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Document of The World Bank
FOR OFFICIAL USE ONLY
Report 25809-DO
PROJECT APPRAISAL DOCUMENT
ON A
PROPOSED LOAN
IN THE AMOUNT OF US$30.0 MILLION
TO THE DOMINICAN REPUBLIC
FOR THE HEALTH REFORM SUPPORT PROJECT
IN SUPPORT OF THE FIRST PHASE OF THE
HEALTH REFORM SUPPORT PROGRAM
JUNE 5,2003
Caribbean Country Management Unit Human Development Sector Management Unit Latin America and the Caribbean Regional Office
This document has a restricted distribution and may be used by recipients only in the performance of their official duties. I t s contents may not be otherwise disclosed without World Bank authorization.
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CURRENCY EQUIVALENTS
(Exchange Rate Effective 05/20/2003)
AIDS APL ARS BHP C A L CAS CAASD CERS S CORAASAN
COPRESIDA CQ cs w D I D A
DR EA EMP EU FMR GDP GODR H I V IADB IBRD I C B IDA IDSS IMR INAPA INSALUD ISSFAPOL IT LAN LCS LGS M&E M D G MIS M M R NCB NGO NHC
Currency Unit = Dominican Pesos US$1= DOP 25.8
FISCAL YEAR January 1 - December 31
Abbreviations and Acronyms
Acquired Immune Deficiency Syndrome Adaptable Program Lending Health Risk Administrators Basic Health Plan Logistic Support Center Country Assistance Strategy Santo Domingo Aqueduct & Sewer Corporation Executive Commission o f Health Sector Reform The Santo Domingo Aqueduct & Sewer Corportion o f the Province o f Santiago The Presidential Commission for HIV/AIDS Selection Based on Consultants’ Qualifications Commercial Sex Workers Affiliates Information and Advocacy Bureau (Direccidn de Informacidn y Defensa de Afiliados) Dominican Republic Environmental Assessment Environmental Management Plan European Union Financial Management Reports Gross Domestic Product Government o f Dominican Republic Human Immune-Deficiency Virus Inter-American Development Bank International Bank for Reconstruction and Development International Competitive Bidding International Development Association Social Security Institute Infant Mortality Rate National Institute o f Water Supply National Health Institute Social Security Institute for the Armed Forces and the National Police Information Technology Local Area Networks Least-Cost Selection General Health Law Monitoring and Evaluation Millennium Development Goals Management Information System Maternal Mortality Rate National Competitive Bidding Non-Governmental Organizations National Health Council
FOR OFFICIAL USE ONLY
PAD PAHO PARSS
PCD PCU PEU PHSP PSS PLWA PPS PROMESE POA QCBS SBD SDSS SENASA SESPAS SFS SIAP SIPEN S IS ALRIL SOE SRS STI TB TFR TORS UMDI UNAIDS UNDP UNICEF USAID USD WAN WB W H O
Project Appraisal Document Pan American Health Organization Health Sector Reform Support Program (Programa de Apoyo al Sector Salud) Project Concept Document Project Coordination Unit Project Executing Agencies Provincial Health Services Project Health Services Providers Persons Living with HIV/AIDS Private Health Providers Essential Drugs Program Annual Operations Plan Quality and Cost-Based Selection Standard Bidding Documents Dominican Social Security System National Health Insurance Secretariat o f Public Health and Social Assistance Universal Family Insurance System Automated Financial Management System Superintendence o f Pensions Health and Labor Risks Superintendence Statement of Expenditures Regional Health Services Sexually Transmitted Infections Tuberculosis Total Fertility Rate Terms o f Reference Modernization and Institutional Development Unit United Nations AIDS Program United Nations Development Program United Nations Children’s Fund US Agency for International Development US Dollars Wide Area Networks World Bank World Health Organization
V ice President: David D e Ferranti Country ManagedDirector: Carol ine D. Anstey Sector Director: Ana-Maria Amagada Sector Manager: Evangeline Javier Sector Leader: William Experton Team Leader: Patr icio MBrquez
This document has a restricted distribution and may be used by recipients only in the performance of their official duties. I t s contents may not be otherwise disclosed without W o r l d Bank authorization.
Dominican Republic Health Reform Support Program
CONTENTS
A . Program Purpose. Project Development Objective
2 . Project development objective .................................................................................
3 1 . Program purpose and program phasing ........................................................................ 3
7 3 . Key performance indicators ..................................................................................... 8
B . Strategic Context .............................................................................................. 9 1 . Sector-related Country Assistance Strategy (CAS) goal supported by the project ...................... 9 2 Main sector issues and Government strategy 9 3 . Sector issues to be addressed by the project and strategic choices ......................................... 15
16
. .................................................................
4 . Program description and performance triggers for subsequent loans ....................................
C . Program and Project Description Summary .............................................................. 16 1 . Project components .............................................................................................. 16 2 . Key policy and institutional reforms supported by the project ............................................. 19 3 Benefits and target population 19
20 . ................................................................................. . ............................................................. 4 Institutional and implementation arrangements
D . Project Rationale .............................................................................................. 22 1 . Project alternatives considered and reasons for rejection ................................................... 22 2 . Major related project financed by the Bank and /or other development agencies ........................ 23 3 Lessons learned and reflected in the project design 23 4 . Indications o f borrower commitment and ownership ........................................................ 24 5 . Value added of Bank support in this project .................................................................. 25
. .........................................................
E . Summary Project Analysis ................................................................................... 1 . Economic .......................................................................................................... 2 . Financial ........................................................................................................... 3 . Technical .......................................................................................................... 4 . Institutional ....................................................................................................... 5 . Environmental .................................................................................................... 6 . Social ............................................................................................................... 7 . Safeguard Policies ...............................................................................................
25 25 25 25 26 27 29 30
F . Sustainability and Risks ...................................................................................... 30 1 Sustainability 30 2 . Critical risks ...................................................................................................... 31 3 . Possible controversial aspects .................................................................................. 3 1
. .....................................................................................................
3
G. Main Loan Conditions. ...................................................................................... 31
H. Readiness for Implementation. ............................................................................. 32
I. Compliance with Bank Policies .............................................................................. 32
Annexes
Annex la: Project Design Summary Annex lb: Linking Outputs, Outcomes and Impact Annex IC: Government Policy Letter Annex 2a: Detailed Project Description Annex 2b: Medical Waste Management Assessment in the Dom. Rep. Annex 2c: Donor’s Assistance in the Health Sector Annex 3: Estimated Project Costs Annex 4: Economic Analysis Annex 5: Financial Summary Annex 6(A) Procurement Arrangements Annex 6(B) Financial Management and Disbursement Agreements Annex 7: Project Processing Budget and Schedule Annex 8: Documents in the Project File Annex 9: Statement of Loans and Credits Annex 10: Country at a Glance
Map: IBRD 19599R
Domin ican Republ ic H e a l t h R e f o r m Support Program
Project Appraisal Document Latin America and the Caribbean Regional Office
Caribbean Country Management Unit
Date: June 5,2003 Country Manager/Director: Caroline D. Anstey Project ID: PO76802 Sector: Health Lending Instrument: Adaptable Program Loan (APL)
Team Leader: Patricio Mhrquez Sector Managernlirector: Ana Maria Arriagada
Theme@): Health/Nutrition/Population Poverty Targeted Intervention [XI Yes [I No
Program Financing Data APL Indicative Financing Plan Estimated Implementation Borrower
Period (Bank FY) IBRD Others Total U S $ m % U S $ m U S $ m
APL 1 30.0 I 70 12.71 42.71 Loan I
I I I I
APL 2 I 30.0 I 70 1 12.00 I 42.00
Loan I APL 3 I 30.0 I 70 1 12.00 I 42.00
Loan
Commitment Closing Date Date June 2003 December Government of the
2007 Dominican Republic
June 2007 December 2011
June 2011 December 12015 1
~~
[XI Loan [ ] Credit [ ] Grant [ ] Guarantee [ ] Other [Specify] F o r Loans/Credits/Others: Tota l Project Cost (US$m): 42.71 Cofinancing : Total Bank Financing (US$m): 30.0 Has there been a discussion o f the IBRD financial product wi th the Borrower? Borrower Rationale fo r Choice o f Loan Terms available on File: Proposed terms (IBRD): Fixed-Spread Loan (FSL) Commitment fee: 0.85 % for the f irst four years, and 0.75 thereafter Initial choice o f Interest-rate basis: Automatic Rate Fixing (ARF) b y period
[XI Yes [ ] No [XI Yes
Front-end fee (FEF) on Bank loan: 1 %
Type o f repayment schedule: [XI Fixed a t Commitment, w i th the following repayment method (choose one): f ina l maturi ty o f 17 years, including a grace period of 5 years wi th level repayment o f principal [ ] Linked to Disbursement
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Feris Iglesias, Executive Directo;, CERSS, Dr. Bernardo-Defillo, Superintendent, SISARIL; and Dra. Alma Bobadilla, Executive Director, SENASA Address: Edif. F.J. Montalvo, Calle Gustavo Mejia Ricart No. 141, Santo Domingo, Rep. Dom. Phone: (809) 547-2509 Fax: (809) 565-2768 E-mail: reformasalud@cerss. g: ob.do
-
~
Financing plan: Source Local Foreign TotaI Government 12.71 12.71
IBRD 14.80 15.20 30.00
Total: 27.51 15.20 42.71
Borrower: Government of the Dominican Republic
Cumulative 5.90 14.43 23.93 30.0
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Dominican Republic Health Reform Support Program
A. Program Purpose and Project Development Objective
The proposed Adaptable Program Loan (APL) aims at:
a) Contributing to achieve by the year 2015 the Millennium Development Goals (MDG) agreed to by the Government o f the Dominican Republic at the Millennium Summit in September 2000. Specifically, the APL would address three MDG goals: reduce child mortality, improve maternal health, and contribute to eradicate extreme poverty by protecting the poorest from financial loss due to ill health and disability;
b) Supporting implementation o f the new legal framework for the health sector, particularly the institutional strengthening of SESPAS in i t s new stewardship role, the development o f insurance mechanisms, and the configuration o f regional health networks; and
c) Supporting preparation, validation and dissemination o f supplementary norms and regulations to the General Health Law (42-01) and the Social Security Law (87 -01).
1. Program Purpose and Program Phasing
1.1 Health Sector Context Today. The Dominican Republic’s health system consists o f multiple public and private providers operating with loose guidelines, minimum regulations, overlapping functions and with scarce coordination to guarantee universal access to quality and efficient health services. With the promulgation o f the new reform laws, the Secretariat of Public Health and Social Assistance (SESPAS) in i t s stewardship role i s responsible for setting health policies, enforcing the separation o f provision from financing public health care, and ensuring quality and effective health care. Existing financing and resource allocation mechanisms are being modified with support of ongoing projects financed by the World Bank, IDB, USAID, EU, among others, following criteria and mechanisms to channel funds according to health needs and other socio-economic variables.
Several entities finance and provide health services in the public sector: SESPAS, the Dominican Social Security Institute (IDSS), the Social Security Institutes for the Armed Forces and the National Police, and other decentralized institutions and NGOs receiving state subsidies. SESPAS’ mandate i s to provide health care to meet the health needs o f the poor and the indigents, which presently are estimated at 64 percent o f the population or 5.4 million people. The IDSS provides health services to 530,000 regular beneficiaries and to about 100,000 temporary workers or at most to 7.5 percent o f the population.
Most private hospitals tend to be small. About 80% of the private hospitals have fewer than 20 beds. Almost all private sector activity i s concentrated in the two largest cities: Santo Doming0 and Santiago. N o statistical data are available on the number, size, and composition of the private sector, which i s largely unregulated and unsupervised. Non-Governmental Organizations (NGOs) have grown throughout the country and are active in health promotion and reproductive health services. The current and the past two governments have been very much aware o f the inequitable access to health services by all Dominicans, the inefficiency and the low quality in the health sector, the dissatisfaction o f the population with public services, and therefore prepared a vast health sector reform program.
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1.2 The Health Sector Reform Laws of 2001 and the Country’s Vision. The executive and legislative work spanning a ten year time period culminated in 2001 with the approval by Congress and the Presidential signature of two laws that reshape the financing, the organization, the management and the delivery o f health services in the Dominican Republic (DR). The f irst one i s the General Health Law approved in March 2001 that authorizes, inter alia, deconcentrating and decentralizing the management of health care services from the central SESPAS level to local administrative units (regional, provincial) and to health care institutions. SESPAS would transfer technical, managerial and administrative tasks to local levels and to SESPAS health facilities within ten years. The General Health Law also defines seven fundamental principles: universality, solidarity, equity, efficiency, efficacy, comprehensiveness, and cooperation (art.ll), and creates the National Health Council (NHC) as the institution responsible for formulating, follow up, and evaluation of health policy.
The second Law that created the Dominican Social Security System, was approved by Congress and signed by the President in May 2001. This law mandates specifically to:
Separate the functions o f (i) stewardship o f the health sector, (ii) financing services, and (iii) service provision. Stewardship would be the responsibility o f SESPAS. Health care would be financed through a family insurance system consisting o f an autonomous national agency for the public sector (SENASA) and for the private sector (Health Risk Administrators or ARS). Health care provision would be the responsibility o f regional health network providers contracting with SENASA and ARS to provide the basic health plan. SISARIL i s the regulatory body o f the new systems;
Define a basic health plan;
Set up private (ARS) and public insurance companies (SENASA);
Gradually move from a supply-driven health care delivery system to a demand-driven system;
Organize Health Service Providers (PSS). Regional Health Service Management Units (SRS) would be created to manage the regional health networks and their respective hospitals, diagnostic centers, health centers, rural clinics and Primary Health Care Units. Regulations would define management and delivery models including the role and functions of governing bodies and organizational structures within a framework o f decentralized decision-making and management agreements. I t i s expected that within a ten-year period a number o f PSS would be accredited as Autonomous Regional Health Network Providers integrating autonomous hospitals and health centers. Asset ownership, labor contracts and payroll, and pension benefits and liabilities would have been transferred to these Autonomous Regional Provider Networks;
Change the remuneration o f individual service providers from a salary to a combination o f a basic salary and payments for results and performance while ensuring satisfaction of human resources;
Promote social participation; and
Assure quality o f care by introducing accreditation and licensing public and private providers, blood banks and transfusion services, and clinical laboratories. Accreditation and licensure would be granted by SESPAS and would be a requirement to contract as a PSS.
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A key objective of this APL is to support the implementation of the mandates contained in these two health sector reform laws.
The Social Security Law classifies the population into three groups:
a) The f i r s t group consists o f workers in the public and formal private sectors; employers and workers would pay contributions.
b) The second group i s semi-subsidized and includes all independent technical and professional workers as well as those self-employed who earn more than the minimum wage. I t i s expected to be financed by workers and by government subsidies.
c) The third group i s independent workers who earn irregular wages below the minimum wage and include the poor, the unemployed and the handicapped. The government would pay their contribution.
As o f May 2003 four sets of norms and regulations to implement the General Health Law and three sets o f norms and regulations to implement the Social Security Law have been approved. They are:
For the General Health Law: a) Stewardship and separation o f functions in the health system b) Licensing o f health facilities c) Health provision networks: affiliation and delivery o f services d) Human resources regulations (in the final review stage)
For the Social Security System: a) Family health insurance and basic health plan b) Control of medicines in the basic health plan c) Organization and regulation o f Health Risks Administrators (ARS)
Details o f the contents for each o f the above regulatory provisions are given in Annex 2.
A key objective o f the proposed APL i s to help the Government o f the Dominican Republic (GODR) achieve three Millennium Development Goals (MDGs) by promoting affiliation o f above-mentioned third population group to the national health insurance, and making the primary health care services and the hospitals at the secondary and tertiary levels more attractive to the potential users and able to solve the medical problems of the patients. This would ensure the poor to have access to a regular source o f quality health services and not to incur financial hardship for medical reasons.
1.3 Relation of the APL to Ongoing Bank Projects. The proposed APL builds upon and complements the ongoing Provincial Health Services Project (Lon. 4272-DO) and the HIV/AIDS Prevention and Control Project (Lon. 7065-DO). Since 1998, the Provincial Health Services Project has supported significant advances in policy and institutional reforms, developed reform instruments, trained personnel, and improved physical and technological infrastructure in the poorest regions o f the country, particularly with a major redistribute impact in the border areas with Haiti. The project’s mid-term review o f October 2001 documented the accomplishments in helping put in place a new legal framework for reforming health care organization and financing by supporting the preparation, consensus building, and approval o f the General Health and Social Security Laws. The provincial subprojects have supported the development o f new health care organizations, financing and managerial models to create provincial integrated delivery systems
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and signing management agreements between provincial units and health care providers. The project also supported the development o f a multi-module information system for improving management at the central and provincial levels and hospitals. The regional hospital Jaime Mota (Region IV) has entered into management performance agreements with SESPAS for financing health services delivery.
The HIVIAIDS Prevention and Control Project i s supporting the implementation o f a multisectoral strategy with broad participation o f different segments o f the society to reduce the spread o f the HIV/AIDS/TB/STI epidemic. Therefore, the health-related MDG for combating HIV/AIDS, malaria and other diseases has not been included in this APL.
1.4 The Program’s Components (Annex 2.a). Program components are geared to help: (i) achieve by the year 2015 the three MDGs of reducing child mortality, improving maternal health, and contributing to the eradication of extreme poverty by protecting the poorest from financial loss due to ill health and disability; and (ii) supporting the implementation o f the health sector reform legislation that provides the legal, financial, organizational and managerial enabling environment to achieve the MDGs. The three program components are:
a) Supporting health services extension to achieve universal coverage. The Program aims to improve the health status of the economically disadvantaged population groups, especially by reducing child and maternal mortality. I t would contribute to eradicate poverty by malung the already approved Basic Health Plan (BHP) accessible to the poorest and most vulnerable population. The main mechanism for providing access o f the poor to the BHP would be through Government partially subsidizing their health insurance premium, thereby providing an incentive to enroll in the national health insurance scheme and thus removing financial barriers to access and protecting beneficiaries from financial loss due to ill health and disability. The APL would strengthen primary health services and hospitals at the secondary and tertiary care levels in order to assist the GODR to reach universal coverage by improving their capacity to provide quality health services, especially maternal and child services to the target population, providing a physical and technological supportive environment and improving staff performance.
b) Supporting implementation of the health sector reform legislation. The Program would assist in implementing the mandates o f the reform laws by supporting the development o f innovative approaches; testing new models; and funding policy studies in the areas o f financing and organizing health care, paying providers and remunerating personnel. It would support implementation o f mandated decentralization policies that provide more autonomy and decision-making authority to lower administrative levels and to service providing institutions. These tested models and studies would provide the financial, managerial and institutional tools and the legal underpinning for achieving universal health service coverage. They would be implemented jointly with the activities under the f irst component.
c) Improving Selected Essential Public Health Functions to promote and protect the health of the population. In addition to supporting the health sector development addressed by components one and two, the Program would support SESPAS in improving two essential public health functions: (i) surveillance and control o f public health risks, follow up on disease outbreaks and risk factors to implement protection and prevention measures, and ensure the safety of water, air, food, waste disposal and pharmaceuticals; and (ii) development of policies, plans and management capacity for assuring SESPAS stewardship in the process o f sector capacity building and coverage o f the national health insurance system.
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(BRD) Triggers’ Assessment Appraisal next phase
These activities would benefit the health of the whole population and would have a direct impact on many sectors o f the economy.
March 2007 March 201 1 June 2007 June 20 11
1.5 Program’s Phasing. The proposed APL program wi l l achieve the stated development objectives in three phases over a period of twelve years. Each phase would have three components plus a component for project management, monitoring and evaluating the results o f each phase and - in the case o f the first two phases - appraising the next phase o f the program. Table 1 presents the summary data on the APL phases.
Table 1. Phasing of APL
Performance Evaluation by Phase. Trigger indicators for moving from Phase 1 (APL1) to Phase 2 (APL2) and from Phase 2 to Phase 3 (APL3) are listed in Table 3 o f Annex 2.a. These triggers would be assessed prior to and reviewed during appraisal o f Phase 11 and Phase 111 APLs.
Trigger indicators would account for the GODR’s readiness to: i) expand the geographic coverage of the reformed insurance system; ii) scale up the provision o f quality care through certified and licensed providers; iii) assign health system management to new regonal authorities; iv) expand deconcentration and decentralization process to additional regions/provinces; and v) scale up the provision o f improved public health services reflecting lessons learned in previous phases. The triggers would be assessed and measured as part o f the monitoring and evaluation o f the program and should be based on evidence that institutional capacity building and legal conditions were sufficient to allow to move to a new phase with minimum risk; they would be “measures of success” when moving on to the next phase.
Compliance with disbursement schedules made as per legal agreements would also be taken into account for moving from one phase to the other.
2. Prqject develoDment objectives (see Annex 1.a)
The project would: a) contribute to eradicate extreme poverty by protecting the poorest from financial loss due to ill health and disability through enrollment o f the target population (people l iving below the relative poverty line in regions 111, IV, VI, VI1 and VIII) in the Government health insurance plan and to make available and promote the use o f basic health services o f high quality standards; and b) support the implementation o f the health sector reform legislation that provides the legal, financial, organizational and managerial enabling environment to achieve the MDGs related to health.
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3. Key performance indicators (see Annex 1.a & Annex 2.a)
3.1 Project performance for three MDGs wi l l be guided by targets and measured by indicators as shown below and described in Annexes 1.a and 2.a for Phase 1. A fourth MDG also related to health i s the control o f HIV/AIDS, malaria and other diseases. This MDG i s not considered under this program as i t i s supported by a freestanding HIV/AIDS project currently under implementation.
Performance Indicators directly linked to MDGs.
Reduce Extreme Poverty and Hunger: Target: by 2015, protect the poorest from financial loss due to ill health. Indicators: % families with health insurance; prevalence of underweight children (under five years o f age), low birth weight, nutritional status.
0 Improve Child Health: Target: by 2015, reduce under-five deaths by two thirds. Indicators: % underweight newborns; % children aged 12-23 months fully immunized; infant mortality rate; under-five mortality rate; mortality and morbidity from upper respiratory infections, diarrheal disease, measles.
0 Improve Maternal Health: Target: by 2015, reduce by three quarters the maternal mortality rate. Indicators: % pregnant women with 4 prenatal visits; % o f births attended by skilled health personnel; maternal mortality rate; contraceptive prevalence rate, total fertility rate, percentage of cesarean sections.
3.2 Performance Indicators indirectly linked to but supportive of MDGs
Anchoring MOH’s Stewardship Role: national health policies issued, consistent communication strategies and public information campaigns organized, monitoring and evaluation of sector performance;
Promoting the Decentralization and Autonomy Process: degree o f transferred decision making to regional management levels and to service providers as measured by autonomy o f service providers for managing financial and human resources; number o f management contracts signed with providers and under implementation; number o f Boards of Directors functioning acceptably; number o f institutions with changed staff remuneration arrangements and associated productivity measures.
Improving secondary and tertiary care facilities: physical structure rehabilitated, electro- mechanical and biomedical waste management equipment with adequate maintenance, productivity incentives developed, staff trained and performing, information systems operating, patient satisfaction and other quality measures implemented, referral patterns and fee schedules operating; and
0 Consolidating National Essential Public Health Functions: complete and accurate epidemiological surveillance information produced, improved coverage and quality o f public laboratory network, environmental friendly medical waste management systems operating, coordinated disaster preparedness facility installed; blood banks and cold storage facilities properly operating, and emergency vaccines available for timely provision in case of need.
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B. Strategic Context
1. Sector-related Country Assistance Strategy (CAS) goal supported by the pro.iect (see Annex 1 .a>
Document number: 19393-DO Date o f latest CAS discussion: June 9, 1999
The CAS discusses a number o f prerequisites for poverty reduction and sustained growth in the Dominican Republic. Among them i s the need to continue supporting social development and - stated explicitly - increasing access by poor people to the benefits of social development and economic growth. These key points o f the World Bank's assistance strategy are the essence o f the development objectives o f the proposed program.
The design o f the proposed program also takes into account the findings and recommendations o f the 2001 Dominican Republic Poverty Report and the 2003 Dominican Republic Public Expenditures Review prepared by World Bank's teams.
2. Main sector issues and Government strategy
Main Sector Issues
Low but Improving Health Status. The Dominican Republic, with 8.4 mill ion people in 1999 growing at a projected average annual rate o f 1.3 percent, i s one of the more densely populated countries in the Americas. Rural to urban migration and urbanization of rural areas i s progressing quickly with 36% of the population l iving in rural areas in 1999 compared to 45% five years earlier. Unequal distribution o f wealth results in widespread poverty. Health indicators do not compare favorably with countries o f similar per capita income (US$1,910 in 1999). Infant mortality has decreased form 42 deaths per 1,000 live births during the period 1990-95 to 34 deaths per 1,000 live births for the period 1995-2000. Still, the 2002 ENDESA survey puts the infant mortality rate (IMR) at 31. This average IMR i s s t i l l too high compared to Chile (lo), Costa Rica (12) or Jamaica and Panama (both at 20) and hides the large variation between urban and rural areas and between income levels. The IMR for the poorest quintile i s 67 whereas the IMR for the richest quintile i s 23. Underreporting confounds the analysis and comparisons over time. For example, the infant mortality rate for 1998 based on reporting would be 10.6 deaths per 1,000 live births (LB) whereas the estimated average for the period 1995-2000 i s 34 deaths per 1,000 LB or an underreporting factor o f 69%. The management information systems contemplated and under implementation are addressing the underreporting issue.
The decrease in infant mortality should be applauded as a positive event. However, when taking a historical perspective in an international context, the apparent positive event tums negative. During the five-year period 1960-65, the IMR for the DR was 118 per 1,000 live births and the reducible gap with other Latin American and Caribbean countries was 49%. The IMR of 42 for the five-year period 1990-95 i s a sharp reduction compared to 118 in 1960-65 but the reducible gap with other Latin American and Caribbean countries increased to 75% leaving the D R farther behind i n a comparison with other countries.
The death o f a newbom during the f i rst year of l i f e can occur during the f i r s t 28 days after birth (neonatal death) or between the 29" day and the f irst birthday (post-neonatal death). The distinction i s important. Neonatal deaths tend to be due to immaturity or certain inherent congenital conditions of birth, while post-neonatal deaths tend to result from deficiencies in
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nutrition or from infectious diseases. The ratio of neonatal deaths to post-neonatal deaths in the DR’s infant mortality has improved significantly in the past decade. Internationally, this ratio i s about 75/25 and the D R i s approaching this ratio with 70/30. The decrease in the post-neonatal death rate indicates more favorable environmental conditions for the infants but the neonatal death rate has remained stable at 22 for the past decade. Reducing the IMR therefore requires initiatives to reduce the neonatal death rate and to manage i t s close clinical relationship with the high matemal mortality ratio (see below).
A distinction between neonatal and post-neonatal deaths i s necessary for two reasons: (i) to better target actions for reducing the IMR; and (ii) health workers have a greater degree o f direct control over health outcomes during the perinatal and the neonatal periods than during the post neonatal period when the environment plays a larger role in causing disease and unnecessary deaths. The six clinical causes o f infant deaths that account for 70 percent o f all infant deaths are: intestinal infections, respiratory problems during the perinatal period, nutritional deficiencies and anemia, delayed intrauterine growth and immature fetus, and acute respiratory infections. Improving the quality o f prenatal checkups, o f the delivery process and o f postpartum care would directly impact half of the causes o f infant deaths. Programs should therefore target the perinatal and neonatal periods while simultaneously sustaining the effort to provide infants with a safe nurturing environment that reduces intestinal and respiratory infections, and nutritional deficiencies.
