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Doct.ment of

The World Bank

FOR OFFICIAL USE ONLY

MICROFICHE COPYReport No. 9816-POL

Report No. 9816-POL Type: (SAR YOUNG, MAR/ X32466 / H-8021/ EMl

STAFF APPRAISAL REPORT

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

MARCH 27, 1992

Human Resources Sector Operations DivisionCentral and Southern Europe DepartmentsEurope and Central Asia Region

This document has a restricted distibution and may be used by recipients only in the performance oftheir oMcrat duties. Its contents may not otherwise be disclosed without World Bank authorzation.

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CURRENCX EOUIYALENTS(March 1992)

Currency Unit - Zloty (ZL)US$1.00 - ZL13,360

WEIGHTS AND MEASURES

Metric System

FISCAL YEAR

January 1 - December 31

ABBREVIATIONS AND ACRONYMS

ACT - Anatomic Chemical Therapeutic SystemA/D - Admission/DischargeCCO - Consortia Coordination OfficeCY - Calendar YearDDD - Daily Drug DosageEC - Comission of the European CommunitiesECU - European Currency UnitFY - Fiscal YearGDP - Gross Domestic ProductICB - International Competitive BiddingIDA - International Development AssociationILO - International Labor OrganizationlcM - Institute of Occupational MedicineLCB - Local Competitive BiddingMOF - Ministry of FinanceMOB - Ministry of Health and Social WelfareMOHPD - MOH Pharmaceuticals DepartmentNBHP - National Board for Health PromotionNBPC - National Board for Primary CareNCDG - National Consortia Development GroupNCHSM - National Center for Health System ManagementNDI - National Drug InstituteNPIU - National Project Implementation UnitOECD - Organization for Economic Cooperation and DevelopmentPCP - Primary Care PhysicianPOM - Project Operations ManualRTU - Regional Training UnitSANEPID - Sanitation Epidemic Prevention SystemSCBP - Steering Comittee for Budget PlanningSCIS - Steering Committee for Information SystemsSCPC - Steering Committee for Primary CareSOE - Statement of ExpenditureTA - Technical AssistanceWHO - World Health OrganizationZL - ZlotyZOZs - Zespol Opieki Zdrowotnej or Integrated Health and Social Services

DEFINITION

Poland is divided into 49 administrative areas called "voivodships".

FOR OMCIAL USE ONLYPOtAND

ijiLTH SERVICES DEVELOPMENT PROJECT

STAFF APPRAISAL REPORT

Table of ContentsPage No.

HEALTH AND POPULATION DATA SHEET . . . .

Loan and Project Summary . . . . . . . . . . . . . . . . . . . . . . . . iv

I. THE HEALTH SECIOR IN POA[D . . . . . . . . . . . . . . . . . . . . 1

A. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 1B. Sector Background . . . . . . . . . . . . . . . . . . . . . . . 2C. Sector Issues . . . . . . . . . . . . . . . . . . . . . . . . . 6D. Government Program .... . . . . . . . . . . . . . . . . . . 11E. Rationale for Bank Involvement . . . . . . . . . . . . . . . . 12F. Role of Other Donors . . . . . . . . . . . . . . . . . . . . . 13

II. THE PROJECT ............. ..... .... .... . . 14

A. Health Promotion . . . . . . . . . . . . . . . . . . . . . . . 15B. Primary Health Care . . . . . . . . . . . . . . . . . . . . . . 16C. Health Management ....... .. .. .. .. .. .. .. . . 18D. Regional Health Services (Consortia) . . . . . . . . . . . . . 21E. Environmental Considerations ..... . . . . . . . . . . . . 24

III. PROJECT COSTS. FINANCING. MANAGEMENT AND IMPLEMENTATION . . . . . . 25

A. Project Costs ......... ... .. ... ... ... . . 25B. Project Financing . . . . . . . . . . . . . . . . . . . . . . . 28C. Project Management and Implementation . . . . . . . . . . . . . 29D. Project Procurement Arrangements . . . . . . . . . . . . . . . 33E. Status of Preparation . . . . . . . . . . . . . . . . . . . . . 36F. Project Reporting, Evaluation and Supervision . . . . . . . . . 37

This report is based on the findings of an appraisal mission that visitedPoland in October, 1991. Mission members were Mary E-Ming Young (PublicHealth Specialist, Mission Leader), Terrice Bassler (Operations Officer,EC1/2HR), Leonardo Concepcion (Sr. Implementation Specialist, EMTPH),Alexander S. Preker (Health Economist, EC1/2HR), Carl Whitehouse (PrimaryCare/Medical Education specialist, Consultant), Jan Blanpain (Health ServicesSpecialist, Consultant), and Kurt Moses (Information Systems Specialist,Consultant). Lia Achsien (EC1/2HR) was responsible for text processing. TaskManager: Mary E-Ming Young (EMTPH); Division Chief: Ralph W. Harbison(ECl/2HR); Director: Kemal Dervis (EC2DR); Peer Reviewers: Anthony Measham(PHRHN); Salim Habayeb (SA2PH); Bernard Liese (HSDDR); Eugene Boostrom(AFTPN).

This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

Table of Contents (cont'd)

IV. BENEFITS MD RISKS ....................... . 39

Benefits .39Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

' V. AGREEMENTS REACHED ANP RECO(ENlDATION . . . . . . . . . . . . . . . 40

Agreements Reached . . . . . . . . . . . . . . . . . . . . . . . . 40Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Text Tables

Table 3.1: Project Cost Summary by Project Component . . . . . . . . . . 25Table 3.2: Project Cost Summary by Category of Expenditure ... . . . . . 26Table 3.3: Financing Plan by Disbursement Category . . . . . . . . . . . 28Table 3.4: Procurement Arrangements .34

An_nexes

Annex 1 : Development of Regional Health Services (CONSORTIA) . . . 42Org. Chart : Structure of the Consortium Management . . . . . . . . . . 45Attachment A: Guidelines for Regional Strategic Plans . . . . . . . . . 46Annex 2 : Detailed Project Cost Estimates . . . . . . . . . . . . . 49Annex 3 : Project Implementation Arrangements . . . . . . . . . . . 57Annex 4 : Technical Assistance Summary by Project Component . . . . 59Annex 5 : Project Implementation Schedule and Monitoring Indicators 65Annex 6 : Schedule of Disbursement . . . . . . . . . . . . . . . . . 73Annex 7 : Documents Available on Project File . . . . . . . . . . . 74Annex 8 : Supervision Plan . . . . . . . . . ' . . . . . . . . . . . 76

ME&: IBRD No. 232282R

HEALTH SERVICES DEVELOPMENT PROJECT

HEALTH AND POPULATION DATA SHEET 1/

A. General Country DatA

Year

1. Population (millions) 38.2 19902. Area (km2 in thousands) 312.7 19903. Population Density (per kW2) 122.0 19904. GNP Per Capita (US$) 1,790.0 19895. Gross Hard Currency Debt (in billions of dollars) 46.6 1990

B. PoDulation and Health

1. Annual Rate Of Population Growth (X) 0.4 19892. Urban Population (X of total) 61.0 19893. Population Age Structure

0-14 Years (X) 25.1 198915-64 Years (t) 65.1 198965(+) Years (X) 9.8 1989

4. Crude Birth Rate (per 1,000 population) 15.0 19895. Crude Death Rate (per 1,000 population) 10.0 19896. Life Expectancy At Birth:2/

- Female 76.0 1989- Male 67.0 1989

Life Expectancy At Age 30:2.1- Female 47.0 1989- Male 39.0 1989

7. Infant Mortality Rate Per 1,000 Live Births- National Average 16.1 1989

8. Risk of Dying By Age 5 (per 1,000 population)2./- Female 17.0 1989- Male 22.0 1989

9. Total Fertility Rate 2.2 198910. Women of Childbearing Age (as a percentage of

total female population) 48.0 198911. Maternal Mortality Rate Per 100,000 Live Births 12.0 198912. Babies Born With Low Birth Weight (S) 8.0 198813. Daily Calorie Supply Per Capita 3,451.0 1988

/ Unless otherwise indicated, figures are World Bank estimates.

/ Annual Health Statistics Report, MOH, Poland, 1990.

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C. Health Sector Resources and Expenditures

Year

1. MOH Health Expenditures as X of 3tate Budget 10.5 1991Public Expenditures on Health as X of GDP 4.5 1991Total Expenditures on Health per Capita (US$) 97.0 1991

2. Physicians per 10,000 Populatior. / 21.4 19903. Hospital Beds per 10,000 Population 2 56.1 1990

2 Annual Health Statistic Report, MOH, Poland, 1990.

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DEFINITIONS OF POPULATION. HEALTH AND NUTRITION TERMS

Average Occupancy Rate - Number of hospital days/(number of beds x 365).

Average Length of Stay - Number of Hbspital days/number of admissions.

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

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

Infant Mortality Rate * Annual deaths of infants younger than 1 year oldper 1,000 live births during the same year.

Life Expectancy at Birth - The number of years a newborn child would liveif subject to the age-specific mortality ratesprevailing at time of birth.

Low Birth Weight (LBW) - Infants whose weight at birth is less than 2,500grams.

Maternal Mortality Rate - Number of maternal deaths per 100,000 livebirths in a given year attributable topregnancy, childbirth, or post-partum.

Rate of Natural Increase - The rate at which a population is increasing (ordecreasing) in a given year due to surplus (ordeficit) of births over deaths expressed as apercentage of the base population.

Rate of Population Growth - The rate at which a population is increasing (ordecreasing) in a given year due to naturalincrease and net migration, expressed as apercentage of the base population.

Total Fertility Rate - The average number of children a woman will haveif she experiences a given set of age specificfertility rates throughout her lifetime. Servesas an estimate of the number of children perfamily.

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PgOLAND

HEALTH SERVICES DEVELOPMENT PROJECT

STAFF APPRAISAL REPORT

Loan and Proiect SuMmary

BORROWER: Republic of Poland.

BENEFICIARIES: Min stry of Health and three project regions.

LO~13ANmO : US$130.0 million equivalent.

TERMS: Seventeen years, including a four year grace period, at theIBRD standard variable interest rate.

PROJECT The project would support the Government's economicOBJECTIVE: reform program by improving health, strengthening the health

sector's contribution to the social safety net, and con:ainingupward pressure from the health sector on the state budget.To achieve these goals, the project would: (a) improve healthstatus by strengthening health promotion and preventionprograms; (b) support the first steps in restructuring thehealth sector by shifting the focus from institutional care toeffective primary care through better trained primary caredoctors and nurses; (c) strengthen institutional capacity inpolicy making, planning, management and evaluation byproviding managers access to improved information systems andmanagement education; and (d) ensure sustainability ofservices and control costs in the health sector in the medium-term by improving effectiveness, efficiency and quality ofservice delivery in three project regions.

PROJECT The project would comprise four components: (a) HealthDESCRIPTION: Promotion; (b) Primary Health Care; (c) Health Management; and

(d) Regional Health Services. For each, it would provide fortechnical assistance, training, equipment and civil works(US$182.6 million equivalent base cost; and US$227.0 milliontotal cost including contingencies). The project would beirplemented over a period of seven years and completed byDecember 31, 1998. A special feature of the project design isthe targeting of components (a), (b) and (c) in three projectregions under component (d) to maximize impact. Healthservices in the three regions would be reorganized as "healthconsortia" of participating voivodships. Concurrently, theproject would also contribute to progressive strengthening ofthe entire health sector through aspects of components (a),(b), and (c) that would be implemented in a phased manner atthe national level.

BENEFITS: Major benefits include increased orientation toward preventionof health problems, more accessible and effectiva primarycare, more efficient and professionally managed healthservices, reduced reliance on the state budget for health carefinancing, and experience in decentralization of healthservices. Improved targeting of poor and vulnerablepopulations would be achieved through better equipped and morehighly trained family doctors. This would also addressfragmentation of primary care and reduce reliance onenterprise-based setvices, thereby facilitating labormobility. A reduction in avoidable infant deaths could beexpect .t. Improved accounting methods, monitoring of drugprescriptions and sales, and professional hospital managementwould all lead to efficiency gains and contribute to costcontainment. Regional restructuring of health services isexpected to permit greater involvement of the private sectorin hospital support services such as laundry, catering andmaintenance. Development of training for primary carephysicians and nurses is also expected to foster high qualityprivate practices. The three project regions would contributeto sustainability of the project through cost containment andimproved efficiency by establishing shared services intechnology and materials management, planning and evaluation.Once materials management is operating, up to 10% savings onoperating budgets could be achieved, and up to 5% savings arepossible on both investment and operating budgets withefficient equipment management. The combined total savingsfrom measures that address pharmaceutical consumption andefficiency in hospitals could be as high as ZL3 trillion or 8percent of the total health care budget. These internalsavings could be redirected toward priorities such as healthpromotion, prevention and primary care.

, RISKS: There are two main risks. The first is continuation of weakproject implementation capacity in the Ministry of Health andSocial Welfare (MOH). Project implementation presents anadministrative challenge unprecedented in MOH, and the numberof qualified staff responsible for implementation needs to beincreased. This risk is compounded by the difficulty inattracting and maintaining staff with the present publicsector salaries. Management capacity at the regional level isalso a concern. To reduce this risk, technical assistance inproject management would be provided during project start-upand implementation. The second risk is that continueduncontrolled rise in health expenditure and further economicdifficulty could compromise financing and sustainability ofhealth services. Project design has been tightly focused onessential investments to rationalize health expenditures andminimize incremental recurrent costs. Management improvementsand cost recovery to be implemented under the project wouldyield substantial efficiency gains.

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Estimated Proiect Costs: i}

Local Foreign Total-(US$ million) ----

Health PromotionHealth Promotion Programs 0.5 1.5 2.0Training of Health Educators 1.5 3.7 5.2Occupational Health 0.1 Q. Q_a

Sub-Thtal 2.1 5.4 7.5

Primary Health CarePrimary Care Practices 15.3 14.3 29.6In-Service Training 2.3, 6.4 _.7

Sub-Total 17.6 20.7 38.3

Health ManagementHospital A/D Information & Accounting (national) 2.3 11.5 13.8Pharmaceutical Monitoring (national) 4.5 20.6 25.1Budgeting 0.1 0.4 0.5Management Development 1.1 4.2 5.3Health Financing O.5 .1 .6

Sub-Total 8.5 37.8 46.3

Regional Health ServicesRegional Management 2.5 4.4 6.9Infrastructure Consolidation 31.9 34.6 66.5Hospital A/D Information & Accounting (regional) 2.5 7.9 10.4Pharmaceutical Monitoring (regional) 0.7 2.6 3.3Materials and Technology Management 0.4 , 3.0 3.A

Sub-Total 38.0 52.5 90.5

Total Base Cost 66.2 116.4 182.6

Physical Contingencies 5.4 10.3 15.7Price Contingencies 11.2 17.5 28.7

TOTAL PROJECT COSTS 82.8 144.2 227.0

I/ Project costs include an estimated 10 percent, or US$6.1 millionequivalent, for indirect taxes on locally procured services and civilworks. Numbers may not total exactly due to rounding.

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Local Foreign Total---- (US$ million)-------

Financing PlAn:GovernmentNational Government 45.9 A/ 0.0 45.9Regional Consortia (voivodships) 26.1 0.0 26.1

IBRD 0.0 130.0 130.0European Community .8 14.2 25.0

Total 82.8 144.2 227.0

j/ Includes US$6.1 million in taxes and duties.

Estimated Disbursements:

Fiscal Year1992 1993 1994 1995 1996 1997 1998 1999-------------------- (US$ million) ------------------

Annual 0.5 9.0 27.6 30.3 24.9 17.0 11.8 8.9Cumulative 0.5 9.5 37.1 67.4 92.3 109.3 121.1 130.0

Rate of Return: Not applicable

MEP: IBRD 23228R

I. THE HEALTH SECTOR IN POLAND

A. Introducelon

1.1 The Government of Poland is committed to major reform andrestructuring of the health sector to improve the bleak social conditions leftby decades of poor standards of living, disregard for the environment,unhealthy lifestyles and misdirected priorities in provision of healthservices. 5ince the mid-1970s, health status in Poland has deterioratedsignificantly while it improved in most western countries. Currently, lifeexpectancy is low and mortality high compared with western Europe. A programof extensive but poorly targeted investments during the early 1970s led to abuild-up of acute care hospitals and training of medical specialists. Littleattention was given to the construction of adequate rehabilitation servicesand long-term care facilities. Training of general practitioners, nurses andother health care personnel was neglected, leading to serious imbalances inthe type and number of health care workers and their geographic distribution.The recurrent budget required to operate the resulting massive National HealthService qutckly outstripped the country's financial resources. In recentyears, underfinancing and neglect have left health services badly in need ofmaintenance, repair and replacement. Hospitals and ambulatory clinics oftenlack even basic diagnostic and therapeutic equipment. Chronic shortages inmany critical drugs and supplies lead to ineffective and low quality care.Finally, there are virtually no incentives to motivate patients to maintaingood health and to use scarce resources judiciously, or to encourage healthcare workers to provide effective, efficient, and high qw-ilty care.

1.2 The health sector confronts these problems during a period ofeconomic crisis. Following a period of hyperinflation, the Governmentlaunched reforms to introduce a market economy in January 1990. Although theeconomy is beginning to stabilize, the annual rate of inflation during thelatter part of 1991 was still about 40 percent and cutput h.;- declined sharplyfor two consecutive years. This has resulted in a seriou .a.iiscal deficit,which could potentially worsen in 1992. Measures taken to confront thepresent fiscal crisis are likely to include real expenditure cuts. Thesereductions could have an important bearing on the health sector, which reliesalmost exclusively on state budget transfers for its financing. It isbecoming increasingly clear that success of the Government's economic reformprogram depends to a large extent on measures taken to balance the budget andreduce the social cost of adjustment. Increasing public expenditure on healthservices and deteriorating standards of care could compromise the reformprogram.

1.3 The Government's fiscal situation is simultaneously a primedeterminant of the fate of the health system and a consequence of it. Healthexpenditure is a significant component of public expenditure which must becontained to trigger a successful economic recovery. Continued inflation andincreased demand for health services drive up health expenditure; pooreconomic growth and public sector budget constraints reduce the healthsector's financial resources. The Government is therefore introducingmeasures to enhance cost-containment, to increase cost recovery and to achievegreater targeting of services. With the collapse of the previous economic

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order, the health sector can no longer depend upon the foundation on which it

was built--public ownership of facilities, public management of services, and

financing through the state budget. In the medium-term, Poland is in critical

need of a radical restructuring of its health sector through the introductionof a new and more appropriate balance in the public/private mix in ownership,

management and financing.

B. Sector Background

Hgalth Status

1.4 From 1947 to 1964, health status in Poland improved significantly.As in other parts of Europe, mortality declined, and degenerative and chronic

non-communicable diseases replaced infectious diseases as leading causes of

death. These trends have continued in Western Europe since the mid-1960's.

Since then, however, mortality in Poland and other Eastern European countries

has risen and life expectancy has decreased. This trend has been especially

pronounced for middle-aged men and women. By 1989, life expectancy at birth

in Foland was 67 years for men and 76 years for women, compared with the OECD

range of 70 to 76 years for men and 76 to 81 years for women. During the same

period, there has been a steady decrease ifi life expectancy for adult males.Between 1970 and 1985 life expectancy for men at age 30 decreased by 1.5

years. The age-standardized death rate from cardiovascular disease increased

by 72 percent for men between 1970 and 1985, whereas there was a reduction of

about 30 percent in most Western European countries. By 1989, male life

expectancy at age 30 was 39 years, and female life expectancy was 47 years.

In contrast to what is observed in other developed and developing countries,urban adults have a lower life expectancy in Poland than rural adults, despite

a higher crude mortality rate and higher infant mortality rate in rural areas.In Poland, urban areas appear to be associated with higher health related risk

factors than rural areas (environmental hazards, stressful work, substandard

housing and unhealthy lifestyle). A similar observation was made in many

western countries during the early period of the industrial revolution. With

increased development, these trends reversed themselves in most western

countries.

1.5 Between 1950 and 1990, infant mortality in Poland declined from 111.2

deaths per 1,000 live births to 16.1, but the rate of decline has slowed in

recent years. The infant mortality rate in Poland is lower than the average

for Eastern European countries (18.5 per 1,000 in 1986), but higher than for

Western European countries (5.0 to 14.2 per 1,000). Half of infant deaths

occur in the population group falling below the lower third'of householdincome distribution. There are significant differences between regions and

socioeconomic groups. About two-thirds of infant deaths are related to

premature births and perinatal problems; both are indicators of access to

health services and quality of basic care. Post-neonatal mortality,accounting for the remaining third of all infant deaths, is higher in Poland

than in most Western European countries. It is used as an indicator of poorenvironmental hygiene, malnutrition, and lack of basic medical care.

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Health Services

1.6 Structure and Organization. Health services provided by the Ministryof Health and Social Welfare (MOH) and voivodships offer a highly structurednetwork of health care institutions to 90 percent of the population in Poland.Additional parallel health services are provided by other Ministries,l/public enterprises, medical cooperatives and a small private sector.Ownership of health care facilities, provision of health services andfinancing is limited almost exclusively to the public sector. The MOH isresponsible for formulating health policies, planning the health care budget,monitoring and providing a limited range of highly specialized tertiary care.The 49 voivodships and 400 ZOZ (Zespol Opieki Zdrowotnej - integrated healthand social service units) are responsible for providing the bulk of primary,secondary and basic tertiary care for the general population. The number ofZOZs in a single voivodship ranges from 3 to 33. The population covered by asingle ZOZ is uneven, ranging from 30,000 to 150,000 people, with an averageof one ZOZ per 100,000 population.

