.0 20.0 200 106.0 3.PCUO 1 r _psu 1 1 1 1 1 5 2206 22 2.2 22 2.2 22 11. 4. _Acuiut 1 1 I 1 1 5 1.666 1.7 1.7 1.7 1.7 1.7 6 S.P _dMutOos CrM 1 1 1 1 1 5 1.56N 1.7 1.7 1.7 1.7 1.7 83 6. swy v 1 1 1 5 1.104 1.1 1.1 1.1 1.1 1.1 5. Sa.*6m TecgIcAjpauj_ 154. 50J 42A 42J A 3251 0. PCU S_ T,*y k hmw m 400* 400 TOMbwe.sosu Comb 3092 - - 42. 2 J79.7 E.= mcmr~omb A V OM 6. 6A 6) 6A GA 34.5 0BEyi 4.uiOuuM 3.7 37 3.7 3.7 17.SA T73d ft.cwmaiCosB 10. 10. I0. 10J 10J6 10I To.d 319 7 692 512Wi37. O s Vafidos fo PCUund TSO lb E_mdbehrfvwi .PCU ud TdWTad Ses c Sadbm_ r P=l=S _hI pu.amm_ dbwmsmuA aid CmupAwTr.*i
Oii ANNEX 3 - 85- Page 14 of 14
Health ServicesRehabilitation Isbursementsby Semestersand GovemmentCash Flow (USs 000)
Financing Coststo be Available Financed The Government IDA Project Cumulative Amount Cosht CashFlow CashFlow I - 807.0 -807.0 -807.0 2 791.0 807.0 -16.0 -823.1 3 791.0 2,483.9 -1,692.8 -2,515.9 4 1.928.8 2,483.9 -555.1 -3,071.0 5 1,928.8 2,538.2 -609.4 -3,680.4 6 1,875.4 2,538.2 -682.9 4,343.3 7 1,875.4 1,665.9 209.5 4,133.8 a 1,355.6 1,665.9 -310.2 4,444.0 9 1,355.6 507.3 848.3 -3,595.7 10 272.9 507.3 -234.5 -3,830.2 11 272.9 - 272.9 -3,557.3
Total 12,447.3 16,004.6 - -3,557.3 - 86 -
ANNEX 4
ALBANIA
HEALTH SERVICES REHABILITATION PROJECT
Supervision Plan
Timing StaffWeeks Staffinm'
CY1995 16 weeks Bank resources (16 weeks) of which: - Task manager (6 weeks) - Implementation/Operationsspecialist (6 weeks) - HealthSpecialist (4 weeks)
CY1996 12 weeks Bank resources (12 weeks) of which: - Task manager (6 weeks) - Implementation/Operationsspecialist (6 weeks)
CY1997 10 weeks Bank resources (10 weeks) of which: - Task manager (5 weeks) - Implementation/Operationsspecialist (5 weeks)
CY1997 10 weeks Bank resources (10 weeks) of which: - Task manager (5 weeks) - Implementation/Operationsspecialist (5 weeks)
CY1998 8 weeks Bank resources (8 weeks) of which: - Task manager (4 weeks) - Implementation/Operationsspecialist (4 weeks)
CY1999 6 weeks Bank resources (6 weeks) of which: - Task manager (3 weeks) - Implementation/Operationsspecialist (3 weeks)
I/ Supp _mty technicalinputs would be requestedthrough bilateral/mullateral cooperationin the following arm: public health specialist,health economics, health planner, managementdevelopment, public health education nd heath infonnationsystems specialist. -87 -
ANNEX 5 Page 1 of 3
ALBANIA HEALTH SERVICES REHABILITATION PROJECT
Procurement Plan
...... PROCUREMENTPACKAGE Total Total IDA Method Procurement Schedule (latest date) ...... Cost of Finan- of No.ot Package cing Procure- Notice/ Document Receive Contract Description Packages USSO000 USSO000 nent Invitatn Issue Proposal Award ...... CIVIL WORKS PHC Rehabilitation:6 Districts Group 1 PHCs 26 840 714 LCB* 11/94 12/94 01/95 03/95 Group 2 PHCs 32 1000 853 LCB* 11/95 12/95 01/96 02/96 Group 3 PHCs 29 935 793 LCB* 11/96 12/96 01/97 02/97 Group 4 PHCs 13 430 365 LCB* 11/97 12/97 10/98 02/9 Hospital Rehabilitation Shkodra Regional Hospital 1 2380 2230 ICB 07/95 08/95 09/95 11/95 Vlora Regional Hospital 1 1470 1370 ICa 07/95 08/95 09/95 11/95 FURNITURE Group 1 PHCs 26 68 60 LS 06/95 06/95 07/95 08/95 Group 2 PHCs 32 86 75 LS 05/96 05/96 06/96 07/96 Group 3 PHCs 29 80 70 LS 05/97 05/97 06/97 07/97 Group 4 PHCs 13 37 32 LS 05/98 05/96 06/96 07/98 EOUIPHENTAND MATERIALS Vehicles 1 76 76 IS 07/94 08/94 09/94 09/94 Office/train equip/computers 4 519 519 Is 07/94 09/94 10/94 10/94 ProprietaryMaterLa/Library 36 36 DP 06/95 07/95 HospitalEquipment Shkodra/VloraPackage 1 1 1500 NBF ICB 04/95 05/95 07/95 09/95 Shkodra/VloraPackage 2 1 1540 1477 ICB 07/97 07/97 11/97 01/98 PHC equipment 4 170 170 ICB four annual purchases1995-19M MCHsupplies/mterials 4 330 280 Is four annual purchases 1995-1998 misc supplies/materiaLs 79 73 LS four annual purchases 1995-1998 SPECIALISTS/TECHNICALASSISTANCE Consulting Firms: Hospitals:Arch/Engg Serv 2 280 280 SL 10/94 11/94 12/94 01/95 District Managemt Training 1 246 246 SOLE 10/94 11/94 12/94 02/95 Drug Pricing Study 1 172 172 SL 10/94 11/94 12/94 02/95 Health Policy and Planning 1 235 235 SL 10/94 11/94 12/94 02/95 Hosp/Equip/FacilitiesPlan 1 336 336 SL 10/94 11/94 12/94 02/95 IndividualSpecialists: Project ImpLement Adviser 1 207 207 Cs 08/94 09/94 10/94 PHC Design/Works Supervian 6 179 179 Cs as needed for works supervfsion Auditor 1 112 112 CS annual audit of )rojectaccounts PCU technicalstaff 38 38 Cs FELLOWSHIPS/STUDYVISITS/TRAINING Project CoordinationIlmpt 42 42 FELL na na na 09/94 ' Basic Health Services gmt 152 152 FELL na na na 09/94 * Financial/DrugPolicy & Planning 481 481 FELL na na na 09/94 * In-serviceTraining Program 788 788 ------I ...... I ------.------