The under-five mortality rate in 1999 was 47 deaths per 1,000 children under five, which i s double the rate o f Jamaica and Panama, three times the rate of Costa Rica and four times the rate o f Chile. The ENDESA 2002 survey reports a lower figure: 38 deaths for children aged 0 - 4 or disaggregated 3 1 for IMR and 7 for the 1 to 4 age group. L i fe expectancy at birth i s a satisfactory 71 years (1999), but s t i l l lower than the four comparator countries used here where rates range from 74 in Panama to 77 in Costa Rica. The illiteracy rate in the population aged more than 15 years i s high at 17’36, contributing to poor health status and levels of extreme poverty.
Slowly Decreasing Poverty. The World Bank 2001 Poverty Assessment report states that 33.8 percent o f the population lives on less than U$$2 a day adjusted for purchasing power parity. Percentages for earlier years are 54.9 percent in 1986 and 53.5 percent in 1992 indicating slowly decreasing poverty. Social indicators o f poverty in the 1996 ENDESA survey showed an inequitable variation between the lowest and highest income quintiles for infant mortality rates by a factor o f three, for child immunization rates by a factor o f two, and for the prevalence o f child malnutrition by a factor o f thirteen.
Still, protecting the poorest from financial loss due to ill health i s an unfulfilled promise in the country. A large segment o f the population does not have any type o f health insurance and out o f pocket expenditures represent more than one half o f total spending in health. The richer contribute as a percentage o f their total income much less than the poor to health care financing and a high proportion o f families get poorer when they have to get care.
Preventable Materna1 Mortality. The ratio o f matemal deaths (MMR) per 100,000 live births as reported by SESPAS was 122 in 1999 and PAHO/WHO l is ts the most recent reported MMR statistic as 80. In either case the MMR is unacceptably high as it i s ten to fifteen times higher than ratios in developed countries. The total fertility rate (TFR) in 1999 was 2.8 births per woman, which i s close to the TFR for the four-comparator countries. However 1996 data show a variation in the TFR from 5.1 in the poorest quintile to 2.1 in the richest quintile. The MMR for Chile and Costa Rica was one third o f the figure for the DR (33 and 35 respectively) but the MMR of the DR was close to the one in Panama (100) and in Jamaica (120). A retrospective
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study o f obstetrical deaths in the DR concluded that 93 percent o f these deaths were preventable'. These are surprising results given that internationally the DR i s positioned very well in terms o f prenatal care (99% of all deliveries), giving birth in a health establishment (95%) and births attended by skil led health staff (97%). Risk factors documented in the study are the quality o f obstetrical care in public hospitals, the behavior of attending personnel, and multiparity. The leading cause o f maternal death i s toxemia (43% in 1997), a manageable condition during the last trimester o f pregnancy. Design and implementation o f incentives to change the behavior o f providers must be a key strategy in the success o f reducing unnecessary maternal deaths.
HIV Prevalence. The Dominican Republic and Haiti account for 85% o f all reported HIV/AIDS cases in the Caribbean Region. The estimated percentage o f people aged 15-49 who are infected with HIV in the DR i s 2.8 percent, which i s among the highest prevalence rates in the Latin American and Caribbean region. This problem i s being addressed frontally by World Bank- and USAID financed HIV/AIDS Prevention and Control projects currently under implementation.
Low Health Care Spending. Total spending on health was estimated by the Central Bank in May 1996 as 6.5% of the gross domestic product (GDP), which i s s im i la r to the average percentage o f GDP spending in L A C countries during the period 1990-98. Total spending was distributed as follows: public sector 26.5 percent, private sector 72.5 percent and outside country sources 1 .O percent. The disaggregated public sector spending share was 16 percent for SESPAS, 6.8 percent for IDSS, 1.4 percent for the Presidency and 2.3 percent for other public sector entities such as other ministries and the Red Cross. Disaggregated private sector spending shows: private hospitals, clinics, and diagnostic facilities with 36 percent, households with 18.5 percent, private insurance with 10.3 percent, and NGOs with 7.7%.
According to preliminary results from a study by the Central Bank, the average public sector spending on health for the period 1996-1999 was 2.0% o f GDP. This i s a low percentage compared with the average public spending in the L A C Region (3.2%), or in countries o f similar per capita income such as Costa Rica (5.2%), Panama (4.9%) or Jamaica (3.2%).
The average percentage o f health spending in total public spending for 1996-99 was 1236 , and health spending i s almost one third (3 1.6%) o f total spending for social services. The 2002 budget proposes 13.6% o f total public spending for the public health sector.
Sources and Uses of Public Sector Funds. The national budget i s the most important source financing, on average 64.9%, followed by the private sector with 31.4% and the balance (3.7%) from external sources, mainly loans and donations. The budget of SESPAS comes from the National Treasury (77.2%), households (1 1.2%), the Presidency (5.8%) and other external sources (5.8%). The expenditure o f IDSS i s financed by payroll taxes (94.8%) as a percentage o f salaries and wages: 7.0% from the employer and 2.5% from the employee.
In terms o f program spending, almost half o f the funds were spent on curative care and another one fourth on the purchase o f pharmaceuticals and medical supplies. Spending on health promotion and preventive care represented only 1.1 % o f total public spending. Hospitals received 60% of SESPAS funds and rural clinics and health centers about 20%.
By expenditure category, about 70% of average public spending was for salaries and wages, followed by medical supplies and pharmaceuticals (12.1 %), materials and non-medical supplies (6.5%) and medical equipment (5.9%).
' Dr. Roberto Cerda Torres: "Realidad de la Mortalidad Materna en Republica Dominicana", 200 I
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Intrasectoral Fragmentation and Lack of Monitoring o f the Private Health Sector. Three entities finance and provide health services in the public sector: SESPAS, IDSS, and the Social Security Institute for the Armed Forces and the National Police (ISSFAPOL). SESPAS’ mandate i s to meet the health needs o f the poor and the medical indigents estimated at about 64 percent of the population or 5.4 million people. SESPAS provides services through 152 hospitals, 448 rural health centers and 236 urban health centers across the eight regions of the country. The IDSS provides health services to 530,000 regular beneficiaries and to about 100,000 temporary workers (with contracts for less than three months) or at most 7.5 percent of the population. The IDSS has 18 hospitals, 27 policlinics and 157 physician offices. ISSFAPOL covers about two percent o f the population.
The budget o f the Presidency finances most investment in plant and equipment o f public health facilities. It also operates the Essential Drugs Program (PROMESE) that initially was created to finance and manage 4 10 Popular Pharmacies (Boticas Populures) that sell generic and essential drugs at a reduced price to poor people. PROMESE has expanded i t s original mandate and now procures pharmaceuticals for all public health facilities. PROMESE supplied an annual average o f US$16 mill ion in pharmaceuticals and medical supplies between 1997 and 1999. A l ittle more than half o f the purchases were for public hospitals, 43 percent for Popular Pharmacies, and six percent for rural health clinics. PROMESE has come under heavy criticism for lack o f transparency in i t s procurement procedures, for high administrative cost (3 1 percent o f i t s purchase cost), and for lack o f quality control o f products purchased. CERSS i s leading the analysis and requesting a full-fledged review with corresponding corrective actions by the Presidency.
Almost all private sector activity i s concentrated in the two largest cities: Santo Domingo and Santiago. N o reliable data are available on the number, size, composition, production or expenditures o f the private sector. For example, the telephone directory for the National District o f Santo Domingo l is ts 119 private clinics and hospitals. This number excludes the separately listed 1,115 private physician offices and 730 dental offices that are also most likely understated. The National Association o f Private Clinics and Hospitals stated that the number o f private clinics in Santo Domingo in 2001 i s more than 300. There is no reliable central source of information to confirm or modify these numbers. Some data are available on spending for private health care services from national household surveys as mentioned above in the section on health care financing.
An accurate description of the number, size, activities and contributions o f NGOs to improving the health status of the population suffers from two idiosyncratic problems: the very broad definition o f what i s an NGO and the existence o f a large number o f ghost NGOs. First, an NGO in the Dominican Republic i s an organization that i s private, not for profit and i s not owned by the government. Essentially, an NGO i s equivalent to a nonprofit organization. They include service providers, research institutes, educational establishments, church organizations, social action groups, etc. Illustrating the definitional complexity i s the case o f the Plaza de la Salud, a large tertiary care medical complex in central Santo Domingo built with government funds, which i s classified in the National Health Accounts of the Central Bank as an NGO. Second, ghost NGOs exist for the purpose of money transfers and tax evasion and provide no services except financial benefits to the organizing members. The proposed 2002 budget includes a US$45 million subsidy for 2,051 NGOs but only about 1,000 NGOs are legally registered. The health sector i s listed with 208 NGOs and the education sector with 270. Almost half (916) o f the NGOs are included in the budget o f the Presidency. The 1999 report o f the Central Bank writes that in 1996 there were 265 NGOs dedicated to health related activities o f which 180 or 68 96
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received subsidies from SESPAS. Most health NGOs are active in health promotion and reproductive and sexual health. This number would not include NGOs with activities in the broader social welfare area or in environmental sanitation. The one reliable source o f information on health related NGOs i s the National Health Institute (INSALUD), which i s an umbrella organization with 76 institutional members that are formally approved and recognized by SESPAS.
Inequitable Access to Health Care. Access to health care i s inequitable with people in the lower income quintiles and in rural areas facing financial and geographic barriers. As a result o f these barriers, the poor seek care less often. This i s more pronounced for chronic illness for which the poor are less likely to seek care on a regular basis. The infant mortality rate for the poorest quintile i s 67 infant deaths per 1,000 live births versus 23 infant deaths per 1,000 LB in the richest quintile. The poor have more children: the total fertility rate for the lowest income quintile i s 5.1 and it i s 2.1 for the highest income quintile. Social indicators o f poverty in the 1996 ENDESA survey showed an inequitable variation between the lowest and highest income quintiles for infant mortality rates by a factor o f three, for child immunization rates by a factor o f two, and for the prevalence o f child malnutrition by a factor of thirteen.
The beneficiaries o f IDSS have an average o f five medical visits per year whereas for the SESPAS population this number i s 1.2 visits. The low number for SESPAS may be due to underreporting, to lack o f access to ambulatory services for geographic or financial reasons, to patients going to a private doctor’s office or to a private clinic. The number o f admissions to hospitals i s 68 per 1,000 people for SESPAS and 72 per 1,000 for IDSS beneficiaries. These are normal hospital admission rates for a middle-income country. SESPAS hospitals are a major source o f emergency care as one third o f all medical visits are to emergency rooms of hospitals. This i s not the case for IDSS where emergency room visits account for a normal one tenth o f all visits.
Inequitable Health Care Spending. Public sector health spending at 2% o f GDP i s among the lowest in the L A C Region yet the public sector i s the largest provider o f health services. Not only are resources insufficient but also they are spent inequitably. SESPAS i s assumed to provide health services to 64 percent o f the population or to 5.4 mill ion people. Based on i ts average budget for the years 1996-99, i t had available US$36.67 per capita. IDSS, on the other hand, for the same time period, spent US$106.67 per beneficiary. Health services provided by the two largest public sector providers account for less than a quarter of total health care spending. Out o f pocket payments at 18.5% were higher than the SESPAS expenditures at 16% as percentages o f total health spending.
The geographic distributional inequity o f public spending on health i s illustrated by the fact that more than 70 percent o f the population in the three poorest health regions (N, V I and VII) i s classified as poor but these three regions together receive less than ten percent o f the public health budget.
Inefficient Allocation of Resources. Resources are allocated inefficiently. More than 70% of public funds are spent on curative care and on the purchase o f pharmaceuticals and medical supplies. Spending on health promotion and preventive care represented only 1.1% of public spending. Administration received 14% in 1999. Allocation o f public funds i s also heavily skewed towards the National District that received an average of 43.5% during the 1996-99 period versus about 20 provinces that each received less than 2% each.
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Inefficient Use of Human Resources. Human resources management i s not efficient. First, both SESPAS and IDSS have a large number o f administrative workers, 35% and 43% respectively. This may be partly explained by the patronage system o f rewarding members of the victorious political party. Second i s the high percentage o f physicians: about one in five workers are doctors. However this number i s misleading as physicians hold more than one job and are double and even triple counted. There are more physicians in the IDSS than nurses and barely more nurses than doctors in SESPAS. Fewer nurses than physicians indicate inefficiency and lower quality care: higher paid physicians carry out tasks that should be done by lower paid nurses, and a shortage o f nurses indicates insufficient time for direct patient care activities. Third, the ratio o f SESPAS staff to population served i s one worker for 127 people and for IDSS it i s one to 55.
Too many Hospital Beds. Only one third o f the hospital beds o f SESPAS are occupied on the average but the average length o f stay (3.2 days) i s favorable. Only half o f the IDSS hospital beds are occupied in spite o f an average length o f stay o f five to six days that i s considered high taking into account that 30 percent o f hospital admissions are in obstetrics. These are averages for the whole country.
A Need to Improve the Quality of Health Services. The population i s not satisfied with the quality o f services offered in public facilities. The well to do patronize the private sector and the 1996 ENDESA survey showed that 26.6% percent o f private sector hospital patients come from the two lowest income quintiles. This means that some poor are wil l ing to pay for private services and/or that some may be treated at lower charges.
Quality in the atomized private sector i s undocumented. Private hospitals tend to be small. The largest private hospital (owned by a private university) has about 100 beds and about 80% of the private clinics have fewer than 20 beds. T h i s raises serious concems about technical quality because o f low volume for some procedures in small facilities. A correlation between volume and quality has been empirically demonstrated. The complete lack o f registration, o f accreditation, o f regulation, o f accountability, o f quality oversight, and the prevalence of solo practice lead to a presumption o f less than adequate clinical quality. Air-conditioned rooms, user- friendly reception and waiting areas, cleanliness, smiling staff and courteous physicians are associated with good quality by the general public.
A high caesarian section rate: 23% o f deliveries in SESPAS facilities were managed surgically abdominally in 2000. The IDSS caesarian section rate i s between 25 and 30 percent. WHO guidelines state that surgical deliveries should not be more than fifteen percent of all deliveries. Physician behavior and the practice of physicians rushing from one job to another are a major explanatory variable. A normal delivery takes much longer than a surgical delivery. The latter can be scheduled and done in one hour.
Deficient quality in the public sector i s well documented and recognized by the government as a major problem. Staff behavior and motivation, insufficient financial resources, irregular supply of pharmaceuticals and medical supplies, poorly maintained physical plant and equipment, water supply and electricity interruptions are impediments to improving quality. Good physical amenities and good interpersonal relations offset the presumptive low clinical quality in the private sector.
The Challenge of Implementing the Decentralization Policy. The President signed the General Health Law No 42-01 (LGS) on March 8, 2001 and the law No 87-01 that creates the Dominican Social Security System (SDSS) on May 18, 2001. Both laws authorize deep and far
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reaching reforms in organizing, financing, and managing the health sector and the social security system. O f special importance to the health sector in general and to the proposed project in particular are the provisions allowing the transfer o f technical and administrative tasks from the central SESPAS level to lower SESPAS levels and to SESPAS health facilities. Increased managerial autonomy at lower levels o f the service delivery system and decentralized decision- making would address more directly the issues faced by the operating units in carrying out their mission to provide quality medical services. The challenge i s to: (i) write the norms and regulations for implementing these policies to complete the legal framework; (ii) make the norms and regulations operational; (iii) transfer financial and human resources to the decentralized levels and institutions; and (iv) break up the historical centralized power and control structure. This wi l l require political will, administrative expertise and a large investment in time and effort to create and/or to strengthen the institutions to which authority has been delegated. These institutions have heretofore been managed centrally, have not been allowed to make any important decision and must now change their ways o f conducting their business. This drastic change in organizational culture and attitudes at all levels w i l l take time, wi l l happen one step at a time and wi l l need the patience and the long term support o f all donor agencies.
Government Strategy and Challenges
The GODR has declared health a priority. Through i t s Health Sector Reform Program formulated in the second half o f the 1990s, the GODR i s seelung to improve health and nutrition status of the population, particularly the poor, by facilitating access to quality health services in an efficient and sustainable way. The strategic thrust o f the reform program i s the gradual introduction into the health sector o f elements o f political, administrative and financial decentralization.
Since 1997, the World Bank has financed a project2 in support o f the reform program. Projects funded by the IDB, EU, and USAID complement the World Bank-financed project. Technical assistance i s also being provided by UN specialized agencies such as PAHONHO, UNDP, UNICEF, among others.
3. Sector issues to be addressed bv the proiect and strategic choices
Consistent with the recommendations in the CAS and with GODR policy, the proposed program would assist in meeting MDGs, reforming the health system, promoting integration o f public and private services within a decentralized context, and reallocating health expenditures to basic health care for the poor. It would do so building upon the initial work camed out with the support of the World Bank-financed Provincial Health Services Project and with projects supported by the IDB, EU and USAID. The GODR has embarked on a long-term process o f health reforms that require substantial political and financial support to bring it to fruition.
More specifically, the proposed project would address the following sector issues frontally:
a> Improve the quality of maternal and child services to help reduce the infant mortality rate, the under five mortality rate and the maternal mortality ratio;
b) Reduce the impoverishment effects o f ill health and disability by supporting the affiliation o f the poor to the health insurance system;
c) Develop and implement integrated health delivery networks as mandated by law by
- Provincial Health Services Project (Report No. 17199 DO).
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strengthening decentralized regional and provincial levels for coordinating and supervising service delivery as a means to reach universal coverage o f primary health care services;
Assist in deconcentrating and decentralizing technical and management decision making to lower levels o f government and to service delivery institutions. This assistance wi l l require training managers, providing them with information for decision making, devising monetary and non-monetary incentives for punctuality, courtesy, timely, and quality service;
Strengthen the stewardship role o f SESPAS ensuring that human and financial resources are effectively decentralized, that national policy i s formulated with executing parties being held accountable for implementing it, that essential public health functions that affect the whole Dominican population are in place and are being executed, that programmatic inter- and intrasectoral coordination takes place, and that results are monitored and deviations are acted upon; changing the physical and management environment of service provision that causes preventable maternal and infant deaths;
Develop new remuneration modalities for physicians - and mainly for specialists - from a straight salary to a basic salary plus performance linked payments. This i s a key incentive payment issue that i s supported by the two new reform laws. I t s implementation may be slow because it wi l l meet with resistance from many professionals who are comfortable drawing a salary for minimal time on the job giving them the opportunity to attend to their private practice; and
Support innovative pilot projects and disseminate their results to the legislative and executive levels o f government and to professional associations and service providing institutions.
4. Program Description and Performance T r i m e r s f o r subsequent loans
Performance triggers for financing subsequent phases
The complex nature o f the health sector reform agenda would be supported through a sustained, multi-phase effort. The APL approach w i l l allow the flexibility needed during the implementation o f the Dominican Republic health sector reform and for the incorporation o f lessons learned during implementation.
Trigger indicators would account for the GODR’s readiness to: i) expand the geographic coverage o f the reformed insurance system; ii) scale up the provision o f quality care through certified and licensed providers; iii) assign health system management to new regional authorities; iv) to expand deconcentration and decentralization process to additional regions/provinces; and v) scale up the provision of improved public health services reflecting lessons learned in previous phases. The triggers would be assessed and measured as part of the monitoring and evaluation o f the program and should be based on evidence that institutional capacity building and legal conditions were successful to allow to move to a new phase with minimum risk; they would be “measures o f success” when moving on to the next phase.
C. Program and Project Description Summary
1. Praiect Components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown)
The APL would implement three components in three phases. A fourth component would
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manage implementation, monitoring and evaluation, and assess changes that would trigger the decision to continue to the next phase or to change action for improving performance, or i n the last resort, to cancel the operation. The four components that would be implemented during the three phases o f the APL were presented earlier in Section 1.4. Activities for the first phase project are summarized here. A detailed description of the f irst phase project and a general description o f the second and third phase projects are presented in Annex 2.
Component 1: Health Services Coverage Extension
The earlier Provincial Health Services Project supported the provision of primary care services to the poorest population with emphasis on maternal and child health (MCH) in three regions (HI, IV, and VII), in one province of Region VIII (SBnchez Ram’rez), and in one Health Area o f the National District (Santo Doming0 Centro). Phase I of this program would: (i) complete coverage of the poor population with a basic health plan, emphasizing MCH care; (ii) add Region V I with the provinces of San Juan de la Maguana and Elias Pifia; and (iii) add the provinces of La Vega and Monseiior Nouel to complete the coverage of Region VIII. A l l these regions carry the largest proportion of poor in the country. The total population covered under Phase I would therefore be 2.3 million of which about 1.7 mill ion are under the poverty line.
A minimum of four essential criteria were used for selecting priority areas to be included under Phase I o f the Program: 1) high proportion o f poorest families; 2) health care networks in operation or about to be completed for operation; 3) health management information systems in place or about to be implemented; and 4) management agreements between SENASA and providers signed. This targeting approach i s fully consistent with the strategy adopted by the GODR to begin the implementation o f the health and social security reforms over the next 10- years in a gradual and incremental manner.
Activities that would contribute to achieve the component’s objective are: (a) support extending health care coverage in three priority regions using the national health insurance financing mechanism to deliver a basic health plan of essential health services, particularly MCH services; (b) strengthen the clinical problem solving capabilities o f the primary health care units ( U N A P S ) , the hospitals at the secondary and tertiary care levels in five regions, improve the quality o f medical services provided, and ensure a functioning referral system among levels o f care and among networks; (c) apply national norms to improve that physical infrastructure o f Regions V I and VI11 that was not covered under the f irst project, Le. equipping, rehabilitation and expansion o f health centers and hospitals at the primary, secondary and tertiary levels, including investments to strengthen the biomedical waste management systems in each facility; and (d) develop integrated and decentralized health care networks at the regional levels as authorized by the health sector reform legislation.
Component 2: Implementation of the health sector reform legislation
This component has two objectives: (a) assist in building the institutions to implement the health sector reform legislation by supporting the development o f regulatory frameworks, organizational structures, financial instruments, training programs and management information systems; and (b) assist in providing the legal and financial enabling environment for achieving the objective o f Component I. The legislature approved a General Health Law (LGS-42-01) and a Social Security System Law (SDSS-87-01) that contains key policy changes. A listing of the most important changes i s presented in Annex 2. Implementing these policy changes requires a large investment in building and/or strengthening institutions that heretofore have been managed centrally and/or have not been allowed to make any important decision.
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To accelerate the decentralization process the project would strengthen national, provincial and local institutions, support budgetary transfers to provincial directorates, grant autonomy to key health facilities and train sector leaders and health care managers. To support the implementation o f sector reforms, the project wi l l fund technical assistance to strengthen the stewardship role of SESPAS and the insurance management capability o f SISALRIL, to transfer gradually demand driven subsidies to the poorest population group, and to develop and implement health management information systems.
Component 3: protect the health of the population
Improving Selected Essential Public Health Functions to promote and
This component would improve two essential public health functions that would benefit the health o f the whole population and would have a direct impact on many sectors o f the economy: a) epidemiological health surveillance and control of r isks in public health by strengthening the information system for epidemiological surveillance, the capacity and quality control o f the National Public Health Laboratory, the cold storage facilities (cold chain), establishing a national pharmacological surveillance system; and relocation and strengthening o f the Forensic Pathology Department; and b) development of policies, plans and management capacity for assuring SESPAS stewardship by supporting the design o f a 10-Year National Strategic Plan for ensuring a gradual build up and consolidation o f the National Health System and the Social Security System. This Plan would become a navigation chart for the National Health Council (NHC) for the next 10 years, and i s expected to define coordination mechanisms for managing international donor support. Support would also be provided for carrying out policy and operational studies, including one focusing o f the training o f physicians, nurses, and other health personnel.
Component 4: Project Management and Impact Appraisal of Next Phases
This component would support project management, including the strengthening o f the monitoring and impact evaluation system to measure the results achieved during implementation. Trigger indicators would used to decide on recommending financing each one of the next two phases of the program, and appraise the technical, financial and institutional aspects o f each phase.
Monitoring and Evaluation Arrangements. The project would finance all efforts required to appropriately monitor and evaluate project outputs, outcomes and impact. Project monitoring would depend to a large extent on the envisaged Health Management and Information System (HMIS). Hence, priority would be given to the implementation of the H M I S during the early stages of the project with the goal of completing the implementation and test phase within the first year o f the project. In Phases I and II of the project, efforts would concentrate on regions and provinces characterized by high levels o f poverty and poor health outcomes. In order to ensure that the project i s achieving the objective o f closing the nation-wide poverty and health gaps, the project would finance national demographic and health surveys in each of the project phases. The annual evaluation o f the project would be outsourced to a non-governmental organization or academic institution.
Investment Financing. In each phase, the Program would finance health facilities rehabilitation and expansion, electro-mechanical and biomedical waste management equipment, medical supplies, vehicles, systems development (eg., management and financial information systems, quality assurance systems), training and technical assistance.
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Front-end fee Total Financine Reauired
Table 2: Estimated Phase 1 Project Costs by Component
0.30 I 0.7% 1 0.30 1 Yo
42.7 1 I 100.0% I 30.0 I 100.0%
2. Key policy and institutional reforms supported by the project
The development objectives o f the proposed project are in l ine with health sector reform principles and health policies enunciated in the health and social security laws. Major reforms sought include:
Stronger stewardship role o f the central level SESPAS with delegated technical and administrative functions to the regions, provinces, municipalities and service providers; Attitudinal and behavioral changes in managers and service providing personnel by fostering performance based incentives and pride in caring for the disenfranchised and poor; Deconcentrated and decentralized regional and provincial levels with more autonomy for decision making at the service provider level; Redirecting the flow of resources to support decentralizing decisions on financial and human resources; Well-defined organizational structures with clearly understood functions.
0
0
0
0
0
3. Benefits and target population Target Population. The proposed program would unwaveringly and insistently focus on gains in the health status of the poorest population groups located in the poorest regions of the country (most o f them bordering Haiti): more accessible quality services, reducing preventable child and maternal deaths, and more courteous and humane treatment with less waiting time in clean and more comfortable waiting areas. The population covered under the Phase I Project would be 2.3 million (28% o f the total population) o f which about 1.7 million are under the poverty line.
Expected systemic benefits over the medium term are:
0 Increased degree o f accountability and financial responsibility by shifting from hierarchical inspection to a supervision approach that i s based on monitoring and economic incentives embedded in results-based management agreements; Changing health care delivery from a supply driven model to a demand driven model; Well defined regulatory frameworks that support management contracts for managing and supervising health services delivery by institutions with a larger degree o f managerial autonomy; and A public sector health network that remunerates i ts personnel partly with financial
0
0
e
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incentives for performance and results and that separates the functions of regulating and monitoring from the functions of providing health care services.
4. Institutional and implementation arrangements Project Implementation Period: 4 years
Executing agencies: Responsibility for project implementation would rest in CERSS, with the participation o f SESPAS as the sector steward, SISALRIL, as the regulatory and supervisory entity o f the insurance and provision of health services, and SENASA as the Public National Health Insurance agency. The CERSS’s Project Coordination Unit (CERSSPCU) would provide technical, administrative and financial support to the implementing agencies and entities.
CERSSPCU. Headed by a Coordinator and staffed with professional and support personnel, would be responsible for providing technical, administrative and financial support to all project activities, including the maintenance o f accounting records, processing disbursements, maintaining administrative records, processing procurement contracts for goods and services, and the carrying out of related activities. This unit would review all contracts and make payments for activities related to the project.