1.7 Public health and disease prevention activities are carried out atboth national and voivodship levels by the Sanitation and Epidemic PreventionSystem (SANEPID). SANEPID stations are responsible for disease surveillanceand reporting, control of communicable diseases, monitoring of environmentalhealth,/ food hygiene, health education and preventive medicine. One of themost tangible achievements of the SANEPID stations has been their contributionto the programs for supplying vaccines to pediatricians and conducting surveysand follow-up action for the control of communicable diseases. They are alsoresponsible for determining the safety of workplaces, measuring levels ofrisk, enforcing orders to change specific occupational practices, andundertaking clinical work on occupational diseases with individual workers.Many of the SANEPID stations have microbiological and immunologicallaboratories which provide clinical testing for local hospitals. In contrast,most public health services found in western countries do not provide clinicallaboratory services for hospitals.

1.8 Health Care Personnel. Since the 1970s, the total number of doctors,nurses, dentists, and pharmacists per capita has increased significantly toreach a doctor/population ratio that is within the mid-range for the OECD, andsimilar to that found in many other eastern European counties. By 1990, therewere 21.4 doctors, 4.8 dentists, 54.4 nurses and 6.3 midwives per 10,000

1/ Ministries that provide parallel health services include the Ministry ofTransport (railways), Ministry of Industries (mines, occupational health),Ministry of Interior (police), Ministry of Defense (armed forces),Ministry of Justice (prisons) and Ministry of Foreign Affairs (embassies).The parallel health services provide health care for the remaining10 percent of the population, while occupational health services providedby enterprises and the private sector overlap with those of the MOH.

/ The Ministries of Environmental Protection and Natural Resources,Agriculture, Forestry and Food Economy share responsibility with the MOH'sSANEPID system for monitoring environmental health.

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inhabitants in Poland. Distribution of medical personnel is uneven, however,ranging from 41.8 doctors per 10,000 people in Warsaw to 9.9 in the Siedlcevoivodship. The mix of medical personnel is characterized by a predominanceof specialists, even at the primary care level, where internists,gynecologists, pediatricians and dentists provide the first point of contactto the health system. More than 72 percent of the physicians are specialists,and 50 percent of these have a subspecialty. There are no formal trainingprograms for preparing doctors for general practice or family medicine. Thenurse/doctor ratio and nurse/bed ratio is low by western standards.

1.9 Physical Resources. Eguipment. SunDlies and Medical Drugs. Theexpansion that took place in Poland's health care resources over the past 20years led to a marked increase in hospitals, out-patient clinics and medicalcenters. By 1990, there were 56 beds per 10,000 population in Poland, whichis in the mid-range of values observed in the OECD. This bed/capita ratiodoes not include additional beds found in the parallel health servicesprovided by other Ministries. There are also 8.9 beds per 10,000 populationin psychiatric hospitals, 1.5 in tuberculosis sanatoriums and 1.6 in othersanatoriums. Although these additional beds were designed and intended foracute care, many are used for long-term chronic care due to a shortage ofchronic care beds and related support services elsewhere in the system. Sinceacute care beds that are occupied by chronic care patients are not availablefor active care, the actual number of active acute care beds in Poland is lessthan what is observed in many western countries despite the high number oftotal beds. Furthermore, the distribution of hospital beds is uneven, rangingfrom 79.6 per 10,000 in Wroclaw to 35.4 in Konin. Construction of hospitalsand clinics has decreased significantly in recent years due to a markedreduction in the investment budget of the health sector. Medical drugs,syringes, gloves, needles, small instruments and electronic equipment (much ofwhich is imported or depends on imported inputs), are in chronic short supply.Although Poland has a large pharmaceutical industry and capacity to produceabout 80 percent of the drugs it needs, many of the raw materials and semi-finished products required for production must be imported. At present,domestic industry is meeting about 60 percent of the country's requirements.

1.10 Utilization of Services. In 1988, the number of hospital bed daysper capita was 1.3 in Poland, compared with a range of 0.7 to 4.9 in OECDcountries. At 12.6 days, the average length of hospital stay is in the mid-range of patterns in Western Europe. In OECD countries, the range of theadmission rates was from 5.5 percent to 22.6 percent, and the length of staywas 6.1 to 34.8 days in 1988, excluding Japan. On average, a person in Polandvisits a physician 7.7 times per year (including dentists), compared with arange of 2.0 to 12.8 physician visits per person reported in the OECD. Localaveiages range from 11.4 in Lodz to 4.5 in Siedlce. Unreported visits tohealth care facilities, including those in the parallel health services andprivate sector, distort what appears to be a low use of health care resourcescompared with the range of norms observed in the OECD. Only 62 percent ofpatients' contacts were provided by primary health care physicians. Queues,waiting lists, low-quality services, and supply shortages create a barrier toaccess that prevents utilization rates being a good indicator of demand.

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Health Financing

1.11 Overall ExRenditures. The estimated total health care expenditure inPoland for 1991 is Zloty (ZL) 48.8 trillion (US$4.23 billion) or 5.4 percentof Gross Domestic Product (GDP). The health sector's claim on GDP in Polandis similar to estimates of health care expenditure for other Central andEastern European countries and for developing countries with similar nationalincomes, but in the low range of expenditure reported by the OECD, excludingTurkey (5.3 to 11.2 percent of GDP). In 1991, the recurrent and capitalexpenditure budget for health services provided by MOH accounted for 80percent of total health care expenditure. MOH's share excludes expenditure onhealth services provided by enterprises, parallel health services provided byother Ministries, and out-of-pocket expenditure by households. During thelate 1970s to mid-1980s, total expenditure on health services provided by theMOH increased both in nominal and constant values. It also increased relativeto GDP and to general government expenditure. This growth slowed dramaticallyin 1989, and both capital and current expenditure on health care decreasedmarkedly in real terms in 1990 and 1991.

1.12 Recurrent and Capital Expenditure. Throughout the 1980s, the mostsignificant rQcurrent expenditure categories in the health sector were wagesat about 30 percent and drugs at about 15 percent. Other categories undermaterial expenses such as food, energy, services and maintenance, made up amuch smaller proportion of recurrent expenditures. The low relative wagestructure for health care workers and high expenditure on drugs and importedmedical equipment distort relative expenditure on these categories in Polandcompared with western countries where salaries comprise more than 60 percentof recurrent expenditure. Construction costs comprise 60-70 percent of totalcapital expenditure and 80 percent of accumulated assets. Capital expenditurehas decreased relative to GDP and in constant values during the late 1980s.In 1991, the ratio of capital expenditure to total expenditure in the healthsector dropped to 8.2 percent.

1.13 Budget Process. The MOH and other ministries that operate parallelhealth services each prepare their own independent budget. MOH has a centralbudget for institutions under its direct responsibility, while institutions atthe regional and ZOZ levels are financed through the central government'sbudgetary transfers to voivodships. The central government budget providesfinancing for the general administration of MOH, specialized nationalinstitutions, university-affiliated hospitals and special national programs.The voivodship budget provides financing for regional, district and communityand associated institutions at the community level. In principle, voivodshipbudgets are to be determined by catchment area population, the number of beds,and the number of medical personnel. In practice, the budget is determined byhistorical allocations adjusted for deficits, inflation, and the individualnegotiating power of directors, local authorities, and other interest groups.

1.14 Source of Financing. Health services provided by MOH, the parallelservices provided by other Ministries, and occupational health servicesprovided by public enterprises are all financed through the state budget(90 percent of total sources of financing). With the exception of nominal co-payments for some drugs and gratuities, there is no direct individual

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responsibility for financing health care such as user charges or insurancecontributions, Out-of-pocket household expenditure is estimated at 10 percentof total sources of financir.g. Private health insurance does not exist. Bycontrast, in most OECD countries, public financing (general revenues, socialinsurance and statutory health insurance) accounted for 41-97 percent of totalhealth care expenditure in 1987.

C. Sector Issues

1.15 Many problems plague the Polish health sector. Those described inthe following sections were identified by a joint World Bank/Government TaskForce during 1990 and 1991 as issues that need to be addressed most urgentlyduring Poland's economic stabilization and transition to a market economy.They include: (a) poor health; (b) ineffective specialization;(c) inefficient bureaucracy; and (d) distorted priorities.

Poor Health

1.16 Health Status. Declining health status, rising mortality rates andlow life expectancy compared with western countries are the most seriouschallenges that face the health sector in Poland. Experience from western anddeveloping countries suggests that life expectancy increases with development,irrespective of specific health sector interventions. The most importantdeterminants of good health are level of income, standards of living, goodhousing, adequate diet, healthy lifestyle and safe workplaces--not healthservices. Poverty, substandard housing, poor diets, smoking, alcoholconsumption, stressful work, accidents and environmental hazards allcontribute to poor health and ultimately to mortality. With the exception ofhealth promotion and public health programs, traditional health services donot address most of these problems. For life expectancy to fall in Poland,some form of reverse development has taken place under which health-relatedliving conditions deteriorated to such an extent that mortality rates rose.The core of this bleak situation lies mainly in rising mortality fromcardiovascular diseases, stroke and cancers, which has exceeded gains fromcontinuing decreases in infant mortality. A major health sector priority mustbe to address effectively this deterioration in health status, whilepreserving achievements in communicable diseases control, and maternal andchild health.

1.17 Public Health Institutions. The SANEPID stations have beenineffective in controlling environmental pollution and reducing lifestyle riskfactors. The total number of epidemiologists per capita may be higher inPoland than in other European countries, but their work is mainly descriptive.Lack of adequate data processing has no doubt contributed to this weaknessalong with the uncompetitive and sheltered intellectual environment of thepast. The activities of SANEPID stations led to few positive outcomes, partlyas a result of an inability to influence legislation, policy or publicattitudes, and partly because of the prevailing attitude that 'to measure theproblem is to solve the problem'. Tests to measure pollution continue to beconducted without introducing effective policies or programs to deal with the

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measured phenomena. Volumes of other data are painstakingly andsystematically collected without effective interventions. Although theGovernment recognizes that health promotion and prevention are the means toreduce morbidity and mortality, clear action and Implementation in this areahave been difficult (e.g., the proposed Smoking Control Bill has not yet beenpassed by Parliament).

1.18 Health Promotion Proframs. Preventive services are especiallyvulnerable during the present economic crisis because they are likely to havetheir budgets cut to a proportionally greater extent than curative services.Such cuts could undermine the continuation of essential and effective servicesfor women and children (e.g., immunization, prenatal care), and could delay orprevent the launching of new initiatives in such areas as family planning.Legal abortion is used extensively to limit fertility. Lack of informationand access to alternative and affordable methods of birth control contributeto this trend. This is both medically inappropriate and economicallyinefficient. In the past, prevention was excluded from the scope of healthcare in Poland. During the 1970s, the deteriorating health status of thepopulation was known by the Government but was not revealed for politicalreasons. A National Health Strategy was approved by the Economic Commissionin June 1990, but the MOH has been unable to mobilize the financial resourcesand institutional capacity to develop and implement proposed programs such asschool health education, anti-smoking measures and workplace safety. Despiteobvious financial constraints, occupational health services continue tomisdirect their scarce financial resources toward curative services forprivileged groups rather than toward protection of workers. Similarly, theSANEPID stations continue to conduct microbiological and immunological testsfor acute care hospitals instead of devoting scarce resources to combattingthe leading threats to public health.

Ineffective Specialization

1.19 Services. Despite the highly structured character of Polish healthservices, functional distinctions between primary, secondary and tertiarylevels of care are often unclear. Lack of basic equipment, supplies, drugs,social services and home care in the primary care setting, and the narrowrange of clinical skills of non-hospital based doctors, make it impossible forservices to function properly at the primary care level. The use of medicalspecialists rather than general practitioners as the first point of patientcontact with the health care system amplifies this problem. Compulsorycatchment areas and the role of primary care doctors as gatekeepers areunpopular with patients who rightfully feel they are wasting time in queuesonly to be told that services they need are not available at that level ofcare. Not surprisingly, patients are willing to pay substantial gratuities tobe referred quickly to higher levels of care. This leads to inappropriatereferrals to more specialized levels of care for problems that could have beentreated adequately at the community and district levels, if equipment andproperly trained staff were available. More specialized, expensive and oftendistant regional and national institutions end up providing first line carenot only to their immediate catchment populations but also to patients fromvastly different parts of the country. Simply designating some centers forhighly specialized care and others for primary care has not solved this

problem. Combined with a chronic shortage of nurses, auxiliary and primaryhealth care workers, the result is ineffective fragmentation of primary careand poor targeting of vulnerable populations.

1.20 Training. The orientation of Polish health services towardssuper-specialization has much to do with unbalanced postgraduate medicaleducation and the power base that specialists enjoy within the medicalestablishment. Postgraduate medical schools in Poland have not kept up withtrends in many western and developing countries of restructuring part of theirmedical education towards training primary care doctors and allied health careworkers, and introducing financial incentives that make community-basedservices attractive to both patients and health care workers. Instead, thenear public sector monopoly and low quality of most ambulatory clinics createstrong negative incentives for doctors who might otherwise be attracted bygeneral practice. A continued increase in the total number of specialists percapita, without a balance in the number of general practitioners, communitynurses and other auxiliary health care workers, will have serious consequencesfor the Polish health care system in the future in terms of quality of care,targeting of vulnerable populations and health care expenditure. A majorhealth sector priority must therefore be to address this problem by providingbetter training and improved conditions of service for primary care doctorsand allied health care workers.

Inefficient Bureaucracy

1.21 Management. Health services in Poland are poorly managed. Rigidbureaucracy, with strict adherence to arbitrary norms, deprive directors andhealth personnel of the flexibility to determine local priorities and toallocate resources according to specific needs. The lack of management-basedinformation systems (data on health outcomes, performance of health servicesand expenditure trends) prevents policy makers, managers and other health careprofessionals from maximizing effectiveness and efficiency in provision ofservices. Instead, administrators implement central dictates with littlescope for individual decision-making. Most hospital directors are doctorswith no training in health care management or access to basic management toolssuch as information systems to assist in record keeping (admission/dischargedata), accounting, personnel management, materials management, equipmentmanagement and tracking utilization patterns (drug monitoring). Highlyspecialized health care workers waste time performing administrative dutiesrather than the medical care for which they were trained, and there are nouniversity programs for training health care managers. As the health sectorcontinues to experience strong inflationary pressures with respect to theprices of pharmaceuticals, imported medical technology, and the relative wageof health workers, and as financial resources from the state budget decreasein real terms, it becomes increasingly critical to achieve marginal gainsthrough more effective use of scarce resources and efficient management.

1.22 Incentives. There are no incentives in the Polish health care systemto stimulate effective and efficient work habits among managers and healthcare providers; there are no deterrents, other than queues and poor qualityservices, to prevent patients from using services needlessly. Rules onnon-fungibility among budget categories prevent directors of institutions from

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adjusting their operations to specific contexts; rules requiring the return ofbudget surpluses and the cancelling of deficits at the end of the yearencourage a mentality of deficit financing and remove all incentive to balancethe budget. Doctors working on salaries have few incentives to deal withcomplex problems themselves, but are easily tempted to minimize their workload by referring patients to higher levels of care. Likewise, directors ofhospitals have a strong incentive to refer difficult cases to higher levels ofcare--the less work, the less strain on their global budgets. Salaries ofmost health care workers are at the bottom of the list for the public sector.As a result of such perverse incentives, there are often queues and waitinglists even though visits and beds per capita are high compared with westernstandards. Improvements in management techniques are unlikely to besuccessful unless underpinned by more positive incentive structures.

1.23 Budgeting. Budget allocation in the health sector is historical andresource-driven, with political factors playing a large part. Institutionsthat have more beds receive larger budgets, irrespective of how well thesebeds are used. This is one of the reasons Poland has such a highbed/population ratio compared with western countries. Directors have beenquick to learn that putting 6-8 beds in a room built for 4 beds significantlyincreases their budget. Not surprisingly, the correlation between recurrentor capital expenditure and populations is weak; the.correlation betweencapital expenditure and accumulated assets is equally weak. Such manipulationof the budget rules reinforces existing geographic disparities. Since mid-1989, inflation has made the budget process extremely difficult for localadministrators. At the regional level, many western countries are movingtowards using demographic, morbidity and socio-economic factors in preparingregional budgets and planning the geographic distribution of health careresources. Poland is looking to introduce a similar system in the future, butlacks knowledge and experience in this area.

1.24 Cost and Financing. Currently, Polish firms faced with increasedcompetition and the possibility of bankruptcy are forced to cut costs notdirectly related to production. This includes expenditure on enterprise-basedhealth services. Heavy reliance on the state budget as the principal sourceof financing makes the health sector in Poland extremely vulnerable torestrictive fiscal policies and high inflation. At the same time as financialresources are decreasing, expenditure on health care is rapidly increasing.Since 1989, there has been an explosion in the cost of pharmaceuticals due toa rapid removal of subsidies, quick deregulation and privatization (importers,manufacturers, wholesalers and retailers), and liberalization of priceswithout effective counter measures to contain utilization. This resulted in adisproportionate increase in expenditure on pharmaceuticals compared with therest of the health sector (20 percent of the total health care budget in 1991and nearly 50 percent of the MOH budget). Imported medical equipment hasfollowed the same trend. Faced with budgetary cuts and increasing expenditureand demand, the MOH has found it necessary to suspend all but the most urgent

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capital investment projects../ A growing part of the health care recurrentbudget is now being spent on the repair of outmoded and inefficientfacilities, with future investment needs increasing over time. Faced withthese problems, the MOH is looking to health insurance as a source of healthcare financing, but has yet to examine the feasibility and draft a concreteproposal for this alternative to financing through the state budget.

Distorted Priorities

1.25 Ineffectiye Planing. Under the previous system, the health sectorrelied on policies that were drawn up at the supra-ministerial level in theform of 5-year national plans. When the last 5-year plan expired, the healthsector was left without direction for the future and without experienced staffto assume this role. Many of the potential advantages of national policymaking were lost in the process. There was little sharing of services at thevoivodship level, and no joint management of materials or equipment. A beliefin economies of scale led to the construction of massive multi-pavilionhospitals and large polyclinics. Most of the advantages of size are lostthrough poor communication between pavilions, poor integration among differentlevels of care and the additional cost to pay for the utilities of thesecomplexes. Large 1,200- to 1,600-bed hospitals make visiting by both familiesand doctors difficult. There are also significant overlaps in some servicesprovided by the MOH, other Ministries and occupational health services whilethere are shortages of other services. These duplications are wasteful andbecoming increasingly difficult to justify in the face of limited financialresources. Enterprises are already looking at how to decrease theirresponsibility for occupational health services which add to their operatingcosts without providing any apparent benefit in terms of production orprevention of occupational related illness. Many spas and sanitoria provideluxury rather than standard rehabilitation. Ambulances are often used forcases that are not emergencies but in which the patients have no other meansof transportation. The resulting health service is costly, and often providesineffective, inefficient and low quality care.

1.26 Integration of Services. Instead of providing comprehensive andintegrated services with continuity of care, the highly structured NationalHealth Service in Poland creates many direct barriers to access. Lack offunctional links between ambulatory and institutional care, and between healthand social services make integrated services and continuity in care anillusion. Lack of same-day surgery, pre-admission testing and post-dischargehome care result in excessive and inappropriate reliance on institutionalcare. Health systems in many Western European countries are striving for moreintegrated ambulatory, hospital, emergency care and laboratory services to adefined catchment population. Poland already nominally has the appearance ofsuch integrated services in the form of its voivodships and ZOZ healthservices, but these structures function poorly and provide little continuityof care. The voivodships often have populations that are too small to support

i/ In 1990, MOH resources fell significantly short of requirements forcompleting investments in planned hospital beds, chronic care facilities,nursery places, outpatient departments and rural health centers.

advanced higher level care. The ZOZ catchment areas are too small for anefficient utilization of resources, and management is ineffective due to thehighly centralized, top-down structure of the system.

D. Government Program

1.27 In 1990, with input from a Joint Government/World Bank Task Force onHealth System Reform, the Polish Government formulated the strategic frameworkfor a fundamental systemic reform in the health sector._/ The Governmentplaces a high priority on improving health as a vital strategy in reversingthe bleak social conditions left by decades of poor standards of living,disregard for the environment, unhealthy lifestyles and misdirected prioritiesin provision of health services. Furthermore, an improved health care systemis critical to strengthening the safety net to protect poor and vulnerablepopulation groups both during and after the transition. The Governmentrecognizes that major restructuring of the health care system will requiretime and cannot take place through simple remedial measures to addressisolated problems. Upgrading health services to western standards is farbeyond the financial resources that will be available to the health sector inthe near future. The Government does not intend now to address all the issuesin the health sector. Instead, it will address only those priorities thatwould have the greatest impact on improving health, increasing effectivenessand efficiency in the provision of health care and transferring some of theresponsibility for financing health care from the state budget to contributorysocial insurance.

1.28 To provide an appropriate legal framework for implementing thesestrategies in the health sector, the Government has introduced a number ofimportant policies since 1990, submitted legislation to Parliament, and is inthe process of passing critical regulations: (a) a National Health PromotionStrategy was formulated in 1990 to develop health promotion programs thatwould address key preventable threats to health; (b) a Health CareInstitutions Act was passed in 1991 that will allow establishment of privatepractice and a greater role of the private sector in the provision of healthservices; (c) a Pharmaceutical Act was passed in 1991 that will increase costrecovery, redefine entitlement, and introduce criteria for a limited drugformulary; and (d) the Health Care Provisions under the Local Government Act,which was passed by Parliament two years ago, would support efforts todecentralize the health care system by significantly increasing theresponsibility of local government for the financing and provision of healthcare. Additional regulations are being prepared in the area of minimum healthdata set, accounting and pharmaceutical monitoring.

i/ The Bank's analytical contribution to the Task Force is documented in aWorld Bank report entitled Poland Health System Reform: Meeting theChallenge, (Gray Cover), Report No. 9182-POL, January 1992.