ICB = InternationalCompetitve Bidding in accordance with IDA ProcurementGuidelines IS = InternationaLShopping in accordancewith IDA ProcurementGuidelines LS = LocaL shopping (minimumof three price quotations)fromIndependent suppLiers accordingto proceduresand documentation agreed with IDA DP * Direct purchase for proprietary Items, trainingmaterials SL = Shortliatingof firm in accordancewith IDA Guidelinesfor Consultant Contracts CS z Competitiveselection of Individualsin accordance with IDA Consultant Guideline. FELL z Fellowships/externaltraining my be procured as part of technicalassistance contract SOLE = Solesource procurumnnt of consulting services ** a Departure date of selected candidate.for external training na * not applicable - 88 -
ANNEX S Page 2 of 3
ALBANIA HEALTH SERVICES REHABILITATION PROJECT
Procurement Responsibilities
Documentation Bid Award Procurement Activity /Bidding Evaluation Clearance Contract Process /Review /Approval Signature Civil Works Contracts: Primrar Health Centers Standard Bidding Document TSD PCU IDA PHC contracts below US$40,000 DPT DPT TSD/PCU DPT PHC contracts below US$100,000 DPT TSD PCU PCU PHC contracts US$100,000 or more TSD/IDA TSD/IDA PCU/IDA PCU Regional Hospitals Contractor Prequalification TSD TSD/PCU IDA Hospital bid package TSD/IDA TSD/PCU/IDA PCU/IDA Minister
Furniture. EquiMnent. Materials Standard Bidding Documents TSD/IDA PCU/IDA --- PHC Furniture Furniture Lists TSD/DPT ----- PCU Furniture package below US$10,000 DPT DPT TSD/PCU DHT Furniture package above US$10,000 TSD/IDA TSD/IDA PCU/IDA PCU Office/Computers/Training Eguipment/Vehicles Equipment Lists TSD/End User ---- PCU/IDA Local Shopping PCU PCU PCU PCU International Shopping PCU/IDA PCU PCU/IDA PCU ICB Packages PCU/IDA PCU/IDA PCU/IDA PCU Medical/HosRitalEguipment Standard Bidding Documents TSD/IDA ----- PCU/IDA Medical equipment lists TSD/IDA PCU/IDA -- Medical equipment bid packages Below US$100,000 TSD/PCU TSD/PCU PCU/IDA PCU Above US$100,000 TSD/IDA TSD/PCU PCU/IDA Minister Proprietary Materials/Medical Supplies List of proprietary materials End User ----- PCU/IDA Proprietary materials procurement PCU/IDA ----- PCU/IDA PCU Medical Supplies for PHCs DPH/IDA PCU/IDA Procurement of medical supplies DPharm/IDA DPharm/PCU PCU/IDA PCU
Consulting Services/Studies/Fellowshivs Arch/Engineering (A&E) Services TORs/contract conditions TSD/IDA PCU/IDA PCU/IDA PHC A&E services procurement DPT/IDA TSD/IDA PCU/IDA DPT Hospital A&E services procurement TSD/IDA TSD/IDA PCU/IDA DHosp Other Consulting Services and Fellowships TORs/contract conditions End User/IDA PCU PCU/IDA -- Consulting services procurement PCU/IDA MOH Unit PCU/IDA Minister Fellowships Dept-unit/IDA Dept/unit PCU/IDA Minister - 89 - ANNEX S Page 3 of 3
ALBANIA HEALTH SERVICES REHABILITATIONPROJECT
Contract Payment Responsibilities
Measurement Prepare Type of Contract /Evaluate Payment Authorize Pay Progress Voucher Eavment Contract Civil Works Contracts:
PHC contracts below US$100,000 DPT DPT TSD/PCU DPT PHC contracts US$100,000or more DPT TSD PCU PCU Regional Hospitals TSD TSD PCU PCU
Furniture.EcuiRment. Materials
PHC Furniture DPT DPT TSD/PCU DPT Office/Computers/TrainingEquipment/Vehicles Local Shopping End User PCU PCU PCU InternationalShopping/ICB TSD PCU PCU PCU Medical/HospitalEquipment TSD/DHosp TSD PCU PCU Proprietary Materials/ MedicalSupplies DPH DPH PCU PCU
Consultine Services/Studies/Fellowshins
Arch/Engineering(A&E) Services PHC contracts DPT DPT TSD/PCU DPT Hospital A&E/ equipmentTA TSD TSD PCU PCU Other consultingservices End User PCU PCU PCU Fellowships End User PCU PCU PCU
IBRD 25813
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