SESPAS. The Modemization and Institutional Development Unit (UMDI) o f SESPAS, composed o f high level officials, has the mission o f coordinating efforts and resources from different sources to enable SESPAS to meet i t s new role in the health system, as mandated by the new legal framework o f the health sector. UMDI with CERSSPCU technical and administrative and financial support would prepare annual operations plans (POA) to strengthen capacity building and effective institutional development o f SESPAS so it can perform as steward, supervisor and evaluator o f the new health system. SESPAS would assign high level officers to plan and execute with CERSSPCU support, day to day activities o f project components for the strengthening o f health care networks and in particular for the carrying out i t s essential public health functions: epidemiological surveillance, national network o f laboratories, disaster preparedness and i ts related functions o f cold storage facilities and blood banks.
With CERSSPCU administrative support and project resources, UMDVSESPAS would strengthen the organizational structures and the stewardship role o f SESPAS as defined in the regulatory guidelines on stewardship and separation of functions (see annex 2). Also UMDWSESAPAS would support improving managerial functions o f the regional, provincial and municipal levels to implement regulations on organization, structure and functioning o f the health network (see annex 2). UMDYSESPAS would help to redirect the flows o f human and financial resources as well as management information to ensure autonomous management o f public service networks. As the deconcentration and the separation o f the stewardship and financing roles from the provision o f health services evolves, UMDI, with project support would strengthen SESPAS institutional capacity to monitor and supervise policies and regulations as implemented through Components 1 and 2.
SISALRIL . As mandated under the Social Security Law (L87-OI), SISALRIL was established in 2002 as an autonomous entity representing GODR interests and i s responsible for the protection o f affiliates, licensing and supervision o f ARS, payments to the PSS and monitoring the financial solvency o f SENASA and the ARS. As such, SISALRIL would have a direct participation and responsibility in the execution of Components 1 and 2, for the formulation and implementation of health policies and regulations, and in the instrumentation and pilot testing of new insurance and financing models developed with project support.
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This would strengthen the supervisory and regulatory role o f SISALRIL, supporting at the same time the implementation at the national level of managerial instruments developed under the Provincial Health Services Project, including management and clinical information systems. CERSSPCU would assist SISALRIL in the transferring o f the know-how developed and pilot tested under the Provincial Health Services Project.
SENASA. This recently created institution i s the public ensure responsible for, inter alia, administering the health r isks o f i t s affiliates with efficiency, equity and effectiveness, ensuring that services are provided with quality, opportunity and satisfaction, and contracting and paying new health providers according to conditions established in the Social Security Law. As such, SENASA, under the supervision o f SISALRIL, and with CERSSPCU support, would participate in implementing components 1 and 2 and developing pilot tests on insurance and financing models.
Phase I- Project Implementation Agreements. For the implementation of project activities, the Borrower w i l l cause inter institutional participation and performance agreements to be signed between CERSS and all participating agencies (SESPAS) and entities (SISALRIL, SENASA) on terms and conditions satisfactory to the World Bank. The purpose o f these inter-institutional participation agreements and arrangements i s to guarantee the allocation and disbursement o f project funds from the CERSSPCU to the participating agencies and entities upon proof o f compliance with obligations and conditionalities that are critical to the health care services coverage extension and the appropriate implementation of the reform legislation. These participation agreements and arrangements would also specify the legal authority o f the persons signing, the scope and duration o f the agreement, responsibilities agreed as part o f approved project operational plans, the total amount o f financing, the allocation o f funds on the basis o f meeting accepted obligations, correspondence with the investment plan and on the appropriate supervisory and monitoring means to evaluate performance. Agreements and arrangements would also specify objectives to be met, indicators to verify that objectives are met, and means o f verification. Also specified would be the duration, review periods, possible future modifications or changes, reasons for termination or suspension, conflict resolution methods and penalties for not complying with the signed agreement.
Particular attention would be placed during implementation to streamlining and close coordination between CERSSPCU and the participating agencies and entities in staying with World Bank’s procedures on the use of funds from the Special Account.
The Borrower would use management agreements to be subscribed between the SENASA and other ARSs and the Regional Health Services Networks or the PSS according to valid and current rules and regulations. Under these agreements, the service providers would commit to provide quality health care services to the beneficiary population in a timely, effective and efficient manner according to specifications contained in the social security law and i t s regulatory guidelines.
Donor Coordination. The five largest donor agencies operating in the Dominican health sector are USAID, IDB, EU, specialized UN Agencies, and the World Bank (See Table 1 in Annex 2.C). The PCU o f CERSS manages the implementation o f World Bank and JDB financed projects. In addition PCU, as part of i ts coordinating role for health sector reform, shares methodologies and experiences with the coordinating units o f the USAID and EU projects that are administered by SESPAS with assistance from international management consultancy firms. UN agencies (UNDP and PAHO/WHO) participate in the implementation o f the ongoing Provincial Health Services Project and the HIV/AJDS Prevention and Control Project and wi l l also participate in the
22
implementation o f this project. Nonetheless concerns have been expressed by some o f the donor agencies that donor coordination should be strengthened within and among regions o f the country and that all donors should align their support behind the ambitious health sector reform program especially because the major donors tend to focus their main activities in different geographic areas. Therefore the government - following the example o f the education sector - i s preparing a IO-year Development Plan for Health Sector Reform as a management tool to coordinate donor strategies and resources and to reduce duplication o f efforts. The 10-year Plan would spell out the respective areas of responsibility for each donor, the willingness o f each donor to accept that responsibility, for how long, under what conditions, with what kind and size o f financial support (with or without cost sharing), and the commitment to coordinate with other donors.
D: Program Rationale
1. Project alternatives considered and reasons for rejection
N o project alternative. The 2001 reform laws challenge the health sector to implement organizational, financial, and health care delivery reforms, while at the same time extending the coverage and raising the quality o f health services for the poor. World Bank financial participation in supporting the reform process i s important but not a critical factor. The GODR and the World Bank agree that the value added o f the loan and the World Bank involvement would be to assist in operationalizing the different aspects o f the reform laws, setting in place a new institutional framework, and in developing the needed instruments such as implementing rules and regulations and monitoring systems. The proposed APL i s using the experience from the ongoing Provincial Health Services Project in order to ensure the timely availability of the needed technical and financial support to implement the complex reforms in the medium term and to improve the health status o f the poor.
Standard investment operation alternative. The GODR and the World Bank team discussed the most appropriate lending instrument for supporting the health sector reforms. The standard investment lending approach was discarded in favor o f utilizing the APL approach to support the proposed project for the following reasons: (i) the long term horizon for meeting the reform program’s objectives; (ii) the existence of a sound sector reform program developed by the GODR and the a 10-year Development Plan under preparation; and (iii) the GODR’s decision to pilot test new institutional arrangements and instruments not yet fully developed and evaluated because o f the level o f complexity o f the contemplated reforms. The APL would support the GODR’s incremental approach to the reform o f the health sector, while developing the long-term political and institutional commitment to the reform process.
A project with a national scope for the provision of health services. This alternative was rejected because i t would limit the potential to have a positive impact on the poorest population group living the regions bordering Haiti that have limited access to quality health services. Selection of areas other than the ones selected for the Phase I o f the program would have created multiple demands and dissipate the efforts and resources that could be otherwise be allocated to the selected regions. In addition, the approach selected i s fully consistent with the gradual and incremental strategy adopted by the GODR for implementing the health and social security reforms over the next IO-years.
23
2. Ma.ior related proiects financed by the Bank andfor other development agencies: (completed, ongoing and planned)
Sector issue
Bank- financed
Health status improvement
HIV/AID S
Other development agencies Health Sector Program
Red Salud
Health Sector Modernization
IP/DO Ratings: HS (Hi
Project
Provincial Health Services Project (Ln.4272-DO)
HIV/AIDS Prevention and Control (Ln.7065- DO)
European Union
USAID
IDB Project
ly Satisfactory), S (Sal
Latest (Bs
Implementation Progress (IP) S
S
S
S
actory), U (Unsatisf
ipervision (Form 590) Ratings &-financed projects only) Development Objective (DO)
The objectives o f the Provincial Health Services Project are to: (I) assist in the expansion o f health care coverage to reach the poorest population groups, focusing on mother and child health care; (ii) assist in improving the quality o f health care services already provided to the poor; (iii) assist in strengthening policy-making and management capacity o f provincial health units; and (iv) assist in fostering community participation in the health system.
This project i s assisting the Government o f the Dominican Republic (GODR) in curbing the spread of the Human Immune-deficiency (HIV) epidemic through the scaling up o f programs and activities targeted to high-risk groups; expanding awareness about HIVIAcquired Immune-deficiency Syndrome (AIDS) among the general population; and strengthening institutional capacity to ensure the effectiveness and sustainability o f the effort.
USAID, IDB and EU are the other three large donor agencies (See Annex 2.C)
The Government i s preparing a 10-year Development Plan for Health Sector Reform as a management tool to align the support o f each development agency and to minimize duplication o f resources and efforts. ,tory), HU (Highly Unsatisfactory)
3. Lessons learned and reflected in proposed Program design:
Program design and content are benefiting from the experience with ongoing operations financed by the WB (Provincial Health Services Project) and other donor agencies (e+, LDB, USAIDS, EU). Key lessons incorporated in project design are: (i) project objectives and scope are linked to a clear legal and policy framework; (ii) strong government and stakeholder commitment at different levels o f the sector has been obtained; (iii) financing of critical investments to improve the quality and effectiveness of health services are linked to the implementation o f policy and institutional reforms; (iv) the project would support systems and human resources development to
24
improve decision-making and management capacity o f sectoral institutions; (v) adequate project monitoring and impact evaluation arrangements have been developed to allow adjustments to be made in project design and implementation arrangements during the l ife of the project; and (vi) strong national teams need to established to ensure the long-term sustainability o f the reform effort.
During i t s f i rst three years of implementation the ongoing World Bank project did not have the legislative support that now exists for this proposed project. Major reform initiatives were therefore slowed down as the executive level was hamstrung by outdated health policies and the lack o f a strong legal foundation. In the early years o f implementing the ongoing World Bank project - and the difficulties faced by the IDB project in modernizing the health sector - it became evident that substantial progress needed to be made on the policy and legal levels. This support became a reality in 2001 with the enactment o f the General Health Law and o f the Social Security Law. The new legal environment created by these two laws provides the legal support enabling sector and institutional reforms. The proposed program i s taking full advantage o f the reform principles in the new health law and social security law. The emphasis o f the two laws on decentralized decision making, deconcentrating technical and administrative functions, and gradually moving from a supply-driven health care delivery system to a demand-driven system supports the health services delivery strategy o f creating integrated health networks that target the poorest segments o f the population.
The two new laws are also an encouraging s ign that the GODR i s committed both to protecting the environment and to reducing the risks posed by the improper management o f medical waste. The laws provide a new framework for managing infectious and other medical waste that poses health r isks to patients and health care staff, as well as to people who are exposed to such waste outside health facilities. The proposed support activities related to the handling o f medical waste build on the WB-financed Provincial Health Services Project, and the recommendations in the assessment o f medical care waste handling and disposal conducted under the HIV/AIDS Prevention and Control Project (See Annex 2.B).
4. Indications of borrower commitment and ownership
There i s strong and convincing evidence o f borrower commitment and ownership, as follows:
A letter was sent by the GODR to Mr. James W. Wolfensohn, President, World Bank, dated April 2,2003 defining the policy framework for the proposed APL. A letter was sent by the Technical Secretary o f the Presidency and by the Health Secretary in October 2001 requesting follow up support for implementing the health sector reform activities. The two laws passed in March and May 2001 provide the legal underpinnings for the proposed sector reforms. Firm and satisfactory agreements were reached during the preparation missions held in June, 2002, November 2002, and March 2003; i.e. agreement with the Government on an outline o f the design o f a health sector reform support program; agreement on the preferred lending instrument to be an APL confirming the PCD review meeting decision held in April 2002; agreement on a program that would consist o f three four-year phases over the period 2003-2016; agreement on a set o f performance triggers, including MDGs, to be evaluated at the end o f the f i rst and second phases and that achieving the agreed upon performance would be a condition o f financing the next phase.
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5. Value added of Bank surmort to this APL Program
The World Bank’s value-added to the proposed program includes experience with APL Programs, performance-based, and investment lending, as well as international experience and expertise on health reform program design and implementation. World Bank involvement in the Dominican Republic has already been a major conduit for exchange o f regional and global experience and exposure to international best practices that have helped shape the reform process. In addition, World Bank involvement would provide oversight on the use o f funds, consistent with i t s procurement and disbursement norms and guidelines. Moreover, the World Bank team and specialized consultants would provide technical assistance during program implementation and facilitate the identification o f adjustments to the design o f the program design if necessary.
E. Summary Project Analysis
1. Economic (See Annex 4):
[ x] Cost benefit [XI Cost effectiveness [ ] Other(specify)
NPV=US$; ERR=%
The GODR has placed improving individual health services and the protection of public health as a high priority relative to other aspects o f i t s development agenda. Having done so, the economic return to the design and level o f interventions proposed under the project are demonstrably high; with cost-benefit ratios under a “most likely” scenario o f national income growth, population growth, reduction in mortality among selected target groups (mothers and infants) estimated at 1: 6.6 if only the costs of interventions in the APLl Regions are accounted for; and 1: 4.0 if the entire cost of APL1 i s accounted for. (Annex 4).
2. Financial (see Annex 4 and Annex5)
NPV=US$ million; FRR=%
The improvements introduced through the project appear to be financially sustainable. Overall, incremental non-personnel post project costs would represent 1.6% o f the 2003 health sector budget and 5.5% o f the 2003 non personnel health sector budget. The Regions being targeted for the initial phase o f the APL are among the poorest and worst served in the country at present. Incremental non-personnel costs would represent 5% o f the 2003 budget for these regions and 17% of the non-personnel budget fort he regions. This large increase would represent a needed re- allocation o f resources towards the poor, and would sti l l , from a macro point o f view, be sustainable.
3. Technical
Project design builds upon the achievements o f the ongoing Provincial Health Services and the HIV/AIDS Prevention and Control Projects and other projects supported by other donor agencies, as well as on the findings and recommendations o f technical studies and evaluations o f the current health sector reform process. As a result, the proposed design fit local conditions, needs, priorities and respond to sustainability issues. In addition, recent studies and ENDESA data were used as the basis for identifying key health problems (e.g., maternal and child health), and recommended approaches to solve them.
Overall, the project i s technically justified on the basis o f the importance of the problems i t
26
addresses, the cost-effectiveness of the interventions to be delivered in project areas, their affordability, and the political consensus on the need for fully implementing the mandates o f the health and social security laws in order to reform health care organization and financing in the country.
4. Institutional
4.1 Executing Agencies. The CERSSPCU as well as the participating agencies and entities have been involved and managed projects financed by international donors, including the World Bank, since the mid-1990s. Lessons learned from the experience have been incorporated in project design. Strong and experienced technical and administrative teams in the participating agencies and entities would be responsible for managing project implementation.
4.2 Project Management. Recent assessments carried out during project preparation found administrative and financial management o f the ongoing Provincial Health Services Project satisfactory. The same technical and administrative teams would be in charge o f supporting project implementation.
4.3 Procurement Issues. Procurement under the project would be centered i n the CERSSPCU, for equipment, goods, works and consultants services financed out o f World Bank loan proceeds. The most recent Procurement Capacity Assessment Review rated the PCU as Average Risk; therefore the CERSSPCU wil l observe the proposed thresholds for the project. The CERSSPCU would be responsible for upstream, procurement-related activities, including preparing and reviewing procurement plans, coordinating procurement reviews, and preparing reports on compliance and prior review activities. Specific guidelines for the solicitation, evaluation, awards, and contracting processes for the acquisition o f goods and services are contained in the Operations Manual.
Procurement would be managed on the basis of annual procurement plans that would correspond to the annual work program. The World Bank would approve both the annual work program and the corresponding procurement plan. The first year’s work program and procurement plan were agreed at appraisal.
The country’s Essential Drugs Program (Programa de Medicamentos Esenciales-PROMESE) has been transformed into a Logistic Support Center (Central de Apoyo Logistico-CAL). As a result o f recent legislation, al l purchase o f medical supplies and pharmaceuticals for the public sector institutions must be made through CAL. However, bidding procedures for any procurement financed with bilateral and multilateral institutions would be carried out according to the norms o f those institutions.
The United Nations Development Program (UNDP) w i l l assist the project in procurement activities as it has done so for the Provincial Health Services Project (Loan 4272-DO). The government w i l l assume the costs o f the administrative fees charged by UNDP from i t s own resources. In addition, GODR i s exploring with UNDP a bridge financing arrangement for project startup activities prior to loan effectiveness (as informed by the GODR team during negotiations, the possible bridge financing would be reimbursed by Borrower with i t s own funds). PAHOWHO would continue to support the GODR in planning, procuring vaccines and other medical supplies, and in undertaking immunization campaigns under the project
Key elements o f the procurement assessment made for the project are included i n Annex 6.
27
4.4 Financial Management Issues. Accounting and financial management for the project would be the responsibility o f the CERSSPCU. This unit would also be the repository for all other project recording, accounting and reporting. Retroactive financing for eligible expenditures up to US$3.0 million would be provided from appraisal to loan signing. Procurement audits would be performed at the same time as financial audits.
Due to the experience o f the CERSSPCU with SOE-based disbursement procedures under the Provincial Health Services Project and the HN/A IDS Prevention and Control Project, traditional disbursement methods would be used to draw down funds from the loan and Financial Management Reports (FMRs) would be used to monitor project implementation on a quarterly basis.
The CERSS/PCU wil l be in-charge o f maintaining, operating and reporting on the Special Account. The CERSSPCU wi l l also operate a Program Account for the purpose o f receiving counterpart funds from the government as well as a transitory account for funds disbursed from the Special Account for the Banks share o f eligible expenditures for which the CERSSPCU i s responsible. Similarly each Program Implementation Units (PIU) at participating agencies and entities would also operate their own Program Accounts for the purpose o f receiving counterpart funds, and Special Account funds as payment to supplier come due for the World Banks share o f eligible expenditures. All Program Accounts would be opened at the Banco de Reservas.
Special Account. The PCU would establish a Special Account in US$, at the GORD’s Central Bank. The Special Account i s only to be used for eligible expenditures under the loan agreement. Under no circumstances may funds in the Special Account be used to cover the share of expenditures corresponding to the counterpart funds. Transfers from the Special Account to other project bank accounts would only be Dermitted to meet eligible expenditures for a limited ueriod o f no more than 30 days.
Audit compliance. According to World Bank records for the Provincial Health Services Project, 2000 and 2001, audit reports have usually come on time and are acceptable. However, the audit reports have both had qualified opinions due to issues regarding the commingling o f counterpart, loan funds, and IDB funds. This issue has been discussed at length with the CERSSRCU and they have agreed to implement measures to ensure that all funds are accounted for and maintained separately.
5. Environmental Environmental Category: B (Partial Assessment)
5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The ongoing Provincial Health Services have contributed to the improvement in healthcare waste management in the country, including: (a) assessments o f medical waste management practices in health facilities; (b) purchase of incinerators and other equipment in the largest hospitals o f the country; (c) training o f health facilities staff i n biomedical waste management; and (d) design and updating o f environmental norms and guidelines. The proposed project would build upon and expand the scope o f activities supported under ongoing projects in order to improve biomedical waste management processes and practices in the health systems.
28
As done with the support of the ongoing Provincial Health Services Project, resources would be allocated under Component I to assist participating health facilities in project areas, as needed, in the: (i) undertaking o f assessment of medical care waste handling and disposal; (ii) updating o f manual to address proper handling and disposal of medical wastes; (iii) rehabilitation of infrastructure and the installation of equipment in the main local hospitals for the disposal o f medical wastes; and (iv) training o f health personnel in the application o f standards to protect patients, health workers, and the community.
5.2 What are the main features of the EMP and are they adequate? The project would have a beneficial impact on the environment in several ways. The project would support substantial improvements in the handling of biomedical waste in participating health facilities. To this end, the project under Component I would finance related civi l works, equipment, materials, training and operating costs. The project would also have a favorable environmental impact through the rehabilitation o f health facilities, where malfunctioning or inoperative basic systems for water, electricity and air conditioning w i l l be repaired andor replaced. This i s expected to improve water quality and sanitation, and reduce environmental pollution. Technical assistance w i l l be provided to the local govemments of each participating locality in order to improve the disposal o f residual waste, without any risk to their staff or to the environment.
Environmental construction and management norms for health facilities, including internal waste management, personnel health and safety provisions for the handling and disposal of biological waste and operation o f equipment w i l l be part o f the Operations Manual for the project.
5.3 For Category A and B projects, timeline and status of EA:
Date of receipt of final draft: May 7,2003
5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft E A report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted?
Project objectives, scope and proposed investments, including those related to improvements in biomedical waste management have been discussed among the different stakeholders who are part of the National Health Council. This includes key public, private and non-governmental agencies and institutions operating in the health sector o f the Dominican Republic.
5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? The Operations Manual for the proposed project would include environmental guidelines for the construction of health facilities, guidelines and framework in the event of any resettlement caused by the project, and norms and guidelines for the proper biomedical waste management in the participating health units. Bidding documents for civi l works would also include related provisions. The compliance with these provisions would be monitored as part of supervision activities in the selected facilities.
The environmental guidelines in the Operations Manual would refer to: (a) biomedical waste management and disposal, including segregation o f waste; (b) personnel health and safety provisions for the handling and disposal of hazardous wastes; and (c) environmental guidelines to be included in the bidding documents for civi l works. I t would also include World Bank
29
guidelines and framework in the event o f any resettlement caused by the project, alongside with guidelines for small construction works.
6. Social:
6.1 Summarize key social issues relevant to project objectives, and specify the project’s socia1 development outcomes
The main social development issues related to the proposed project refer to the inequality in access to health services, inequality o f health status among different population groups and between urban and rural regions, high child and maternal mortality rates for the country as a whole, and the impoverishment impact o f ill health and disability among the poor uninsured population. The main sector issues section flagged the low but improving health status, the slowly decreasing poverty, the preventable maternal mortality, HIV prevalence, inequitable access to health care, low and inequitable health care spending, and the need to improve the quality o f health services.
To help address the above issues, project design i s geared to: i) expand the population and geographic coverage o f the reformed insurance system; ii) scale up the provision of quality care through certified and licensed providers, particularly to improve child and maternal health; iii) assign health system management to new regional authorities; iv) to expand deconcentration and decentralization process to additional regions/provinces; and v) scale up the provision o f improved public health services reflecting lessons learned in previous phases.
6.2 Participatory Approach: H o w are key stakeholders participating in the project?
a. Primary beneficiaries and other affected groups:
Different public, private and non-governmental stakeholders who are part of the National Health Council actively participated in the design o f project related activities, as well as in the design of macro-sectoral reform and processes. As such, key stakeholders were consulted regarding both the pertinence of the program and the willingness to participate during all the stages of the project with positive responses.
b. Other key stakeholders:
Regional and provincial health authorities in selected areas to be covered under Phase I o f the APL were also consulted and involved in the preparation o f the project. The participatory activities initiated during preparation would continue during implementation, particularly to inform and mobilize the beneficiaries and their representatives at the national, regional and provincial levels, in participating health facilities, and with the Presidential and Congressional candidates for the elections to be held in 2004.
As noted above, special emphasis would be placed during project implementation to develop mechanisms to strengthen international donor coordination.
6.3 H o w does the project involve consultations or collaborations with NGOs or other civil society organizations? The National Health Council i s the forum where all the key stakeholders in the Dominican health sector participate, discuss and agree on the major decisions related to the health sector reform process.
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6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? The proposed project i s building upon existing arrangements that had been put in place since 1996 with the support of the ongoing Provincial Health Services Project and more recently with the support o f the HIV/AIDS Prevention and Control Project. T h i s allows active participation under the National Health Council o f key sectoral stakeholders.
6.5 H o w will project monitor performance in terms of social development outcomes? As defined in Tables 3 and 4 o f Annex 2, specific triggers and performance indicators would allow monitoring in terms o f social development outcomes. Triggers and performance indicators would respectively be assessed by December 2007 and by December 2012.
7. Safeguard Policies:
7.1 Are any of the safeguard policies triggered by the project? [ Policy I
Environmental Assessment (OD 4.01 ) Natural Habitats (OP/BP/GP 4.04) Forestry (OP 4.36) Pest Management (OP 4.09) Cultural Property (OPN 11.03) Indigenous Peoples (OD 4.20) Involuntary Resettlement (OP 4.30) Safety o f Dams LOP 4.37’) Projects on International Waterways LOP 7.50) Projects in Disputed Areas (OP 7.60)
7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies:
As has been done on the ongoing projects, resources have been allocated under the project to finance improvements in the biomedical waste management in the different participating institutions, including equipment purchase, training o f personnel and development o f guidelines and internal norms. Also, please see 5.5 above.
F: Sustainability and Risks 1. Sustainability
The project would be sustainable because i t i s anchored in the new laws for reforming the health sector and therefore has the support at the highest political levels. These laws were prepared, reviewed, and approved after an extensive participatory process in the health sector. Major sectoral stakeholders have been involved in project preparation and would participate in project implementation assuring country ownership.
GORD has demonstrated strong and increasing budgetary commitment to the reform process. The GODR top priority in the health sector i s to extend health insurance coverage over a 10-year period. World Bank financial participation represents only a fraction o f the health reform effort. In addition, as the implementation o f the health insurance reform proceeds in the upcoming years, the GODR envisions the gradual conversion o f budgetary transfers to health facilities on the basis o f historical budgets into transfers for financing the affiliation of the subsidized population. This conversion, along with the allocation o f additional resources, would help ensure the long-term
31
sustainability o f the reform effort. Productivity and efficiency gains expected to be achieved through the project would contribute in the medium term to reduce the modest fiscal impact of project investments. Also, the strengthening and consolidation o f sectoral institutions (e.g., SESPAS, SISALRIL, SENASA) would ensure a sustainable health insurance system in the Dominican Republic.
2. Critical Risks: Risk
From Outputs to Objective Insufficient capacity to implement complex technical and politically difficult reforms, particularly at the regional and provincial level.
Political and budgetary commitment to the program not preserved over time, particularly during changes o f Administration and due to fiscal problems.
From Components to Outputs Limited progress in advancing the decentralization o f the entire public sector apparatus, delaying the reforms in the public health sector. Insufficient capacity at the provincial level to meet fiduciary requirements regarding procurement and financial management.
Overall Risk Rating: Risk Rating - H (High Risk), S (Substa
3. Possible Controversial Aspects
G. Main Loan Conditions
1.1 Negotiation Conditions
Rating
S
S
S i a l Risk), M (Modest Risk:
Risk Minimizing Measures
Technical assistance wi l l be part o f the package o f services financed under the project. Local agencies wi l l be prepared for the transition to the new system. Information, communication and education campaigns, as well as consensus building initiatives, would be supported involving key sectoral stakeholders. The adoption o f the reform laws was based on a strong commitment from different stakeholders and political authorities f rom different parties. Support would be provided to develop new health care financing and resource allocation mechanisms to gradually move from financing the supply o f health services to financing demand.
Worked closely with political and economic authorities to ensure that health sector reforms are supported by public sector reforms. Conduct workshops and seminars to develop local capacity.