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1.29 In a clear departure from past centralized state control, theGovernment's strategy for reform in the health sector is to address many ofthe issues that were discussed above by reorganizing the provision of healthservices in regions of more appropriate population size, integrating thevarious tiers and providers of health services within a given region, anddecentralizing their management. Within each region, the Government wouldsupport specific programs to strengthen public health and prevention, primaryhealth care, and health care management and would reorganize the structure andfunction of health services. In designing its health reform strategy andprograms, the Government has determined that it is necessary to launch well-integrated national initiatives on a broad front. Given limited fiscalresources for the initial capital investment required, the Government willneed to proceed selectively with regional restructuring of health services.In view of these factors, the Government has identified a first group ofregions where health services will be restructured and where national programscan be introduced and refined, prior to nationwide implementation. Thisapproach, which is necessarily complex and phased in its development, is thebasis for the design of the proposed project.

E. Rationale for Bank Involvement

1.30 As the second year of Poland's Economic Transformation Program drawsto a close, it is becoming increasingly clear that success will depend to agreat extent on measures to reduce the social cost of the transformation to amarket economy. Measures to alleviate the initial wave of unemployment andpoverty have stood up well, but continued restructuring of the economy, inparticular of public enterprises, could lead to additional unemployment in theimmediate future. Although these factors are fostering doubts in Poland aboutthe soundness of the economic reform program, a return to low growth andcontinued hyperinflation would waste important gains made so far and lead tofurther economic hardship in the near future. The alternative to a reversalin the country's economic strategy is to alleviate some of the associatedsocial burdens by radical reform in some of the vulnerable programs that arepart of the safety net. Unless quickly addressed, critical issues relating topublic expenditure on health care and deteriorating standards of care nowthreaten to jeopardize this strategy.

1.31 The Bank's sector dialogue and involvement in project preparationhave already assisted the Government to develop new strategies, policies andprograms to restructure the health sector in support of a new and moreappropriate balance in the public/private mix. The proposed Health ServicesDevelopment Project would provide more effective targeting of poor andvulnerable populations; increase the effectiveness, efficiency and quality ofcare; and improve institutional capacity in policy making, planning andevaluation of the MOH and related institutions. Many components of theproject have foreign currency requirements and need for foreign technicalassistance that are far beyond the capacity of local financial resour^os orthose that can be mobilized through the international donor communit,. TheGovernment is therefore seeking a World Bank loan to launch its health sectorreform. The proposed loan and project are envisaged as a first phase in asustained program of World Bank support for the health sector in Poland.

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F. Role of Other Donors

1.32 The Commission of the European Communities (EC) has been closelyinvolved in project development. EC-sponsored health specialists participatedin the July 1991 preappraisal and October 1991 appraisal. The EC has approvedEuropean Currency Units (ECU) 20.0 million (about US$25.0 million) in grantfund cofinancing. MOH is being supported in its project preparation effortswith technical assistance mobilized by the Bank and funded by the Governmentsof Denmark, Japan, Sweden and the United States, and by direct technicalassistance from Project Hope. The Government is also receiving support in the

health sector from the United Nations Fund for Population Activities, UNFPA(population policy and analysis); United Nations Development Program, UNDP(short-term advisory services); World Health Organization, WHO (technicalassistance in policy evaluation and AIDS control); Austria (fellowships formedical students); Italy (equipment for a hospital in Zamosc); the Netherlands(fellowships and hospital quality improvement); Switzerland (technicalassistance and medical equipment); the United Kingdom (technical assistance);and the U.S. (emergency medicines, hospital development and technical supportto the MOH through Project Hope).

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II. THE PROJECT

2.1 The project would support the Government's economic reform program by

improving health, strengthening the health sector's contribution to the social

safety net, and containing upward pressure from the health sector on the state

budget. The project would have four specific objectives:

(a) to improve health status by strengthening health promotionand prevention programs;

(b) to support the first steps in restructuring the health sector by

shifting the focus from institutional care to effective primary care

through better trained primary care doctors and nurses;

(c) to strengthen institutional capacity in policy making, planning,management and evaluation by providing policymakers and managersaccess to improved information systems and management development;and

(d) to ensure sustainability of services and control costs in the healthsector in the medium-term by improving effectiveness, efficiency andquality of service delivery in three project regions.

2.2 The project would provide technical assistance, training, equipment

and civil works (US$182.6 million equivalent base cost; and US$227.0 million

total cost including contingencies). It would comprise the following four

components and would be implemented over a period of seven years:

(a) Health Promotion(i) Health Promotion Programs(ii) Training of Health Educators(iii) Occupational Health

(b) Primary Health Care(i) Primary Care Practices(ii) In-Service Training

(c) Health Management(i) Hospital Admission/Discharge Information and Accounting

(national)(ii) Pharmaceutical Monitoring (national)(iii) Budgeting(iv) Management Development(v) Health Financing

(d) Regional Health Services(i) Regional Management(ii) Infrastructure Consolidation(iii) Admission Discharge (A/D) Information and Accounting (regional)(iv) Pharmaceutical Monitoring (regional)(v) Materials and Technology Management

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2.3 A special feature of the project design is the initial targetedapplication of components (a), (b) and (c) in three project regions undercomponent (d) to maximize impact. Health services within the three regionswould be reorganized as "health consortia" of participating voivodships.Concurrently, the project would also contribute to progressive strengtheningof the entire health sector through specific aspects of components (a), (b),and (c) that would be implemented in a phased manner at the national level.

A. Health Promotion(estimated base cost US$7.5 million)

2.4 The Health Promotion component would help: (a) consolidate nationalefforts to support selected health promotion activities focused on criticaland preventable risk factors (tobacco and alcohol consumption, and unhealthydiets); (b) strengthen capacity in health education (public awarenesscampaigns, schools and family planning). The project would also (c) supportstudies, policy development, and planning of programs to address occupationalhealth and safety issues.

2.5 Health Promotion Programs. This subcomponent would support policiesto improve health status by strengthening health promotion and preventionprograms. Improving health of the population should be the most importantpriority of the new health care system in Poland. The project would increasethe institutional capacity of the National Board for Health Promotion (NBHP),established by the MOH in the Institute of Hygiene, to design and coordinatethe implementation of such programs at national and regional levels.j/ NBHPwould implement the National Health Promotion Strategy drafted and approved bythe MOH in 1990. A first priority for the NBHP would be preparation ofeducation and counseling programs to address critical and preventable healthrisks stemming from tobacco and alcohol consumption, unhealthy diets andoccupational hazards. It would also develop programs in family planning, andmaternal and child health. During the first phase of the project, the NBHPwould develop a capacity to assist the three project regional health promotionunits in designing and implementing health promotion programs. Duringsubsequent phases of the project, the NBHP would assist other regions inPoland to introduce similar programs. The NBHP would also develop a capacityto monitor and evaluate health promotion programs implemented in the threeproject regions and other parts of Poland. This would include support forcommunity outreach programs.

2.6 The project would strengthen the NBHP through: (a) fellowships anddegree programs in public health, health education, mass marketing andcommunications; (b) technical assistance to design health promotionstrategies, monitoring and evaluation; and (c) provision of equipment andtechnical assistance to design, produce and disseminate health promotion and

1/ The NBHP comprises a full-time director, who has already been appointed,and assistant directors for programs, research, resources and publicrelations, who will be developed and trained under the project.

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health education materials. The project would provide a total of 72 staffmonths of technical assistance, 12 staff months of fellowships, officeequipment, audio-visual equipment, teaching aids, and computer hardware andsoftware.

2.7 Training of Health Educators. This subcomponent would support designof health education curricula and training of health educators, other healthprofessionals, and non-health professionals (such as journalists and primaryschool teachers) in the School of Public Health at the University oE Krakow,National Institute of Hygiene, Institute of Occupational Medicine at Lodz, andInstitute of Cardiology. The project would provide fellowships and degreeprograms for faculty development. The facilities and equipment of the schoolwould be upgraded to support the new program. Capability in design andediting of health education materials would be developed through technicalassistance, training, equipment and other materials. The project wouldprovide a total of 7 staff months of technical assistance, 626 staff months offellowships, and in-service training of about 800 local staff.

2.8 Occupational Health. This subcomponent would strengthen theinstitutional capacity of the Institute of Occupational Medicine (IOM) in Lodzto design and implement occupational health policies. It would assist the MOHto adopt the International Labor Organization (ILO) Convention 161, whichpr,vides for protection of employees against health hazards at the workplace.The project would provide study tours and in-country technical assistance tothe IOM in developing occupational health standards, workplace inspectionguidelines and policies to enforce surveillance of workplace safety standards.Assistance would be provided for the IOM to organize a team of nationalexperts in occupational medicine. Thiis team would participate in study toursabroad to increase their understanding of design and implementation ofoccupational safety programs and th-ereafter develop standards in occupationalhealth and safety to protect workers from occupational diseases and injuries.The project would provide a total of 36 staff months of technical assistanceand 5 staff months of fellowships.

B. Primary.,.ealth Care(estimated base cost US$38.3 million)

2.9 The Primary Health Care component would initiate a fundamentalrestructuring of the health sector by strengthening community-based primarycare teams which would include family doctors, community nurses and alliedprimary health care workers. Family doctors would be trained to providecomprehensive first line care, including family planning, to the generalpopulation, to ensure continuity in care by specialists, and to coordinate theresources needed to provide adequate long-term chronic care in the community.Academic training units would be established at existing academicinstitutions, while in-service training would be established in community-based teaching practices. Nurses and other allied primary health care workerswould also be trained. As an incentive for general practitioners to undergoretraining, the Government would introduce licensing requirements andcontinued accreditation of family doctors. Licensing of doctors in private

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practice would samilarly be contingent upon adequate training andcertification. The project would provide local training of 500 primary caredoctors, and upgrading of the physical facilities and equipment of 500 primarycare practices (200 supported by the Bank and 300 by the EC).§/ The EC wouldalso provide additional training facilities in academic institutions outsidethe three project regions.

2.10 Primarv Care Practices. This subcomponent would support developmentof primary care training units associated with existing medical academicinstitutions in the three project regions. Following faculty development andcurriculum design in 1992-93, the three regional training units (RTUs) wouldprovide an intensive course in the techniques of teaching family medicine to200 doctors. These doctors would subsequently become the clinical teachersfor the future cadre of family practitioners in the three project regions.The project would support upgrading of the clinical facilities, equipment,teaching materials and library materials used in family medicine teachingpractices in the community and hospitals. The project would subsequentlysupport a three-year certification program in family medicine for aspiringdoctors. Each RTU would provide a formal three-year postgraduate program infamily medicine. These programs would include clinical training at designatedhospitals, supervised in-service training in approved primary care teachingpractices and in disciplines necessary to operate a family practiceeffectively and efficiently (practice management skills, budgeting, resourceallocation, monitoring and evaluation). The initial teaching practices wouldaccommodate up to 200 students per year in the three-year program. A SteeringCommittee for Primary Care, appointed by the MOH during project preparation,has already initiated start-up activities. The project would providetechnical assistance to allow the Steering Committee to evolve into a NationalBoard for Primary Care, which would be responsible for overseeing curriculumdevelopment for family medicine, research and information-sharing. Theproject would provide a total of 91 staff months of technical assistance, 495staff months of fellowships, in-service training of local staff, medicalequipment and refurbishment of 500 PCPs, office equipment, audio-visualequipment, materials, and computer hardware and software.

2.11 In-Service Traininj. This subcomponent would strengthen the primarycare team by upgrading in-service training in selected teaching hospitals,community clinics and training practices of teachers of family medicine. Itwould provide technical assistance in short-term manpower planning, upgradingof training facilities and development of programs needed to strengthen in-service training of doctors, nurses and allied primary health care workers(community nurses, midwives, rehabilitation workers and social workers). Itis expected that the activities initiated under this component would attractadditional investments from other external donors. The project would provide

i/ The Commission of the European Communities (EC) has approved a grant(ECU 20 million) to train 300 of the 500 primary care doctors and toupgrade the facilities and equipment of 300 of the 500 practices to bedeveloped under the project. Upgrading costs of the 200 PCPs supported bythe Bank are included under the Infrastructure Consolidation subcomponentof Part D - Regional Health Services (para 2.25).

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a total of 82 staff months of technical assistance, 614 staff months offellowships, 800 staff months of in-service training of local staff, computerhardware and software and training materials.

C. Health Management(estimated base cost US$46.3 million)

2.12 The Health Management component would strengthen institutionalcapacity in health care management by providing managers with the tools andknowledge to operate their institutions more effectively and efficiently. Itwould support strengthening of institutional capacity in budgeting and thefirst steps in restructuring health care financing away from nearly exclusivereliance on the state budget. The component comprises six inter-linkedsubcomponents: (a) hospital admission/discharge information systems;(b) accounting information systems; (c) budgeting; (d) pharmaceuticalregistration and monitoring; (e) management education; and (f) healthfinancing. Activities are focused on improving decision-making through basicinformation systems and developing professional health services management inPoland through education and training.

2.13 Hospital Admission/Discharge (A/D) Information (national). Datacollection on patient admission and discharge would be standardized forhospitals nationwide. Training would be provided in data coding, transferfrom paper to electronic form, aggregation of data from local to nationallevels, and analysis and interpretation of data. Local managers would betrained to use the data for decision-making. Automation of the system wouldbe undertaken initially in the three project regions and later throughout thecountry to provide by project completion a comprehensive nationwide data base.A disease monitoring system, using population-based techniques, would bedeveloped and implemented later during the project to permit routinemonitoring of hospital utilization patterns and eventually of the costs ofhospital services provided to defined populations. A Steering Committee forInformation Systems (SCIS) has been appointed by MOH, with representativesfrom the three project regions, to coordinate the automation of the A/Dinformation, accounting, and drug monitoring systems. Minor renovation wouldbe provided for selected admission/discharge offices to accommodate their newactivities. The system would have the capacity to be expanded, as skillsdevelop and resources become available, to include outpatient services,personnel management, materials management, technology management and otherservices such as laboratory services and radiology centers. The project wouldprovide technical assistance to develop and implement the system, in-servicetraining of staff and the needed software, hardware and materials.Computerization of the A/D information would be closely coordinated with theaccounting and pharmaceutical subcomponents and similarly phased incountrywide. As a condition of loan effectiveness, the MOH would issue aregulation on the recommended minimum data set of patient information.

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2.14 Accounting (national). This subcomponent would introduce nationalstandards for accounting practices (new charts of accounts and double entryledger systems) throughout the health sector. The system would be introducedin three phases: (a) during the first phase, selected health careinstitutions in the three project regions would serve as development sites todesign and fine-tune the system; (b) during the second phase, the system wouldbe introduced in most health care institutions in the three project regions(small institutions of less than 200 beds would be provided with only minimalcomputer equipment) and the accounting offices in the voivodships; and (c) inthe third phase the system would be introduced countrywide. Local managers ofhealth services would be trained to use the system to track expenditures,identify ways to contain costs and operate their services effectively andefficiently. Clinicians would be trained to identify cost effective treatmentby combining financial data with information from the admission/dischargeinformation system. The project would also develop the capacity to aggregatefinancial data in a meaningful way at the local, regional and national levels,to use these data to analyze costs and expenditure trends, and provide adynamic and continuous feedback to policymakers, managers and health careproviders. The project would provide the software, hardware, officeequipment, training and needed renovation to computerize the accountingsystems in the health sector..Z/ The project would provide a total of 187staff months of technical assistance, 11 staff months of fellowships, in-service training of local staff, equipment, materials, computer hardware andsoftware, and reference materials for the hospital A/D information(para. 2.13) and accounting subcomponents of the project. As a condition ofloan effectiveness, the KOH would lssue a regulation on accounting practicesin health care institutions.

2.15 Pharmaceutical Monitoring and Ouality Control (national). Thissubcomponent would address the recent escalation in public expenditure ondrugs and the resulting budget crisis in the health sector. The project wouldsupport development of policies, institutions and technical capacity toexamine drugs, assess their cost-effectiveness and monitor their utilization.The project would support computerization of the pharmacy outlets (forexample, in public hospitals and clinics) that remain public after extensiveprivatization of pharmacy retailers. The new computer system would enablecomprehensive reporting of utilization patterns and prescription practices.Private pharmacies would be required to comply with similar reporting bysubmitting billing in electronic form. The subcomponent would first beintroduced in the three project regions and subsequently countrywide, parallelto development of the A/D information and accounting systems. The projectwould also provide technical assistance to begin upgrading existing drugregulations to European standards. The project would support restructuringand strengthening of the National Drug Institute (NDI) and Department ofPharmacy in the MOH. A National Pharmaceutical Monitoring Center established

]/ Computer hardware purchased for the Hospital Admission/DischargeInformation system would be used also for the Accounting system. The twoactivitiez are therefore combined as a single subcomponent in projectcosting.

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in NDI would be strengthened. Activities would include: (a) creation of anationwide standard data set for reporting the utilization of prescription andnon-prescription drugs financed by the Government's drug program;(b) identification of doctors, pharmacies and patients through the use ofstandard identification numbers; and (c) development of a capacity toaggregate data at regional and national levels, analyze the information at thenational level, and provide a dynamic and continuous feedback to policymakers,managers and health care providers. Local managers and clinicians would betrained to use the system to control needless expenditure on drugs. Theproject would provide a total of 116 staff months of technical assistance, 11staff months of fellowships, 294 staff months of in-service training of localstaff, equipment, materials, and computer hardware and software. As acondition of loan effectiveness, the MOH would issue a regulation requiringregistration of drugs and a standard format for drug prescriptions (reportingin Daily Drug Dosage [DDDsI and use of an Anatomic Chemical Therapeutic [ACT)coding system or similar international standards).

2.16 Budzetine. This subcomponent would develop a more efficient andequitable basis for preparing the yearly recurrent health budget for thevoivodships and setting priorities for capital investments. New objectivecriteria would be introduced in the later years of the project by the MOH andMOF during preparation of the annual voivodship budgets. These criteria wouldbe based on demography, morbidity, socio-economic factors, existing healthcare resources, cross-boundary flows and market forces. Data generatedthrough the admission/discharge and accounting information systems wouldcontribute to the new budget process. The project would provide a total of 26staff months of technical assistance, 8 staff months of fellowships, in-service training of local staff, equipment, materials, computer hardware andsoftware, and reference materials.

2.17 Management Development. This subcomponent would strengtheninstitutions, programs and information resources needed to train health caremanagers. Centers for undergraduate and graduate education in health servicesmanagement would be established in relevant departments of universities(Warsaw, Wroclaw, Krakow and Lodz). Once established, these centers woulddevelop degree and continuing education programs in health services managementduring the project. Faculty development would be supported throughpostgraduate degree fellowships abroad in health economics, health servicesmanagement, human resources management (personnel), business administration,medical sociology, information science, and technology assessment. Existingfaculties would be provided support for short-term study abroad andparticipation in professional conferences. The project would provide 317staff months of specialist services to develop curricula for degree programsand continuing education. The project would also provide 531 staff months offellowships abroad for these programs and 63 staff months of in-servicetraining of local staff. Each of the centers would be equipped with computerhardware and software, library resources, and other materials.

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2.18 Health Financing. This subcomponent would assist Poland to assesspotential sources of health care financing other than the state budget. Theproject would support feasibility scudies on: (a) the introduction ofcontributory health insurance; (b) cost recovery; (c) private sector healthservices; and (d) preparation of draft legislation on health financing. Theproject would provide 12 staff months of fellowships, technical assistance,equipment, and materials.

D. Regional Health Services (Consortia)(estimated base cost US$90.5 million)

2.19 The Regional Health Services component would initiate adecentralization of the Polish health care delivery system in voivodshipsbelonging to three project regions known as Ciechanow, Pomerania, andWielkopolski (see Map). These regions comprise 10 of Poland's 49 voivodshipsand account for 16 percent of total population. One hundred twenty five ofPoland's 750 health care institutions are located in these three projectregions. Ciechanow region consists of two voivodships in central Poland(Ciechanow and Ostroleka) and has a population of 0.48 million. Pomeraniaincludes three voivodships in north western Poland (Koszalin, Szczecin, andGorzow) and is inhabited by 2 million people. Wielkopolski consists of fivevoivodships in midwest Poland (Kalisz, Konin, Leszno, Pila, and Poznan) andhas a total population of 3.4 million people.

2.20 The three project regions were selected in April 1991 through anationwide competitive process organized by MOH. In consultation with theBank, the MOH developed a request for preposals on the regionalization ofhealth services and evaluation criteria that were provided to all voivodshiphealth authorities (see Annex 1). The competition provided impetus forvoivodships to collaborate on health reform initiatives. Approximately 20

proposals were received by the MOH. Technical assistance was provided duringproject preparation to assist the three selected regions to develop theirproposals for a regional management structure. A National ConsortiaDevelopment Group (NCDG), comprising experts from the MOH, National Center forHealth System Management and Polish universities, facilitated projectpreparation in the regions and coordinated joint technical assistanceactivities.

2.21 The new regional organizational structures are called "healthconsortia". Relying heavily on local application of capacities and programsdeveloped in the preceding three components, the project would support in eachof the project region3: (a) strengthening of policy making, planning;management and evaluation capacity through design of priority health programs(health promotion, primary care, strategic master plans for health carefacilities, management information systems and human resources development)that would be implemented later during the project; (b) beginning of arestructuring of health services to provide more effective care through aselective upgrading of the infrastructure and equipment of primary care andinstitutional care facilities, and establishment of a new balance betweenacute and chronic care; (c) strengthening of the management capacity of localinstitutions to provide efficient services through the introduction ofmanagement information systems (A/D information, accounting and monitoring ofdrug utilization described in the previous sections); and (iv) improvement in

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the management of expensive and scarce resources through joint materials and

technology management. The regional health promotion and primary careprograms of the project are costed under the national components. Experience

gained in the initial three project regions would be evaluated and used inplanning for establishment of similar health regions in other parts of Poland.

The Government of Switzerland is already preparing an investment ofSF10 million (US$13.8 million equivalent) in Silesia region based on theregional health services concept.

2.22 Regional Management. This subcomponent would strengthen the policymaking, planning, and evaluation capacity of regional health services. In a

clear departure from the previous centralized control over the operationalaspects of service delivery, the Government has decided to decentralizeresponsibility and accountability for management of health care services in

Poland.ff/ This requires that senior management in three project regions

quickly develop a capacity to formulate regional policies to support acoordinated decentralization of the health care system, design programs toimplement these policies and evaluate their effectiveness. Preparation of the

project has already successfully initiated the process of policy making andplanning by providing an incentive for several voivodships to regroupthemselves into three project regions.

2.23 Each region has already prepared statutes based on agreements reached

among participating voivodships. The statutes define: (a) consortiummembership; (b) content of membership agreements; and (c) main statutorymechanisms. The mechanisms are the: (i) Supervisory Board assisted byadvisory committees; and (ii) Board of Directors assisted by managementoffices. These statutes delineate the powers and responsibilities of the newregional management. The Supervisory Board comprises leaders of theparticipating voivodships, local parliamentarians, and representatives ofvarious community interests to help guide and provide broad endorsement for

the regional effort. The key element is the Board of Directors with itsmanagement offices. Eventually, this board with an executive director will be

assisted by consortium wide management offices for planning and evaluation,accounting and budgeting, human resources development, health promotion,primary health care, materials management, technology management, and

pharmaceutical monitoring. The required upgrading of existing managementstaff, the clustering of management offices and the phasing in which they are

implemented will differ for each region, depending on the size of theconsortium, degree of shared services envisioned, and the availability of

potential management staff in the participating voivodships. To expedite thestart of the management offices, each region has established a Consortium

Coordination Office (CCO), consisting of a core group of four managers to

address the urgent planning and coordination issues arising from thiscomponent and from the development within the region of other components(hospital A/D, accounting, drug monitoring, etc.). It is envisaged that these

managers will become the core of the cluster of management offices(see Organization Chart in Annex 1).

L/ See Government of Poland, Health Care Institutions Act, 1991. All healthcare units in the three regions, including units under MOH as well asthose operated by other ministries and enterprises, would be incorporated

into the new regional management structure.

23 -

2.24 The project would provide the technical assistance, training, andequipment necessary to allow local policy makers and managers to furtherdevelop the regional management structure over the next seven years. Theproject would support ongoing development of regional health policies,regional implementation of programs in priority areas (public health, primarycare, strategic plans for health care facilities, management informationsystems and human resources development), and design of ongoing evaluation.The project would provide a total of 292 staff months of technical assistanceto support project management and preparation of strategic plans andoperational proposals for consortia development. The project would alsoprovide 12 staff months of fellowships, 200 staff months of in-servicetraining of local staff, equipment and materials, and vehicles to the threeCCOs to facilitate project supervision.

2.25 Infrastructure Consolidation. This subcomponent would support theinitial upgrading of the infrastructure and equipment of primary care andinstitutional care facilities, and establishment of a new balance betweenacute and chronic care. The project would provide civil works and equipmentbased on a survey of physical resources within the three project regions(completed in May 1991) and regional strategic plans for consolidating andupgrading existing health facilities and medical equipment (to be completedduring the first year of the project). The consolidation of health facilitiesunder the project would rehabilitate about 50 percent of the acute careinfrastructure in the Wielskopolski and Pomerania consortia, and all of theacute care facilities in the smaller Ciechanow consortium. Consolidation ofservices would be based on 3.5 acute care beds per 1,000 population. Thehealth infrastructure masterplan developed for the three consortia would alsoprovide for the consolidation of chronic care beds at the rate of 1.5 beds per1,000 population. However, the upgrading costs2/ of chronic care beds wouldnot be financed under the project. Guidelines for strategic plans weredrafted during project appraisal (see Annex 1, Attachment A). The phasing outof the facilities identified for closure, upgrading of equipment, andredeployment of the affected personnel and resources would be carried outwithin three years of completion of the regional strategic plans. As anincentive for the regions to undertake these changes, the project wouldprovide rehabilitation and upgrading of targeted hospital facilities andclinics, and much needed medical equipment. Detailed engineering plans forthe civil works and equipment specification would be prepared by localarchitectural/engineering firms after the regional management authorities havecompleted their strategic plans. Both the strategic and detailed engineeringplans would include provisions for appropriate disposal of sanitary, medical,and laboratory wastes. The project would provide for lump-sum contracts fordetailed engineering and construction supervision, civil works, and medicalequipment for the consolidated consortia facilities. The guidelines,procedures and timetable to be used by the MOH to review the regionalstrategic plan were finalized at negotiations. In addition, about 200 primarycare practices within the three consortia would be upgraded as part of theinfrastructure consolidation program (para 2.10). A condition ofdisbursement for the infrastructure consolidation subcomponents in each

2/ Upgrading costs for chronic care beds are estimated at about US$7,800 perbed for buildings and US$11,100 per bed for equipment.

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project region would be provision to the Bank of regional health servicesstrategic plans and investment proposals acceptable to the Bank.

2.26. Admission Discharge (A/D) Information and Accounting (regional).This subcomponent would support further regional design and implementation ofthe admission and discharge (A/D) information and accounting systems describedearlier (para. 2.13). It would strengthen the management capacity of localinstitutions by providing them with information systems to provide moreeffective, efficient and higher quality services. The regional phase of theirdesign would adapt national standards to local needs in the three projectregions. The experience gained from introducing these systems in the threeproject regions would be used during the fourth to seventh years of theproject when they would be implemented countrywide. The project would providea total of 66 staff months of technical assistance, 26 staff months offellowships, 48 staff months of in-service training of local staff, computerhardware and software, and reference materials.

2.27 Pharmaceutical Monitoring System (regional). This subcomponent wouldsupport further regional design and implementation of the pharmaceuticalmonitoring system described in earlier parts of the project (para. 2.15). Theregional phase of their design would adapt national standards to local needsin the three project regions. The experience gained from introducing thesesystems in the three project regions would be used during the later phase ofthe project-when they would be implemented countrywide. The project wouldprovide a total of 67 staff months of technical assistance, 47 staff months offellowships, 47 staff months of in-service training of local staff, officeequipment, reference materials and computer hardware and software.

2.28 Materials and Technology Management. This subcomponent would supportcost containment measures through systematic procurement, handling, storageand utilization of expensive and scarce resources (materials, drugs,equipment, linen and food) by groups of institutions within different areas ofthe three project regions. Technical assistance and training would beprovided for managers to learn equipment and materials management techniques.The project would support development of guidelines for technology andmaterials standards. The project would provide a total of 78 staff months oftechnical assistance, 36 staff months of fellowships, in-service training oflocal staff, medical technology maintenance equipment and tools for 90 healthcare institutions, reference materials, and computer hardware and software.

E. Environmental Considerations

2.29 The components of the project have been individually evaluated withregard to their potential environmental impact. All components have beenplaced in environmental Category "C" (not requiring environmental analysis)with the exception of the Regional Health Services component, which has beenplaced in Category "B" (requiring limited environmental analysis as perO.D. 4.0). The designs adopted for project funded support for rehabilitationof existing health facilities would comply with environmental design standardswhich are acceptable to the Bank. Provisions would be made in the strategicplans and detailed architectural plans for proper disposal of sanitary,medical and laboratory wastes (para. 2.25).

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III. PROJECT COSTS. FINANCING. MANAGEMENT AND IMPLEMENTATION

A. Proiect Costs

3.1 Summary of Proiect Costs. The total project cost is estimated atabout ZL3.3 trillion or US$227.0 million equivalent at the current exchangerate (March 1992) of ZL13,360 to the U.S. dollar. Total contingenciesrepresent 24 percent of the base cost. Major cost categories are computerhardware and software, technical assistance (fellowships, training andspecialist services), diagnostic and treatment equipment, and civil worksrelated to the consolidation of regional health physical facilities.Incremental recurrent costs included in the project would arise mainly from:(a) the operation and maintenance of computer systems, including the annuallicensing and upgrading of computer software; (b) maintenance of physicalfacilities; and (c) limited additional staff. The estimated cost distributionby project component is shown in Table 3.1. The summary of project costestimates by category appears in Table 3.2. Detailed cost estimates for eachproject component are shown in Annex 2.

TAble 3.1: PROJECT COST SUMMARY BY PROJECT CCMPONENT

- of X----Zloty billion----- ------US$ Million---- Base ForeignLocal Foreign Total Local Foreign Total Costs Exchange

Health Promotion

Health Promotion Program 6.1 19.5 25.6 0.5 1.5 2.0 1S 75XTraining of Health Educators 19.6 49.3 61.9 1.5 3.7 5.2 31 711Occupational Health _.0 2.9 3.9 0.1 L.2 L. 0 67X

Subtotal 2.7 71.7 98.4 3 54 7.5 4X 72S

Primarv Health Care

Primary Care Practices 204.1 190.6 394.7 15.1 14.3 29.6 161 48SIn-Service Training 1.Z 86.1 117.3 _, J.4 8.7 5S 74S

Subtotal A2l.3 LZ Z 134 174 2.7 3.3l 31 A5

Health ,Manaaement

Hospital A/D Information & Accounting 30.1 154.3 184.4 2.3 11.5 13.8 8S 831Pharmacoutical Monitoring 60.0 275.0 335.0 4.5 20.6 25.1 142 86ZBudgeting 1.7 4.9 6.6 0.1 0.4 0.5 01 801Management Development 15.1 56.2 71.3 1.1 4.2 5.3 3S 79XHealth Financing 6 5 I.I7I _0.5L_ 4 1.1 _. _1 I69

Subtotal 1I. 508.0 8I1L9 8I 37.8 46.3

Resional Hcalth Services

Regional Management 32.9 59.5 92.4 2.5 4.4 6.9 4X 641Infrastructure Consolidation 423.8 462.6 886.4 31.9 34.6 66.5 361 521Hospital A/D Information & Accounting 32.8 106.0 138.8 2.5 7.9 10.4 61 761Pharmaceutical Monitoring 9.1 35.5 44.6 0.7 2.6 3.3 21 791Technology/Materials Management 5.9 _J39 45.4 0.4 3.0 .LI ZX in

Subtotal 54.S 703.1 1207.6 38.0 52.j M. 4 58X

TOTAL BASE COSTS 879.5 1557.5 2437.0 66.2 116.4 182.6 1001 641Physical Contingencies 72.7 137.1 209.8 5.4 10.3 15.7 91 661Price Contingencies 14I9 232.5 382.4 11.2 17.5 HL 16S gax

TOTAL PROJECT COSTS ,110.1 1927.1 3029.2 82.8 1442 227.0 124S 64S

Note: Project costs include an estimated 10 percent, or US$6.1 million equivalent, for indirect taxes onlocally procured services and civil works. Numbers may not total exactly due to rounding.

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Table 3.2: PROJECT COST SUMMARY BY CATEGORY OF EXPENDITURE

I of X

------Zloty Billion---- ------USS Million---- Base Foreign

Local Foreign Total Local Foreign Total Costs Exchange

A. Technical Assistance

Staot Training 121.6 30.4 152.0 9.1 2.3 11.4 8S 202

Fellowships 0.0 214.2 214.2 0.0 16.0 16,0 9X 1002

Specialists 73.0 170.3 243.3 5.5 12.7 18.2 10S 702

Program Development/Studies _20 7 48.2 68.9 .. 3 6 _5. 1 _ 71S

Sub-total Technical Assistance 115 4363.1 678.4 1J6 34.6 50. 7 U fl

B. Eauiment and Software

Equipment 24.4 413.7 438.1 1.8 31.0 32.8 182 95S

Computer Systms 0.0 336.7 336.7 0.0 25.2 25.2 142 100X

Proprietary Software/Books Q0. 141.6 141 6 0 0 10 8 L. _0 6X

Sub-total Equipment and Software 244 f92.0 916.4 1. 8 a so 68 6 3X9

C. Civil Works

Consolidation/Upgrading 4330.7 77.0 507.7 5&I 7i 38 5 £I5

Sub-total Building Facilities 430.7 77.0 507L7 3L28 au 7 3l

D. Incremental Recurrent Coats

Local Staff Salaries 36.0 0.0 36.0 2.7 0.0 2.7 12 0S

Computer O&M 72.8 72.8 145.6 5.4 5.4 10.8 6S 502

Equipment 08M 68.7 51.2 119.9 5.1 3.8 8,9 5 43S

Building OUM 26.0 1.4 27.4 1.9 0.1 2.0 1X 52

Non-salary Operational Costs 8.0 0.0 5.6 0 4 0 0 0 4 _S OS

Sub-total Incr. Rec. Costs 209.1 1SL44 1S .15 5 9-3 2l 8 1 38X

TOTAL _BSE COSTS 879.5 1557.5 2437.0 66.2 116.4 182.6 1002 642

Physical Contingencies 72.7 137.1 209.8 5.4 10.3 15.7 9S 662

Price Contingencies 149j9 232.5 382.4 11.2 17.5 28 7 16X 61X

TOTAL PROJECT COSTS 1102-1 .1V1 3029.2 82.8 144.2 227 124X 64S

Notes: Project costs include an estimated 10 percent or USU6.1 million equivalent, for indirect taxes on

locally procured services and civil works. Recurrent costs for local staff salaries refer only to

incremental costs. Numbers may not total excactly due to rounding.

Exchange rate: US$1 - 13,360 Zloty (March 1992).

3.2 Basis of Cost Estimates. Project costs were estimated as follows:

(a) Base Costs. Base cost estimates are derived from: (a) unit costsfor comparable technical assistance (TA) and services in the PolandEmployment Promotion and Services Project (Loan 3338-POL); (b) adetailed survey conducted during preparation of the costs toconsolidate health facilities (buildings and equipment) in the threeproject regions (Ciechanow, Pomerania, and Wielkopolski); and

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(c) recent quotations from suppliers of computer equipment andsoftware. Consolidation costs of civil works are estimated at aboutUS$2,200 per bed. The cost of upgrading medical equipment inconsolidated clinics/hospitals is estimated at US$2,300 per bed.

(b) Contingency Allowances. Project costs include a contingency forunforeseen physical additions (US$15.5 million) equal to 10 percentof the estimated cost of each project item financed by the Bank.The EC did not provide for such physical contingencies in itsfinancing of elements under the Primary Health Care component.Annual rates of foreign price increases have been estimated at3.9 percent in CY1992-1998. Average local price increases have beenestimated at 25 percent in CY1992, 10 percent in 1993, and5.0 percent from 1994 through 1998. Because of the largedifferential between the estimated foreign and local price increases,the overall price increases for the project have been calculated onthe basis of the estimated foreign price escalation rates. Thisapproach is justifiable on the assumption that the policy ofadjusting the Zloty exchange rate to reflect the inflationdifferential between Poland and its trading partners would continue.The following calculation shows the effects on project cost estimatesin Zloty when applying the project local price increases to local andforeign costs. The projected Zloty amount required during theproject implementation period is substantially increased.

Local Foreign Total---- Zlotys Billion --------

Total Base Costs 879.5 1,557.7 2,437.0Physical Contingencies 72.7 137.1 209.8Price Contingencies 590.7 1,021.8 1,602.5

Total Proiect Cost 1,532.9 2,716.6 4,249.5

(c) Foreign Exchange Component. The foreign exchange component wasestimated as follows: (a) consolidation/upgrading of physicalfacilities--15 percent; (b) computer hardware and software (andannual licensing/upgrading costs)--100 percent; (c) equipment--91 percent; (d) specialist services--70 percent; (e) fellowships--100 percent; and (f) incremental recurrent costs for the operationand maintenance of physical facilities--5 percent for buildings and50 percent for equipment. The resulting foreign exchange componentincluding contingencies is estimated at US$144.2 million, or about64 percent of total project cost.

(d) Customs Duties and Taxes. Project costs include an estimated10 percent, or US$6.1 million equivalent, for indirect duties andtaxes on civil works and locally procured services. Technicalassistance and equipment and goods imported directly for the projectwould be exempt from taxes and duties.

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3.3 Incremental Recurrent Costs. Project recurrent costs include onlyincremental costs. The total additional recurrent (base) costs would be aboutUS$24.8 million equivalent (US$32.6 million including contingencies) duringthe seven year project period or 0.2 percent annual increase over the 1991recurrent budget. In 1991, the health services budgets for the three projectregions were equivalent to US$29 million in Ciechanow, US$493 million inPomerania and US$870 million in Wielkopolski. Of the total recurrent cost,about 80 percent would be incurred by the voivodships of the project regions,and 20 percent would be incurred by the MOH. MOH would monitor the adequacyof recurrent funds for maintenance and operation of facilities and newlyinstituted programs, and advise the MOF of need for additional measures to betaken.

B. Prolect Financing

3.4 The project would be financed by the Bank, the Government (centralgovernment and the voivodships that constitute the three project regions) and,on a parallel basis, by the EC. The proposed Bank loan of US$130.0 millionwould finance 90 percent of the foreign exchange component of the project.The EC has approved a grant of ECU 20.0 million (US$25.0 million equivalent)which would finance 10 percent of it:he foreign cost and 13 percent of localcost. The Government would finar.ce about 31 percent of project costs(US$72.0 million). Project financing would be in accordance with Table 3.3.

Table 3.3: FINANCING PLAN BY DISBURSEMENT CATEGORY(US$ million)

Govornment of Poland European TotalWorld Bank MOH s/ Consortia Community Financing

Category of Expenditure Amount X Amount X Amount X Amount % Amount X

Technical Assistancs 479 79S LQ 000 % 12 8 21X 60.7 100X

Staff Training 10.4 768 0.0 0% 0.0 0X 3.2 24% 13.6 100%Fellowships 11.3 61X 0.0 0X 0.0 0X 7.2 392 18.5 1001Specialists 20.1 91% 0.0 0X 0.0 0% 2.1 92 22.2 1001Program Development/Studies 6.1 95% 0.0 0X 0.0 0% 0.3 5% 6.4 100%

Ecuilment and Software ALI 9 0 0 0X 0 0 06 86.2 100X

Equipment/Computer Systems 68.8 94% 0.0 0% 0.0 0% 3.6 5% 72.9 100%Software/Books/Copyrights 13.3 100% 0.0 0% 0.0 02 0.0 0% 13.3 1002

Civil Works 0 0O 3t 9 82X 0.0 OX 8.6 18% 47.5 1002

Consolidation/Upgrading 0.0 0S 38.9 822 0.0 0X 8.6 18S 47.5 1002

Incremental Recurlrnt Cost 0.0 0X 6.5 20% 26.1 802 0.0 02 32.6 100%

Local Staff Salaries 0.0 02 1.3 452 1.6 55% 0.0 02 2.9 100%Building/Equipment/Computer O&M 0.0 OX 3.2 122 24.5 882 0.0 02 27.7 1002Non-salary Operational Costs 0 0 OX 2 0 1002 0. 0 OX 0 0 02X 2.0 100X

TOTAL FINANCING DOA 57X 4S_9 _20 26 1 1ll 25 0 11% 227.0 100X

I/ Includes US$6.1 million in taxes and duties.Note: Numbers may not total exactly due to rounding.

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The Bank has approved a Project Preparation Facility (PPF) Advance in theamount of US$1.5 million to cover the cost of equipment and technicalassistance needed to equip the NPIU and CCOs and train key project staff fortimely project start-up. The PPF Advance enables the MOH to finalizetechnical assistance agreements, prepare strategic plans for the consolidationof consortia facilities and prepare equipment specifications and biddingdocuments, and train key project staff. The PPF Advance would be refinancedfrom loan proceeds upon loan effectiveness. Assurances were obtained atnegotiations that the Government would ensure that: (a) in its budget, anyfunds to be made available to the voivodships participating in the healthconsortia under the project are treated as supplemental to the normal budgetallocation for any such voivodship; and (b) all voivodships and healthinstitutions participating in the health consortia will provide adequate fundsto cove'r the operating costs of the regional management structure.

C. Proiect Management and Implementation

3.5 The project's four components are interdependent. About 51 percentof the total investment is allocated to programs and activities implemented inthe three project regions. These regional activities would be carried out inclose coordination with tasks defined/executed at the national level. Projectmanagement and implementation arrangements have been designed accordingly to:(a) delegate decision making to the lowest appropriate levels to expediteaction; (b) develop managerial capacity at all sectoral levels; (c) developclose collaboration among institutions within and outside the sector; and(d) achieve economies of scale in procurement of goods and services. Duringappraisal, the mission reviewed with the MOH a staffing plan for projectimplementation, which includes staffing details and specifies theresponsibilities of line departments in MOH and of the national (NPIU) andConsortia Coordination Offices (CCOs) to support implementation of the variousproject components.

3.6 To support institutional strengthening at both the regional andnational levels, the project would finance the services of a projectmanagement firm (194 staff months) to support and train NPIU and staff in themanagement of multiple project tasks, procurement and contract administration,accounting and program budgeting, and project performance evaluation. Staffappointed for the NPIU and CCOs are skillful managers who have activelyparticipated in project design and in the formulation of strategies forinstitutional reforms. Their extensive contact to date with externaltechnical assistance (see para. 1.32) will facilitate their furthercollaboration and integration of technical assistance provided through theproject. Employment of consultants to assist with project management would bea condition of effectiveness.

3.7 The following paragraphs, summarized in Chart 1 in Annex 3, definethe management and implementation responsibilities for each project component.The terms of reference for technical assistance services are specified in theProject Operations Manual (POM), which is available in the project file.