\I (Negligible or Low Risk)
The Govemment provided by appraisal the following documents:
0
0
Normative Guidelines for Regulating the General Health Law. Copy of the Rules Goveming the National Social Security Council Copy of the Rules Goveming the National Health Council
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Copy o f the Rules and Regulations governing the Stewardship os SESPAS and the Separation of Functions of the National Health System Copy o f the Rules and Regulations for Provision o f Health Services Network; Copy o f the Rules and Regulations governing the Family Health Insurance Scheme. Alternative Basic Health Plans and their associated costs. General Guidelines for Licensing Health Care Facilities and Services Letter o f Development Policy drafted by GODR. Model Management Agreement to be signed between SENASA and the Health Services Network, approved by the relevant national authorities (the first agreement was signed on May 9, 2003 between SENASA and the health providers in Region IV). Submission of the FMR format to be used by PCU for reporting purposes.
’
1.2 Effectiveness Conditions
Loan effectiveness conditions are: (i) adoption by the Government o f an Operations Manual satisfactory to the World Band; and (ii) submission o f a model Inter-Institutional Participation Agreements.
The following Financial Management actions are also conditions for project effectiveness: (i) open Special Account at the Central Bank, and (ii) the first deposit to the Program Account o f counterpart funds in the amount of US$l.5 million has been made.
2. Other Implementation o f the project in conformance with an Operations Manual Maintenance o f the PCU acceptable to the Bank Timely allocation o f counterpart funds
H. Readiness for Implementation [ ] 1. a) the engineering design documents for the f i rs t year’s activities are complete and ready
for the start of project implementation. [XI 1. b) Not applicable
[XI 2. The procurement documents for the f irst year’s activities are complete and ready for the start o f project implementation. [XI 3. The Project Implementation Plan has been appraised and found to be realistic and o f satisfactory quality. [ ] 4. The following items are lacking and are discussed under loan conditions (Section G):
I. Compliance with Bank Policies I. The project i s expected to comply with all applicable Bank policies.
&W/, Ana-Maria Amagada, SMU Direct%
- C x n e D. hsbey , CMU Director
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Annex l a Dominican Health Sector Reform Support Program
Project Design Summary Note: if not otherwise indicated:
Indicators refer to the target population of Phase I o f the Program, the people l iving in regions 111, IV, VI, VI1 and VIII; Baseline information refers to the year 2002 and targets to the year 2007 "*" Indicates baseline data that are either outdated and/or o f questionable quality; efforts w i l l be taken by the GODR to update information within the first year o f project implementation "**" Indicates targets that are professional judgments but do not reflect a broader national consensus and/or build on weak baseline data. In either case, a review o f the target i s envisaged within the first year of project implementation For some indicators, no information was available regarding baseline data (N.A.) and/or discussions concerning targets not concluded. These information gaps w i l l be closed during the first year o f project implementation.
.
. . 9
. Hierarchy of objectives CAS Goal Poverty reduction; increased share o f the poor receiving the benefits of social development and economic growth
Progress towarc
A. Improve maternal health
See progress towards health related Mil lennium Development Goals
health related Millennii Maternal mortality rate
Total fertility rate
n Development Goals Unit: maternal deaths per 100,000 l ive births Baseline: 122 [1999]* Target: -20% (98) ** Unit: total number o f children that would be born to a woman during her reproductive years'
Baseline (Target) 111: 2.8 (2.5)"" IV: 3.9 (3.5)"" VI: 4.3 (3.9)** VII: 2.8 12.5)""
SESPAS health statistics
ENDESA survey
Critical Assumptions
(From goals to Bank mission)
Other macroeconomic and social variables within and beyond the control of the government o f the Dominican Republic are neutral or favorable
See above
35
1 Hierarchy of ob'ectives 1
Indicators
Percentage of underweight newborns Under 5 mortality rate
Infant mortality rate
Neonatal mortality rate
See also A
Baseline & Targets
VIII: 2.8 (2.5)**
Baseline: 5.9 [1999] Target: 4.1 Unit: under 5 deaths per 1,000 live births Baseline (Target) 111: 30 (24)"'" IV: 66 (53)** VI: 68 (54)** VII: 28 (22)** VIII: 43 (34)**
Unit: infant deaths per 1,000 live births Baseline (Target): 111: 25 (20)** IV: 44 (35)** VI: 50 (40)** VII: 25 (20)** VIII: 34 (27)**
Unit: neonatal deaths per 1,000 l ive births 111: 17 (14)** IV: 21 (18)** VI: 28 (24)** VII: 15 (13)** VIII: 22 (19)**
:ans of rification
Critical Assumptions
Project DeveloF I. Increase the proportion o f the target population utilizing services provided under the Basic Health Plan
ent Objectives (2003 to Percentage o f pregnant women with at least 4 antenatal care visits
Percentage o f births attended by skilled personnel
Percentage o f women in reproductive age that use modern family planning methods
Percentage o f children aged 12 to 23 months fully immunized (DPT, Polio, Measles)
Percentage o f children under 5 with diarrhea that are medically diagnosed and treated
306) Baseline (Target): 111: 92.4 (98) IV: 90.2 (98) VI: 90.3 (98) VII: 95.5 (98) VIII: 9 I .3 (98)
Baseline (Target): 111: 98.2 (98) IV: 91.5 (98) VI: 93.7 (98) VII: 96.8 (98) VIII: 97.6 (98)
Baseline (Target): 111: 67.9 (73)** IV: 61.0 (66)** VI: 65.1 (70)** VII: 70.4 (76)"" VIII: 69.4 (75)**
Baseline (Target): 111: 42.1 (54)** IV: 26.0 (41)** VI: 35.3 (48)** VII: 33.8 (47)** VIII: 33.0 (46)**
Baseline (Target): 111: 41.4 (53)** IV: 47.6 (58)** VI: 41.0 (53)** VII: 34.0 (47)"" VIII: 37.2 (50)**
SESPAS health statistics
ENDESA Survey
Health Service Statistics resulting from the to be established electronic Health Management and Information System
Special studies and surveys
(From objectives to goals)
Determinants o f maternal and child health outside the control o f the project remain neutral or favorable
Interventions included in the Basic Health Plan are effective i n reducing maternal and child mortality
37
11. Improve the quality o f services provided under the BHP to the target population
111. Remove financial barriers to access and protect the target population o f financial consequences o f ill-health IV. Improve afficiency o f health system
Percentage o f women receiving antenatal care that are immunized against tetanus (at least two injections)
Percentage of women diagnosed with severe pre-eclampsia or eclampsia referred to tertiary care facilities
% of staff in facilities incorporated in PSSs present during working hours
% o f target population satisfied with the quality o f BHP services % o f population eligible to government subsidies under the Social Security Law enrolled in National Health Insurance Plan
Private expenditure as a % of total health expenditure % o f SENASA's financial resources allocated to primary care level services
NurselMidwife per doctor ratio in PSSs (excluding auxiliary nurses)
Hospital beds per 1,000 population in PSSs
% of administrative and managerial positions created in the reform process at the regional, provincial and municipal level of SENASA that are filled with SENASA employees
Baseline (Target): 111: 92.7 (100) IV : 89.6 (100) VI: 92.6 (100) VII: 94.4 (100) VIII: 93.1 (1 00)
Baseline: N.A. Target: 100%"
Baseline: N.A. Target: 95%
Baseline: N.A. Target: 75%
Target: 80%
Baseline: 73% [2000] Target: Pending
Baseline: N.A. Target: > 30%**
Target: 0.8:1.0**
Target: 1/1,000**
Target: >90%
38
Project Output I. Public Health Service Mana, Dement Units (SRS) are established at the regional, provincial and municipal level and operate based on clearly defined responsibilities, authority, and with sufficiently trained staff
2. The National Health Insurance System i s established and operational under the supervision o f SISALRIL
x SRS are established at the regional and provincial level
Legislation i s enacted that transfers and regulates responsibilities and authorities o f SRS
% of managers and administrators o f SRS received training
See also: 6
Number o f National Health Insurance bodies (SNSs) that reimburse contracted PSSs timely and according to contractual arrangements
Financial resources flowing from SENASA on the basis o f service production as a % o f total financial resources allocated to project regions
Regional SNSs are solvent and financial management i s :ontinuously monitored sy SISALRIL
Target Regional: 5 Provincial: 18
Target year: 2003
Target: 100%
Target: 5
Target: 25%
Target year: from 2004 onwards
Project monitoring and evaluation
Progress reports
Project monitoring and evaluation
Progress reports
Special surveys
Health Service Statistics resulting from the to be established electronic Health Management and Information System
(From outputs to PDOs)
The current and future governments o f the Dominican Republic remain committed to the project and continue the institutional and health system reforms
Capacity building activities are sufficient that institutions are able to implement the reform agenda
Administrative, management and health staff are committed to make the reforms work
Counterpart funding w i l l be available
The institutional reforms w i l l result in improved accountability and transparency and thus improve the resDonsiveness o f
3. Autonomous networks o f public and private providers (PSS) are created at the regional, provincial and municipal level and operate autonomously with sufficiently trained managerial and administrative staff
4. PSs, SNSs and SRSs reached and implemented contractual arrangements that govern performance- based reimbursement procedures
5. SRSs developed and implemented a quality assurance program that includes provider licensing and accreditation
Number o f regional PSSs established
Number o f primary care facilities participating in each regional PSS
Number o f PSS and hospitals integrated in PSSs that assumed full responsibility and authority to manage human resources
% o f managers and administrators o f PSS that job specific received training
See also 1, 5, 6
% o f SNS that contracted al l existing PSS for service provision
% o f the contracts signed between SNS and PSS that include performance elements (e.g. quality, consumer satisfaction)
% o f providers participating in PSSs that are registered under the corresponding regional licensing scheme
x regional administrative bodies (SRS) operate provider accreditation schemes
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Target: 3
Target Primary: min. 1 per 2,500 population**
Target: Hospitals: 1/3 PSS: 2
Target: 100% **
Target: 100%
Target: 100%
Target: 100%
Target: 3
Project monitoring and evaluation
Progress reports
Special surveys
Project monitoring and evaluation
Progress reports
Special surveys
Project monitoring and evaluation
Progress reports
Special surveys
he health system .o the health needs I f the target iopulation
4utonomous nulti-sectoral irovider networks dl be effective n removing ;eographical Jarriers to access
The health nsurance system w i l l remove the nost significant Financial barriers io access The improved medical quality o f services and behavioral changes o f staff w i l l encourage the target population to utilize basic health services
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6. The BHP i s delivered through PSs with an infrastructure meeting nationally defined standards and sufficiently trained staff that makes appropriate use o f well functioning medical equipment and supplies and take advantage o f internet based medical information sources
7. Staff makes appropriate use of an electronic health management and information system that links SNS, SRS and PSS. networks, national insurance systems and administrative bodies
% o f nurses and physicians affiliated with PSS that received additional training in the provision o f the B HP
x PSS facilities with insufficient infrastructure (capital & equipment) rehabilitated andlor expanded
% o f PSS facilities that have essential drugs available at any time
% o f PSS health professionals trained i n IT technology and use internet based resources in daily work
SRS, SNS and PSS are linked by an electronic HMI system
% o f administrative, managerial and professional health staff trained in the use of the H M I S
x regional SNS and PSS use H M I S for budget planning and control
Baseline: 100%
Target: 3
Target: 100%
Baseline: 70%**
Target year: 2004
Target: 100%
Target:
Project monitoring and evaluation
Progress reports
Special surveys
Project monitoring and evaluation
Progress reports
41
8. A network o f public health laboratories provides services to diagnose communicable and non- communicable diseases and communicate results to a central public health service that monitors and reports the epidemiology o f diseases, develops control strategies. 9. The central drug administration licenses new drugs, monitors the drug market and ensures the availability and the rational use o f drugs
x types o f test are routinely provided by public health laboratories
% of test results are available to providers through the HMIS within x days
% of test results are centrally collected through the HMIS and reported in annual epidemiological reports
x staff of central drug administration receive additional training in pharmacoepidemiology and pharmacosurveillance
A continuous education program for pharmacists, physicians and nurses i s designed and implemented with x graduates per year
A drug licensing scheme i s designed and all new drugs approved before entering the market
See also: 5
Baseline: N.A. Target: Pending
Target: Pending
Baseline: N.A. Target: Pending
Target: Pending
Target: Pending
Target year: 2004**
Project monitoring 3nd -valuation
Progress reports
Special surveys
Project monitoring and evaluation
Progress reports
Special surveys
10. The Program Management Unit i s established and operational
The PCU i s staffed w i t k appropriately skilled and experienced technical, administrative and financial professionals
% o f supervision and financial requirements met by the PCU
% o f implementation milestones (outputs) achieved in time
% o f performance indicators tracked and reported to decision makers
42
Target year: 2003
Target: 100%
Target: 90%
Target: 100%
Project monitoring and evaluation
Progress reports
I
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Annex l b Dominican Health Sector Reform Support Program
Linking outputs, outcomes and impact
Annex 1 summarizes project outputs and expected outcomes (development objectives) and impacts (MDGs) with corresponding indicators to monitor project progress. The purpose of this section i s to describe key causal links between outputs, outcomes and impacts.
The CAS, as well as the 2001 Poverty Report and the 2003 Public Expenditures Report, identify the increased share o f the poor in the benefits of social development and economic growth as a sine qua non for poverty reduction. This objective of World Bank support i s coherent with the commitment to achieve the Millennium Development Goals - development objectives that the government and c iv i l society o f the Dominican Republic endorsed at the Millennium Summit in September 2002. The MDGs stipulate significant improvements in maternal health and substantial reductions in child mortality. Mortality and morbidity among pregnant women and children results from a small set o f diseases and conditions. Effective and cheap interventions exist to prevent the fatal consequences and are included in the Basic Health Plan o f the Dominican Republic. Key for progress towards the MDGs i s therefore achieving universal coverage o f the Basic Health Plan (Project Development Objective I) and ensuring the quality and effectiveness of the services provided under the Basic Health Plan (Project Development Objective 11). Increased coverage o f the Basic Health Plan results f rom removing not only geographical but financial barriers to access (Development Objective 111). Removing financial barriers through a National Health Insurance Plan that reaches beyond enrollees formally employed would also protect the target population from financial consequences o f ill health. Thus, Development Objective I11 w i l l also contribute to the Millennium Development Goal o f reducing poverty and hunger. However, the reduction o f poverty and hunger depends on too many determinants that the impact o f Development Objective 111 could be monitored at the level o f generic poverty indicators.
The following project outputs would result from effective project implementation: 1.
2.
3.
4.
5.
6.
7 .
Public Health Service Management Units are established at the regional, provincial and municipal level and operate based on clearly defined responsibilities, authority, and with sufficiently trained staff. The National Health Insurance Plan i s established and operational under the supervision o f SISALRIL. Autonomous networks o f licensed public and private providers are created at the regional, provincial and municipal level and operate autonomously with sufficiently trained administrative and managerial staff. Autonomous provider networks, Public Health System Management Units and National Insurance Plan Secretariats reached and implemented contractual arrangements that govern performance- based reimbursement procedures. Public Health Management Units developed and implemented a quality assurance program that includes provider licensing and accreditation. The Basic Health Plan i s delivered through public and private provider facilities with an infrastructure meeting nationally defined standards and sufficiently trained staff that make appropriate use o f well functioning medical equipment and supplies and take advantage of internet based medical information sources Staff makes appropriate use o f an electronic health management and information system that links public and private provider networks, the National Insurance Plan secretariats and Public Health Management Units.
44
I. A network o f public health laboratories provides services to diagnose communicable and non-communicable diseases and communicate results to a central public health service that monitors and reports the epidemiology o f diseases and develops control strategies.
2. The central drug administration licenses new drugs, monitors the drug market and ensures the availability and rational use o f drugs.
Replacing a highly segmented with an integrated, cross-sectoral delivery system (PO 1) i s expected to remove geographical barriers to access. Implementation of the National Health Insurance Plan (P02) would remove financial barriers to access. The establishment o f Public Health Service Management Units (P03) would primarily oversee and ensure the effectiveness o f the provider networks and the National Insurance Plan (PO 18~2). Thus, Project Output 1 to 3 wil l contribute to Development Objective I, the increased utilization o f the Basic Health Plan. The decentralized nature o f project outputs 1 to 3 i s expected to contribute to the effectiveness of the envisaged financing and service delivery system by improving accountability and transparency.
Project outputs 4 to 6 and 8 and 9 are expected to improve the quality of the services provided under the Basic Health Plan and thus would contribute and ensure progress towards Development Objective I1 (improvement o f the quality o f services providing the BHP). The implementation o f the National Health Insurance Plan would ensure progress towards Development Objective I11 (removing financial barriers to access and protecting from financial consequences o f ill-health). The implementation o f a comprehensive and effective Health Management Information System i s expected to improve the effectiveness o f the system as a whole (including the financing, delivery, stewardship and surveillance function).
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Annex l.C Dominican Republic Health Reform Support Program
Government Policy Letter
s D.N. 2m3
n:
46
47
48
4
49
50
51
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Annex 2.a
Dominican Republic Health Reform Support Program
Detailed Project Description
The proposed Adaptable Program Loan (APL) aims at:
a) Contributing by the year 2015 to achieve the Millennium Development Goals (MDG) agreed to by the Government o f Dominican Republic at the Millennium Summit in September 2000. Specifically, the Program would address three MDG goals: reduce child mortality, improve maternal health, and contribute to eradicate extreme poverty by protecting the poorest from financial loss due to ill health and disability;
b) Supporting implementation of the new legal framework for the health sector, particularly the institutional strengthening o f SESPAS in i t s new stewardship role, the development of insurance mechanisms, and the configuration o f regional health networks; and
c ) Supporting preparation, validation and dissemination of supplementary norms to the General Health L a w (42-01) and the Social Security L a w (87 -01).
The APL builds upon and complements the ongoing Provincial Health Sewices Project and the HIWAIDS Prevention and Control Project. The main legal framework is built upon the General Health Law and the Social Security Law, both approved in 2001 and a set of regulatory provisions derived from these laws. The most important ones are the following:
“Regulatory Guidelines on Stewardship and Separation o f Functions o f the National Health System”: They enable SESPAS to convert the public health network into one or several “prestadoras de servicios de salud”(PSS) (art. 160) and promote the creation o f regional health services.
“ Regulatory Guidelines for Licensing Health Facilities ”. They establish minimum operational procedures and requirements for operation in order to obtain clearance for providing health services. The aim i s to ensure safety and quality in health care delivered by public, private national and international providers in the country. These requirements have to be met before starting service delivery.
The National Health Council approved other rules and regulations for operating blood banks and clinical laboratories, and a reagents l ist.
“ Regulatory Guidelines for Health Care Networks ”: Affiliation and provision. They allow SESPAS to differentiate personal health care from preventive services and provisions for affiliating beneficiaries.
“ Human Resources Regulatory Guidelines ”: They regulate contracting and remuneration o f human resources according to the Civ i l Service and Administrative Career Law No. 14-91 o f 1991 and the Labor code for private workers. I t looks especially for stability in performing functions in the health system.
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Regulatory Guidelines to the Social Security System:
" Regulations on the Family Health Insurance and the Basic Health Plan": These by-laws approved by the National Health Council in 2002, regulate the benefits contained in the Social Security System, and conditions, limitations and exclusions of the Family Health Insurance, and compel al l private and public entities to participate in the system by delivering one or several components o f the family health insurance scheme.
" Regulatory Guidelines for the Control of Drugs for the Basic Health Plan": the National Social Security Council approved these by-laws in 2002. They remiate the incorporation and use o f drugs in the Basic Health Plan defined by a Basic chart of essential drugs and therapies. Also, they entitle SESPAS to design therapeutical guidelines to assist health providers in drug prescription.
Three components in each one o f three phases of four years address the above three goals of the Program. The three program components aligned with the three development objectives are:
Supporting health services extension to achieve universal coverage. The Program would contribute to improving the health status o f the economically disadvantaged population groups, especially by reducing child and maternal mortality. I t would contribute to reduce poverty by makmg the already approved Basic Health Plan (BHP) accessible to the poorest and most vulnerable population. The main mechanism for providing access by the poor to the BHP would be through government subsidies o f their health insurance premium, thereby removing financial barriers to access and protecting them from financial loss due to ill health and disability. The APL would promote affiliation by strengthening primary health services and hospitals at the secondary and tertiary care levels. It would improve their capacity to provide quality medical services, especially MCH care to the target population, providing a physical and technologically supportive environment and improving staff performance'.
Supporting implementation of the health sector reform legislation. The Program would assist in implementing the mandates o f the reform laws by supporting the development o f innovative approaches, testing new models, and funding policy studies in the areas o f financing and organizing health care, paying providers and remunerating personnel. I t would support implementation o f mandated decentralization policies that provide more autonomy and decision-making authority to lower administrative levels and to service providing institutions. These tested models and studies would provide the financial, managerial and institutional tools and the legal underpinning for achieving universal health service coverage. They would be implemented jointly with the activities under the first component.
Improving Selected Essential Public Health Functions to promote and protect the health of the population. The Program would support SESPAS in improving two essential public health functions that would benefit the health o f the whole population and would have a direct impact on many sectors o f the economy:
a) Epidemiological health surveillance and control of risks in public health: The following activities would be implemented: (a) strengthening the information system for epidemiological surveillance to monitor incidence and prevalence of communicable and non-communicable diseases and to decide on control measures. Coordination with the HIV/AIDS/STIs
Consejo Nacional de Salud: Reglaiirewto de Esrrrirrura, orgaiiizacich !,ficiicictiiaitrieiito de 10s redes piiblicas de I
provisiuiz de seniicios d e areircidii a las per-soilus. Marzo 2003. R.D.
54
surveillance system would be established; (b) Strengthening the capacity and quality control o f laboratory and blood bank practices, including further development iiz extenso of the Norms for Good Practices in Public Health Laboratories’; (c) Better equipping and staffing the National Public Health Laboratory to perform virologic, bacteriologic and chemical analyses for food and water safety, air pollution control, vector disease diagnosis and control, and other analyses related to sanitation; (d) strengthening the cold storage facilities for vaccines and other biomedical products, and blood banks; (e) establishing a national pharmacological surveillance system to ensure that the pharmaceutical market fulfils the basic criteria o f efficacy, safety and a reasonable costs o f the authorized medical, nutritional and cosmetic substances; and ( f ) relocation and strengthening of the Forensic Pathology Department.
b) Development of policies, plans and management capacity for assuring SESPAS stewardship: Under component 2, SESPAS would be substantially strengthened to ensure effective policy formulation and management. This component would support the design o f a 10-Year National Strategic Plan for ensuring a gradual build up and consolidation o f the National Health System enacted by the General Health Law approved in March 2001, and the Social Security System enacted by the Social Security Law approved in May 2001. Partial implementation of this 10-year Strategic Plan would allow for field testing o f implementation arrangements for both systems as proposed in components 1 and 2. Coordination arrangements for bilateral and multilateral cooperation to help consolidating the health sector reforms nation-wide would be an essential part o f this Strategic Plan. This Plan, therefore, would become a navigation chart for the National Health Council (NHC) for the next 10 years, and i s expected to define coordination mechanisms for managing international donor support3. Support would also be provided for carrying out policy and operational studies, including one focusing o f the training of physicians, nurses, and other health personnel.
Program Phasing
The proposed Program wi l l achieve the stated development objectives in three phases over a period o f twelve years. Each phase would have three components plus a component for project management, monitoring and evaluating the results o f each phase and - in the case o f the first two phases - appraising the next phase of the program.
Phase I Components
Component 1: Support Health Services Coverage Extension
Geographic Definition. The earlier Provincial Health Services Project supported the provision of primary care services to the poorest population with emphasis on maternal and child health in three regions (111, IV, and VII), in one province o f Region VI11 (Sanchez Ramirez), and in one Health Area o f the National District (Santo Doming0 Centro). Phase I of this program would promote: (i) completing and deepening coverage o f the poor population with a basic health plan, emphasizing MCH care; (ii) adding Region V I with the provinces of San Juan de l a Maguana and Elias Piiia; and (iii) adding the provinces o f L a Vega and Monsignor Nouel to complete the coverage o f Region VIII. All these regions carry the largest proportion o f poor in the country. A minimum of four essential criteria were used for selecting priority areas to be included under the Program: (a) high proportion o f poorest families; (b) health care networks in operation or about to be completed for operation; (c)
SESPAS: Norinas para [as Biierras Prdcticas de Laboratorios de Salud. R.D., 1999. Consejo Nacional de Salud: Reglame,rto de Recoria y separacidri de Fitnciones del Sistenra Naciorral de 3
Suiiid.Capitulo IV. Diciembre 17. 2002.
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health management information systems in place or about to be implemented; and (d) management agreements between SENASA and providers signed.
The three priority regions border Haiti and have the highest percentage o f poor: about one mill ion people l ive i n Regions IV, V I and VI1 and about 76 percent o f this population qualifies for the subsidized scheme under the family insurance system. Two more adjacent regions (I11 and VIII) equally poor would be supported for their incorporation into the strategy o f gradual expansion o f the universal family insurance system. About 1.3 mill ion people live in these two regions o f which about 70 percent are under the poverty line. The total population covered under Phase I would therefore be 2.3 mil l ion o f which about 1.7 mill ion are under the poverty line.
The following activities would contribute to achieve the component’s objective:
Support extending health care coverage in three priority regions using the national health insurance financing mechanism to deliver a basic health plan o f essential health services, emphasizing M C H services.
Strengthen the clinical problem solving capabilities o f the U N A P S , the hospitals at the secondary and tertiary care levels in five regions, improve the quality of medical services provided, and ensure a functioning referral system among levels and among networks;
Applying national norms to improve that physical infrastructure of Regions V I and VIII that was not covered under the f i rs t project, i.e. equipping, rehabilitate, and expand health centers and hospitals at the primary, secondary and tertiary levels, including the financing of investments needed to strengthen the biomedical waste management systems in each facility; and
0 Develop integrated and deconcentrated health care networks at the regional levels as authorized by the health sector reform legislation.
Strengthening the provision of M C H Services. The highest priority would be assigned to ensure the delivery o f MCH services included in the Basic Health Plan of the National Social Security System (see Table 1 below). This Plan includes prenatal, partum and postpartum care, including hospital care for normal deliveries and surgical deliveries (cesarean section) when necessary, and premature baby care. I t also includes medical care for pregnant women with clinical pathology, emergency and hospital care, and family planning. For children, the Plan includes comprehensive care for children (immunizations, growth and development, pediatric care, and school health). (See table 1 below). I t i s expected that 80% of M C H care would be delivered in NUAPS, 10-15% in secondary care hospitals, and 5-10% in tertiary care hospitals. The NUAPS are the Primary Health Care Units with a catchment population size o f 2,500, capable (in theory) o f providing most o f primary health care. Presently, the outstanding issue i s precisely i t s meager capacity to address effectively the health problems o f the population under i t s catchment area, especially due to constraints o f staff quality and lab support.
The Program would finance the strengthening o f the infrastructure o f 359 primary health care units (UNAPS) to ensure an efficient and effective response capacity (capacidad resolutiva) for delivering the above maternal and child services. Specifically, the project would finance physical facilities, laboratory and medical equipment, training, information systems, drug and other medical supplies. I t would also support a study and i t s implementation to modify the incentive system.