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3.8 Proiect Coordination and Procurement/Accounts Administration.Project start-up and implementation would be facilitated by three CCOs and theNPIU in the MOH (Annex 3). Overall responsibility for coordinating theimplementation of the project would rest with the NPIU. A full-time projectmanager has been appointed. The NPIU would be staffed by a project managerand 5-7 full-time technical and support staff who would have skills inaccounting, procurement, contract administration, preparation of reports, andoffice coordination. The NPIU would be the principal liaison with the Bankand other donors for project administration and supervision purposes, andwould facilitate procurement for the project. NPIU would not design orimplement programs and activities supported by the project, as this would bethe responsibility of MOH technical staff, the three project regions and theother implementing institutions. However, NPIU would be responsible for:(a) channeling information to, from and among key individuals and units inPoland and in communication with the Bank; (b) channeling resources providedcentrally (e.g., proceeds of the World Bank loan, specially designated centralgovernment funding and specialist services) to the project implementinginstitutions and agencies; (c) consolidating/undertaking procurement ofselected equipment, limited civil works (for localities outside the threeproject regions) and TA contract packages, where economies of scale andefficiency are overriding considerations; (d) monitoring project costs andproject accounts; (e) monitoring performance of the regions and other projectimplementing institutions; and (f) preparing consolidated periodic reports onproject implementation progress and the audits of accounts. At negotiations,assurances were obtained that the Borrower will maintain throughout theproject a NPIU with staffing, functions and authorities acceptable to theBank.

3.9 The CCOs would be responsible for: (a) coordination of tasks andmonitoring of performance of consortium units; (b) administration of financialresources to carry out project tasks in the consortium; (c) procurement ofequipment and technical assistance (TA) contract packages which cannotappropriately be packaged for bulk procurement at the NPIU (national) level;(d) procurement of consortium civil work contracts and supervision of theirimplementation; (e) monitoring project accounts and costs; and (f) preparationof periodic reports on the performance of consortium implementing units. TheCCO's management staff would comprise: (i) an accountant; (ii) procurementofficer; (iii) technical assistance/training officer; (iv) architect/engineer;and (v) part-time lawyer. One of these professionals would be designated asCCO Manager.

3.10 Health Promotion Component. The newly created National Board forHealth Promotion (NBHP) and regional units for Health Promotion would beresponsible for the implementation of this component. NBHP would work inclose collaboration with the three project regions for the delivery of healthpromotion programs at the regional level. The training of health educatorsand other health and non-health professionals would be undertaken by theSchool of Public Health at the University of Krakow, Institute of OccupationalMedicine in Lodz, National Institute of Hygiene and National Institute ofCardiology. NBHP would work with the Institute of Occupational Medicine inLodz in developing policies, standards and activities related to occupational

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health and safety. Procurement of equipment and technical assistance andcoordination of fellowships for this component would be undertaken by the NPIUfor the major consolidated packages and by CCOs for minor items.

3.11 Primary Health Care Component. A Steering Committee for Primary Care(SCPC) has been established to oversee initial implementation of thiscomponent. The SCPC has a Secretariat which is being supported by long-termfaculty development of the three Regional Training Units (RTUs) for primarycare physicians. In the second year of the project, the SCPC would evolveinto the National Board for Primary Care. The CCOs would be responsible forthe procurement of equipment and works related to the upgrading and equippingof primary care clinics and practices of physicians from the three regions whoare trained under the project. The NPIU would be responsible for procurementof technical assistance for the entire component and of equipment and works ofpractices supported by the project in areas outside the three project regions.

3.12 Health Management Component. The NPIU would be responsible for theprocurement of all major equipment, software and technical assistancerequirements under this component. The Steering Committee for InformationSystems (SCIS) established in October 1991, with representation from each ofthe project regions, would be responsible for coordinating the computerizationof the Hospital Admission/Discharge Information, Accounting, andPharmaceutical Monitoring subcomponents. Specific responsibilities would beas follows:

(a) Hospitnl Admission/Discharge (A/D) Information System. The MOHDepartment of Health Policy would be responsible for nationalimplementation of the A/D system based on the experience obtained inthe three project regions. The CCOs would be responsible forensuring that there is close coordination with the Steering Committeefor Information Systems to automate the systems in the projectregions.

(b) Accounting. The initial phase of implementation would use a modifiedversion of the existing chart of accounts developed by an accountingtask force during project preparation. This chart of accounts wouldbe used by the three project regions until a new, more advanced anddetailed standard chart of accounts has been developed. The SteeringCommittee for Accounting would be responsible for developing thenational standard for accounting practices, as well as the design ofan education program needed for the implementation of this accountingsystem. The Kopernika Voivodship Hospital in Lodz would be thedevelopment site for the steering committee's work.

(c) Pharmaceutical Monitoring and Drug Oualitv Control. The SteeringCommittee for Pharmaceutical Monitoring and the Drug RegistrationCommittee, working in close collaboration with the National DrugInstitute, would oversee the implementation of this subcomponent anddeveloping the monitoring system for drug utilization andregistration system for quality control. The CCOs would beresponsible for implementing the system in the consortia.

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(d) Budgeting. The Steering Committee for Budget Planning (SCBP), wouldbe responsible for implementing this subcomponent. SCBP willcomprise representatives from the MOF, MOH Budget Department,National Association of Economic Directors and research institutions.

(e) Management Development. The Steering Committee for ManagementDevelopment would oversee the implementation of this subcomponent.

(f) Health Financing. The Health Financing Task Force, in associationwith the Institute of Labor and Social Affairs, would be responsiblefor implementing this subcomponent.

3.13 Regional Health Services (Consortia). The CCOs would oversee theimplementation of project subcomponents and programs in their respectiveproject regions. A National Consortia Development Group (NCDG), establishedduring preparation to facilitate development of this component, will continueto support development of the regional management structure in the threeproject regions as well as disseminate the project experience countrywide andassist initiatives in other parts of the country. The NCDG comprises workinglevel staff of the MOH Health Policy Department. Specifically, for eachsubcomponent:

(a) Regional Management. The CCOs would be principally responsible forimplementation of technical assistance and training, procurement ofequipment and development of facilities for the regional managementstructure. Where there are economies of scale in meeting commonrequirements of the regions, the NCDG and NPIU will continue toprovide support and coordination in procurement and implementation.

(b) Infrastructure Development. The NCDG would have responsibility forthe development of strategic planning guidelines. Working in closecollaboration with each CCO, NCDG would assure quality in preparationof regional strategic plans and architectural pre-design plans.Review and approval of each region's strategic plan would entail:(i) peer review by regional health service managers in the other twoproject regions; and (ii) technical review by the NCDG.Subsequently, the CCOs would be responsible for carrying outinvestment activities in each project region, including the tender,award and administration of civil works consolidation contracts, andmedical equipment procurement and installation in consortiafacilities. The CCOs would also be responsible for upgrading ofprimary care clinics and practices within the project regions(para. 3.11). The NCDG and the CCOs would ensure that the equipmentprocured and delivered to the consolidated facilities is inaccordance with the strategic plan requirements.

(c) HosRital Admission/Discharge (A/D) Information System and Accounting.Each CCO, working in close collaboration with SCIS, would beresponsible for establishing a hospital admission/dischargeinformation system, including staff training and installation ofcomputer equipment provided under the project, to a total of about 90health care institutions in the three project regions. Each CCO, in

- 33 -

close collaboration with the SCIS, would be responsible forimplementing the automated accounting systems and would coordinateimplementation of the admission/discharge data set and pharmaceuticalmonitoring system subcomponents that require accounting data. TheCCOs would also oversee staff training and installation of computerequipment in about 90 health care institutions in the three projectregions.

(d) Eguipment and Materials Mianagement. Each CCO would be responsiblefor introducing technology and materials management within theproject region.

D. Prolect Procurement Arrangements

3.14 The procurement arrangements under the project are summarized belowin Table 3.4. Specifically:

(a) Procurement of EguiDment. To the extent practicable, invitations forbids on equipment would be grouped by the NPIU and CCOs in sizablebid packages, so as to enhance competition and benefit from economyof scale in bid prices. Contracts for equipment estimated to costthe equivalent of US$500,000 or more per contract/package, would beprocured following international competitive bidding (ICB) proceduresin accordance with the Bank's Guidelines. In the evaluation andcomparison of bids for equipment to be procured through ICB, domesticmanufacturers would be granted a margin of preference of 15 percent,or the relevant duty, whichever is lower, in accordance withAppendix 2 of the Bank's Guidelines. Equipment procured through ICBwould account for about 78 percent of the total cost of Bank-financedgoods, or about 50 percent of the total loan amount. The remaining22 percent of the equipment value would be in minor packages,suitable for procurement methods other than ICB.

The exceptions to ICB procurement would be as follows:

(i) Limited International Bidding (LIB). Procurement of smalleritems of equipment and related parts and supplies thatpractically cannot be grouped into bid packages larger thanUS$500,000 but are estimated to cost more than US$200,000 percontract/package, up to an aggregate amount of US$1.5 millionequivalent, will be done following LIB-procedures in accordancewith the Bank's Guidelines.

(ii) International Shopping. Contracts for equipment and furniture,estimated to cost less than US$200,000 per contract/package, notto exceed an aggregate amount of US$2.0 million equivalent,would be awarded under international shopping procedures, basedon comparing price quotations obtained from at least threeeligible suppliers from at least two different countries.

- 34 -

Table 3.4: PROCUREMENT ARRANGEMENTS &/(US$ million)

Category of Expenditure ICB LIB LCB OTHER N/A TOTAL

Technical Assistance, 47.9 hI 12.8 / 60.7Training and Studies (47.9) (0.0) (47.9)

Medical/Office Equipment, 64.8 1.5 3.0 Q/ 3.6 f 72.9Computer Hardware (64.8) (1.5) (2.5) (0.0) (68.8)

Computer Software, Books, 13.3 A/ 13.3AV/Training Materials (13.3) (13.3)

Civil Works - Upgrading & 38.9 8.6 f 47.5Consolidation of Health facilities (0.0) (0.0) (0.0)

Incremental Staffing 2.9 g/ 2.9(0.0) (0.0)

Building/Equipment Operation 27.7 a/ 27.7& Maintenance/Supplies (0.0) (0.0)

Non-salary Operational Cost 2.0 n/ 2.0(0.0) (0.0)

64.8 1.5 38.9 64.2 57.6 227.0(64.8) (1.5) (0.0) (63.7) (0.0) (130.0)

j/ Figures in brackets are the onounts disbursed under the IBRD Loan.k/ Procurement in accordance with Bank Guidelines for Use of Consultants.J International shopping (aggregate - US$2.0 million), packages estimated at less than US$200,000 each

contract; prudent local shoppinc/off-the-shelf purchases less than US$50,000 each contract (aggregate -US$0.5 million).

d/ Intellectual property purchased directly/negotiated with publishers and/or proprietors (aggregate -US$13.3 million).

!/ Hiring of staff and procurement of supplies and non-salary items of expenditure financed by theGovernment in accordance with local procedures.

/ Procurement in accordance with SC procedures.

Note: Numbers may not total xactly due to rounding.

(iii) Local Shopping. Minor sundry items not exceeding US$50,000 percontract up to an aggregate amount of US$500,000 equivalent, maybe procured through prudent local shopping by comparing pricesobtained from three different independent suppliers.

(iv) Direct Contracting. Contracts or purchases related tointellectual properties, such as books, technical journals,training materials, audio-visual materials, computer software(including annual upgrading and licensing arrangements),copyrights, translation and reprinting rights, and othelproprietary items (estimated to cost about US$13.3 millionaggregate) would be procured either directly from the

- 35 -

publishers/copyright owners or their authorized distributors, oron the basis of competitive price quotations solicited fromretailers/book vendors for discounts on retail list prices.

(v) Civil Works. Contracts for the consolidation/upgrading ofhealth facilities (US$38.9 million equivalent) are to befinanced from local resources and would be awarded to pre-qualified civil works contractors on the basis of localcompetitive bidding (LCB) procedures satisfactory to the Bank.Procurement of civil works financed by the EC (US$8.6 millionequivalent) would be in accordance with EC procedures.

(vi) Locallv financed materials. local staff salaries and services(a total of about US$32.6 million equivalent) would be procuredin accordance with local procedures satisfactory to the Bank.

(b) Technical Assistance. Qualified short-listed firms would be invitedto submit proposals for comprehensive packages of consultant servicesand fellowships in accordance with the Bank's Guidelines for the Useof Consultants. As needed, the services of individual specialistswould also be contracted. The qualifications and proposed contractsfor these individual specialists would be reviewed by the Bank priorto the engagement of services. All technical assistance serviceswould be procured in keeping with the terms of reference for suchservices described in the POM and in keeping with the Schedule setout in Annex 4.

3.15 Procurement Review. The Bank would conduct a prior review of theprocurement documents for each package that is to be procured under ICBprocedures in accordance with paras 2 and 4 of Appendix 1 to the Bank'sGuidelines. Prior review would thus cover more than two thirds of the totalvalue of Bank-financed contracts for goods and works. Other contracts wouldbe subject to post reviews in accordance with paras. 3 and 4 of saidAppendix 1.

3.16 For contracts to be awarded under the Technical Assistance categoryin accordance with the Bank's Guidelines for the Use of Consultants, the shortlists of firms/individuals to be invited, the proposed Terms of Reference, thebudget, text of the Letter of Invitation and the employment terms would besubject to the Bank's prior review and approval.

3.17 Disbursements. The loan is expected to be disbursed over a period ofseven and one-half years (Project Implementation Schedule and MonitoringIndicators--Annex 5, and Schedule of Disbursement--Annex 6). The disbursementprofile for health sector projects in the Bank is about 8 1/2 to 9 years. Theproject is expected to disburse slowly during the first three quarters, mainlyfor technical assistance and fellowships. It is expected that during thethird and fourth years of project implementation, the disbursement pace wouldaccelerate considerably with purchases of computer hardware and softwareapplications, and better the pace of the sector profile. Disbursements wouldbe completed after 30 quarters. The loan closing date would be June 30, 1999.Disbursements would be made as follows:

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(a) 100 percent of foreign expenditures for equipment, vehicles,furniture, materials and software; 100 percent of local expenditure(ex-factory) for locally manufactured goods; and 90 percent for othergoods procured locally; and

(b) 100 percent of expenditures for specialists, fellowships andtraining, studies, and program development and evaluation.

3.18 Disbursements against contracts for goods and services exceedingUS$200,000 equivalent would be made against normal documentation. Forcontracts below that level, disbursements would be made on the basis ofStatements of Expenditure (SOEs), available for examination by Bank missions.A condition of disbursement for the infrastructure consolidation subcomponentsin each project region would be provision to the Bank of regional healthservices strategic plans and investment proposals acceptable to the Bank(para. 2.25). One Special Account denominated in US Dollars would beestablished in the National Bank of Poland, under terms and conditionsacceptable to the Bank. The World Bank would make an initial deposit ofUS$8.0 million. This amount is judged adequate to meet about four months ofexpenditure under the project. The Special Account would be administered andreplenished in accordance with applicable Bank guidelines.

3.19 Proiect Account and Audits. Project accounts, including the specialaccount, would be audited in accordance with the Bank "Guidelines forFinancial Reporting and Auditing of Projects Financed by the World Bank"(March 1982). The Bank would be provided within six months of the end of eachfiscal year of the Government, an audit report of such scope and detail as theBank may reasonably request, including a separate opinion by an independentauditor acceptable to the Bank, on disbursements against certified SOEs. Theseparate opinion should mention whether the SOEs submitted during the fiscalyear, together with the procedures and internal controls involved in theirpreparation, can be relied upon to support the related withdrawalapplications.

E. Status of PreDaration

3.20 Proiect PreDaration. At the time of negotiations (March 1992),substantial project preparation had been accomplished which would permit anexpeditious start on implementation. The current status of preparatoryactivities is as follows:

(a) Designation of Proiect Coordination and ImDlementationResponsibilities. Implementing and coordinating responsibilities ofMOH institutional units and the participating project regions havebeen defined, but MOH and the project regions lack personnelexperienced in project implementation. The principal officers andsupport staff of the NPIU and CCOs have been appointed.

- 37 -

(b) Regional Infrastructure Development. The Government has promulgatedthe Health Care Institutions Act which would decentralizeresponsibility and accountability for provision of health careservices in Poland. Three health consortia have been formed, andeach region has drafted an agreement that delineates the powers andresponsibilities of the new regional management structures. A surveyof health facilities, hospitals and clinics in the threeparticipating consortia was completed in May 1991. The surveyincluded preliminary assessments of the physical status of healthinfrastructure and equipment, and analysis of consolidation/upgradingcosts. For the subsequent implementation phase, the services of anarchitectural/engineering (A&E) firm would be needed to draft thestrategic plan for the consolidation of consortia facilities. Withthe availability of the PPF (para. 3.4), the regions expect to haveproposals for the detailed A&E services by December 1992.

(c) Eguipment Lists/Bidding Documents. A preliminary list of diagnosticand treatment equipment has been prepared as part of the facilitiessurvey. Computer hardware and software needs have also been defined.Both types of equipment need to be consolidated and further detailed.Invitations for proposals on technical assistance in medicaltechnology and computing technology will be invited in March 1992.The services of these specialists will support preparation of biddingdocuments.

(d) Technical Assistance packages have been defined, and draft terms ofreference for TA have been prepared. A Project Operations Manual(POM) is available in project files.

F. Project ReRorting. Evaluation and SuDervision

3.21 Reporting. The NPIU and CCOs would prepare semi-annual descriptiveand financial reports (beginning from the date of Loan Effectiveness) on eachproject component, objective and activity describing: (a) current status;(b) deviations, if any; and (c) reasons for deviations and corrective actionsbeing taken. Reporting and Bank supervision would focus on in-depth reviewsof the policy framework for sectoral improvements, the consistency ofactivities for each component and subcomponent with agreements reached atappraisal, performance of the implementing groups and institutions, assessmentof emerging needs for adjustments to project parameters, and possible follow-up operations which could be supported by the Bank. The bases of Banksupervision would be the semi-annual progress reports and the annualevaluation of project activities by the MOH/NPIU. This would be supplementedby a review of project expenditures and availability of financial resources,in addition to substantive discussions with technical assistance groupsimplementing/assisting in the implementation of various components, anddiscussions with higher echelon officials of MOH. The Project OperationsManual would also be used to assist supervision and reporting. Atnegotiations, assurances were obtained that the Government will prepare and

38 -

furnish to the Bank, by December 1 of each year, a technical and financialreport in a format acceptable to the Bank, and review with the Bank theconclusion and recommendation of the report, including proposed budgets forthe KOH and the voivodships participating in the three project consortia, andany measures that need to be taken during the subsequent year to ensure properexecution of the project.

3.22 Interim Review/Evaluation. In view of the pilot characteristics ofthe project, its intended future expansion nationwide, and the need toevaluate the success of regional management of health services, interimreviews of the project would be conducted not later than December 31, 1994 andDecember 31, 1996. At negotiations, assurances were obtained from theGovernment that it will carry out jointly with the Bank interim reviews ofproject implementation not later than December 31, 1994 and December 31, 1996,according to terms of reference prepared by the Government and furnished tothe Bank, in a format acceptable to the Bank, not later than September 30,1994 and September 30, 1996, respectively. The interim reviews would serveto: (a) determine implementation progress and ways to improve projectoperations; (b) allow opportunity to effect changes in policy which may bedesirable based upon experience during the initial period, and effect mid-course adjustments, if necessary, in project procedures: and (c) identifypossible follow-up operations for continuity in the Bank's involvement in thesector. The project is expected to be completed by December 31, 1998. Withinsix months of the Loan Closing Date, MOH would prepare and forward to the Bankits input for the Project Completion Report which would summarize projectperformance and evaluate the project's outcomes and implementation experience.

3.23 SuDervision. The project will require intensive supervision andsupport in diverse technical areas. Approximately 20-25 person weeks onaverage annually of Bank staff resources will be needed in the first two yearsof implementation; Annex 8 provides an initial supervision plan. Bank staffresources will need to be supplemented with technical specialists fundedthrough bilateral and multilateral cooperation as a continuation of supportprovided through project preparation. In addition, the EC will provide fourperson years of consultant services to supervise and coordinate the PrimaryCare Program jointly funded by the EC and the Bank loan. Finally, the termsof reference for the project management consulting firm also provide fortechnical assistance to MOH to support project monitoring and evaluation.

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IV. BENEFITS AND RISKS

Benefits

4.1 Major benefits include increased orientation to prevention of healthproblems, more accessible and effective primary care, more efficient andprofessionally managed health services, reduced reliance on the state budgetfor health care financing, and experienc6 in decentralization of healthservices. Improved targeting of poor and vulnerable populations would beachieved through better equipped and more highly trained family doctors. Thiswould also address fragmentation of primary care and reduce reliance onenterprise-based services, thereby facilitating labor mobility. A reductionin avoidable infant deaths could be expected. Improved accounting methods,monitoring of drug prescriptions and sales, and professional hospitalmanagement would all lead to efficiency gains and contribute to costcontainment. Regional restructuring of health services is expected to permitgreater involvement of the private sector in hospital support services such aslaundry, catering and maintenance. Development of training for primary carephysicians and nurses is also expected to foster high quality privatepractices. The three project regions would contribute to sustainability ofthe project through cost containment and improved efficiency by establishingshared services in technology and materials management, planning andevaluation. Once materials management is operating, up to 10% savings onoperating budgets could be achieved, and up to 5% savings are possible on bothinvestment and operating budgets with efficient equipment management. Thecombined total savings from measures that address pharmaceutical consumptionand efficiency in hospitals could be as high as ZL3 trillion or 8 percent ofthe total health care budget. These internal savings could be redirectedtoward priorities such as health promotion, prevention and primary care.

Risks

4.2 There are two main risks. The first is continuation of weak projectimplementation capacity in MOH. Project implementation presents anadministrative challenge unprecedented in MOH, and the number of qualifiedstaff responsible for implementation needs to be increased. This risk iscompounded by the difficulty in attracting and maintaining staff with thepresent public sector salaries. Management capacity at the regional level isalso a concern. To reduce this risk, technical assistance in projectmanagement would be provided during project start-up and implementation. Thesecond risk is that continued uncontrolled rise in health expenditure andfurther economic difficulty compromise financing and sustainability of healthservices. Project design has been tightly focused on essential investments torationalize health expenditures and minimize incremental recurrent costs.Management improvements and cost recovery to be implemented under the projectwould yield substantial efficiency gains.