In addition to financing these inputs, the project would support the establishment of Maternal and
56
Child Mortality Committees to study each maternal and child death for identifying human errors, malpractice, technical deficiencies, negligence and ethical issues. The Committee would take appropriate actions to correct the identified issues and possible factors explaining maternal and child deaths. Among options for addressing the issues identified, the project would support a) workshops on medical education, obstetrics and gynecology, and medical ethics to improve medical and nursing skills; b) workshops on how to improve the clinical response capacity (capacidad resolutiva) o f the health network to address technical deficiencies (e.g., lack o f laboratory, drugs, and other medical inputs for obstetric and pediatric care); and c) sanctions to staff found responsible for negligence, malpractice and ethical misconduct. These committees have been established by a Government decree in March 2001 but s t i l l need to be operational (SESPAS: Comitd Nacional de Prevencibn, Estudio, y Seguimiento de la Mortalidad Materno Perinatal. March 2, 2001)
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Table 1. Basic Health Plan and Costs
Presidencia de la Republica
SUPERINTENDENCIA DE SALUD Y RIESGOS LABORALES
COSTOS PERCAPITA DEL CATALOG0 DE PRESTACIONES DEL PLAN BASIC0 DE SALUD
Version 1.4 aprobada por el CNSS el 30 de octubre del 2002
Partos 1 0,030370 1 270.000 I 168,75 Atencion de parto normal 1 0,019741 I 175.500 I 75,66 IAtencion de parto por cesarea 1 0,010630 1 94.500 1 93,09 I
58
Cirugia
Cirugia General
TIP0 DE SERVlClO FRECUENCIA DEMANDA COST0 I I I
0,008616 76.601 48,22
0,00861 6 76.601 4 8 , ~
Cirugia
Cirugia General
0,008616 76.601 48,22
0,00861 6 76.601 4 8 , ~
Component 2: Support implementation of the health sector reform legislation
This component has two objectives: (i) assist in building the institutions to implement the health sector reform legislation by supporting the development o f regulatory frameworks, organizational structures, financial instruments, training programs and information systems; and (ii) provide the legal and financial enabling environment for achieving the objective o f Component I. The legislature approved 8
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General Health Law (LGS-42-0 1) and a Social Security System Law (SDSS-87-0 1) that contains key policy changes. The most important changes are:
Developing a universal family insurance system (SFS) consisting o f two parts: SENASA in charge of the public sector, and Health Risk Administrators (ARS) i n the private sector. The SFS covers the whole family members and includes health promotion, prevention, care, and rehabilitation benefits, as well as pregnancy and delivery care. I t does not include care for traffic accidents; Organizing providers into legally sanctioned Health Services Providers (PSS) that can be public, private, or mixed public/private; Separating financing health care from providing health care; Gradually introducing a comprehensive basic health plan for all Dominicans irrespective of their socio-economic conditions and o f their insurance status (see table 2 below); the law sets a transition period o f 10 years for allowing the separation o f functions in SESPAS (financing and provision o f services), the conversion of the Dominican Institute o f Social Security -DISS- into an ARS while terminating i t s service provider function. All financial resources for service provision from SESPAS and DISS would be transferred to the Treasury o f the National Council of Social Security; Changing how providers are reimbursed and personnel are paid; and Deconcentrating decision-making by transferring technical and administrative tasks from the central MOH level to lower MOH levels and to M O H health facilities. The 10-year National Strategic Plan for supporting the implementation o f the National Health System and the National Social Security Plan would include the mechanisms and partial financial support provided through this Program and complementary financial support needed from other sources (see component 3).
Implementing these policy changes requires a large investment in building and/or strengthening institutions that heretofore have been managed centrally and/or have not been allowed to make any important decision. Key programs in developing these institutions would require:
Implementing the organizational structures, defining the stewardship and normative roles and the regulatory functions of SESPAS, SENASA, SISALRIL, Social Security Treasury, and regional and provincial levels, and redirect the flows o f human and financial resources and o f information to manage networks and to give the supervisory capacity to the deconcentrated technical and managerial levels.
Developing regulatory and contractual frameworks for managing and supervising deconcentrated networks, and creating governing Boards;
Ensuring that the basic health plan reaches all poor;(see table 2 below)
Applying financial instruments for modifying the behavior o f providers such as: (i) mechanisms for paying providers: per capita, per diagnostic procedure, and for achieving coverage targets; (ii) developing transparent fee schedules the efficacy o f the national network o f public health laboratories in detecting and controlling diseases affecting large population groups; at facilitate cost recovery through contracting with other providers and charging for services provided to the insured population; and (iii) increasing productivity by paying staff a basic salary or professional honoraria plus incentives for achieving goals at specified levels o f quality, for results obtained and for performance according to approved standards;
Developing trainins programs to trainhetrain and to increase the management capacity o f the managers of the network facilities and regulatory levels: central, regional and provincial;
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Implementing and consolidating management information systems already developed under the first project; and
f) Developing and implementing quality assurance systems and institution-specific quality enhancement plans, and introducing accreditation and licensing o f health care providers to raise the quality o f services provided.
Advances have been made i n building networks and in granting more autonomy to hospitals and lessons have been learned in Region IV under the Provincial Health Services Project. Now that there i s the legal support o f the two new laws the work initiated in Region IV can be completed. The experience from Region I V would be extended to Regions 111, VI, VI1 and VIII. The managerial, financial and service delivery tools legally authorized by the new laws (e.g. contract management, provider behavior modification incentives, quality improvement) would be in place in five regions at the end of the f i rs t phase. Phase I would also try out innovative approaches to manage the health sector; test new models for financing health care, for paying providers and for managing personnel; and carry out supporting policy studies with a view o f mainstreaming and extending these seminal health sector reform actions during the second phase.
In order to accelerate the decentralization process, the project would give priority to support management in order to strengthen provincial and local institutions, through installation and operation o f health management information systems, budgetary transfers to provincial directorates, and legal autonomy to provincial and local health facilities for human resources management. The employee payroll would be managed locally with discretion for directors to introduce incentives for good performance. Intensive management training programs, health management information systems and national and international technical assistance drawing upon experiences from other countries would be financed.
The Program would provide technical assistance to SESPAS in the strengthening o f i t s stewardship role and i t s planning and managerial capacity at central level; the reengineering and instrumentation o f regulatory and licensing responsibilities at central, regional and provincial level including the development and implementation of new governing and managerial structures and the separation o f the provision o f services through the development o f regional integrated health delivery networks.
Technical assistance w i l l be provided to SISALRIL in the development o f insurance management applications to standardize ARS billing, utilization review and medical auditing processes, risk management and actuarial studies, including the installation o f the information technology platform in at least 4 1 regional and provincial levels (Intendencias). The infrastructure provided w i l l also assist SISALRIL and the Social Security Treasury in the establishment o f efficient and equitable price structures for the Basic Health Plan, standard billing mechanisms to implement transparent electronic banking transactions and reimbursement processes.
The allocation o f financial resources through SENASA wi l l gradually allow the transfer of demand driven subsidies to the poorest population, introducing efficiencies through the implementation o f quality and performance based incentives. The Project wi l l support the establishment o f SENASA’s national and regional capacity to manage affiliation and beneficiary databases; the purchase of services through management agreements with regional network providers; the utilization review, medical auditing and reimbursement through automated insurance management applications and respective information technology platform.
The Program would allocate resources trough the executing agencies for the training o f sector leaders, health managers, ARS, health service providers (PPS) and other actors in the new health insurance
61
products, the use of standard applications and the pricing and reimbursement mechanisms; health sector reforms, laws and regulations; strategic planning and management; quality clinical and managerial processes and protocols; the use o f information technology and clinical and management information systems in decision making processes.
To support the implementation o f sector reforms in participating institutions, the project w i l l fund technical assistance, the selection, acquisition, development and implementation o f health management information systems and required IT platform (hardware and software) for the installation and operation of voice, data and video local area networks (LAN) and communication and voice Ip systems for wide area networks (WAN); the training o f sector leaders, clinical, management and administrative staff; the procurement and installation o f office and medical equipment and the rehabilitation o f health facilities required for licensing and delivery o f quality care.
Component 3: Improving selected essential public health functions to promote and protect the health of the population
This component would start with the establishment o f the epidemiological surveillance system and IT platform at SESPAS central level and two project regions, and carrying out the following studies and action programs in support o f activities under this component. Implementation of these studies and action programs would take place in Phases I1 and 111:
During the first year o f Phase I, a 10-Year National Strategic Plan proposal for gradual build up and consolidation o f the National Health System would be developed. Init ial implementation o f the 10-Year National Strategy Plan would be financed under components 1 and 2. This Plan would become the navigation chart o f the National Health Council for the next 10 years, and would help i t in coordinating national and international technical and financial cooperation.
In the third and fourth year o f Phase I, diagnostic studies and action programs would be carried for a) strengthening the National Public Health Laboratory, the Laboratory Department and Blood Banks, and lab facilities for surveillance o f food and water safety and clean air standards; b) strengthening the national cold storage facilities (cold chain); c) establishing the pharmaceutical surveillance system, including processes of approving and registering new drugs, surveillance of the drug market, marketing, pricing and distribution o f drugs, and the rational use of drugs by assuring compliance behavior by prescriber and patients. The study would make recommendations on how best to support and strengthen the Drug Regulatory Authorities, and Pharmacy Faculties at public and private universities, over what time period, at what cost and under what financing conditions. The action program would also propose and cost programs to train in pharmaco- epidemiology, pharmaco-surveillance as well as programs o f continuous education for physicians, pharmacists and nurses; and d) relocation o f the National Forensic Pathology Institute. Support would also be provided for carrying out policy and operational studies, including one focusing o f the training of physicians, nurses, and other health personnel.
All these studies and preparation o f action plans would be financed under Phase I of the Program
Component 4: Phase I Management and Appraisal Next Phase
This component would support project management, and use o f performance indicators for monitoring and evaluation in terms o f impact achieved with implementation. Also it would use trigger indicators to decide on recommending financing the next phase o f the program, and appraise the technical, financial and institutional aspects o f the next phase.
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Investment Financing. Phase I would finance health facilities rehabilitation and expansion, electro- mechanical and biomedical waste management equipment, medical supplies, vehicles, systems development (e.g., management and financial information systems, quality assurance systems), training and technical assistance.
Monitoring and Evaluation. The project would finance all efforts required to appropriately monitor and evaluate project outputs, outcomes and impact. Project monitoring would depend to a large extent on the envisaged Health Management and Information System. Hence, priority would be given to the implementation o f the HMIS during the early stages o f the project with the goal o f completing the implementation and test phase within the first year of the project. In Phase I and I1 of the project, efforts would concentrate on regions and provinces characterized by high levels o f poverty and poor health outcomes. In order to ensure that the project i s achieving the objective o f closing the nation- wide poverty and health gaps, the project would finance national demographic and health surveys in each o f the project phases. The annual evaluation o f the project would be outsourced to a non- governmental organization or academic institution, which would directly report to the presidential office.
Phase I1 Components
Phase I1 would consist o f the same four components as Phase I, one component for each o f the three development objectives and one component for project management, evaluating the results of Phase I1 and appraising the third phase o f the program.
Component 1: Support Health Services Coverage Extension
Under Phase I1 this component would continue to assist the extension o f the provision of the basic health plan in program terms and in geographic terms. I t would critically review the health services offered under the basic health plan and add cost effective services guided by a financial sustainability analysis. Programmatic and geographic extension would take into account three criteria: (i) it must benefit the poorest and most vulnerable population groups; (ii) priority would be given to women and children; and (iii) i t must implement the mandates o f the health sector reform legislation.
Component 2: Support implementation of the health sector reform legislation
The 10-Year National Strategy Plan would specify the mechanisms for expanding health sector reforms achieved during the f i rst four years o f the Program (see triggers) and would specific funding sources for this expansion. Under Phase I1 this component would continue and extend the activities proposed and detailed under the Phase I component earlier. Specific activities for supporting the implementation o f the laws would be the result of the evaluation o f the Phase I implementation and of the triggers for deciding on the appropriateness of financing Phase III. Pilots and experiments carried out under Phase I would be evaluated, corrections made to those activities that performed below expectations, and mainstreaming the programs that are judged to be efficient, effective and sustainable. Prior to initiating Phase I1 the results o f applying the health sector reform principles to three regions would be evaluated. After making the required corrections two more regions would be selected to expand and deepen the health sector reform.
Component 3: Improving selected Essential Public Health Functions to promote and protect the health o f the population
The second phase would implement action programs prepared during Phase I for strengthening the National Health Laboratory, the Department o f Laboratories and Blood Banks, and the cold storage
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facilities for vaccines and other biomedical products. Options for establishing regional capacity to perform some public health laboratory functions would be explored in this phase (e.g. quality control o f water, air, food standards; confirmatory testing for suspected disease outbreaks). Investment would be made i n equipment and supplies and in ongoing technical sk i l ls training programs. The pharmaceutical system improvement, including the rational use of drugs, would be in full operation and would continue with training programs for consolidating the national pharmaco-surveillance system integrated in the WHO International Monitoring Program (WHO MC- Uppsala).
B y the end o f Phase 11, the studies and action programs done in Phase I would have been implemented, including the strengthening the National Public Health Laboratory, the Department of Laboratories and Blood Banks, and the epidemiological surveillance system. These activities would ensure reliably and timely reporting o f any disease outbreaks and report communicable diseases and changes in the prevalence o f non-communicable diseases. They would also monitor the pharmaceutical market to ensure that i t meets the basic criteria o f efficacy, safety and reasonable costs of authorized drugs. The relocation o f the National Forensic Pathology Institute would have been implemented.
Component 4: Phase I1 Management and Appraisal Next Phase
Similar to the fourth component under Phase I, this phase would also support project management, monitor the progress o f implementation at the hand o f performance indicators, use trigger indicators to decide on recommending financing the third phase o f the program, and appraise the technical, financial and institutional aspects of the next phase.
To a lesser degree than under Phase I, Phase I1 would also finance health facilities rehabilitation and expansion, electro-mechanical and biomedical equipment, medical supplies, vehicles, systems development (e.g., management and financial information systems, quality assurance systems), training and technical assistance. Exact needs and costs would be determined during Phase I1 preparation activities.
Phase I11 Components
Analogous to the f irst two phases, Phase I11 would also consist o f four components, one component for each o f the three development objectives and one component for project management, evaluating the results o f Phase I1 as part o f designing Phase 111, and a rigorous evaluation of the whole health sector reform program. Providing a detailed blueprint anticipating the contents of the four components for Phase I11 at this early stage i s not advisable. The contents would be strongly guided by the lessons leamed f rom the first two phases, by an evaluation o f the political environment, and by a financial sustainability analysis within the context o f the macro economic environment. A major objective of Phase 111 would be consolidating the gains o f the f i rs t two phases with a shifting emphasis towards assuring quality o f health services provided.
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Component 1: Support Health Services Coverage Extension
The emphasis under Phase I11 would be consolidating the universal provision o f the basic health plan achieving equitable health services coverage. An evaluation o f the impact of the first two phases may reveal: (i) population groups with limited or insufficient access to the basic health plan causing unacceptable rates of neonatal and post neonatal mortality, of avoidable maternal deaths, of preventable child deaths, and o f premature deaths; (ii) health services that should be provided but that are not routinely part o f the basic health plan and that are justified on cost effective and humane grounds; and (iii) geographic areas (municipalities, provinces, regions) that require more intensive support for managing and developing their human resources and their institutional capacity. The f i r s t two phases should have enabled achieving an acceptable degree o f equity in the availability and accessibility o f the basic health plan. A key objective o f Phase I11 would be to assure that equitable services are o f similar quality for all recipients and that discrepancies are corrected.
Component 2: Support implementation of the health sector reform legislation
Phase I11 would continue and extend the activities proposed and detailed under the second component o f the first two phases. The results of the evaluation o f the f i rst two phases and of al l trigger indicators would guide the specific activities for continuously supporting the implementation o f the laws and the successful implementation o f the coverage extension component. Prior to initiating Phase I11 the results o f applying the health sector reform principles to three regions and i t s impact on the equity and the quality o f essential health services would be carefully evaluated. After malung the required corrections the remaining regions would be included in the health sector reform program. This component therefore would simultaneously expand activities and consolidate gains.
Component 3: Improving selected Essential Public Health Functions to promote and protect the health o f the population
Phase I11 would remedy any deficiencies or shortcomings observed during the evaluation of Phase I1 to ensure that the National Public Health Laboratory and the epidemiological surveillance system are monitoring health status, particularly o f mothers and children, and that related health indicators to MDG are achieved.
Component 4: Phase I11 Management and Impact Evaluation. Similar to the fourth component under Phases I and 11, this phase would also support project management, monitor the progress o f implementation at the hand o f performance indicators and appraise the technical, financial and institutional aspects of the health reform program. A major objective would be assessing and evaluating the successes and failures o f the health reform program, carrying out a financial analysis, recommending appropriate changes and modifications, and documenting the lessons learned.
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Phase I (US$42 million; IBRD, US$30
Table 2 presents the summary data on the APL:
Phase I1 Phase 111 (US$42 million; (US$42 million; IBRD, US$30 IBRD, US$30
Implementation Period million) million) million)
FY 2004-2008 FY 2008-2012 FY 2012-2016 Periodic Monitoring
Triggers' Assessment Appraisal next phase
(BRD)
Performance Evaluation by Phase. T&ger indicators for moving from Phase 1 (APL1) to Phase 2 (APL2) and from Phase 2 to Phase 3 (APL3) are listed in Table 3 of Annex 2. These triggers would be assessed prior to and reviewed during appraisal of Phase 11 and Phase I11 APLs.
Twice a year Twice a year Twice a year
March 2007 March 201 1 June 2007 June 201 1
Trigger indicators would account for the GODR's readiness to: i) expand the geographic coverage o f the reformed insurance system; ii) scale up the provision o f quality care through certified and licensed providers; iii) assign health system management to new regional authorities; and iv) scale up the provision o f improved public health services reflecting lessons learned in previous phases. The triggers would be assessed and measured as part o f the monitoring and evaluation o f the program and should be based on evidence that institutional capacity building and legal conditions were successful to allow to move to a new phase with minimum risk; they would be "measures o f success" when moving on to the next phase.
Compliance with disbursement schedules made as per legal agreements would also be taken into account for moving from a phase to the other.
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Annex 2.b
Dominican Republic Health Reform Support Program
Medical Waste Management Assessment in the Dominican Republic
The recent enactment o f new General Health and Social Security Laws are an encouraging sign that the GODR i s committed both to protecting the environment and to reducing the risks posed by the improper management o f medical waste. These laws provide a new framework for managing infectious and other medical waste that poses health risks to patients and health care staff, as well as to people who are exposed to such waste outside health facilities.
The solid waste produced in health facilities i s potentially hazardous, infectious, contagious, or toxic, producing the risk o f the spread of diseases.
The proposed Program, building on the ongoing Provincial Health Services Project, and the recommendations in the assessment of medical care waste handling and disposal conducted under the HIV/AIDS Prevention and Control Project, would support activities related to the handling of medical waste in the Dominican Republic. Specifically, i t would support (1) necessary investments under Component I to strengthen biomedical waste management systems and processes in participating facilities; and (2) related training o f health personnel associated with these activities.
The following sections o f this document:
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Describe what constitutes medical waste and discusses the management of medical waste;
Provide an overview o f the new legal and institutional framework for addressing the problem o f medical waste in the Dominican Republic;
Discuss investments financed under the ongoing WB-financed Provincial Health Services and the HN/AIDS Prevention and Control Projects in the Dominican Republic; and
Identify how the proposed Program would contribute to addressing the problem o f medical waste in the Dominican Republic.
A. What Constitutes Medical Waste
Medical waste i s defined as any material disposed o f by a health facility, whether i t i s in solid, liquid, or gaseous state. Health facilities are understood to be public hospitals, private centers, clinical laboratories, pharmacies, etc.
According to the international standards dictated by the WHO, medical waste falls into the following categories:
General medical waste. This category includes paper and byproducts, plastic and glass products, and non-infectious materials.
Special biomedical waste. This i s infectious or other waste produced by a health facility that poses health r isks both within the health facility and beyond it.
Infectious biomedical waste. This includes blood, secretions, needles, syringes, vaccines, and pointed or sharp materials that may have been contaminated with infectious agents. Preventive measures in handling and final disposal of such waste are important.
Chemical waste. This includes disinfectants and other chemicals used for examinations, research, cleaning, etc. Special regulations are required for the handling and final disposal o f such chemical waste.
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Radioactive waste. This i s waste contaminated with radioactive substances used in diagnostic examinations or special therapeutic procedures. The elimination of radioactive waste requires specialized procedures because o f i t s hazardous nature.
Anatomical waste. This consists of corpses or human remains from births, abortions, mutilations, or surgical operations. Anatomical waste poses a great risk spreading infection. Both forensic medicine regulations and ethical considerations are important in the handling o f such waste.
Internationally accepted standards establish a total production of medical waste between 3.3 and 11 pounds per bed per day. Eighty percent o f this consists o f general medical waste and the remaining 20% consists o f special biomedical waste, approximately 14% of which corresponds to infectious waste. A study performed in 1992 by the Universidad Aut6noma de Santo Domingo, based on the analysis o f a sample o f 29 public and private health facilities in the DR, found that the production o f medical waste per bed per day was 5.5 pounds.
Internationally accepted standards for the percentages o f waste produced by various components o f health facilities are as follows: food service (50%); hospitalization service (18%); maternity service (8%); emergency service and orthopedics (8%); surgery (5%); and administrative, diagnostic and other services (11%). The 1992 study o f 29 public and private health facilities in the Dominican Republic found the following distribution o f waste production by type o f service: (25.6%); kitchen (20.8%); surgery (1 1%), and outside consultation (9.2%).
B. Approaches to the Management of Medical Waste
The management o f medical waste requires special care, including the provision o f information and training to the staff o f a health facility that are involved in the various aspects o f waste production and management. The waste management process has several phases, which control waste from the point of production to i t s final disposal, as detailed below:
Classification. Classification o f waste at the point o f production (i.e., separating infectious and hazardous waste from the conventional waste stream with the goal of reducing the amount of waste that needs to be specially treated) makes it possible to reduce the volume o f infectious waste and minimize treatment costs.
Internal collection. Intemal collection refers to the use o f special containers, designed for the type o f waste to be handled, placed near where the waste i s produced and used only once.
Internal transfer. The shortest route between the point o f production and intermediate storage o f waste should be selected for the internal transfer o f waste. Waste containers should be checked to ensure that they are closed. Special measures should be taken to protect the staff involved in transfers.
Storage. The storage place where the containers with waste are held before the treatment and/or final disposal o f the waste should be equipped with hermetically sealed containers.
External transport. The transport o f waste from the point o f intermediate storage to the waste treatment point should be done using special vehicles that can be disinfected.
Treatment. Waste treatment includes methods, techniques, or procedures that change the characteristics o f waste, reducing or eliminating the possibility that the waste w i l l affect people’s health or the environment.
The WHO has identified several procedures for medical waste treatment:
Incineration. Incineration involves burning waste in a medium under controlled conditions to oxidize the carbon and hydrogen present in the waste. This method reduces the volume o f solid waste by 80-95%. Although incineration can produce environmental toxins such as dioxin if
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adequate controls are not adopted, it i s often recommended because i t i s the only waste treatment method applicable to all types o f biomedical waste.
Steam sterilization. This method involves submitting the waste to steam inside an Autoclave, at an adequate temperature and pressure and for a determined time.
Gas sterilization. This method consists of destroying pathogens present in waste by placing them in a compressed air chamber in which sterilizing agents are introduced, such as ethylene oxide or formaldehyde.
Chemical disinfection. This process involves treating waste with liquid chemical disinfectants.
Other methods of sterilization. Other methods of waste treatment that are less commonly used are including exposure to ultraviolet radiation or microwaves.
C. The Dominican Republic’s New Legal and Institutional Framework for Handling: Medical Waste
The enactment o f the General Law on the Environment and Natural Resources in August 2000 and the enactment o f the General Health Law on March 8, 2001, that was prepared with support o f the Provincial Health Services Project, are an auspicious development in the Dominican Republic. The enactment o f these laws indicates that environmental protection and the improving the management o f medical waste have become priorities for the GODR. As discussed below, the laws also provide a clear legal and institutional framework for addressing the management o f potentially hazardous, infectious, contagious, or toxic waste produced in health facilities.
General Law on the Environment and Natural Resources
The purpose o f the General Law on the Environment and Natural Resources was to establish guidelines for the conservation, protection, improvement, and restoration o f the environment and natural resources, thus assuring their sustainable use and to create institutions to take the lead in addressing issues related to the protection o f the environment and natural resources.
The General Law on the Environment and Natural Resources created the State Secretariat o f Environment and Natural Resources as the lead agency for environmental management. In addition, it designated the National Council for the Environment and Natural Resources as the body responsible for programming and evaluating policies and for a biodiversity conservation strategy. This council i s composed o f the State Secretariats of Environment and Natural Resources, o f Agriculture and Livestock, o f Public Health and Social Assistance, Education, Public Works, Armed Forces, Tourism, Industry and Commerce, Foreign Affairs, Labor, along with the Municipal League, the Natural Resources Institute, and regional representatives of NGOs, peasant organizations, universities (public and private), and the national business sector.
Responsibility for the handling and disposal o f waste water i s distributed by territoriality: the Santo Doming0 Aqueduct and Sewer Corporation (CASAD) of the National District; the Santiago Aqueduct and Sewer (CORAASAN) o f the province o f Santiago; and the National Institute o f Drinking Water and Sewers (INAPA) in the country’s other provinces.
Several special offices and commissions created by decree also have objectives related to environmental preservation, including the Commission for the Study o f Causes o f Environmental Pollution (Decree 2596-72); National Council o f Radiology Protection (Decree 413-9 1); National Commission to Monitor Agreements o f the United Nations Conference on the Environment and the development o f the “Land Summit” (Decree 340-92); Office for the Reform and Modernization o f the Drinking Water and
4
Prior to the enactment of the General Law on the Environment and Natural Resources in August 2000. the responsibility for environmental protection in the Dominican Republic was shared by several institutions. They included the State Secretariat o f Public Health and Social Assistance [SESPAS): the Dominican Social Security Institute (IDSS): city councils: the State Secretariat of the Armed Forces: and the General Bureau of Forestry.
1
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Sanitation Sector (Decree 203-98); National Institute of Environmental Protection (Decree 216-98); and the Coordinating Commission o f the Natural Resources and Environment Sector, created by Decree 152- 98.
General Health Law The General Health Law enacted on March 8, 2001, incorporates major changes in the Dominican Republic’s health care organization and financing. Provisions o f the General Health Law pertaining to the management o f medical waste, which supersede provision o f previous laws dealing with this topi^,^ are summarized below.
SECTION IV-Solid Waste Art. 46. The State Secretariat o f Public Health and Social Assistance (SESPAS), in coordination with the State Secretariat o f Environment and Natural Resources and other relevant institutions, shall prepare the official regulations that govern the disposal and management o f solid waste whose use, collection, treatment, holding, recon version, industrialization, transport, storage, elimination, or final disposal may be hazardous to the population’s health.
Art. 47. The institutions o f the health system and all those health facilities which, due to their operations, utilize toxic or radioactive materials or substances, contaminants or other substances that may spread elements which are pathogenic or harmful to health, should have waste elimination systems developed in terms of the pertinent regulation prepared by the SESPAS, in coordination with the State Secretariat o f Environment and Natural Resources and other relevant institutions. Medical waste shall be stored separately, technically treated in the establishment o f origin and/or delivered to the corresponding municipality or institution, as the case may be, for transport and proper final disposal.
Art. 48. Health authorities must inform the State secretariat of Environment and Natural Resources about those establishments or places which constitute a hazard to the health or l i fe o f the population due to undue, unhygienic accumulation o f solid waste, so that said Secretariat may order them to be cleaned and may execute the corresponding administrative and safety measures.
SECTION V-Disinfection and other Measures Art. 67. Those substances or objects that, by favoring the spread o f diseases and causing harm to people’s health, are considered hazardous shall be handled, sterilized, or destroyed by their owners or those in charge, or by the health authority itself, following the instructions and regulations that are prepared for this purpose by the health authority, in coordination with the relevant environmental authority and without jeopardizing compliance with prevailing environmental regulations and measures.