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V. AGREEMENTS REACHED AND RECOMMENDATION

Agreements Reached

5.1 At negotiations, assurances were obtained that the Government will:

(a) in its budget, ensure that any funds to be made available to thevoivodships participating in the health consortia under the projectare treated as supplemental to the voivodship's normal budgetallocation (para. 3.4);

(b) ensure that all voivodships and health care institutionsparticipating in the health consortia provide adequate funds to coverthe operating costs of the regional management structure (para. 3.4);

(c) maintain throughout the project a national project implementationunit with staffing, functions and authorities acceptable to the Bank(para. 3.8);

(d) furnish an annual audit of expenditures six (6) months following theend of each fiscal year (para. 3.19);

(e) prepare and furnish to the Bank, by December 1 of each year, atechnical and financial report in a format acceptable to the Bank,and review with the Bank the conclusion and recommendation of thereport, including proposed budgets for the MOH and the voivodshipsparticipating in the three project consortia, and any measures thatneed to be taken during the subsequent year to ensure properexecution of the project (para. 3.21); and

(f) carry out jointly with the Bank interim reviews of projectimplementation not later than December 31, 1994 and December 31,1996, according to terms of reference prepared by the Government andfurnished to the Bank, in a format acceptable to the Bank, not laterthan September 30, 1994 and September 30, 1996, respectively(para. 3.22).

5.2 Conditions of loan effectiveness would be:

(a) MOH issuance of the following regulations: (i) recommended minimumdata set for hospital patient admission/discharge information(para. 2.13); (ii) accounting practices in health care institutions(para. 2.14); and (iii) registration of drugs and a standard formatfor drug prescriptions (para. 2.15); and

(b) employment of consultants to assist with project management(para. 3.6).

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5.3 A condition of disbursement for the infrastructure consolidationsubcomponents in each project region would be provision to the Bank ofregional health services strategic plans aad investment proposals acceptableto the Bank (paras. 2.25 and 3.18).

Recommendation

5.4 Subject to the above, the proposed operation would provide a suitablebasis for a loan of US$130.0 million (equivalent) to the Government of theRepublic of Poland.

* 42 Annex 1Page 1 of 3

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

DeveloDment of Regional Health Services (CONSORTIA)

Design and Development

1. Regionalization provides a powerful impetus for achieving cooperationbetween hospitals. The progression from stand-alone institutions towardmultiunit health care organizations and the concomitant introduction ofcorporate management is probably one of the most significant and synergisticdevelopments that have reshaped the delivery of health care in theindustrialized world in the past 30 years. This development is basedprimarily on hoped-for economies of scale, better access to the capitalmarket, and more expert management.

2. In its attempt to decentralize the delivery and management of healthservices, the Polish Government has opted for health consortia for thedevelopment of its regional health care delivery systems. Why consortia? Thereorganization of health institutions into a consortium aims to harnessindividual institutions into an organization that can guarantee greaterefficiency and effectiveness in the delivery of health care and preventdiseconomies of health care provision through independent and individuallyadministered institutions. Thus the strength of a regional level ofmanagement is its ability to formulate strategies that implement nationalpolicy, modified to suit the needs of its area of responsibility, while at thesame time being able to coordinate activities through developing a broaderperspective over and above smaller organizations.

3. The benefits of a regionalized delivery of health care are economiesof scale, the better use of scarce resources, the ability to rationalizeservices ard the ability to secure equity and equality of provision. Yetthese benefits can only be achieved if there is a strong interrelationshipbetween improved quality in primary care and better use of secondary carefacilities, integrated with a health promotion strategy that underpins themajor reform process.

4. Various types of health consortia exist. They differ according tothe degree of comprehensiveness of the combined services and the (regionwide)extent and direction (vertical and/or horizontal) of integration. Healthconsortia also differ according to the number and capacity of participatinginstitutions, the size of the populations being served, and whether theconsortium is based on a catchment area or a subscriber population. The legalcharacteristics will differ among health consortia: (a) with respect to thedelegated legal statutes defining duties and rights, including the formalrelationships of the constituent members with the consortia and/or theregional health authorities; (b) the parallel health services in the regions;

* 43 -Annex 1Page 2 of 3

and (c) the national authorities, in particular MOH, Finance, Transport,Environmental Protection, Public Works, and eventually national or regionalsocial insurance.

The Introduction of Health Consortia to Poland

5. The Minister of Health established a task force to facilitate thecreation of pilot health consortia. A conference on health consortium washeld on February 28, 1991, for local government officers, voivodship doctors,representatives of physicians chambers, trade union members andrepresentatives of the parliamentary committee on health. The conference waspreceded by the dissemination of information on health services integration tothese groups and by papers in the medical press. There were 200 participants.Topics covered included models of health consortium, financing, integration ofmedical and logistics services. Participants at the conference were invitedto submit pilot project proposals for the implementation of regional healthconsortium, to be supported by a proposed World Bank loan. A deadline tosubmit proposals was set for March 21, 1991. The selection criteria werespecified and these were:

(a) Project Content.

(i) existing institutions forming the health consortium;(ii) demonstration of ability to use available data;(iii) establishment of strategic goals based on data analysis;(iv) demonstration of innovative structures and solutions; and(v) anticipated results

(b) Availability of manpower and technical resources necessary forproject implementation.

(c) Experience in health services restructuring undertaken within theprevious year.

(d) Level of support and acceptance by potential partners of projectimplementation.

(e) Feasibility of the proposed plan to develop a new health consortium.

(f) Financial sustainability in the absence of significant support fromthe World Bank or other foreign aid.

6. By the closing date in March 1991, the Ministry received twenty-oneproject proposals. An evaluation committee was formed from among task forceleaders and the committee selected projects based on the above criteria.Three proposals were selected with the final choice confirmed by the Ministerof Health. These included three regions: Wielkopolska (five voivodships);Szczecin (three voivodships); and Ciechan6w (two voivodships).

- 44 Annex 1Page 3 of 3

Assessment of Existing Physical Infrastructure in the Three Regions

7. A survey, conducted in May 1991, showed that the health carefacilities in Poland have deteriorated to a stage where major consolidationand upgrading will be required within the coming years.l/ Despitedifferences in the consortias' economic and demographic structures, thephysical facilities and major equipment in the three consortia do not show anysignificant differences in their present condition. A substantial number ofhealth care facilities are constructed more than 50 years ago, and generallythe functions of those buildings are inappropriate for a rational andefficient hospital operation. Buildings constructed during the past 10-25years are of low quality. Neglect of maintenance during the past 10 years dueto lack of funds will require substantial capital investment in buildings,technical installations, and equipment within the near future if the presentlevel of health care services is to be maintained.

8. The survey determined the frame of capital investment necessary toconsolidate and upgrade physical facilities and equipment. However, moredetailed strategic planning is needed to establish detailed investment plans,implementation schedules, and work programs. Criteria for the regional healthservices (consortia) strategic planning were developed during the appraisalmission (see Attachment A). The criteria were agreed at negotiations. It wasagreed that the Health Policy Department of the MOH jointly with the NationalConsortia Development Group will coordinate the process for assessment of themasterplans and proposed investments. The strategic planning studies willdetermine how the capital investment will be used to improve the efficiency ofthe system, such as the degree of upgrading and consolidation to be done, andwhich elements of the health care system should be reorganized, expanded,merged, closed or reequipped.

9. The survey has shown that major upgrading and consolidation oftechnical services such as heating, ventilation systems, water supply systems,and electrical services will be required urgently. Minor investment inbuilding physical conditions is necessary to obtain a satisfactory hygienicstandard and an attractive working invironment for the staff.

1/ Capital investment requirement can be divided into: (a) consolidation,and (b) upgrading. Consolidation is aimed at immediate reforms, andincludes urgent replacement of outdated or obsolete physical facilities,or part thereof, and medical and nonmedical equipment that havedeteriorated to a stage at which basic functions cannot be carried out.Thus, consolidation should be considered as the minimum investmentrequired in order to maintain the present level of health care services.Upgrading is aimed at short-term reforms and includes upgrading ofphysical facilities and replacement of equipment to improve the efficiencyof the existing health units. Upgrading does not include establishment ofnew facilities or completion of facilities that have been planned or arealready under construction or major functional changes of the health careunits.

STRUCTURE OF THE CONSORTIUM MANAGEMEN

SUPERVISORY BOARD#mfe of dv*nd)

BOARD OF DIRECTORS- Dkedor)

PLANNING BDWGETING MAkTERIALS HUMA HEALTHAND AND INFORMATION LEGAL AFFAIRS ADRE-SOURCES PRIMARY SECONDARY PROMOTION

ELON ACCOUNTING EIPMENT DVLOPMEE CARE ANDMANAGEMENT PREVENTION

Lsw:

H_ N sl _stahd care gtp m to Cansost Coosdlknao OfficeOQD

N

0

ft

- 46 -tachment APage 1 of 3

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

Guidelines for Regional Strategic Plans

1. The objective of regional strategic planning of health services is toachieve a better fit between health needs and the use of resources. Thestrategic plans for regional health services restructuring and infrastructuredevelopment in Poland under the proposed project will need to address thefollowing key areas: (a) consolidation and rationalization of services;(b) technical and design standards; and (c) human resources management. Theparagraphs below provide guidelines for development of plans in these threeareas.

Consolidation and Rationalization of Services

2. HosDital Services. To reduce pressure on short-term care facilities,it will be necessary to plan for expansion of extended care beds for patientassessment and rehabilitation. Nursing home facilities will need to bedeveloped. The regions' efforts to increase extended care beds, along withthe improvement in the quality of primary care, will lead to reduced capacityor closure of some institutions now providing "acute' care. The plans shouldbe developed according to the following parameters:

(a) Acute care, short-term beds are to be provided at a ratio of 3.5beds/l,000 population;

(b) Extended care beds are to be located closer to population areas thanat present and at a ratio of 1.5 beds/l,000 population.

(c) Redundant facilities are to be closed.

(d) Hospital units that produce a volume of care inefficient to ensurethe necessary proficiency of the providers and quality of proceduresare to be closed.

(e) Consolidation and upgrading of health facilities are to be undertakenin a phased manner so as to minimize disruptions in delivery ofhealth services.

(f) Plans for upgrading of hospital equipment, in particular the locationand numbers of highly specialized and expensive equipment, are toreflect the strategic plan for facilities consolidation.

3. Primary Care Services. The plans will need to provide for trainingand retraining of doctors to accelerate the introduction of an effectiveprimary care service. Health centers will need to be established to screen

- 47 - At&Ament APage 2 of 3

and examine patients and offer treatment outside a hospital environment.Procedures need to be developed for monitoring the efficiency and quality ofindividual clinics.

4. Rationalization of Iransport Services. The ambulance servicesprovided by a multiplicity of agencies will need to be appraised. There willneed to be plans for introducing computerized scheduling of transport servicesto address problems of inappropriate usage of existing vehicle fleets.

5. Telecommunication. Plans should be established for an appropriatenetwork of communications among health service providers within the region.The network should incorporate both hospital and non-hospital services.

Technical and Design Standards

6. An acceptance of the need for fewer beds will automatically improvespace areas in health facilities. Progress to a safer and better workingenvironment within hospitals is critical to better health services. Thestrategic plans will therefore need to provide for:

(a) Space standards of not less than 60-70m2 per bed in generalhospitals, 90-100m2 per bed in teaching hospitals, and 30m2 per bedin nursing wards as part of the space allowance for general orteaching hospitals.

(b) Technical services, such as heating and ventilation systems,distribution of fluid and gases, communications systems, and securitysystems, at appropriate comfort levels (e.g., distribution of medicalgases on a local unit network instead of a hospital-wide distributionsystem; natural ventilation with air conditioning in operatingrooms).

(c) Proper disposal of sanitary, medical, radioactive and laboratorywastes and adherence to national norms for environmental and wastedisposal.

(d) Flexibility for future expansion and/or internal reallocation offunctions.

(e) Energy conservation measures.

(f) Establishing an effective patient care environment through provisionfor adequate support care (e.g., intra-hospital patient transport,wheel chairs), development of infection control guidelines.

(g) Accessibility for handicapped persons.

-48 - AttachmentPage 3 of 3

Human Resources Management

7. Planning for human resource development will need to be an integralpart of health services restructuring to ensure appropriate participation andcommitment of all health sector staff. The regional management will thereforeneed to incorporate the following into their strategic plans:

(a) establishment of a process for identifying future health carestaffing requirements and an effective personnel plan for the medium-term (5 to 10 years);

(b) introduction of training and career development programs for allgroups of staff. Management development programs and professionaltraining schemes will be essential;

(c) a communications strategy to secure the commitment and motivation ofhealth sector staff; and

(d) provision for access of health sector staff to employment services(including assistance with mass layoffs, if necessary) from localemployment agencies.

- 49 - Anex 2Page 1 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

:*2Rwtsu,,..suaggsXs3iuuu.u ww,ls:*,S.t|sgs2.a,su.z,gs,.zl 1us:wswa a::gsazsus:g:33;SU Ttl* *tZIWSuh58huus3,8,3*.,,w:.s2*:3,wI:uzw8g

Twoe Uni t total 8Dm Costs Physical Conttnoencies Escalated Costsof of Descriotion of lnouts Stv of -----------.---------- ---- -- .....................

Input Intut lnout Local FortiOn Total Local Foretqn Total Local Foreign Total

A. HEALTH PROMOTIONIIhSS32I38g2.I*S2223w8SE.IS,.ZBga, ... ,assas.8g.s I.... 1. Health Promotion Prograes

:..........--------------------- . . . .............. .:...... .....

ST/HI. Cons a/month Tech Assessst/Curr Oev/Eval 27 130 302 432 13 30 43 157 367 525UL Consult s/lonth Progras Evaluation 45 15 ;5 51 2 4 5 19 44 63ST Follos c/month Hlth Curr Otv/Proo Evaluation 12 0 96 96 0 10 10 0 114 114Develooment I Spread Health Survey 75 175 250 8 18 25 90 210 300Developstnt 7 Spread HP Progras Oeveloosent 15 35 SO 2 4 5 19 44 62Computer packaqe PC Harduart/Peripherals 5 0 25 25 0 3 3 O :8 28lCoopu 0OU annual 0om - Computer Hardware 8 8 15 1 1 2 10 10 19EquiPsenc PaCkaqe Office Equipeent 5 3 48 50 0 5 5 3 54 57Equip G&I annual 0OU - Office Equiopent 18 12 30 2 1 ; 23 16 39Equipment package AV EOveatIlsBoaro.3 req,l schl 5 13 238 250 1 24 5 14 269 283 i

:Equip o0m annual OVI - YV Ecuspeent 180 120 300 18 12 30 234 156 389:Software Package looks/Technical journals 35 0 350 350 0 35 *S 0 446 446:Softyare package PC desktop publishing Softtare 10 0 12 12 0 1 1 0 11 15Software annual PC Software license/uoqrade 0 4 4 0 0 0 4 3 5------.....--......... ......._----------------- ---.-- ------------- ---- --.-- --- ---- ----- --------------- - ----- :

Subtotal Health Promotion Proarass 455 1460 1915 t 4l 146 191 t 509 !777 2345

:2. Training of Health Educators:- - - - - - - . .. ... ... .. ... ... ... .. ... ... ..

:ST/HL Cons ilnonth Organize annual wortsnoos 7 34 78 112 3 8 !I 43 100 143

ST/HL Cons 2 Spread Arch/Engg sirvices:upgrd Univ Krak 8 18 :5 1 3 5 9 1. ;0l/T Fellow sl/onth HSc Public Health/HP I(O felIl 440 0 1760 1760 0 176 1?o 0 2165 21I5

:S/T Fellow a/month HP Prog/Nedialtour (50 fell) 186 0 1488 1488 0 149 149 0 1825 1825Train4ng a/month Vtshops HP Prog(l wkl:20 part 30 72 18 90 7 2 9 9- '5 117Training a/month Nkshops SpI subio(l Wt750 part 376 902 226 11:8 90 23 113 1175 294 1468

18uildings I Spread UpgradingsUnnv Krakow trg facil i 213 38 250 21 4 25 255 45 300:Build Otl 2 Spread 0111: Univ Krakow training fcil 21 1 23 2 0 : 28 1 30:Equipment I Spread Training Equipment: Univ Krakou 5 3 7 60 0 6 6 4 70 73

Equio 0&1 I Spread Ois Univ Krakow training equip 14 10 24 1 1 2 19 13 3i1Salaries /eonth Nati HP Centeri 7 add staff 546 109 0 109 11 0 11 140 0 140Salaries i/month Consor HPt 2 add staff/Consor i 468 94 0 94 9 0 9 120 0 120

: - -*------*------: :-~~~~~~---- --- ---- ------------------------------------------ -- -- --

Subtotal Training of Health Educators 1470 3693 5162 147 369 516 1887 4557 6443:~~~~~~~~~ ~ ~ ~ ~~~~~~~~~~ ~ ~ -- ----------:------------------- . ..........

:3. Occupational Health

:ST/HL Cons e/oonth Occup health 116 ecoertsl 15 70 162 232 7 16 23 81 190 271LL Consult a/month OtCcuP/idust health ustetv 22 7 17 25 1 2 2 9 20 28:S/t Follow 8/oonth Tours Occ hith plan/mgt/eval 5 0 40 40 0 4 4 0 45 45

----- s- -- - ---- - ----- -- -------- --------- ---- 1-1------- 1-------------

Subtotal Training of Health Educators 77 220 297 8 22 30 90 255 , 345........ ....... - ---

- 50-AnePage 2 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

il of )ecr tl3 !g outs :Q5V .i. -... ------------- ..........Ieou: haeut : blost ; Local !uroiqo fotul FxI orei;n tot4i -.ocal Fort:qo iotal

:69-9 ............. .................. ... S.............. ......... ......... t.... ...........

:5. P815*0 EAo.TN CARE

:1. Pritarv Care Practices

ST/NI. Coosa o *.th POK an# PCP 38 : 1o0 420 400 IS 42 00 215 502 717LI Coaselt */sth Project Evaluationi 3 1 2 3 0 0 0 I 3 4

:SIT Poilow etaith Study tiars 13 0 104 104 0 10 10 0 120 120SIT Folio* msteso Train.. ?CPs/PN trainers 260 1 0 2080 2080 0 208 208 0 2473 2473;tEalntal sheoath Mkee.olpPC "t,fIe&A.,4cil.1i. 40 94 24 120 10 2 12 115 29 144!Traais" a/auth Coatiwwao edoatiha W 0 1920 480 2400 192 46 240 2394 500 2003

ttrai.inq 2 Sor4ad 8ksho: PK CucrraCelse plawel Li 1 4 20 2 0 2 10 5 24ilevelepeet I Srerad 8es,rt Support : 720 1480 2400 72 M4 240 024 2155 3079i:111eelose..t t Soread Publicatiuons 75 175 250 8 to 25 94 225 321*Dvvsola.ot2 ISoread Public Educaticon ISO 350 S00 1, Is 50 192 440 04281a11dtn1 I Sore4sl Upqrado Matisetal PlC cuter 213 38 250 "1 4 :s 250 44 204

:hilhd OS OSperad Vl4 CCoter OOl 24 1 25 2 o 3 31 2 133:Cosoater packs9e PC Oareeare/PeriehArals 5: 0 25 I'5 o 3 3 20 20Momosga 4N &aoal, 04t- Cso.eter oirdware : 4 13 I 1 I 8 s 1731quipsmat I Soread NOC CtrotaficelilllIoo,cil "p 3 102 170 1 14 17 to 183 10?1:Esoip 05 I Spread #PKI *ooiwast 040 1 1 41 102 4 4 14 70 53 132:Eouaaaat pactsqe ?rce.ing "muaps 5 iaude.ies 5 : 5 95 100 1 10 10 a 112 1161auuop 000 wm,ua 040 - traoinin "uiS 30 20 50 2 5 40 26 54:Sof tar. 9ackaqo PC Software: S acatealoos 5 0 4 4 0 3 I 0 .1 7:Software auwfeal PC Software lic"soeusqrade 0 2 2 0 0 a 0 3 3Softeare wdkaqe Audiovisual satlsi I acade. 15 0 150 1SO 0 15 is a 101 101:Softwarep paclage SookslT.ch journals, S icaadn 15: 0 300 300 0 30 30 0 392 382Salaries almenth Steorseg Comes 110. staff 21 Lb1 0 14 2 0 2 1a 0 loSalaries .Ioath Steerln4 Cmia 2 LL staff : 42: 14 0 14 2 0 lo ) to3alarieu a/aoath Nat Pris Ciro SrG:1 dirtetor 40 : 8 0 60 7 0 7 80 0 093Salaries seamts Nat Prie. Care Ordil 41 staff ISO8 135 0 035 14 3 14 1"8 0 1783alartes a/lsoth sat Pris Care artists add staff 0024 203 0 205 21 0 23 244 0 214liser/Recurr I Spreso SPOC noo-salary uper costs : 120 0 120 1., 0 !2 154 O 154

EC Ftinanced Eleseetsi

:St/NI Coos c/ccith Devsacia eiitsltrq needs assets. 41 "IS1 503 718 0 0 :.0 534 703:SIT Fellos ai"nith Study tours/delloaswitso 2122 0 1804 1804 0 0 1 0 1915 1915;Traininq as tlasM Morkshohusc:v aM team 375 :2435 400 3044 0 2 587 a47 3234U CosOet alsath Swsiqeofe FfacPiclities : 9q 2 4 a 0 0 0 2 0 8:Sbevelopceest I Spread Public Education so3 Be 125 0 0 0 40 03 133fStlccec11t I Spretod Curriculum comfercoce : 13 1t 0 0 0 4 14 28Seveltoecet I boread Sesoari svoept 191 44 43 0 0 0 20 04 44%jildsols sa&ts oeqradss9 of 300 PCP 300 6 424 1134 7540 0 0 0 4824 1205 8031.1asl UN1 "sanaI PC? buidiseg Sill :75 30 405 0 0 0 771 41 812

1hillings I Spread tomsato 3 kcadecic facslitin, : 479 84 543 0 0 0 50800 9 0 8S!Build ON t Soread kacadic aldOeq O4ft 43 2 45 0 0 0 45 2 aS:11"somat skacla KPC eowsut 3300 1 19 3204 3375 0 0 0 170 3404 3355iIga0 ipOf &Mgal 844- PCP fqsjpauat $ 10 540 1350 0 0 0 1007 725 18122!Saf twre t bpreed Library & Info resourosa 0 38 38 0 0 0 0 40 40

Seibtotal Prissy Care Practice. 1 :5280 14240 20544 404 414 1023 L7447 16362 3374

:2. le-Serntce Trai51n5

:STiI1. Cu.t oa/cath flaacsriurse aalcurr I 38 00 120 A 0 33 45 L0S 150ILLC.ewlt weasth Pro,ct evaluation 3 I 2 3 0 0 0 i 4::Iraiseip efaueth PIIt staff training 800 1920 480 2400 102 40 240 2477 010 3004Wateare I soreat Oratleseg catersals , : 0 t0 10 0 I 1 !0 13 i3:

IC Puse.ced Ilecets.

'ITIIL CD c/gUt Pr" 8d515/kipt/qSt/iYal I 47 3UV 36 1230 5 0 4 392 914 1301 lI/ Felios a/math stadvtcgwr llel,meuas 1 74I 8 194 594 0 I 0 0 430 401I151 P685ws c/ath taso-tra felleewaip I s4I 1 438 43115 0 0 5 0 444 46401 1Moasm,e I 111oead Caagtsw r Swdea fre/P ga0s I 0 13 13 0 0 0 0 is IsI11Ipop0u ZhrassM 6I- Cccterw ds I 3 7 8 5 5 3 3 71

twintkai8a4eusa raauieg i 3? 4446 g77 194 so 254 291 64900 "ToI

- 51 - Annex 2Page 3 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estmates (US$'000)

;fhfnnnwsnnsne3"wwwwwnmnnn.. ltv. -tbt-n..nf:tti.lfnusmhinwifwn.ifluhnnnswwtaltwl.flflTpoV Lut Total las. Costs Physical Cooteoesncoes Eslcalted Costsof o lescription of Inputs MY Df -----o-- - -…

lInwt loput Input Local Feruin Total Local Foreign Total Local Foreign total I

. HEALTH RMA6ZEEHTn...nn.fhw nfhn ..n.n.sa.n.nn. n.s a.nt.t

:1. Hotltal AID inofrat:onlAccgunting (Nationall I

:ttlHE Cps 0 eOnmth A/D cCt IapagoiOt 31S 149 34? 49t IS 35 SO 179 4IT S5 ILt.lH Catn aultjth A/D ACct aoaenqnst n 313 730 1043 31 73 104 380 I81 12U U Consivt a/owtth kcet .gtldosganlval 1 11 121 22 403 12 21 40 145 339 4U4Slt Follow sleuth AID, *ct uOunqottnt 11 0 1 1 n a 9 9 0 107 1071TraiLtipg alonth £10, kct s n^toong t 04 154 36 192 1s 4* it 17 47 231

Moaputer pWkaqc ItOH Coop HaKri/Sotar 1 0 350 350 0 35 35 0 390 390 1CN OM o a nual 00 Cosoutor systs OAR 1 l S10 210 11 11 2. u3 1 272:ctOuter packge Vouvod: Coop Hard/Softsare 38 0 53 3 0 4 54 0 47 447ICssou OM anuaal Voivd Ctoeutor systto o0a I 110 11l 231 12 12 23 154 154 30 1Moiouter packaqe Sall Koop: Cotop HorfISoftuars i 212 o 0 flO 1903 0 191 191 0 2330 230Cosau O anofal SaliHoos Cteoutor ontns CiII 1 38 305 7o 39 1 77 517 517 1034oasoutir paciage HIdOiS Hoso: Coo Oafd/Softro 1 327 0 2941 2943 0 294 294 0 3579 357

Coops Gin lt tisl ISNeHoap Cosputer srst. OUt It10 00O 1220 01 Al 122 317 o17 143ICoator package Pilot Larqe HKato tard/Softero 2 0 13 IS 0 2 2 0 20 20CuC 00GIN osnual Pilot LrgHoote Cut sYst U :L 5 5 11 1 1 1 7 7 14

:Cteputor pckage Large Hosop Coop Hard/Softart 79 711 711 0 71 71 0 653 351toueu OUt a0tnual *rqg Hosr: Cowp cytes 0 OU 1t 154 309 15 15 31 200 200 412E4ulliatt pckaqe RCH. Office (opeotant 1 1 10 10 0 1 1 1 11 11EgoioOUM ataoeal OAR - Office Ecupto t 4 2 £ 0 0 5 3 ISoftware packaga ItOHlookso:ckh journals 71 0 i4 S4 0 3 I 0 107 10?

ISoftwore packale YOavol boohs/Tech journols 1 t 0 441 461 0 40 44 o 50 53 Softure 4cila'e Small Hosp:BoelTkTech jourialos AA44 0 515 515 0 52 32 0 452 52Software package Ao Hioii:a oks/Tlech jooraals 1029 0 313 23 0 12 82 0 1040 10401Setwtre package Large Acs;slaeks/Tech journals 274 0 I 329 0 33 33 0 41 414 S3alories, also th NOW ecreetstatl Stoff 672 134 0 14 13 is 171 0 171

Subtotal Hospital A/C lnforotion/klcoustng 1 2250 11551 1I300 225 1155 1100 2100 14274 17180

12. Phreascutioal sonitarog I

STIN Cns * alenoth Evaluation I 4 1t 4 44 2 4 0 24 54 33MTIMI. Coos ls th Drug regullget 53 223 SIT 742 22 52 74 270 £31 901

IU Cooselt *I,istk Drug reguwleuol 59 207 295 9 21 30 107 250 3531Sn Felilc olalth Dreg ""storing 11 0 I4 34 0 S 3 0 102 102

:Trainso 016.10 Drug mtrog 21 70 17 r 2 71 if U 353 213 10071Coomptar ackagle ICm Coop NHrdlloftvore 21 0 1100 1100 0 110 11 0 1270 12701Coo" IUR Gautt l ItON eute ro steo U0lt I J3O3 303 t00 30 30 01 39 792Mtonptter pcttge pilot hPl PhOr Coot Hardisofty U 1s 0 IU I 0 1 14 0 17 17 1tConsOu l eu a pl olt tbh Phar Cecp stitno OU I 1 47 47 IS J I 9 1 01 13i

:Ctptear paclae Potl Pors Coop Ou trSottUoare 23 * 2993 2993 0 29 2" 0 330 35 1:Cups CAR aoo ual Put POore Ceoputar systn OU I *7 135 AS d 135 902 902 11041tCoeuater pCttkag Volvdi Cop Hard/Softsare n: 3 o 0 50 550 0 55 15 0 045 u45Ceoos 0u &Aal Vying Coopter systeo tlU I : 111 111 235 12 12 2C 1m7 1U7 l4 1tCeopute packaeo Small Hospt Coop HardSoftmare 212I 0 m 222£ 0 223 225 0 2713 2713:

ICespsOlU m ta So/l/ to spCoter Cstae OM I N4 t 449 399 45 43 90 003 003 u 101ICosapter packae oitto Keptj Coo kardlloftware 1 m327: 34 34 0 343 43 0 4175 417 I

:Cew 0011 aaNeul HedHnoop cnotter Ietn an I 712 7i2 1424 iti t7 142 93 953 1907 1ICapeter pckagPe PUlt tLarge Htt:Cmoe Hardleft 21 0 29 29 0 3 3 0 3 331CpO4Ni W aotal Pilot Lrgl stC ptetpttr sysO N I I 9 9 I 1 2 11 11 23tCapttr package Large Nasal Coop Hard/Softeas 73e , : 0 1 10 0 1O ? 107 0 1291 1211:Co e OM asal LreH/osp Cooputer ntbe.t ON 237 237 475 24 24 47 Sib 314 0 ItmPnuat I Spread AOalytical messooot I 40 700 100 4 7& S0 47 694 941IEMovi 0u t Spread OiI - Arnlpticol topi7ttt : "I 240 144 40to 24 U 40 317 211 52 JZEllgopsont pckage Office lipest 1 1 10 10 0 1 1 1 11 i1

lEgaioCN aau al OAR - OfficE Eoaat * It4 2 4 0 0 1 J3 1Software packagqe IIOJSoksllech joernals I 0 312 312 0 31 3U 0 01 401Softare package Pth Pub raile t loorals 1030I 0 1o03 10 O 101 to 0 1355 135I

eSftware package Heovod:looehslech sourols 1 12t I 0 l 7 7 0 77 7 0n 9£ 9W 7 3Sotaore packagte Sull o IboealitTKIC IWll 1 I441 0 44 444 0 4 04 '0 IU5 I1sSoftare p llae Hod 1be0:l0 tICK jtruals t02l 0 1029 1029u 103 103 0 f 19 1299 I.ltt ted" paclae Large Nl: eel/7Tec% oroals 2A 0 03 as t 49 09 u 3U2 U2:Salarlie gatk lON ispreetal staff : £24 121 e 5 12 0 12 I0O 0 14 ISalaries e6nt.1 Veoed croutal Ualft 1 2472 44 3 49 4 t 949 449 49 1

Setoal thParoate,tical totoilo I 441l 2303 2507 449 209 20 54 25377 31ll1

-5 2 -Annex 2-Page 4 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

...................ISSSSSSS.SSStSuSSflflSS*S*SSUESSSSSS *$S*SI* mahwSSwwS..sn, , ss.ss zs.8s.e..st. .s5.ss.s.ss.. .............. ... ;

lose Unit . total inse Costos Pnysical Contunaocis Esculte Costs

of of Descriotosn of Inputs 0 of 0 ---- ------------ .....................lftut lnout Inwt Local Foriqo fOtail Local Foreign rOtal Local Foreiqn Total

:C. HEALTH WhCEIIENT:sw..w..fluuw.2 . . . ......... ...... ..........

:3. Soagtotn;

ST/IL Cons s/ooth Rt90urte Illoc/elvl 15 72 146 240 7 17 24 87 202 281IU Cosult s/ooth projtct oeVlation 3 t 9 0 1 1 3 6 11ItlT Fellos so/onth Study tour 3 0 0 40 0 t 6 0 72 72iTrainanq /soo1 th Local training: center stiff 4 10 2 12 1 0 1 12 3 15lCoeuter paCkage Suuee Hardware package 1 0 7 7 0 1 I 0 a 8Cooou 0th annual 060 - Servrl aCkoae ' 2 0 0 ' 3 3 S

Cosouter packag PC HardwareaPeripoarls 4 0 20 20 0 : 2 0 '3 23Coeo 0U annul 0UI Co wter HKroure o 12 1 1 1 a 9 16Equouent package Offtce Eiuipjent I 1 10 10 0 1 1 1 11 11Equ:1 021 K nnual 06i - Office Eoulpeent 4 2 o 0 0 1 S 8'

:softear Package Serverl Software 1 0 1 1 0 0 0 0 1 1Licenste nnual Serrerl Softvare licens/uggro° 0 1 1 0 0 I I loftware package PC Softuare 5 0 6 t 0 1 0 7 7

icense annual PC Software lacenseoqograe 0 3 3 0 0 0 3 3

Software package looks/tech journals 7 0 70 70 0 7 7 0 89 99Salaries e/santh Center staff: 4 oad stiff 160 34 0 34 3 0 3 3 0 43

.___ __ ~~~~~~~~~................. _ ._._ ............ ... ___.. ._......... ......... .. . ..... .... ........ .....................

Subtotal Bufqetinq 130 364 494 1 :3 o6 40: 17) 441 401:-------.-............. . ..... . .............. . .................... ............ ------------------------------. ..... .......

:4. hanaqeent Osvelopoent

:571T Cons w,eonth Canuaeeunt develoonwnt 34 173 4aS 576 !7 4 s5 209 489 497

ILT/IL Cons esonth O qnagenmot dfeeloownt 62 240 406 049 26 1 07 3!1 726 1037:LL Consult s/soth Kanaqe#ent develooeent 142 55 I2' 182 5 13 18 ?7 155 222Llt Fellow a/sooth Long-tere fellosnlics 464 0 1854 195S 0 184 lob 0 2320 2:20

1SJT Fellos SoOnth Short-tur. fllosslstudv tours *7 °0 534 53o 54 54 0 645 645Turaining soooth Local training 43 151 30 169 15 4 19 184 46 230Eouiousnt Package Cowoutur lab 110 placesl I 2 43 4" a ' ' °0Esuio 0U0 annual 0IA -O fftce Eouioent 1' 10 4 : 19 : 31Cosouter package Seryer2A Hardware/Perinherls 3 0 40 b0 0 a 0 71 71CoCow 001 annual 04U - Serrvo2R Iarduare 15 15 30 2 2 3 20 20 40

1cguip1ent pactage EoulotAlV/office/CD Ron 3 3 40 43 0 o 4 4 70 74Equi 040 All nIul 00 -O ffice Egaipemnt 19 13 32 1 3 2: 17 42Softvare pac9uale Pacaloots/Rlo tls/CORos lit to 0 378 376 0 s3 I' 0 490 490

Mottsare patlaoe Sermvr2A Sftware I 0 39 36 0 4 4 0 44 44Li.cose annual Server2R Software lic/upgrade 0 13 13 0 1 1 0 17 171hilstngs Z Soread Refurbish faculitilqsl cntrn 51 9 40 S 1 t 40 11 71haildOU 2I oread Facilitin 0 N 0 1 0 1 9 0 8Salaries s/sth 4 Stff r center(l\ n34 79 0 79 I 0 8 104 0 104i'Ooe/rcturr I Spread l-Salary oler costs I3 cntsl So00 0 300 30 0 30 '31 0 331

-~~ ~ ~~ .- .. .: ..... .............

Subtotal anesqmnt eloaent 1129 4204 5335 I 113 421 533 I 1343 5182 652t:~~~~~~~~~~~ _..-.- ---------...... ...... .... _, ... _ . .......... . .. . ......... ___...........

:5. Health Fiwancinq

h1o1 loosnt I S#read Health financing study 450 1050 1500 45 105 130 519 !:" 1732:S/T Fellou s/sooth Health EconosicSInIlurance 1: 0 96 94 0 1O 10 0 11 114tE4aipent packag Office Egipsent 1 1 10 10 0 1 1 I 11 11*EvupOM 0 avual 0C0I- Offlc Eoulouent : 4 2 e 0 0 I 5 3 aCosouter packaqe PC Hlardu Preeiueharais 1 0 5 0 1 I * ,Co&l% I aut OaI - Cospwter lardare 2 2 S 0 0 0 2 2 4

Software eaclt Pc Software I 0 1 o 0 0 0 0 I o

:L.ceess as1l PC SoTae a liceasruuqrage 0 1 1 0 0 0 0 1 1

tshtateil le tAl *1 lsferUt,aufcouotmiaio 436 1144 1622 1 46 117 142 1 527 1352 1171

- 53 - Annr 2Page 5 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

,,S,SSS Sfl3S3asaS33 ;s;.s..,S, 3S3SS SSflStSa =.3SSS8.S.., .,ash * awhts a.w ssz.:a.::zs w. * s * :sssznsawsss wsas.s:..;..;s :s.sssu,.:...

Type Unit Total east Costs Physical Contingencies Escalated Costsof of Ouscriotion of Inputs OtY of ----------------- -------------- ---- ---------------------Input Input Input Local Foroeqn total Local Foreign Total Local Fortign Total

: .... w8 8.w.w,wwwwu.w.wsw...tlst.:ss83uwu3ww3stass-.-..:w RRSSU*E 338***X$S Rw32,-Uasa S*aSUaisagaw.aauw.wsa saaasSa..Ia..BuugUwUa

:0. RESIONAL HEALTH SERVICES

.1. Regional inagesnt*:1................-.- .............................

N ATIONAL PROJECT INPLEKENTATION UIIT

!STlHL Cons s/ooth Prep sestroplan/gudelines/stds 50 240 560 800 24 5 80 285 666 951ILt/HL Cons a/sonth Prolect esqtl4 snorts) 194 1 815 1901 2716 81 190 27J 996 2323 3318LL Consult s/eonth Proj evil/translation 48 16 s8 54 2 4 S 20 48 63ILL Consult s/sonth Coordinator: NPIU 84 28 ab 95 3 7 9 36 84 120LL Consult a/eonth ML Tech: 05 for NPIU 420 95 221 315 9 22 32 120 281 401LL Consult i/sonth LL Tech: 14 for NPIU ' 336 38 88 126 4 9 13 48 11: 160S/T Fellow o/sonth Rasterplan devel/PIU visits 3 0 24 24 0 2 2 0 28 28 1Training s/sooth Consortia devil 150 Darticl 200 480 120 600 46 12 60 554 139 693

ICosputer package PC Hrdurts6S for NPIU 3 0 15 15 0 2 2 0 17 17ICospu O&R annual OAR - Cosputer Hardwart 5 5 9 0 0 1 6 6 121Software package PC Soft:Q3 for NPIU 3 0 4 4 0 0 0 0 4 4License annual PC Sottnar license/upgrade 0 0 0 0 0 2:Equipeont package Office eqp/furn: NPIU 1 I1 10 10 0 1 1 1 IL 11:Equip Oll annual OtR - Office EQuissent 4 2 6 0 0 1 5 3 8Vehicles unit Vehicles: IPIU I 1 19 20 0 2 2 1 22 23IVeh OA annual Oca - Vehicle 7 5 12 1 0 1 9 6 16lRatertils I Spread laterials,supplies:NPIU 50 0 50 5 0 5 65 0 65

CONSORTIA COORDINATION OFFICES IWielskopolski. Pomerania, Ciecnanoel

L Consult istwnth Coordinator: I CCOs 252 08 198 284 9 20 28 108 253 361ILL Consult Vsuonth HL Tech, C5 for 3 CCOs 1260 284 62 943 28 66 95 361 843 1204LL Consult */sonth LL Tech: @4 for 3 CCOs 1008 113 265 378 11 26 38 144 337 481

;S/T Fellow s/eonth Rasterplan devel/PIU visits 9 0 72 72 0 7 7 0 83 831Cosouter package PC Hrdurt:f3 for 3 CCOs 9 0 45 45 0 5 5 0 1 51

ICoopu OCA annual ODi - Cosputer Hardware 14 14 27 1 1 3 18 18 31Software package PC Softt13 for 3 CCOs 9 0 11 11 0 1 1 0 12 12License annual PC Software license/upgrade 0 5 5 0 0 0 0 6 6lEQuopsent package Office eqp/furns 3 CCOs 3 2 29 30 0 3 3 2 32 34Equip OR annual Otl - Office Equipsent I 11 7 L8 I 1 2 14 9 23Vehicles unit Vehicles: 3 CCOs 3 3 57 60 0 6 6 3 65 681

IVfhh OiR a al OAI - Vehicles 22 14 36 2 1 4 28 19 47Raterisls t Spread Raterials,iupplises 3 CCOs 151 0 151 15 0 15 194 0 194

U. - :-- -----

Subtotal Regional Ninagesent 2462 4456 6918 246 446 692 3018 5476 8495: :-… ,...... .… ~ … - :

-54 - Annex 2Page 6 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

s..s.8u..a.h s..8*Ie.2 u.:.w.h.. sshhuu h.nu..u.us............a:

home Unit Total last Costs Phisical Contneqocies EWcalited Costsot at inooun ftv of ---------------- - ---------------- D----- --------o .....------

Inwt lnut 1 Iout Local Forolga total Local Foreiqn total Local Foreign total8531123818818131331838U282*88 1313183wgl$sw$gsgasls$ss hDS hISISIS hh*I8ala$888$SI *SIIIIII*3638338U**II IUI21IUUU8I|aEUIU*

:0. PEIONAL HEALTH SERVICESa .s.ssusfg$sua.......sIshsu..hssZff...aS.*2.t3SiS.a#tS?.......