SESPAS shall collaborate with the State Secretariat o f Environment and Natural Resources on the preparation o f a l i s t o f hazardous substances and products, on the constant updating o f this l ist , and on the preparation o f regulations governing the waste management o f these substances.
Art. 68. The owners, directors or heads o f health or medical care facilities and other places where human groups stay or pass through, should avoid the spread o f transmissible diseases within their establishment or towards the community, and shall be responsible for ensuring that the establishment has the necessary elements to avoid such spread, and that the staff o f their agency carry out prophylactic practices in a timely and proper manner.
Art. 100. SESPAS i s responsible for equipping the institutions or health establishments and, together with the advisory unit o f the National Commission for the Accreditation o f Clinics and Private Hospitals, for
‘Prior to the enactment o f the General Health Law. medical waste problems were addressed by a diversity o f codes and laws. including the National Public Health Code (1956) and general health care guidelines contained i n Health Law 456-38: Law 1459-38 on Health Procedures: the 1956 Labor Code: and Law 1896-62 on Social Security and General Hospital Regulations (Decree 35 1-99).
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accrediting these institutions, ensuring the application o f rules related to the minimum requirements which, according to their classification, said institutions should meet, with regard to physical installations, equipment, personnel, organization and operation, to ensure that the user receives a proper level o f care, even in the case of disasters.
Paragraph I. I n coordination with the corresponding institutions o f the national health system, SESPAS shall regulate, by resolution, the equipping, operation and accreditation of health establishments and promote quality assurance, which shall be carried out through the assessment of public and private establishments, by rules and mandatory minimum criteria, and of their staff.
Paragraph 11. SESPAS shall establish the general regulatory guidelines based upon which the duties assigned in this article shall be complied with.
Art. 101. The professionals or technical directors o f health establishments in which natural or artificial radioactive material, or equipment designed for the emission o f ionized radiation for diagnostic, medical therapy or dental purposes or for scientific research, i s used should seek a permit from SESPAS that endorses their activities, without jeopardizing the duties o f the State Secretariat of Environment and Natural Resources in this regard.
Art. 102. The boards o f directors and the administration of health establishments shall be responsible for ensuring that staff correctly and properly performs their duties, so as not to expose the health or l i fe of patients to unnecessary risk due to the lack o f technical or therapeutic elements for reasons of unhealthy environmental conditions.
Art. 106. Health laboratories shall be directed by an expert in the subject who i s duly accredited in the corresponding discipline and who shall be responsible for the establishment’s progress, compliance with biosafety regulations, suitability o f operations, and precision and quality in reports issued on the results of analyses.
Paragraph. Authorized staff who perform analyses or special testing in public, private, civilian, military, and other laboratories, should adjust their work to the technical regulations stipulated by the Laboratory and Blood Bank Divisions of SESPAS. Said staff shall be subject to technical control o f the quality of their analyses o f the aforementioned divisions.
SECTION V I - Blood Banks, Blood Transfusion Services, And Serology Control Art. 107. The drawing o f human blood, the fractionating and industrial transformation o f human blood, and the practice of any of the activities mentioned in this article, may only be performed in blood banks and in blood derivative plants authorized SESPAS, which shall define, through the corresponding regulation, the rules for the installation, operation and control o f these establishments, in coordination with pertinent institutions.
Paragraph I. The supply and transfusion o f blood and i t s derivatives constitutes an act o f legal and ethical responsibility. Doctors shall be the health professionals trained and authorized to therapeutically prescribe human blood, i t s components and derivatives, in accordance with the disease to be treated.
Paragraph 11. The institutions o f the National Health System shall ensure that their blood banks perform mandatory testing o f blood and i t s derivatives, according to the prevailing international regulations of WHO, as well as pre-transfusion compatibility testing. No product may be transfused without the respective quality certification. SESPAS shall ensure compliance with this provision.
Paragraph 111. A duly accredited staff member in terms o f the nature o f such banks and centers shall direct blood banks and hemotherapy centers.
Paragraph IV. The technique of aphaeresis, as a means o f fractionating to obtain blood derivatives, may only be used by blood banks that are qualified and expressly authorized by authority of SESPAS. This
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should correspond to a concrete program, associated with the country’s needs, in accordance with the regulation prepared by SESPAS, and in coordination with institutions specialized in this subject.
D. Related investments financed under the WB Provincial Health Systems Proiect in the
In 1999, SESPAS, requested that CERSS, through the Provincial Health Systems Project and a parallel project financed by the IDB, support the provision of technology for the treatment and final disposal of waste in the main health facilities around the country. As a result, the Provincial Health Systems Project has invested nearly US$1 mill ion to date to strengthen the medical waste management capacity o f some o f the main SESPAS’ health care facilities. The vast majority o f the resources (apart from about US$50,000 devoted to civi l works) has been used to helped several hospitals purchase incinerators to treat medical waste and to support training o f staff in the operating of this equipment and the management of medical waste:
Dominican Republic
Purchase of incinerators by hospitals for the purpose of treating medical waste. Incinerators, along with peripheral equipment (identified containers) and services related to training in the operation and maintenance of equipment, have already been purchased and installed in several hospitals. They include the San Vicente de Paul Hospital in Duarte Province, Luis Bogaert Hospital in Valverde Province, Pascasio Toribio Piantini Hospital in Salcedo, Jaime Mota Hospital in Barahona, as well as the Armed Forces Central Hospital, Nuestra Sefiora de la Altagracia Maternity Hospital, Los Minas Maternity Hospital, Moscoso h e l l o Hospital, Robert Reid Cabral Children’s Hospital, and the Luis E. Aybar Complex i n the city o f Santo Domingo. Of the incinerators installed, most o f them are operating at full capacity.
Training. Training courses in the operation and maintenance o f the medical waste incinerators and in managing medical waste within the hospital were carried out successfully in al l hospitals:
Training in the operation and maintenance o f the medical waste incinerators was provided to at least three people per hospital. I t included training relate to the features of the equipment (e.g., electrical installation, gas-oil connection, ash removal) and the operation o f the equipment (e.g., startup, shutdown o f the installation, operating regulations, safety checks),
Training in the management o f medical waste within the hospital was provided to hospital staff (20 per establishment). This course was generally well accepted, both in terms of attendance and participation, and it has raised expectations about improving the way in which medical waste i s managed. At most hospitals, attendance was complete, with between 25 and 30 people, including mid-level and higher level staff, on average per course. The exception was Los Minas Hospital, where only about 10 people (mostly maintenance staff) attended. At Luis E. Aybar Hospital, about 50 people attended, including nursing students who were very interested in the subject. In some cases, technical staff, especially from central services departments attended the course at different hospitals. At several hospitals, the instructors were asked to repeat the talks at another time so that staff that was not able to attend the first time could then do so.
A key challenge in the Dominican Republic’s health facilities i s to devise mechanisms to keep the trained personnel who work in the waste collection and storage process. Furthermore, it was confirmed during the training process that the problem o f handling such waste in health facilities i s considered a housekeeping problem-so medical and paramedical staff does not participate in the waste management process.
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Hospitals’ Strong and Weak Points in Addressing the Problem of Medical Waste
The Provincial Health Systems Project assessment team reported prior to the installation o f the incinerators in 2001 that there i s no management of medical waste in most of the Dominican hospitals, with the exception of Robert Reid Children’s Hospital, where waste selection i s performed and some clear criteria exist. In general, hospitals exhibit the same strengths and weaknesses i n addressing the problem o f medical waste:
Weak points in addressing the problem:
All waste at the hospital i s treated in the same way.
There i s no differentiation o f medical waste by types, based on their danger andor the social alarm produced, except for the separation of needles and sharp objects in some hospitals.
The only type o f waste that i s treated differently i s a placenta, which in some centers i s washed manually to keep fluids from dripping (La Altagracia Maternity Hospital) and in others ends up in septic tanks (Pascasio Toribio Hospital).
Where bags are used for waste, they are only one color;
Where bags are used, they are not as thick as i s advisable (>55 m.), so they often break.
In most cases, sufficient means for possible waste separation are lacking. There are no proper trash containers.
There are no special containers for sharp or pointed objects.
The staffs that generate waste lack proper training in the elements o f correct management. The bags are so overfilled that they cannot be closed. Capped and uncapped needles are thrown in the bags. In some emergency units, needles can be observed on the floor.
Waste collection personnel are unaware o f minimum safety standards for waste management. In some cases, they do not use gloves or they use inadequate ones, and they do not wear specific clothing for the task. Bags are not handled correctly (e.g., bags are sometimes carried on the shoulders).
The transport o f waste from the units to the waste dump i s sometimes done in vehicles, sometimes not.
In waste dumps, it i s common to find a large quantity of waste that has been thrown out without use of plastic bags.
With the exception o f centers whose installations have a municipal storage container, waste storage sites are in poor conditions. They lack doors and allow the access o f children and animals. They lack cleaning hoses and/or fire extinguishers.
Strong points in addressing the problem:
There i s awareness in hospitals o f the issue o f waste, both by personnel and management. Awareness i s not as strong among janitorial and trash collection staff, especially because they are unaware of the risk.
There i s an important potential among persons interested in participating in and doing something about waste management.
There i s external awareness about the current way in which waste i s eliminated, both among the public and authorities.
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A credible process has begun, aimed at improving waste management. The installation o f incineration plants in the seven hospitals i s a sign of this.
A draft plan for Hospital Hygiene Standards developed by SESPAS has been put in place.
Conclusions
The Provincial Health Systems Project assessment team concluded that implementation of a waste policy for any hospital would come up against two essential difficulties: (i) material means, and (ii) the awareness and preparation of staff. The assessment team made the following recommendations currently under implementation with respect to improving the preparation of staff
Create a Waste Management Commission in each hospital. Each hospital’s Waste Management Commission should include staff from different occupations who participate in the hospital’s daily operations or in that environment-i.e., an epidemiologist, a nurse, a janitor, and an engineer-and should be charged with preparing a Waste Plan for the hospital that establishes waste generation points, collection routes, storage points, and waste management responsibilities for various parties.
Offer hospital staff training in waste management. Staff should be offered a three to four hours training course on waste management that i s tailored to their particular needs. For example, maintenance and janitorial staff are at special risk in handling waste. Nursing staff and nursing students (very important) could benefit from training related to the generation o f medical waste.
Involve outside consultants. Outside consultants should be involved in the presentation o f training courses and subsequently to provide support to the Waste Management Commission in: (i) the establishment o f an initial work plan, (ii) follow-up/correction, and (iii) final evaluation.
E. Related Investments financed under the HIV/AIDS Prevention and Control Project
As suggested earlier, public health problems generated by the management o f medical waste affect the hospital population-that is, medical and paramedical staff, patients (and visitors), and service employees-but also affect the population outside the hospital. One o f the main concerns regarding medical waste in the DR i s the possible transmission o f diseases such as H N / A I D S or hepatitis B through wounds caused by contaminated needles. The population groups at greatest risk from this are: (i) patients and health personnel; (ii) staff o f hospital support services (trash collectors, treatment plant operators, etc.); and (iii) patients at high risk o f contracting infections (e.g., people with diabetes, people with AIDS; drug addicts).
The HIV/AIDS Prevention and Control Project, building upon and complementing the activities supported under the Provincial Health Services Project, contemplates interventions under Component 2 to reduce HIV/AIDS transmission, aimed at protecting high-risk human groups such as patients and health staff within and outside hospitals, preserving the environment by establishing proper systems and processes for the management and treatment o f contaminated hospital waste. Specifically, it i s supporting: (i) an assessment o f medical care waste handling and disposal related to HIV/AIDS programs and activities under the project; (ii) the revision and updating by COPRESIDA (the Presidential Commission for HIV/AIDS), through the SESPAS’ General Directorate o f Sexually Transmitted Infections and AIDS (DIGECITSS) and other specialized institutions, o f the existing manual for medical waste handling and disposal; and (i i i) the training o f health personnel associated with HIV/AIDS programs and activities under the project in the application o f these standards to protect high-risk human groups such as patients as well as health staff in the participating facilities.
The manual addresses procedures for health center staff with regard to the handling, transport, treatment, and final disposal o f medical waste, as well as the provision o f required equipment and inputs, with special attention to the handling o f sharp and pointed objects (the main risk o f viral contamination inside
79
hospitals), beginning at the point where the waste i s generated, through the use o f receptacles for the collection. storage, and disposal of sharp and pointed objects. The receptacles for sharp objects should be synthetic fiber containers, with a hermetically sealable translucent cover to keep liquids from spilling. They should have rounded edges to avoid cuts to staff involved in handling and should be identified with international coding for biohazard us waste. Differentiated routes within the health establishment are being defined to transport the special containers, physical identification of routes, as well as inputs and training for the staff responsible.
F. The Proposed Health Reform Support APL
The proposed project would complement the provision o f hospital waste treatment equipment financed under the Provincial Health Services and the HIV/AIDS Prevention and Control Projects, and the parallel IDB project, as well as the training of staff assigned to do this work. Technical assistance would be provided to the local governments o f each participating locality in order to improve the disposal of residual waste, without any risk to their staff or to the environment. More specifically, to strengthen the biomedical waste management system in the participating health facilities, the proposed project w i l l support under Component I the following activities:
Create a Waste Management Commission in each hospital. Each hospital’s Waste Management Commission should include s ta f f from different occupations who participate in the hospital’s daily operations or in that environment-i.e., an epidemiologist, a nurse, a janitor, and an engineer-and should be charged with preparing a Waste Plan for the hospital that establishes waste generation points, collection routes, storage points, and waste management responsibilities for various parties.
0 Purchase of incinerators by hospitals for the purpose of treating medical waste. Incinerators, along with peripheral equipment (identified containers) and services related to training in the operation and maintenance o f equipment, would be purchased and installed in the hospitals according to the findings of investment needs assessments. To this end, the project’s Operations Manual wi l l include the World Bank guidelines for such investments.
Offer hospital staff training in waste management. Staff should be offered a three to four hours training course on waste management that i s tailored to their particular needs. For example, maintenance and janitorial staff are at special risk in handling waste. Nursing staff and nursing students (very important) could benefit from training related to the generation of medical waste.
Involve outside consultants. Outside consultants should be involved in the presentation o f training courses and subsequently to provide support to the Waste Management Commission in: (i) the establishment of an initial work plan, (ii) follow-up/correction, and (iii) final evaluation.
0
G. Bibliography
Informe Ambiental and Social-BLD-D-0078 1997 [IADB Environmental and Social Report]
Marco Regulador Juridic0 SESPAS. [Legal Regulatory Framework]
Consideraciones Sobre Manejo de Residuos Sanitarios en Amir ica Latina. OPSIOMS, 1992 [Considerations on Medical Waste Management in Latin America]
Manejo de 10s Residuos S6lidos Hospitalarios en la Republica Dominicana. UASD. 1992 [Mana, cement o f Hospitals’ Solid Waste]
Managing Medical Wastes in Developing Countries. OMS, 1994.
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Proyecto Ley General de Salud [Draft o f General Health Law]
Ley General de Medio Ambiente y Recursos Naturales [General Law on Environment and Natural Resources]
Anilisis Comparativo Proyecto Ley General de Salud and Ley General. Sobre Medio Ambiente y Recursos Naturales. PCU 2001 [Comparative Analysis o f Draft of General Health Law and General Law on Environment and Natural Resources]
Descriptivo TCcnico Incinerador Saunier Duval Setri Espafiola, SA [Technical Description o f Saunier Duval Setri Espafiola Incinerator]
WHO Information, Fact Sheets. Backgrounder No. 1. WHO 2000.
Boletin Estadistico Aiio 1, No. 1-SESPAS 2001 [Statistical Bulletin year I]
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Current Legislation on Management of Environmental Risks of Civil Works in the Dominican Republic
Unt i l the year 2000 when the Ministry o f the Environment and Natural Resources was created through the passing o f Law 64-00, the Dominican Republic did not have a set of environmental standards and regulations except for a series o f codes and laws that dealt generally on certain environmental aspects.
In this portfolio a series o f environmental standards and regulations are designed, discussed, and approved and, as o f today, the following have been designed and approved: “Air Quality Standards and Control of Atmospheric Issues” establishing the maximum allowable pollutant values in the air aimed at protecting the health o f the general population, with special emphasis on the most vulnerable groups; “Noise Protection Standards” establishing the maximum allowable levels as well as the general requirements for protection against environmental noises produced by fixed and mobile sources; “Solid Waste and Radioactive Waste Standards” establishing the guidelines for solid waste management and the sanitary and management requirements to be met in the storage, collection, transportation and final disposal o f the same; “Water Quality and Discharge Control Standards” that classify surface and coastal waters in accordance with their prevalent use, aimed at protecting the quality o f these bodies o f water through the control o f liquid effluents, both industrial and municipal, public and private, produced by different human activities. On the subject o f forests, the following standards have been prepared: “Technical Standards for the Establishment and Certification of Forest Plantations,” “Technical Standards for Forest Management Plans,’’ “National Transportation Route of Forest Products”, “Standards and Procedures for Forest Permits”, “Regulations for Environmental Permits and Licenses Systems,” “Forest Regulations” and “Operational Regulations for the Wood Processing Forest Industry in the Dominican Republic.”
The Ministry o f the Environment and Natural Resources has not issued specific regulations with regard to restrictions on building materials; on the other hand, the sector’s regulatory entity, the Ministry o f Public Works and Communications (SEOPC) has issued 22 (twenty-two) regulatory manuals o f which only one, the M-20 “Environmental Manual for the Design and Construction of Road Works,” deals with specific aspects on environment preservation, that is, the construction aspect which i s not part o f the investments o f our project.
Environmental Guidelines to be used by Contractors for the Civil Works Components of the Project
The conditionalities established in the technical specifications o f the bidding documents for the public works to be financed through the Health Sector Reform Support Project with regard to the materials to be used in public works are based on the regulations contained in M-009 “General Specifications for the Construction of Buildings” issued by the Ministry o f Public Works; these are the current regulations that establish the nature, origin and composition o f materials, aggregates and inputs used in construction works.
This standard specifies the manner in which the construction o f structures should be carried out, from clearing the land up to the conclusion o f the works. Certain environmental aspects are included in the regulations, such as procedures for land clearing indicating the need to “conserve and protect trees, shrubs or decorative plants located ~vitl i in the construction area;” indicating also the need to have the corresponding permits for final disposal o f waste products derived from clearing o f land for the works. With respect to building materials to be used in the works, both for the composition o f land fillings, as well as for coarse and fine aggregates. it establishes the need that the latter be free from “organic
82
matter, organic rubble, or other IzarinjLd materials” and, i n the specific case of water, that i t be ‘yree from excessive quantities of organic matter, oils, colloids, alkalis, acid salts and other impurities.”
I n addition to what has been formally established, there are certain restrictions observed through use and custom in the use of construction materials as i s the case of roofing plates made with asbestos- cement, now i n disuse since the public became aware o f their polluting potential and the danger they represent to health.
In regard to management o f waste products derived from public works, the Environmental Standards for Solid Waste and Radioactive Waste of the Ministry of the Environment and Natural Resources, in its Article 5 “Technical Specifications”, paragraph 5.1 “Prohibitions and General Requirements”, subparagraph 5.1.1, states: “The deposit or disposal of any type of solid waste on roads or public areas, lots, vacant properties, sewerage systems, wells, and in any type of open or closed space on state, municipal or private lands that has not been duly authorized for this purpose in accordance with the Environmental Law and Standards, i s hereby prohibited. ”
Likewise, the Standards designate the Municipal Councils o f the different localities in the country responsible for managing the final disposal of solid wastes.
In this regard, the section on technical specifications of the standard documents for the rehabilitation, expansion, and substitution o f physical infrastructure financed with Project funds states that: “The Contractor wil l be equally responsible for obtaining the permits from the responsible authorities for forest felling, as well as for the disposal of waste materials in the sites authorized for these purposes.” This i s a priority aspect in the supervision o f works and one that i s vigorously monitored by the local authorities in our country.
Compliance with current legislation by contractors i s mandatory in the Dominican Republic, and i s thus specified in the bidding documents for works under Section 3 “Conditions of the Contract”, paragraph 3.3 “Language and Applicable Law” and i t s provision in Section 4 o f the “Special Conditions of the Contract.”
With respect to the safety o f construction workers, the Dominican Republic ratified Agreement C-167 “On Safety and Health in Construction” approved at the session o f the 75” Conference o f the International Labor Organization in Geneva on June 20, 1988, that became effective on January 11, 199 1. This agreement includes recommendations on prevention and protection measures for the safety o f workers, and covers safety aspects o f hand ladders and scaffolding; elevators and hoisting devices; transportation vehicles and earth movement and manipulation o f materials machinery; installations, machines, equipment, and manual tools; works in heights, including roofs; excavations, wells, ramparts, underground works, and tunnels; cofferdams and caissons; frames and casings; works above water surface; demolition works; electricity and management o f explosives.
This agreement sets conditionalities to diminish the health risk to workers “exposed to any chemical, physical or biological hazard to such extent that it may be dangerous to their health“ and recommends measures to prevent exposure. I t also makes recommendations on precautions against fires, on clothes and equipment for personal protection, first aid and declarations on accidents and diseases.
The recommendations in this agreement have been included in Dominican legislation, such as in the following resolutions o f the Secretariat of Labor:
Resolution No. 34-91, which defines the content o f f i r s t aid emergency kits in the work place.
8 3
Resolution No. 02-93, which defines dangerous and unhealthful jobs i n the work place and establishes the responsibility o f the contracting party in providing workers with adequate means o f personal protection to alleviate the existing danger or unhealthful conditions.
Resolution No. 03-93, which defines dangerous and unhealthful jobs for children.
With respect to those aspects concerning social protection of workers, the Dominican Social Security System was created through Law 87-01, which was drafted with support from the Provincial Health Systems Development Project, co financed by the World Bank, which establishes and regulates the mutual rights and duties of the State and o f citizens with regard to the financing o f protection against the risks o f old age, disability, pension due to old age, protection of surviving dependents, disease, maternity, infancy and occupational risks.
The responsibility o f the Contractor regarding occupational risks i s established in the bidding documents for public works to be financed by the project, Section 3 “Conditions o f the Contract”, paragraph 11, “Risks of the Contracting Party,” and insurance obligations on behalf o f workers i s also established in the same section, paragraph 13 and i t s provision in Section 4 o f the “Special Conditions o f the Contract.”
These regulations w i l l be included as an Annex to the Operating Manual of the Project (effectiveness condition), as well as part of the bidding documents for public works.
84
Health Region
Site screening criteria capable of detecting the possibility of environmental or social impacts f rom the rehabilitation or construction of health facilities such as involuntary resettlement, presence of historical monuments, cemeteries or other physical cultural aspects, and critical natural habitats.
Province Facilities with beds Ambulatory facilities Maria Trinidad Sinchez 5 16
Health facilities to be covered under the proposed project. The implementation o f the Support to the Health Sector Reform Project (PARSS, in Spanish) w i l l encompass 17 (seventeen) provinces in the 111, IV, VI, VI1 and VI1 Health Regions, which include 3 11 (three hundred eleven) Health Ministry facilities, 57 (fifty-seven) of which have hospitalization services and the remaining 254 (two hundred fifty-four) are ambulatory, distributed as follows:
Samani 3 12 Salcedo 3 7
*-
I I -- I San Juan de la Mamana I 4 I 25 I
Duarte 4 38 Bahoruco 3 8 Barahona 5 16
I V Pedernales Independencia
I I J , I
1 3 3 13
VI1
" V I Comendador Daiab6n
3 7 3 17
I Santiago Rodriguez I 3 I 9 I
Montecristi Valverde
5 18 2 12
Civil works financed under ongoing Provincial Health Services Project. The geographical scope o f the Provincial Health Systems Development Project, was comprised by the 111, IV and VI1 health regions, giving priority among them to region I V formed by the Barahona, Bahoruco, Independencia and Pedemales provinces, and as a result of the integral development o f the implementation strategies of the project, this region has been the entry point o f the new Dominican social security system.
VI11
The objective o f the interventions to improve the infrastructure within the framework of the Provincial Health Systems was to enhance the response capacity of health facilities that faced physical plant and equipment problems, after determining the level of complexity o f the facility according to the role it w i l l fulfill in the delivery network. In this regard, the f i rst stage of the execution o f the component included a preliminary diagnosis and the activities leading to the creation o f a planimetric f i le o f the health facilities.
L a Vega 4 33 Monseiior Nouel 3 9 SAnchez Ram'rez 3 11
Subsequently, field visits were undertaken to ascertain the basic intervention needs, which determined the prevalence of the following problems: ceil ing leaks, deficiencies in sanitary and electric systems, inoperability in Emergency area, as well as in the Obstetrics area and waste disposal in facilities with bed; also, general rehabilitation needs in rural ambulatory centers.
TOTAL 57 254
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As a result o f the PDSPS, there i s now a Planimetric file in CAD platform containing all the ambulatory centers in the 111, IV and VI1 Health Regions, totaling 169 (one hundred sixty-nine), as well as 26 (twenty-six) facilities with bed.
I n this regard, fifty-one (5 1) interventions were carried out through shopping processes and twelve (12) through Local Competitive Bidding processes, aimed at improving serious problems such as ceiling leaks in nine (9) facilities with bed; improvement o f water supplies, drainage, and electrical installations in eleven (1 1) facilities with beds; functional rehabilitation in Emergency and Gynecology/Obstetrics areas in nine (9) facilities with beds; expansions and general rehabilitation in eleven (1 1) rural ambulatory facilities; substitution o f one (1) provincial hospital and four (4) ambulatory facilities; rehabilitation and/or expansion works in four (4) Provincial Health Departments; conversions for the implementation of MIS and VE in eleven (11) facilities with beds; functional conversions in seven (7) operational units at the SESPAS central level; in addition to installation o f solid waste management system in ten (10) facilities with beds.
With respect to interventions for the improvement of solid waste management, double chamber pyrolytic-static type incinerators were acquired, with standards required by the World Health Organization. This equipment decomposes the waste in the first chamber through a thermal combustion process in an oxygen-poor environment, a process that reduces waste volumes between 85 and 95% without need o f prior treatment to i t s incineration and processes waste containing 40-60% moisture; in a second reaction chamber, these unbumed gases are forced to circulate in close union to a large input o f secondary air, i.e. in a very oxidant atmosphere, they post-combust, all this with the assistance o f a bumer that maintains a minimum temperature o f 1000°C at all times. This bumer regulates i t s operation through a thermocouple-regulator, which i s programmed at the adequate temperature in the process.
Complementing the acquisition o f the equipment, within the incidental services included with the acquisition o f the incinerators, was the training o f at least three (3) persons per hospital in the operation and maintenance o f the equipment, as well as in the identification and solution o f low complexity operational problems; training o f hospital personnel (20 per facility) in hospital management o f sanitary waste; recommendations per facility for packaging instead o f production o f sanitary wastes, including the supply of color-coded containers for the first year of operation.
Civil works investments contemplated under the proposed project. The interventions to be carried out within the scope o f the PARSS wi l l include similar aspects to those o f the PHSP. To date, the interventions pending implementation in the 111, IV and VI I health regions have been identified, where waterproofing w i l l be carried out in three (3) facilities with bed; general functional rehabilitation works that wi l l include expansions i n the Emergency and GynecologylObstetrics areas in at least thirteen (13) facilities with bed; substitution of two (2) facilities with bed and general rehabilitation works in approximately twelve (12) ambulatory facilities. In the rest o f the regions o f the new project, that is, regions V I and VIII, interventions are planned in seventeen (17) facilities with bed and thirty (30) ambulatory facilities.
I t i s important to point out that, as observed during the implementation o f the Provincial Health Services Project and based on recent evaluations made by the Project team, it i s expected that the environmental and social impacts resulting from the execution of public works during the implementation o f the new project wi l l be minimal, in view o f the following: for the most part health system facilities are located in rural centers with low population density; the vast majority o f the interventions are rehabilitation works within the interior of the facilities, thus they w i l l not affect the activities nor the traffic in the neighborhoods; substitution o f facilities i s carried out prior to the
86
demolition o f those existing in the same location, thus acquisition of new land implying resettlements or new environmental impact assessments are not foreseen. The project’s Operations Manual w i l l include World Bank guidelines and framework in the event of any resettlement caused by the project, alongside guidelines for small construction works and for improving biomedical waste management and disposal in the participating institutions.
As indicated previously, programming o f works for the new project includes the updating of procedures for supervision o f works with the inclusion o f the regulations in force, and in detail in the bidding and contracting documents for the protection o f the environment and occupational safety.
Investments Proposed under the Project to Improve Medical Waste Management
As done with the support o f the ongoing Provincial Health Services Project, resources would be allocated under Component I to assist participating health facilities in project areas, as needed, in the: (i) undertaking o f assessment of medical care waste handling and disposal; (ii) updating of manual to address proper handling and disposal o f medical wastes; (iii) rehabilitation o f infrastructure and the installation of equipment in the main local hospitals for the disposal o f medical wastes; and (iv) training o f health personnel in the application of standards to protect patients, health workers, and the community.
Public Consultation
The Project PCU’ s has held several meetings during project preparation with public, private and nongovernmental sectoral stakeholders grouped under the National Health Council to discuss and obtain feedback on project objectives, components, assessments (including technical, environmental, and economic and financial assessments), and implementation strategies. The consultation program has involved both formal and informal presentations and meetings with the target groups. More recently, in a National Health Council meeting held on May 2, 2003, presided by the Secretary of Health, the latest version o f the PAD was reviewed and the proposed standards and guidelines for project implementation and required investments were endorsed.
87
Annex 2.c. Dominican Republic Health Reform Support Program
Donor's Assistance in the Health Sector
On average, public sector spending on health for the period 1996-1999 was 2.0% of GDP. This i s a low percentage compared with the average public spending in the LAC Region (3.2%), or in countries o f similar per capita income such as Costa Rica (5.2%), Panama (4.9%) or Jamaica (3.2%)6.
Health expenditure i s financed by a mix o f national budget allocations (65%), private funding (3 1.4%) and external sources (3 .70%)7. Although low in absolute terms, external funding has increased over time. According to the preliminary results provided by the 2002 DR Red Book, in 2002, the country could count on approximately US$364.25 million in current and projected loan and grant commitments, that i s almost 9% o f external funds made available to the country by multilateral and bilateral cooperation agencies (See table 1).
Table 1: Health Assistance provided by external donors Expensed To Be >kpirpcnsed
Undrrbmrd Secrur T ~ ~ ~ L han a,d Iiidrcnuve Loan Commrwenrs Ind'cauve aIttounI as of Calendar ~ e o r Cakndar i'ear Calendar Catendor Calendar
C"7lS JIN2IZ0OO 2001 2002 Yeor 2003 Year 2004 Year 2005
0.W 3.13 0 68 4.42 0.W 0.33 9.58 l5.W I I 5 40 0.00
38.59 40.05 6 I .20
26.21
0.00
0.00 0.00 0.00 2.82 0.00 0.00 0.00 0.00 0.00 0 00 0.00 90.00 61.20
0 00
0 00
000 ~
3.13 0.68 I .60 0.W 0.00 9.58 1S.W lI5.10 0.00 38 59 0.05 OW
26.21
0.W
0 w 0.00 0.00 0 36 33.77 OW 9.58 0.00 57 45 OW 38.29 10.50 45.86
4 30
0.W
~~
0.W OW 0.W 0.49 7 66 000 0 50 3.00 5 80 0.00 0 35 6 51 9.32
5.30
0.00
~~
0.W 0.W 0.00 0.00 0.36 1.08 1.03 103 0.00 OW 0.23 0.18 0 33 0.40 0.40 0.40 4.90 2.90 2.90 2 YO 0.00 0.W 0.W 0.W 3.06 1 I O 0.00 0.M) 3.W 3.00 3 W 300 7.W 17.30 17.60 20.70 0.00 0.00 0.00 0.00 1.80 8.33 8.03 5 9 9 8.40 18.03 1386 0.00 11.29 10.50 14.75 0.W
3.83 10.26 9.04 2.22
0.03 0.00 OW 0.W
'rmi >M.3 154.02 2111.2.1 Z0ll.l 1 .4X.W 4.*.(,6 7 2 . 9 ~ 7n.w .II~.J~
Source: 2002 DR Redbook (preliminary results -validation in process)
Al l the major donor agencies (USAID, IDB, EU, and the World Bank) are supporting the government's modernization sector o f the health sector with complex reform projects* calling for separation of functions, decentralization and deconcentration, institutional strengthening at central and local level, and incentives to link salaries and budget to performance.
Although sharing common objectives, and advocating for a common approach to reform, coordination among said projects has often been difficult to achieve, thus hampering the pace o f a coherent health
Source: Central Bank (2002) ' Source: Central Bank (1996) More precisely: USAID committed USDl 15.14 million through their Health Strategy and Health Programs.
while IBRD's commitments amount to USD90.05 million through the ongoing 1272-DO Provincial Health and 706.50-DO HIV-AIDS Prevention and Control Program, in addition to the proposed Health Reform Program APL l presented in this PAD. Finally. IDB's presence i s limited to a USD61.20 million Health Sector Modernization and Restructuring Project. while EU's grant commitments are currently at USD38.59 million, out o f which USD 12.90 million refer to the Health Modernization Reform Prqject.
88
modernization process. To reduce duplication o f efforts and resources, the donors agreed to deepen their coordination, at least at the policy level, by means o f periodic sector roundtables chaired by the European Union.
Although at a very preliminary stage, dialogue seems to have improved and a clear awareness to promote a common stance towards reform has been emerging. Donors have recently agreed on a common platform of indicators to monitor advances towards achieving the MDGs, an initiative that has been welcomed by the Technical Secretary o f the Presidency as a f i rs t , though important, step towards the elaboration of national MDG strategy. Yet, the Government wants to stredngthen the coordination among donors and - following the example of the education sector - i s preparing a 10- year Development Plan for Health Sector Reform as a management tool to coordinate donor strategies and resources and to reduce duplication o f efforts. The IO-year Plan would spell out the respective areas o f responsibility for each donor, the willingness o f each donor to accept that responsibility, for how long, under what conditions, with what kind and size of financial support (with or without cost sharing), and the commitment to coordinate with other donors.
89
Works 9.46 Goods:
Hardware I Software 3.11 MedicaVBiomedical Equip 6.82 VaccinesNed supplies 0.60 Furniture 1.21 Materials 0.47
Firms 4.48 Individuals 7.10
Training 7.91
Incremental Operational Costs 1.15
Front-End Fee 0.30
TOTAL PROJECT COSTS 42.71
Consulting Services:
Annex 3
Dominican Republic Health Reform Support Program
Estimated Project Costs
ANNEX 3A: ESTIMATED PROJECT COSTS BY COMPONENT Dominican Republic, Health Reform Support APL
US$ Million
1. EXTENSION OF HEALTH SERVICES COVERAGE 15.34 2. IMPLEMENTATION OF HEALTH SECTOR REFORM LEGISLATION 3. IMPROVEMENT OF SELECTED PUBLIC HEALTH FUNCTIONS 4. PROJECT MANAGEMENT AND IMPACT APPRAISAL NEXT PHASE 5.35
TOTAL PROJECT COSTS 27.5 1
~ 1::: FRONT-END FEE
TOTAL FINANCING REOUIRED 27.5 1
10.63
2.44
0.60
1.23
14.90
0.30 15.20
25.97
7.20
2.66
6.58
42.41
0.30 42.7 1
ANNEX 3B: ESTIMATED PROJECT COSTS BY CATEGORY US$ Million
ESTIMATED SOURCE OF FUNDING -1 PROJECT COSTS PER COST
5.68 3.78
2.02 1.09
4.43 2.39 0.39 0.21 0.78 0.42 0.30 0.16
3.58 0.89 5.68 1.42
6.33 1.58
0.50 0.75
0.30 0.00
30.00 12.71 70%
60
65
65 65 65 65
80 80
80
40
100
90
Annex 4
Dominican Republic Health Reform Support Program
Economic and Financial Analysis
The first phase o f the project i s expected to produce significant reductions in maternal and child mortality and morbidity in the target population in regions 111, IV, VI, VI1 and VIII, accounting for about 2.2 mill ion persons. The principal means o f accomplishing this would be through an extension o f the basic health package, focused on the disadvantaged segment o f the population. This would be reflected in the number o f deaths prevented by the availability o f the first phase extension o f the program. Table 1 shows the number o f prevented deaths by year, in the project area. I t i s assumed that the benefit lags by one year behind the provision o f the health service.
Numbers o f deaths prevented have been calculated as the reduction in the mortality rates assumed for the project, multiplied by the population in Regions 111, IV, VI, VII, and VIII, in the respective group, for the project years, 2003-2007. These are crude rates and do not account for accidental deaths or morbidity reductions short o f death.
Estimating the monetary valuation o f this result builds on the human capital approach. It i s assumed that benefits would not occur before the second year o f project implementation (2004) and those economic gains o f the l i fe that i s preserved extend over 30 years. Current GDP per capita, adjusted for the average annual growth over the period 1982 to 2001 i s used as the basis for the monetary weights for future l ife years saved. As the targeted population i s among the poorer segments o f society, however, only 90% o f this average i s assumed in the calculation. Future eamings are discounted in order to assess the value of the project in terms o f i t s present value. Monetary values are assigned to saved, productive adult l i f e years only (that i s when the individual reached the ages 15 to 55). The estimated present values o f the prevented deaths by project year are given in Table 2. Overall, the Dominican economy may be considered to gain a minimum of about US$ 167 mill ion in discounted present value terms as a result of the project.
These results reflect reductions in under-5 and maternal mortality only and do not account for the likely mortality reductions in the rest o f the population, which would also benefit from abatement in the disease burden, generated by improved access to health care.
In addition, these benefits account only for the direct and short term effects on mortality o f program activities, and do not account for the longer term benefits accruing to improved public health services, nor improvements in heath system efficiency and efficacy also supported under phase 1.
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Source 20031 20041 20051 20071 20071 ITotal Maternal Infants Child 1-5 Total
Alternative Scenarios
Two additional scenarios have been examined; one (pessimistic) assuming that productive l ife would be significantly shorter for the lives saved, leading to a higher discount rate on future earnings; a lower than projected impact on maternal mortality, and a lower monetary value to the life-years saved. A second (optimistic) scenario assumes infinite productive life, the full achievement o f project outcomes and monetary value of productive lives equal to the projected national average. The aggregate net present value o f these scenarios are compared to the base case in Table 3
0 934 1824 2668 3094 8520 0 16260 30795 43533 48618 139205 0 2 194 4187 5968 6729 19078 0 19388 36806 52168 58440 166803
Table 3 Sensitivity of Project Benefits
million) Benefit in Targeted Regions related to full cost o f APL I (US$42 million)
Note: * reflects average GDP deflator over the period 1992 to2001
1:4.0 1 :0.9 1:8.8
CostBenefit Assessment
The estimated cost for the first phase of the pro gram (APL1) i s US$ 42 million, including contingencies. O f this amount, US25.2 mill ion would be for the expansion o f health care services in the targeted area, focused on the provision of the basic package for the disadvantaged.
Table 4. Cost-Benefits Ratios (calculated as benefit, Table 3, divided by cost)
Assumptions I Likely case benefit 1 Pessimistic case benefit I Optimistic case benefit Benefit in Targeted 1 1: 6.6 I 1:14.6 Regions related costs in targeted region (US$25.2
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The “likely case” scenario would produce a benefit that significantly exceeded the cost of the provision of the services in the targeted area (CB ratio of 1:6.6) as well as the cost o f the full first phase program (CB ratio of 1:4.0). Compared to the “optimistic” scenario, these cost-benefit rations would be much smaller. Lastly, in the case of the “pessimistic” scenario, the cost benefit ration of the direct benefit and the direct service cost would be distinctly favorable (CB ratio of 1: 1.5) while the ratio with respect to the full phase cost would be only marginally unfavorable (CB ratio of 0.9: 1).
Financial Sustainability
Recurrent incremental annual post project costs of the project are estimated to be US$3.7 million, net o f personnel costs, and excluding project specific administrative costs assuming replacements andor maintenance o f
a. Works; 10%of investment per annum (pa) (US$946,000pa) b. Hardware and software; 10%of investment pa (US$324,000pa) c. Medical equipment; 20% of investment pa (US$1,338,000pa) d. Materials; 20% of costs pa (US$309,000pa) and e. Training, 10% of project costs pa (US$814,000pa).
Post project incremental costs i n regions covered by the project (111, IV, VI, VII, VIII), net o f national personnel and project administration costs, are estimated to be about US$3.0 mill ion assuming replacements andor maintenance of
f. Works; 10%of investment pa (US$767,OOOpa) g. Hardware and software; 10%of investment pa (US$245,000pa) h. Medical equipment; 20% o f investment pa (US$1,337,000pa) i. Materials; 20% of costs pa (US$70,000pa) and j. Training, 10% of project costs pa (US$485,000pa).
The 2003 budget o f SESPAS i s about US$225 million, o f which about US$ 158 mill ion would be national personnel costs and US$67 mill ion i s for non-personnel costs. The annual incremental post project cost o f the project would be about 1.6% increase in the total budget and a 5.5% o f this non- personnel budget, which would be financially sustainable.
The 2003 budget o f the 5 regions included in the project i s US$60 million, of which US$42 mill ion i s estimated to be personnel and US$18 million, non-personnel costs. The annual post project incremental cost would represent an increase o f 5% increase in the total budget and 17% in the non- personnel budget or these regions. Considering the priority being given to poor regions, GODR should be able to accommodate the cost increases created by the project.
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Year 1
Annex 5
Dominican Republic Health Reform Support Program
Financial Summary
Project Financing for Years of First Phase (US$ Million)
Year 2
PROJECT COSTS
7.41 Investment Costs
Recurrent Costs
11.51
TOTAL PROJECT COSTS
0.40
7.8 1
0.30
8.11
19%
Front-end Fee
0.46
1 I .97
11.97 28%
TOTAL FINANCING REQUIRED
Implementa I
I
Year 3
13.07
0.52
13.59
13.59 32%
Financing Sources
IBRD/IDA 30.00 Government o f the Dominican Republic 12.71
Total Project Financing 42.71
Year 4
8.56
0.48
9.04
9.04 21%
40.55
1.86
42.41
0.30
42.7 1
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Annex 6.a
Dominican Republic Health Reform Support Program
Procurement Arrangements
A. Procurement
Procurement for the proposed project would be carried out in accordance with World Bank "Guidelines: Procurement Under IBRD Loans and IDA Credits", published in January 1995 (revised January/August 1996, September 1997 and January 1999); and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" published in January 1997 (revised in September 1999, January 1999 and May 2002), and the provisions stipulated in the Loan Agreement.
Procurement Responsibility: The CERSS'PCU would be responsible for the overall procurement regulation and supervision activities, in compliance with procedures agreed with the World Bank as stated in the Loan Agreement and the Operations Manual. The CERSS'PCU has successfully coordinated the implementation o f the Provincial Health Services Project and has supported the startup implementation o f the H N / A I D S Prevention and Control Project. The Project's participating agencies and entities-SESPAS, SISARIL, and SENASA-would present to the CERSS'PCU yearly action and procurement plans, satisfactory to the World Bank, although the administrative, financial management and procurement responsibilities for the implementation of the project would remain in the CERSS'PCU. Specifics of the solicitation, evaluation and awards, and contracting processes are contained in the Operations Manual. The CERSS' PCU wil l also coordinate with the participating agencies and entities the implementation o f several project component activities.
UNDP would assist the project in major procurement activities as it has been supporting the Provincial Health Services Project (Loan 4272-DO). The government would assume the costs o f the administrative fees charged by UNDP from i ts own resources. In addition, the GODR i s exploring with UNDP the possibility o f bridge financing to support startup implementation after loan signing and before effectiveness.
Procurement o f vaccines and other medical supplies needed for immunization campaigns may be procured through direct contracting with PAHO and should comply with para. 3.9 of the World Bank Guidelines. PAHO would submit the current market surveys for World Bank review as means o f providing evidence of using competitive market prices. Although Cuba i s a PAHO member country, it i s not an eligible country for provision of vaccines or any other goods/services financed out o f the loan proceeds. PAHO would sign an agreement with the Government acceptable in advance to the World Bank and would submit to the World Bank for i ts review the plan for distribution of the drugs and medical supplies purchased.
B. Procurement methods
A procurement plan would be prepared along with the annual work plan. The procurement plan for each year would be submitted by the Government to the World Bank for approval, not later than October of the previous year and would use a pre-defined standard format which would l i s t as a minimum: (i) goods and services to be procured for the year; (ii) their value; (iii) the method of procurement; and (iv) the timetable for carrying out the procurement.
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The tentative methods to be used for the procurement described below, and the estimated amounts for each method, are summarized i n Table A. The threshold contract values for the use of each method are fixed in Table B.
a) Procurement of Works
Works procured under the Project would include the construction and refurbishing o f some selected health facilities totaling $9.5 million. Civi l works totaling over US$3 million w i l l be procured through International Competitive Bidding using World Bank-issued Standard Bidding Documents (SBDs). C iv i l works contracts totaling over US$250,000 but less than US$3 mill ion may be procured using National Competitive (NCB) procedures up to an aggregate amount o f US$4.4 million using standard bidding documents agreed in advance with the World Bank. Small works costing less than US$250,000 up to an aggregate amount of USs5.1 million may be procured on the basis of at least three quotations, received in response to a written invitation to qualified contractors, which wi l l consist o f a detailed description o f the works, including basic specifications, the required completion date, a basic form o f agreement acceptable to the World Bank, and relevant drawings, when applicable.
b) Procurement of Goods
Goods procured under this Program would include medicines and vaccines, laboratory and medical equipment and supplies, computer and office equipment, and educational and campaign publications totaling US$11.6 mill ion equivalent. To the extent possible, contracts for goods (except for vaccines and related medical supplies for immunization campaigns) w i l l be grouped into bidding packages of more than US$250,000 equivalent and procured following International Competitive Bidding (ICB) procedures, using Bank-issued Standard Bidding Documents (SBDs). Goods (except for vaccines and vaccine campaign supplies) with estimated values below this threshold per contract may be procured using National Competitive Bidding (NCB) procedures up to an aggregate amount of US$6.9 million, using standard bidding documents agreed in advance with the Bank. Contracts for goods (except for vaccines and vaccine campaign supplies) which cannot be grouped into larger bidding packages and estimated to cost less than US$lOO,OOO per contract, up to an aggregate amount of US$2.3 million, may be procured using National /International shopping procedures based on at least three quotations received in response to a model request for quotations which w i l l include detailed technical specifications, required delivery date, guarantees and conditions and a basic form of agreement satisfactory to the World Bank.
Procurement o f vaccines and vaccine related supplies would be procured through direct contracting through PAHO up to an aggregate amount o f US$0.6 million.
c) Selection of Consultants
Consulting services would be contracted under this project in the following areas of expertise: studies, IEC campaigns, surveys, technical assistance and training, monitoring and impact evaluation, development and maintenance o f information systems and workshops. These services are estimated to cost US$l1.6 mill ion equivalent and would be procured using World Bank Standard Request for Proposals and mutually agreed documents.
Firms. All contracts for firms estimated to cost US$lOO,OOO or more, and NGOs would be selected using Quality and Cost-based Selection (QCBS); all contracts estimated to cost US$200,000 or less may be selected from al l national candidates. other smaller and simple contracts estimated to cost less than US$lOO.OOO would be selected based on the Qualification o f the Consultants or Least Cost Selection (LC).
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- Individuals. Specialized advisory services would be provided by individual consultants selected by comparison of qualifications of three candidates and hired in accordance with the provisions o f paragraphs 5.1 through 5.5 o f the Consultant Guidelines, up to an aggregate amount of US$7.1 mi 11 ion.
d ) Training.
Training activities to be financed under the project would include (a) developing training programs to trainhetrain and to increase the management capacity o f the managers of the network facilities and regulatory levels: central, regional and provincial; (b) implementing and consolidating management information systems already developed under the first project; (c) strengthening SESPAS’ information systems, (d) developing and implementing quality assurance systems and institution-specific quality enhancement plans, and (e) introducing accreditation and licensing o f health care providers to raise the quality o f services provided. These services are estimated to cost ~ ~ $ 7 . 9 million, equivalent to be delivered both by firms and individuals in accordance with the provisions o f the World Bank Guidelines.
e) Operational Costs
Sundry items, utilities and general operating costs would be procured by the CERSS’PCU using World Bank procedures up to an aggregate amount o f US$1.5 mill ion equivalent.
Prior review thresholds. The proposed thresholds for prior review are based on the procurement capacity assessment o f the PCU and are summarized in Table B.
C. Assessment of the Agency’s Capacity to Implement Procurement
The implementation o f the Program would be coordinated by the CERSS’PCU, currently in charge of managing implementation o f on-going World Bank- and IDB- financed projects. I t s Financial and Administrative team also supervises and oversees al l the procurement and financial activities of the HIV/AIDS Prevention and Control Project.
The Operations Manual would include among others, the terms of reference for each staff of the CERSS’PCU, procurement procedures for goods and works, selection o f consultants, and filing and monitoring system. Standard Bidding Documents to be used for each procurement procedure, Consultant Selection methods, as well as a description o f responsibilities and f low o f authority between the CERSS’PCU and the participating agencies and entities.
The Regional Procurement Advisor approved the Procurement Capacity Assessment on May 12, 2003.
Most o f the issues concerning the CERSS’PCU have been considered and implemented by negotiations. They included: (i) need to appoint additional procurement support staff; and (ii) the need to clearly outline in the Operations Manual the flow of interaction and responsibilities between the CERSS’PCU and the participating agencies and entities. The Operations Manual also specifies the procurement documents to be filed, the CERSS’PCU staff that would have access to the files, and the internal security measures for record keeping.
The overall project risk for procurement i s AVERAGE given the proven transparency, capacity and knowledge of the procurement team.
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D. Procurement Plan, Monitoring and Filing
The Borrower has presented a general tentative procurement plan for the four years of the project and a detailed one for the first year implementation on the basis of aggregate amounts for the procurement methods (Table A). At the beginning o f each calendar year, the Borrower would update the Procurement Plan with a detailed procurement schedule for the coming year. The Operations Manual describes the procurement monitoring and filing systems that should be available to supervision missions from the World Bank and auditors upon request.
E. Frequency of Procurement Supervision
In addition to the prior review supervision to be carried out from World Bank offices, the capacity assessment o f the CERSS’PCU has recommended one full supervision mission to visit the field to carry out post review o f procurement actions once every 12 months. Based on the overall risk assessment (AVERAGE) the post-review field analysis should cover a sample o f not less than 1 in 20 contracts signed.
F. Procurement Audits
A procurement audit would be performed in conjunction with the financial audit annual audit o f the Project.
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Expenditure Category
1. Works
Table A: Project Costs by Procurement Arrangements (in US$ mill ion equivalent)
Total Cost Procurement Method
N.B.F NCB Other ZCB
4.4 5.1'' 9.5 i
2. Goods Computers hardware/ software, Medical/ biomedical Equipment, furniture & materials
3. Vaccines and related
4. Consultant Services supplies
5 Training
(2.5) (3.2) (5.7) -
2.4 6.9 2.3 11.6 (1.6) (4.5) (1.4) (7.5)
0.6 c/ 0.6 (0.4) (0.4) 11.6 11.6 (9.3) (9.3) 7.9 7.9
(6.3) (6.3) ~~
Note: N.B .F. = Not Bank-financed (includes elements procured under parallel co-financing procedures, consultancies under t rust funds, any reserved procurement, and any other miscellaneous items). Figures in parenthesis are the amounts to be financed by the Bank loadIDA credit
6. Operating Costs
7. Front-end Fee
Total 2.4 (1.6)
Footnotes: a. Three quotations b. Shopping (National and International) c. Direct purchase o f vaccines from PAHO d. Consultants Services: Details provided in Table A- 1 e. Training includes Consultants and Logistics through the applicable competitive process.
1.2 1.2 (0.5) (0.5) 0.3 0.3
(0.3) (0.3) 11.3 29.0 42.7 (7.0) (21.4) (30.0)
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Annex 6, Table Al: Consultant Selection Arrangements (optional) (in US$million equivalent)
Expenditure Categorj
0 (0.8) (1.8) (5.5) (9.3) I Note: QCBS = Quality- and Cost-Based Selection
QBS = Quality-based Selection SFB = Selection under a Fixed Budget LCS = Least-Cost Selection CQ = Selection Based on Consultants' Qualifications
Other = Selection o f individual consultants (per Section V of Consultants Guidelines), N.B.F. = Not Bank-financed. Figures in parenthesis are the amounts to be financed by the Bank loan.
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Expenditure Category
1. Works
2. Goods
Contract Valw Procurement Contracts Subjecl (Threshold) Method Prior Review
US $ thousands US $ millions >3.0 ICB All <3.0 - >.250 NCB First 2 contracts >. 250 Three Quotations None
>250 >50 < 250 <50
NCB Shopping
ICB I All I First 2 contracts None
3. Consultants Firms >loo QCBS All
<loo QCSS, Qualification of None (post review) Consultants, Least Cost
Individuals
Overall Procurement Risk Assessment: H igh Average ~
Low
> 50 See Section V of All (TOR, contract, CV)
<50 See Section V of None (Post Review) Guidelines
Guidelines
Frequency of procurement post-review supervision missions proposed: One every 12 months, reviewing a sample of 1 in 20 contracts signed.
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Table C. Allocation of Loan Proceeds
Premia for Interest Rate Caps and Interest Rate Collars
Expenditure Category Works
0
Goods: (a) Hardware and software (b) Medical/Biomedical Equip men t ’ (c) Furniture, materials
(d) Vaccinedand related supplie
Front-end fee
Consultants’ Services and training (including audits)
300,000
Amount in US$million 5,680,000
7,770,000
390,000
153 80,000
Incremental Operating Costs 500,000
Total I 30.000.00
Financing Percentage 60%
65%
80% until total expenditures under this subcategory have reached an amount equivalent to US$120,000, and 60% thereafter.
80%
50% until total expenditures under this category have reached an amount equivalent to US$300,000, and 30% thereafter. 4mount due under Sectior 2.09(c) of this Agreement
Amount under Section 2.04 o f this Agreement
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Annex 6.b
Financial Management and Disbursement Arrangements
A financial management assessment was carried out on February 11-14, 2003, to assess the adequacy o f the financial management arrangements in place at the CERSS’PCU. The assessment was performed in accordance with World Bank requirements under OP/BP 10.02 and the Guidelines for Financial Management Assessments issued by the Financial Management Board in September 2001.
On the basis o f the assessment performed, the financial management team concludes that, upon completion o f the proposed action plan, the financial management arrangements of the PCU would satisfy the World Bank’s minimum financial management requirements. Therefore, the team would advise that the conditions listed in the assessment be considered as conditions o f effectiveness in the Legal Agreement to be prepared and signed with the Borrower.
Funds Flow
Procedures for the flow o f funds from the loan and the required counterpart contribution should be implemented with due regard to safeguarding the project’s resources and ensuring timely execution o f payments.
Due to the experience o f the CERSS’PCU with SOE-based disbursement procedures under the Provincial Health Services Project and the HIV/AIDS Prevention and Control Project, the SOE method would be used to replenish funds to the Special Account. Traditional disbursement methods would be used to drawn funds from the loan and Financial Management Reports (FMR) wi l l be used to monitor project implementation on a quarterly basis.
The CERSS’PCU would be in-charge o f maintaining, operating and reporting on the Special Account. The CERSS’PCU would also operate a Program Account for the purpose o f receiving counterpart funds from the government as well as a transitory account for funds disbursed from the Special Account for the Bank’s share o f eligible expenditures for which the PCU i s responsible. Similarly each participating agency and entity would also operate i t s own Program Account for the purpose o f receiving counterpart funds and from the Special Account as payments to suppliers come due for the World Bank’s share o f eligible expenditure. All Program Accounts w i l l be opened at the Banco de Reservas.
As eligible expenditures are incurred in accordance with agreed annual work plans for each participating agency and entity, as well as for the PCU. The CERSS’PCU would withdraw the amount to be financed by loan funds from the Special Account, and initiate a transfer from the SA to the Treasury. Once the funds are cleared, the Treasury would inform the CERSS’PCU that a check in Dominican Pesos i s available for pick up. The PCU then picks up the check at Treasury and deposits it into the corresponding Program Account.
Counterpart funding would be provided by the GODR. The amount o f counterpart funds anticipated for the f irst four years o f the APL i s US$12.71 million.
In order to obtain counterpart funds, the CERSS’PCU submits i t s annual budget request and the approved funding levels are included in the annual budget. In the past, projects in the Dominican Republic have experienced problems obtaining their allocation for counterpart funds. Therefore i t i s recommended that prior to effectiveness, the government deposit in a separate project account, the
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counterpart funds corresponding to the first 6 months o f the first year o f implementation o f the Program.
Staffing
The CERSS’ PCU includes the following staff members:
. Program Coordinator, . Financial Management Director . Procurement Manager Accountant . Accounting Clerk . Administrative Assistant
m Secretary
The Project Coordinator, the Financial Management Director and the Procurement Manager have all have extensive experience with World Bank policies and procedures. Therefore the staff assigned to the CERSS’PCU i s considered to be qualified and capable of handling al l financial management aspects of the Program.
Accounting Policies and Procedures
Accounting and administrative procedures would be in place as sections o f the Operations Manual to ensure that financial transactions are made with consideration to safeguarding project assets and ensuring proper entry in the accounting/monitoring systems. The CERSS’PCU’s accounting system has the capacity to record assets, liabilities and financial transactions in accordance with World Bank recommended procedures and i t can produce financial statements useful to for management and that meet the World Bank’s fiduciary requirements.
Project Operations Manual. Policies and procedures defined in an Operational Manual should aim to control project activities and ensure staff accountability. The CERSS’PCU intends to use the same policies and procedures used for the Provincial Health Services Project and the HIV/ALDS Control and Prevention Project.
The Financial Management section o f the Operations Manual was in draft form at the date of the assessment and appeared to include all Bank recommended procedures. The participating agencies and entities would be required to prepare operations and accounting manuals wi th the same policies and procedures where applicable.
Segregation of duties. The CERSS’PCU organizational structure and established procedures support an adequate segregation of procurement, accounting and recording activities. The authorization to execute a transaction i s the main responsibility of the Program Coordinator. The recording o f the transaction and monthly reconciliation are the main responsibility o f the Accountant and are supervised by the Financial Management Coordinator.
Annual Work PlansBudgeting. The loan agreement, the procurement plan, the implementation plan and the cost tables would provide the main input for the annual work plans. The PCU would prepare an annual budget and work plan. I t i s anticipated that the participating agencies and entities would also prepare annual work plans with the assistance of the CERSS’PCU. The annual work plans wil l serve as the basis for transferring funds from the SA to each participating agency and entity’s Program Account. The work plans w i l l include:
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An annual execution plan classified by major goal/objectives, including physical and financial programs. I t i s important to note that these goals and objectives must be measurable and quantifiable within a reasonable period o f time (i.e., one to three months). A budget proposal (broken down at least quarterly) specifying the detailed expenditures by major component, category and sources o f funds.
Each quarter, the CERSS’PCU would produce monitoring reports (FMRs) to assess progress against financial and physical goals to be shared with the Program Coordinator. These reports would also be presented to the World Bank on a quarterly basis.
Payments and operation of bank accounts. Before payments for acquisition o f goods, services or c iv i l works are processed by the PCU, a purchase order andor contract must exist. On the basis o f these documents, payment requests are prepared and after approval has been obtained payment i s issued, provided that there i s available funds.
After the Accountant has prepared the payment requests, the authorized signatories would s ign the bank draft or check. The PCU would initiate payment by sending a check issued from the CERSS’PCU’s Program Account or by send a direct payment request to the Bank in the case o f intemational vendors.
Bank account reconciliation would be prepared on a monthly basis by the Accountant and reviewed by the Financial Management Director.
The participating agencies and entities would be required to follow the same accounting and reporting procedures.
Accounting. The CERSS’PCU would maintain the Program’s records and accounts using the cash basis o f accounting and following Generally Accepted Accounting Practices and those recommended by the Bank. Bank loan funds and counterpart funds w i l l be accounted for separately. I t i s anticipated that each participating agency and entity would manage i t s own accounts using the same automated system and practices as the CERSS’PCU.
The proposed chart o f accounts was reviewed and found satisfactory.
The participating agencies and entities would be required to adopt a s i m i l a r chart o f accounts and fol low the same accounting and reporting procedures.
Safeguard over assets. The CERSS’PCU would maintain a detailed asset register. The amounts in the register would be reconciled against a physical inventory performed twice a year. Each asset would have a code assigned to i t and this code w i l l be maintained using an automated asset register that would include the following information:
Date o f Purchase m Physical Description
Supplier
m Physical Location m Asset Custodian
Form o f Payment and Reference Number (Le., check number)
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Audit Report Project financial statements SOE
The automated asset register had been previewed already during a supervision mission o f the HIV/AIDS project. The system was found to be capable of safeguarding all Program assets.
Due Date 4 months after fiscal year end (April 30) same as above
The CERSS’PCU would also ensure that adequate insurance i s obtained for all assets.
Internal Audit
The CERSS’PCU has i t s own internal audit function. There i s an internal auditor who would review both the operational and financial aspects o f the Program with the objectives o f ensuring compliance with applicable norms and regulations.
External Audit
The CERSS’PCU intends to hire the same external audit firm used to audit the Provincial Health Services Project and the HIV/AIDS Prevention and Control Project.
Audit compliance. According to World Bank records for the Provincial Health Services Project, 2000 and 2001, audit reports have usually come on time and are acceptable. However, the audit reports have both had qualified opinions due to issues regarding the commingling o f counterpart, loan funds and IDB funds. This issue has been discussed at length with the PCU and they have agreed to implement measures to ensure that all funds are accounted for and maintained separately.
Audit arrangements. Annual project financial statements would be audited in accordance with Intemational Audit Standards, by an independent firm and in accordance with terms o f reference (Torso) acceptable to the World Bank. Auditors should provide audit opinions on project financial statements, Special Account and Statement o f Expenditures (Sues), a report on internal controls and a report on compliance with the terms o f the loan agreement and applicable laws and regulations.
In order to relieve some o f the administrative burden o f hiring the auditors on an annual basis, the CERSS’PCU was informed that i t could issue a multi-year contract. However, the contract w i l l need to stipulate that as each participating agency and entity begin to assume i t s own accounting and reporting responsibilities, the scope o f the audit w i l l need to include the review o f the their accounts and records.
The CERSS’PCU, and eventually the participating agencies and entities, would prepare, if needed, a plan to address any issues and recommendations contained in the audit reports. The action plan and follow-up activities would be communicated promptly to the World Bank.
The table below summarizes audit requirements:
Special Accounts Special purpose
1 same as above 1 same as above (internal control and compliance)
Reporting and Monitoring
Financial statements and reports would be prepared in formats satisfying both the Government and the World Bank’s monitoring and fiduciary purposes.
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The CERSS’PCU would be responsible for producing quarterly Financial Monitoring Reports (FMRs) to be submitted to the Bank 45 days after the end of each quarter. The Fh4Rs would include a narrative outlining the Program’s major achievements for the quarter, the sources and uses of funds, a detailed analysis o f expenditures by sub-component, a physical progress report, and a procurement report. FMRs should be submitted to the World Bank no later than 45 days after the end o f the reporting period.
The FMR format was agreed to by negotiations, after the PCU submitted a draft format for review and comment to the World Bank.
The annual financial statements would include the Program’s sources and uses o f funds, a detailed analysis of expenditure by sub-component, the schedule of SOEs presented during the year and a reconciliation o f the Special Account. These reports would be made available to the auditors after the end o f the fiscal year.
In format ion Systems
The CERSS’PCU would use an automated financial management system - S U P (Spanish acronym). The system allows for expenditures to be segregated by project componentlactivity, major disbursement category and financing source, which i s compatible with the Bank’s recommended practices for project accounting. In addition, many financial reports required by the Bank for monitoring purposes can be produced directly from this system.
Disbursement Arrangements
The proposed loan would be disbursed over an implementation period o f about four years. Disbursements would be made in accordance with guidelines set out in the World Bank’s Disbursements Handbook (Le., traditional disbursement procedures).
Special Account. The CERSS’ PCU would establish a Special Account in US$ at the Central Bank. The Special Account i s only to be used for eligible expenditures under the loan agreement. Under no circumstances may funds in the Special Account be used to cover the share of expenditures corresponding to the counterpart funds. Transfers from the Special Account to other project bank accounts would only be permitted to meet eligible expenditures for a limited period o f no more than 30 days.
Total advances to the Special Account at any given time would not exceed the authorized allocation amount to be determined at loan negotiations.
For replenishment o f the Special Account, the CERSS’PCU would submit monthly requests for reimbursement o f expenditures made.
Use o f statements of expenditures (SOEs). Loan withdrawal applications would be supported by SOEs for expenditures relating to contracts that are not subject to the World Bank’s prior review. Reimbursement o f other expenditures would require submittal to the Bank o f full supporting documentation.
Documents in support of SOEs must be maintained by the CERSS’ P C U or the participating agencies and entities at least until one year after the World Bank has received the audit report for the last
I07
Flow of funds Open the Special Account in US Dollars in the bank selected, and the project account for counterpart funds. Request the initial deposit o f counterpart funds in the Project Account.
withdrawal from the loan account. Such documents must be available to review by external auditors and World Bank staff.
By effectiveness By effectiveness
The World Bank may require withdrawals from the Loan Account to be made on the basis of statements o f expenditure (under such terms and conditions as the World Bank shall specify by notice to the Borrower) for:
PCU Staffing
once they sign/define participation agreementdarrangements, project executing units’ role and functions would be determined as part o f the agreements. None. However, PCU w i l l need to review job descriptions and CVs for participating agencies and entities’ staff before funds are transferred to their responsibility. Accounting and internal control Submit to the Bank a sample format o f the FMR to be used for reporting purposes. External audit Prepare the audit TORS and short l i s t o f firms and submit to the World
As part o f the obligations o f the participating agencies and entities,
a) works under contracts which are not subject to prior review costing less than US$3.0 mill ion with the exception o f the f i rst two contracts;
b) goods under contracts which are not subject to prior review costing less than US$250,000 with the exception o f the first two contracts;
c) consulting firms under contracts costing less than $100:000 equivalent; d) individual consultants under contracts costing less than $50,000 equivalent; e) training; and f) operating costs.
BY effectiveness
Submitted at negotiations
Prior to
Other procedures. Upon request from the Borrower and subject to the World Bank’s approval, payments may be made: (i) directly to a third party (supplier or consultant) for goods, works and services; (ii) to a procurement agent; or (iii) to a commercial bank for expenditures against a World Bank Special Commitment covering a commercial bank’s letter o f credit.
Bank for review and clearance. Once the World Bank clears the TOR and short l i s t o f auditor firms,
Financial Management Action Plan
effectiveness BY
proceed with bidding process and the appointment o f the auditors. I effectiveness
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Financial Covenants
Section 4.01 "Standard" wording: audit reports to be furnished to IBRD no later than four months after the end o f each fiscal year.
Section 4.02 "Standard" wording: the due date for the first FMRs i s 45 days after the end o f the quarter in which effectiveness takes place.
Supervision Plan
After effectiveness, a FM Specialist must review the annual audit reports and should perform at least one supervision mission per year or more often as needed.
Conditions
The following Financial Management actions are also conditions for project effectiveness: (i) open Special Account at the Central Bank, and (ii) the f irst deposit to the Program Account o f counterpart funds in the amount o f US$1.5 mill ion has been made.
I09
Project Schedule Planned
Time taken to prepare the project (months) 12 June 2002 First Bank mission (identification)
Appraisal mission departure May 5,2003 Negotiations May 13,2003 Planned Date o f Effectiveness September 2003
Annex 7 Project Processing Schedule
Actual
12 June, 2002
May 5,2003 May 13,2003
September 2003
Dominican Republic Heal th Reform Support Program
Alberto Fiallo Billini Gisela Quiterio B. Amarilis Shnchez Yima Gonzilez Sabrina Hi1 Hued Miguel Geraldino
Coordinador UMDI SESPAS Coordinadora TCcnica CERS S Coordinadora Financiera CERSS Asistente TCcnica CERSS Asesora Legal CERSS Coordinador Infraestructura y Equipamiento CERSS
Prepared by: the Government o f the Dominican Republic
Vicente Ruiz
Alma Bobadilla Directora Ejecutiva
Coordinador Sistema de Informaci6n CERSS Gerencial
Roberto Cerda Kenia Mej ia Zoila Guerra Kerima Marra
Roberto Blondet Julio Estrella
Coordinador Garantia de Calidad CERS S Consultora CERS S Asistente administrativa CERS S Consultora Legal Banco Central
Director TCcnico SISALRIL Asesor, STP STP
Jose Colon Eusebio Garrido Chanel Rosa Sarah Estrella Jeffrey Lizard0 Wilfred0 Ruiz Eric Raful Fernando Morales
I Angelina Guillen I Especialista Financiera, STP I STP I Subsecretario, SESPAS SESPAS Subsecretario, SESPAS SESPAS Directora Afiliacion SENASA Consultora Juridica SENASA Director. Dept. Estudios Economicos Gerente Financier0 CERS S Consultor Legal CERSS Asistente Ticnico del Coordinador Eiecutivo CERSS
Secretaria de Finanzas
110
Peer Reviewers: Khundavi Kadiresan, LCOQE; Christian Baeza, LCSHH; Wil ly De Geyndt, Former Wor ld Bank Principal Health Specialist and now Assistant Professor George Washington University
QER . The panel met on February 12,2003 and discussed the program proposal with the task team, the country team as well as other staff. The panel also provided a report with i t s main findings and recommendations soon after completion of the review. Panel members included:
Armin Fidler : Cristian Baezd Pablo Gottret: Diana Wei l : MDGs RobertCrown : APL Triggers and Phasing BobSaum : Fiduciary Arrangements Tawhid Nawaz /Kundhavi Kadiresan: Quality
Chairperson (Strategy, Design and Approach) Sector issues and Health Insurance System
Annex 8
Documents in the Project File
Dominican Republic Health Reform Support Program
A. Project Implementation Plan Project Implementation and Procurement Plan.
Draft Operational Manual.
B. Bank Staff Assessments Back -to-Office-Report, Preparation Mission, June 13-20,2002 Back-to-Office Report, Preparation Mission, November 2-9,2002 Back to Office Report, Preparation Mission, March 10-15,2003
C.
1. 2.
3. 4.
5.
6. 7.
8. 9.
Other
Ambiente y Recursos Naturales- PCU 2001 AnBlisis de Situaci6n de Salud de la Republica Dominicana, Secretaria de Estado de Salud Publica y Asistencia Social, 2000 (Documento preliminar) Boletin Estadistico Aiio 1, No.1-SESPAS 2001 CAceres, Francisco. Mortalidad Materna en Rep6blica Dominicana, el cas0 del Distrito Nacional, 1998. Cerda, Robero. Analisis de 10s Principales factores de la Mortalidad Materna en Repliblica Dominicana, 1999. Cddigo de Protecci6n Niiios, niiias y adolescentes, Ley 14-94 Comunicacion especial de la Direcci6n Gral. de Epidemiologia de la SESPAS, febrero 23 de 1998 Consideraciones sobre manejo de residuos sanitarios en Amkrica Latina- OPS/OMS 1992 Desarrollo Humano en la Republica Dominicana 2000. PNUD
10. Descriptivo Te'cnico Incineridor Saunier Duval Setr i Espaiiola, SA 1 1. En Defensa de la vida de la nifiez y de la mujer 1997-2000. UNICEF-ONAPLAN 12. Encuesta DemogBfica y de Salud 1996 y 2002 (ENDESA 1996 y 2002).
13. Encuesta Nacional de ingresos y gastos de la familia. Banco Central de la Rep. Dom. 1998. 14. Estado Mundial de l a Infancia 2000. Fondo de las Naciones Unidas para la Infancia
15. Estudio piloto Encuesta DemogrBfica y Salud 1999, CESDEM / PROFAMILIA. (Documento
16. Indicadores BBsicos de Salud, Republica Dominicana,1999. SESPAS - OPS 17. Indicadores sociales y econ6micos en Ame'rica Latina y e l Caribe. Instituto Interamericano
18. Informe Ambiental y Social-BID-D-0078 1997 19. Informe Programa Nacional de salud Integral de 10s y las adolescentes, Secretaria de Estado
de Salud Publica y Asistencia Social, 2000 20. L a Situation de Salud de la Republica Dominicana, 1996. Secretaria de Estado de Salud
Publica y Asistencia Social (SESPAS).
CESDEM/PROFAMILIA/AID/MACRO-INTERNACIONAL.
(UNICEF).
preliminar).
para el Desarrollo Social (INDEYBID). 2000
21. Ley 24-97, No Violencia contra la Mujer. 22. Ley 8-95 de Promocidn de la Lactancia Materna. 23. Ley General de Medio Ambiente y Recursos Naturales 24. Ley General de Salud (42-0 1) 25. Ley que crea el Sistema Dominican0 de Seguridad Social (87-01) 26. Linea de base de la mortalidad materna en la Republica Dominicana. Secretaria de Estado de
27. Managing Medical Wastes in Developing Countries -OMS 1994 28. Manejo de 10s Residuos Sdlidos Hospitalarios en l a Repiiblica Dominicana-UASD 1992 29. Marco Regulador Juridic0 SESPAS. 30. Normas Ambientales Sobre la Calidad de Aguas y Control de Descarga, SEMARN, 2002 3 1. Normas Ambientales Sobre la Calidad del Aire y Control de Emisiones Atmosfdricas,
32. Normas Ambientales Sobre Residuos Sdlidos y Desechos Radioactivos, SEMARN, 2002 33. Normas de Atencidn a la Mujer durante el Embarazo, Parto, Puerperio y ReciCn Nacido,
34. Normas de Atencidn a las Principales Urgencias Obstetricias, SESPAS, 1999. 35. Normas Nacionales para la Vigilancia Epidemiol6gica de la Mortalidad Materna. SESPAS,
1998. 36. Normas Tdcnico-Administrativas del Programa Nacional de Atencidn Integral a la salud de 10s
y las adolescentes. SESPAS, 1999 37. Oficina Nacional de Presupuesto. Ingresos Fiscales del Gobierno Central, Rep. Dom. 1994 -
1998. 38. Plan de Movilizacidn Nacional Para la Reduccidn de l a Mortalidad Materna e Infantil,
Republica Dominicana, 1997-2000 39. Programa de Educaci6n Sexual Integral y Familiar, Secretaria de Estado de Educacidn y
Cultura. Orden Departamental y Documentos de trabajo. 1996 40. Proyecciones Nacionales de Poblacidn por Sex0 y Grupo de edad, 1990 - 2025. Oficina
Nacional de Planificaci6n, ONAPLAN, REP. DOM, 1999. 41. Republica Dominicana: Perfiles bisicos de salud de 10s paises, Restimenes 1999.
Organizacidn Panamericana de la Salud. OPS/OMS. 42. Sistema de Vigilancia Epidemiol6gica de la Mortalidad Materna, Direccidn General de
Epidemiologia. SESPAS. Informes 1998 y 1999. 43. Sistema dominicano de seguridad social (Ley 87-01) 44. Situacidn Enfermedades del PAI, Enero-Junio 1999. SESPAS 45. Sobre las tendencias de l a mortalidad infantil en l a Republica Dominicana. Secretaria de
46. WHO Information, Fact Sheets- Backgrounder N o l - WHO 2000 47. USAID/SESPAS/Population Council. Strategic Assessment o f Reproductive Health in the
Dominican Republic. 2002. 48. PAHO/WHO. RICC Task Force on Maternal Mortality. Latin America and the Caribbean
Regional Strategy for the Reduction of Maternal Mortality -2002-2010. Sept. 2002. 49. Berg, C., Dane1 I., Mora, G. Guidelines for Maternal Mortality Epidemiological Surveillance.
PAHO/CDC/UNFPA, 1998. 50. World Bank. Dominican Republic Poverty Report. 2001. 5 1. World Bank. Dominican Republic Public Expenditures Report 2003.
Salud Publica y Asistencia Social. 2000
SEMARN, 2002
SESPAS, 1999.
Estado de Salud Ptiblica y Asistencia Social. 2000
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Domin ican Republic at a glance
i”- 96 97 98 99 00 01
-GO1 - O ’ G D P
911 6102
POVERTY and SOCIAL
2001 Population, mid-year (millions) GNI per capita (Atlas method, US$) GNI (Atlas method, US$ billions)
Average annual growth, 1995-01
Population (“A) Labor force (%)
Most recent estimate (latest year available, 1995-01) Poverty (“A of population below national poverty line) Urban population (% of total population) Life expectancy at birth (years) Infant mortality (per 1,000 live births) Child malnutrition (?A of children under5) Access to an improved water source (“A ofpopulation) Illiteracy (‘A of population age I.%) Gross primary enrollment (% of school-age population)
Male Female
KEY ECONOMIC RATIOS and LONG-TERM TRENDS
GDP (US$ billions) Gross domestic investmenffGDP Exports of goods and services/GDP Gross domestic savingsiGDP Gross national savings/GDP
Current account balance/GDP Interest payments/GDP Total debUGDP Total debt service/exports Present value of debUGDP Present value of debuexports
(average annual growth) GDP GDP per capita Exports of goods and services
1981
7.3 23.6 20.8 19.4 18.0
-5.6 2.0
31.6 26.0
1981-91 1991-01
2.8 6.3 0.7 4.5
10.2 6.7
Dominican Republic
8.5 2,230
19.0
1.7 2.6
66 67 39 6
79 16
133 136 130
1991
7.6 21.7 28.2 14.5 20.7
-1.1 1.1
59.2 10.3
2000
7.3 5.5 7.3
Latin America &Carib.
524 3,560 1,862
1.5 2.2
76 70 29 9
85 11
130 131 128
2000
19.6 24.0 27.8 14.4 18.8
-5.2 1.1
23.5 6.6
22.2 55.0
2001
2.7 1.1
-7.9
Lower- middle- income
2,164 1,240 2,677
1 .o 1.2
46 69 33 11 80 15
107 107 107
2001
21.2 23.4 23.9 15.2 19.5
-4.0 0.9
24.0 8.2
2001 -05
I Development diamond‘
Life expectancy
T
GNI Gross per - pnmaiy capita enrollment
Access to improved water source
I Dominican Republic __ Lower-middle-income group
1 Economic ratios*
I Trade
I T
Investment Domestic savings
Indebtedness
-Dominican Republic - Lower-middle-income orom
STRUCTURE of the ECONOMY 1981 1991 2000 2001 1 Growth of investment and GDP (%) i
(% of GDP) Agriculture Industry
Services
Private consumption General government consumption Imports of goods and services
Manufacturing
(average annual growth) Agriculture Industry
Services
Private consumption General government consumption Gross domestic investment Imports of goods and services
Manufacturing
18.6 13.9 27.6 30.6 15.6 18.5 53.8 55.5
30
20
10
0
2ooo 2o01 1 Growth of exports and imports (%) I 1981-91 1991-01
-0.6 3.9 5.0 5.1 3.8 7.3 7.1 0.0 2.9 4.8 7.5 -1.3 3.2 6.2 7.9 3.9
3.8 5.6 8.2 3.1
20 - j
1 0 4 A - I 7
-54 158 -1 4 147 ! - l o 1 4 7 6 5 1 1 “---Exports +Imports 5 2 1 10 7 6 4 6 9 -4 9 I
Note: 2001 data are preliminary estimates
” The diamonds show four key indicators in the countn, (in boid) compared with its income-group average. If data are missing, the diamond will be incomoiete.
116
Dominican Reuublic
PRICES and GOVERNMENT FINANCE
Domestic prices (“7 change) Consumer prices Implicit GDP deflator
Government finance (% of GDP. includes current grants) Current revenue Current budget balance Overall surpluddeflcit
TRADE
(US$ millions) Total exports (fob)
Raw sugar Raw cocoa Manufactures
Total imports (cif) Food Fuel and energy Capital goods
Export price index (1995=100) Import price index (1995=100) Terms of trade (1995=100)
BALANCE of PAYMENTS
(US$ millions) Exports of goods and services Imports of goods and services Resource balance
Net income Net current transfers
Current account balance
Financing items (net) Changes in net reserves
Memo: Reserves including gold (US$ millions) Conversion rate (DEC, local/lJS$)
EXTERNAL DEBT and RESOURCE FLOWS
(US$ millions) Total debt outstanding and disbursed
IERD IDA
Total debt service IBRD IDA
Composition of net resource flows Official grants Official creditors Private creditors Foreign direct investment Portfolio equity
World Bank program Commitments Disbursements Principal repayments Net flows Interest payments Net transfers
1981
16.8 5.3
1981
1981
1,512 1,818 -306
-293 193
-406
296 110
1 .o
1981
2,293 93 22
396 8 0
13 195 -32 80 0
34 2
32 6
25
1991
59.4 58.2
13.3 6.5 0.7
1991
1,103 115 31
578 2,188
52 507 367
1991
2,154 2,706 -551
-360 829
-82
439 -358
426 12.7
1991
4,491 254 20
264 54
1
18 22 -15 145
0
42 31 11 23
-12
2000
7.7 7.9
16.0 2.1
-2.1
2000
2,674 71 22
1,708 6,416
403 1,507 1,197
2000
5,902 7,789 -1,888
-1,041 1,902
-1,027
957 70
818 16.4
2000
4,592 292
14
52 1 43
1
44 -84 115 953 74
8 39 22 17 22 -5
2001
8.9 8.9
16.7 3.8
-1.7
2001
2,486 65 38
1,691 5,937
356 1,240 1,285
2001
5,485 7,232
-1,747
-1,119 2,028
-839
1,357 -519
1,341 17.0
2001
5,083 317
13
62 1 46
1
-55 530
25 49 24 25 23 2
96 97 98 99 00
-GDP deflator b C P I
Export and import levels (USS mill.)
/8.000 , 95 96 97 98 99 00 01
Exporls m Imparts
1 Current account balance to GDP (%)
Composition of 2001 debt (USS mill.)
1 317 I 13 ..
1295 ~
E - Bilateral
G - Shod-term ~ i: D - Other multilateral F - Private 1 C . IMF
Development Economics 911 6102