2 Infrastructure Consolidation (Three Consortial

Wielhol selohi Consortia

*tldind s I Spread Consolid:502 Short-tore care facil 11145 1947 13112 1115 197 1311 14590 2575 MI765hald OAK 7 Soread 041 short-tere care facal 5U1 30 590 54 3 59 746 40 lobtisoquapnt t Spread Consolid:501 Short-tore care equti 478 12874 13554 60 1289 1355 639 16864 17774Eouip 0AN 2 Spread 0: short-tore care equip 1789 1193 2982 179 119 290 2451 1634 4064

ualdings units Upgradte Pris Cae Pract bldgs 117 24tU 439 2925 249 44 293 3237 571 3808ikl 0d11 anual 0O611 Prio Care Pract hiUqs 133 7 140 13 1 14 182 10 191 i1E4ousoa nt package Upgradet Pris Care Pract equip 117 70 1334 1404 7 133 140 92 1742 1833Equip OM annual 0411 Pris Care Pract equip IS4 130 324 19 13 32 266 178 444

ItNI. Cons 2 Soroad Arch/engiterionq services 385 898 1083 38 90 128 499 1165 1844: --....-.. - -- - -- - -- - -:

Subtotal elaiskopolski 17442 10873 36314 1744 1687 3631 22971 24799 47770| -__----_---_------__--_--__---------_ ------ *-- *- -- *--- - -s------ ------- ---- ---------------

Poetrania Consortia-=- - ---------- ^--: ::

:1u1idings 2 Spread Consolid:507 Short-tore care facil 4523 1151 7674 652 115 767 9539 1507 1OO46hPuild 041 2 Soread 01: short-term care focil 329 17 345 33 2 35 448 24 472Eqoinent 2 Spread Consolid:502 Short-tore care tauip 397 7536 7933 40 754 793 520 9883 10403:Equip 0IN 2 Spread 06i11 short-tore care euip 1047 898 1745 lO5 70 175 1434 956 2390Iluildings units Upgrade: Prim Care Pract bldgo 68 1445 255 1700 145 26 170 1675 331 22043uild 01 annual O: Prim Care Pract ldgqs 8O 4 55 a 0 5 1u9 6 1151EQuapment pactage Upgrade: Pris Care Pract euio 68 41 775 816 4 78 8: 5L 1009 1o6lEquip 0O1 annual 0411 Pris Care Pract equip 118 79 197 12 8 :0 181 Loa 1 96ULT/HL Cons 2 Spread Arch/engineering services 225 525 750 :: 52 75 292 681 972

.......... .o- -- o-v--- . -v---*- :- - - - ----- ---------- - --------------------------------------

Subtotal Posorsm 10204 1104l 21245 1020 1104 2124 13432 14502 27434

Citchanag Consortia

hl1oldings 2 Spread Consolidil002 Short-term care ficill 2940 519 3459 294 52 346 3849 679 4528bhild OUI t Spread M: short-term care facil t14O 15e 15 1 14 202 11 213

1E4iuopst t Soread CensolidalOOl Short-totr care euip; 1179 3397 1376 16 340 358 234 44)) 4U6Equip OU1 2 Spread 0611t short-term care uip 1 472 315 787 47 31 79 646 431 1077

lhildings uaite Uoprade: Prio Care Pract bldg 15 sit 56 375 32 6 38 385 48 453hld04 Os1 aual o0: Prig Care Pract ilds 1 31 2 33 3 0 3 41 2 431Eoitusent wackage Upgrades Prim Ciro Pract tUip i 15: 9 171 150 1 17 18 LI 209 220Etw 011 A ual UAt Prio Care Pract qio 43 29 72 4 3 7 s8 39 97

ILTINL Cons I Sptad Srchitnmnoeranq servicn 12 215 307 9 21 31 119 278 S9

Subtotal Ciechtao 14233 4711 n944 423 471 894 5)47 6172 11711

Subtotal Infrastructuro Consolidation 3178 34624 44502 3168 3462 6650 4194t9 45473 17423:--------......-.... --..-.--....-...---... -I----. -…---------- -----------------------------

- 55 - Annex 2Page 7 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

Type Unit Total lase Casts Physical Contingencies Escalated Costsof of Description of Inputs Oty of ------------------ - --------- ---

Input Input Inout Local Foreign Total Local Foreign Total Loctl Foreign Total

:D. RE61ONAL HEALTH SERVICES* ZSIUS,38a363333333au3suaul l .ula3agssga3lgwaaasssssuas

S3. Hospital AID Inforsation/Accounting Iregionall)-… .. _ . ._ _. .... .. ..... ..... .....

WSTHL Cons a/month A/l Act glt/eval/finan audit 40 192 448 U40 I 45 64 239 559 7" 1LL Consult l/month cct mgt/project eval 26 1 39 91 130 4 9 13 46 113 IU:

:S/T Fellow o/month AID, kcct anagment 261 0 204 204 0 20 20 0 247 241!Training n/month AID, Acct menagement 46 I 114 29 143 11 3 14 139 35 173 Computer package Regions Coop Hard/Software 22 0 28 28 0 3 3 0 33 33 Conou at" dnual Region Computer system OA 0 7 1 14 1 1 1 9 9 1 9 1.Computer pickaqe Voivodt Como Hard/Software 10 0 470 470 0 47 47 0 570 570ICoeou O1R annual Voavod Computer system 0ill 99 99 197 10 10 20 132 132 264Computer package Sall Hosp: Coop Hard/Softatre 3: 0 1768 1766 0 177 177 0 2160 2160

*CaNpu OU annual Sol/Hasp Cooputer system 0U1 356 356 712 34 36 71 478 478 955IComputer package Redium Hasp: Coop Hard/Softuare 21 0 149l 1491 0 149 149 0 1620 16201

*Cooou Oa" annual Ned/Hoso Computer system 011 302 302 404 30 30 60 405 405 610Computer package Pilot Lrge HaspComp Hard/Software I1 0 84 84 0 s a 0 95 95

*Coopu OAR annual Pilot Lrg Hosps Coop syst OAR 25 :5 50 3 3 5 33 33 A5lComputer packIge Large Hasp: Camp Hard/Software l8 0 1512 1512 0 151 151 0 1845 1645

.Cooou OAR annual Lrg/Hoso Commuter systes OAR 0 307 307 613 31 31 a1 411 411 822:Software package Regaon:Iaoko/Tmch journals l8 0 43 43 0 4 4 0 16 56Software package Voivod:Iooks/Tech journals 32 0 115 115 0 12 12 0 146 1461Software package Smll HNpslooks/Tech journals 115 0 230 230 0 23 23 0 291 2911Software package Red Hospilooks/Tmch journals 721 0 144 144 0 14 14 0 162 182Software package Large Hosp:Iooks/Tech journals 60 0 150 180 0 to le 0 227 227Salaries o/month Regional staff 1728 346 0 34I 35 0 35 0 0 0SalAries i/month Vaivod staff 3121 62 0 62 6 0 4 0 0 0Salaries el/onth Staff: Sall hospital 1152 1 230 0 230 23 0 23 0 0 0Salarles i/month Staff: Redium holsptal 1 720 1 144 0 144 14 0 14 0 0 0Salaries c/sonth Staff: Large hospital 1176 235 0 23S 24 0 24 0 0 0

........ . . ..... .... ..... ..... ...... .. -

Subtotal Hospital A/0 Inforeation/Accounting 2458 7932 10390 246 793 1039 1894 9846 11740 I:~~ ~~ ~ ~ ~~~~~~~~~~~ . .--. -.- .-- ..---:---- -.-- ....... -.-.-.

- 56- Annx 2Page 8 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Detailed Project Cost Estimates (US$'000)

, ............................................................ ..................................................................... 2

Type Unit Total lls Costs Physical Contigtaces Escalated Costsof of Qscriotion of Inouts Mty of --.------------------- *- -------- --------.-------------.

Input Inwut tnlout Local Foreign Totai Local foroign Total Local Foreign Total

O0. OIIIWIAL WALTH ItlVICES: .-stoggsta s .............. ssa*s*aa. .. a,

:4. Pharmaceutical Noitorusq Irigionall:,,,,,,,,,................. ........ . .. . .. .. _ . .. .

:STINL Cons o/simth krq RAqI/goUontMal I 36 112 426 606 1 43 it 229 533 762ILL Cuuslt o/euth Srq ReIul/oot/oevl 2 29 10 23 33 1 2 3 12 29 41:SIT Folleo slth ir" matetrianq 0477 0 372 372 0 37 37 0 452 452:ITromaiml o/eth Ing oitorirq 4 4I 114 29 143 11 3 14 139 35 1735Cooputer pochaq* t opIsi Cp Hard/Softear : 3 0 42 42 0 4 4 0 49 491CoHo Ol aual RI qso. Coepoter sosteo 01 I 11 11 21 1 1 2 14 14 2S:Coaputer package Vosvods Coop HardiSoftuare 10: 0 141 141 0 14 14 0 il 171i:Co.w 011 annual Voivod Cosgater systu 0iH 30 30 59 5 3 6 40 40 79Cowuter ckage Suall teosp Cuo Hard/Softuare 1 3 0 323 323 0 32 32 0 395 39CoMo 0611 aual Sol/Nosv Coobetr syst 0611 N65 65 130 7 7 Is 67 67 174

tCodouter pkate Pilot NWd nosteCo Hard/Softwaro 21 0 17 17 0 2 2 0 19 It:Coo Wl aU N ull pilot dN Hlop: Cooostsst 0 I 5 5 10 I I 1 7 7 13Cospoter package digu Hps: Coop Hard/feftoaro 21: 0 179 179 0 16 16 0 218 216Coso 011 annual Ile/Hoeo Coowtur sto. 061H 36 36 72 4 4 7 46 46 97

:C0ooutar bachage Pilot Lrqo hosoiCoao Nard/Softuro I 0 13 1I 0 1 1 0 14 14:Coou 061 annual Pilot Lrq H9sp: Coop system 0ih 4 4 8 0 0 1 5 5 10ICoasator packaqo Large Hopot Coop Hard/Softwoar l1 0 227 227 0 23 23 0 277 277Coou 0U6 mual Lrq/Hovo Cospotor systOs 0UI 46 46 92 5 5 9 62 62 123Equioannt packagq Office 14p: Ro"Ionl OffiCe : 3 2 29 s0 0 3 3 2 34 i5:EQUiP 011 Annual 0ih - office Equipnont 9 6 IS I 1 2 12 S 20Softuare packago ReplonoBsoo/Toch journals It 0 106 106 0 11 11 0 140 140Softor. paokagqo veoivod:ookslTlch journals 32 0 192 192 0 19 19 0 243 243Softoaro package Stall bosp:books/Tech journals 115 S 1 S 115 0 12 12 0 145 145Soeftsar. package 11d Hostpoks/Tech journals 74 0 74 74 0 1 7 0 93 95:Software oachge Large Ho spokhs/Toch ournals 60 0 150 150 0 15 15 0 169 159Salaris o/senth Rgional staff I 64 17 0 17 2 0 2 924 0 924Salaries V enth ivoaed staff 744 L49 0 149 15 0 1 0 0 0

Suthotal Phareacootical Oonitort ng Irogionall 167 2659 35 6S 266 334 1560 3307 4667:~~~~~~~~~~~~~~~~~~~~~~~~ .:... .. . ..........

:5. NatetraIs/tochnoloy anagoennt

:StItL Cons e/ath Equioltochno/atls sanagot 12 5 134 192 0 13 19 70 163 234LL Consvlt o/aati Eqgiptochno/outlos eanagoot 66 22 52 74 2 5 7 27 63 91

t/t Follow sle th Stoh tnuro 1041sEgpoatlo got 3 0 266 266 0 29 29 0 350 350:Training m q proad Rater7als/loch oegt 12 3 15 I 0 2 15 4 I1ICoutor wackae Sorver2bl@ pilot hoe ctnter Il 0 220 220 0 22 22 0 249 249Coom 0i1 aual 01 - Cooptor Haretaro 66 66 132 7 7 13 86 S 6 171

1CoHWer pk4ag PC h rdare: (10 lilot hospl 10 0 50 50 0 5 S 0 57 57iCooO UN aUI ual 0IN Ce torHNvduaro 1 is 30 2 2 3 19 19 391ICoutor pckaqe PC Hardw/Pfrill IS0 hop) *0 0 40 400 0 40 40 0 40 4W:CHoan a nAal 0O - Coutr Harduare i i 0 90 1t0 9 9 Is 120 120 240

ivoicloo package ltatuco n ebictloo 110 hosol 10 20 360 400 2 36 40 23 430 453Movop 0M ana 01 Na*latosance ehileis 1144 96 240 14 10 24 167 125 311Equagant pckage Officef guapont 4 2 36 40 0 4 4 2 43 41EQip 0111 aD n ual 0611 C - Offic E nposHt I14 10 24 1 1 2 19 12 31Softuare packag E uipsant uaqot 0ftuno 91: 0 137 137 0 14 14 0 163 163

!License amal Software lc"uco./ugradf 0 45 45 0 4 4 0 59 5tSoftoaru pCacage 1atoerials saagot eoftare SI 0 12 12 0 1 1 O LS ISLicnsu annal Softuare licnseopgra e 1 0 3 3 0 0 0 0 4 4Software package PC Sefttare 91 0 109 109 0 11 11 0 130 130Licenue a"uAl PC Softvar. lIcoatulograedo 0 34 36 0 4 4 0 47 47saftre r ckage g ooks/Tech journals 77 0 770 770 0 77 77 0 91 9681i

i - -- - -: : -4-- --I9-4--0------:letotal hatofsals/Tschlogy baaoet UJ144 2954 3397 44 295 340 503 3601 4I16

-57- Annex 3

Page I of 2

POLAND

Implementation Arrangements forHEALTH SERVICES DEVELOPMENT PROJECT

(Proposed for World Bank Support)

REGIONAL

supervisorySupervisor Supevisory Board of

Board ot Bpoard o

CIECHANOW POMERANIA WIELKO-CONSORTIUM CONSORTIUM CONSORTIUM

Consortla Consortia ConsoaCoordination Coordinatlon Coordination

Office Office Office

* COMMITTEES * COMMITTEES * COMMITTEES

* TASK FORCES * TASK FORCES * TASK FORCES

NATIONAL tMINISTRY OF HEALTH

NATIONAL PROJECT IMPLEMENTATIONUNIT

* NATIONAL CONSORTIADEVELOPMENT GROUP

* PROJECT TASK FORCES

* STEERING COMMITTEES

* M.O.H. INSTITUTESAND LINE DEPARTMENTS

sads\w50391 a

Annex 3- 58 - Chart 1

Page I of 2

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

STAFF APPRAISAL REPORT

Programs Technical Assistance Reguirements

Policy SettingPart of the Project Responsible Line Monitoring Implumenting Agencies

Department of MDR Reviowing Progrem

Part A. Dept. of Public Health Steering Comomittee for HP Regional BP UnitsHealth Promotion (HP) School of PH Krakow

Nat. Inst. of HygioneDept. of Health Policy National Board for HP Nat. Inst. of Occupt. Mod.

Inst. of CardioLogy

Pert B. Dept. of Research and Steering Committee for PC Training Centres associatedPrimary Care (PC) Higher Education with:

- Pomerania regionDept. of Health Policy National Board for PC - Wielkopolski region

Core - Ciechanow region

Part Cl. Dept. of Health Policy Steering Committee for Rogional Health Care Inst.Admission/ Info. System - A/D MDSDischarge MDS

----------------------- ---------------------- ------------------------- -------------------------- ~~~~~~--------------------- 1

Accounting Dept. of Economics Steering Commitee for Regional Health Care Inst.Arcounting

Part C2. Dept. of Pharmacy Steering Comittee for Regional Health Care Inst.Phamon utical Pharncoutical MoitoringMonitoring and ---------------------- ------------------------- --------------------------Drug Registration Dept. of Pharmaey Drug Registration Drug Institute

Cciittee

Part C3. Budgeting Dept. of Economics Steering Co itco for Ministry of Health______________________ Budget PlanningDept. of Investment

Part C4. Dept. of Research end Steering Comittee for Academic Centres in:Management Development Higher Education Management Devolopment - Wroclaw

- Lodz- Warsaw- Krakow

Part C5. Dopartment of Research Health Finaneing Task Institute of Labor andHealth Financing and Higher Education Force Social Affairs

Pert D. Ministry of HealthConsortia - Legal Department Consortia Dav. Group Consortia Coordination

- Policy Department Office- Economic______________________t pa tment

- 59 - Annex 4Page 1 of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Technical Assistance Summary by Project Component

- - -- -- -- -- - - -- - - -- -- - --- - -- -- - ---- -- - -- - --- --- -- --- - -- -- -- -- : … - -- -- ---- - .….

Role Schedule of Availability/ActivitvFIELD OF EIFERTISE of ------ -- ------- --- ------ REMARKS finn-

I I Exoert Cu1992 CY199 :CY9"41CY199S C096:CYI",7:C0199":TOTAL I cier

TOTAL TECHNICAL ASSISTANCE REOUIREMENTS (staft-sonthsl )wafssflhSeSfl*3*3S*SZSfSStS ES flZflSfl"

Soecialist Services I1225.5 :414.0 1315.5 :231.0 90.0 35.0 41.0 1352.01

t per Year as I of total I 16.7%: 30.63: 23.331 17.11 6.7V: 2.61U 3.01S 100.01of shich IERD financed 1188.0 362.5 N85.3 1210.0 190.0 35.0 41.0 11232.0 I 11DRof which EC financed 37.5 13.5 30.0 21.0 : 120.0 EC

Ftllowshios/Studv ToursI ----------------- :3c6.0 :717.0 1691.5 1491.0 1157.0 21.0 12443.5

per year as I of total I1.0: 29.331 28.31% 20.1S1 6.431 0.921 .100.011 of which IERO financed 150.0 1421.0 1493.0 1366.0 :157.0 21.0 . 11608.0 : IPRDof which EC financed :21.0 29b.0 19 .5 15.0 835.5 EC

I HEALTH PRONOItON1

Consultant/Soecialist Services:

I Inforsation technolo;v assessment Lead solst: 1.0 1 .0 IEFD2 Health curriculus develooment/evaluation Lead solst 3.0 9.0 2.0 2.0 1.0 1.0 1 .0 19.0 110D3 Halth Prosotion orooras eviluation :Lead solst: 2.0 2.0 1.0 1.0 ! 1.0 7.0 1ISRO4 Health Prosotion oroqras evaluation :Assoc .0 12 .0 12.0 12.0 2.0 2.0 2.0 45.0 1 6RD5* Oraniation of annual HP orkishoos :Lead solst 1.0 1.0 1 0 1 1.0 1 0 1.0 1 .0 7.0 1IRO6Occuoational medicine :Lead slist : 1.3 1.3 15 soecialists I1RO7 teveloo Occupational health safety frasework :Leid salst: 6.3 16.3 2 soecialists I102S Develon Occupational health safety framelwork Assoc 3.0 3.0 :2 soecialists IERO9 Develop inspection/enforcesent standards/frasewori :Lead solst: 2.0 2.0 :2 soec;ilists IE1D

1 10 Develoo instection/enforcement standards/framework Assoc o6.0 6.0 o 4 soecialists 180O11 Industrial sector health safety *Lead solst: 1.0I 4.0 5.014 soectilists I 1kD

: 12 Industrial sector health safety 'Assoc 1.0 4.0 5.0 R 1U013 Identify personnel availab!iity/preo training preorams Lead solstl 4. 4.0 8.0 16RO

Subtotal Consultant Services 27.0 43.5 16.0 15.0 5.0 4.0 5.0 111.5 5

Felloeishoos/Studv Tours:

tI Helth curriculum develoosent/evaluation :Foreign 3.0 6.0 3.0 12.0 1BR11 2 letric HP progroas .Fortign 12.0 20.0 20.01 20.0 20.0 92.0 146 oarticioants ' 16RDI ISc Public Health/Health Promotion Foreign 24.0 1100.0 148.0 126.0 42.0 O440.0 20 candidates IERD:4 Health Promotion media training :Foreiqn 1 4.0 20.0 34.0 24.0 6.0 R880 14 particisonts I 0iRD: 5Study tour:Health Promotion programs 'Foreinn t 6.0 6.0 16 university staff IIRD: 6Study tour:planning/management/eval occupational healthWForeign 5.0 5.0 IERD

Subtotal Fellowships/Study tours 54.0 1146.0 1202.0 1173.0 68.0 643.0

- 60 -Annex 4Page 2 of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Technical Assistance Summary by Project Component

------------------ --- ----- ------------------ ------- - ------- ---...

Role Schedule of AvailabilitviActivitvFIELD OF EXPERTISE of i------i ----- a----- --- - ---- -- - REMARKS lFinan-1

I Excert 1CY19921CY1993:CY1994:CY1995:CY1996:CY19971C11998:TOTAL : cier:-- ----- -- ----- -*------------:-------:-----:---- :-- -: ---: .--:-- :------:- --- --:-:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..* … I--- - --- -- - .. ~.,

12PRIMARY HEALTH CARE I : 1 I :

: Consultant/Soecialist Services: . : : : : : : :- -- -------- - - - -

I Establishent of National Exec BArd for PHC Lead solst 2.0 0.5 0.5 3.0 IIRD: 2 Primary Care Practices curriculus develoosent/training Lead splst? 3.0 12.0 3.0 1 5 1.0 1.0 20.0 IIRD:

3 Nurse/Primary Care Practices (PCP) expert Lead solsti 1.0 2.0 1 i 1 3.0 13RD04 PC technology assessment Lead solst 2 2.00 138RD5 PCP Finance !Ltid solstl 1.0 . 1.0: IIRD

I 6PCP oractice eanaqement :Lead solstl ;.5 1.5 IIRD7 PCP Training Soecialist Lead solsti 2.0 12,0 1.0 1.0 i 1.0 7.0 1 18RD8 lnoower planning Lead solst: 1.0 i 11.0 Deoloyment of nurs, 18RD9 Prisary Health Care (PHCI Nurse/educator Lead splst: 3.0 3.0 1IRO

10 PHC curriculum develooont/training Lead solst 1.0 3.0 4.0 18RD11 Development of Acadesic Units Lead solst 6.0 6.0 2 0 18.0 EC12 Assesseent of Practice needs Lead solst 2.0I 2.0 2.0 6.0 : EC13 Tendering Procedures (EC Procedures) Lead solst: 1.0 11.0 1 0 5 3 EC14 Assessment of Training needs Lead solst 2 2.0 2.01 EC115 Develop AHP team :Lead solst 3.0 3.0 3.0 3.0 1 12.0 EC16 Finalize PhC Program Budget !Lead solist 0.5 0.5 EC17 EC HP Program Administrator :Lead solst 12.0 12.0 12.0 12.0 48.0 EC

118 Management Soecialist Lead solst? 6.0 3.0 3.0 3.0 15.0: EC119 Mid-term EC Project review !Lead sIst t 1.51 1.51 EC20 EC Project evaluation !Lead solst. 3.0 2 3.0 EC21 budgetarv Policy review !Lead splst: 2.0 1 1 2.0 IEC:22 Architect/engineering design/spn of PCP facilities Lead sDlst: 3.0 3.0 3.0 3.0 3.0 3.0 3.0 21.0 In 3 Project Consortia I18R

123 Architect/engineering design/son of EC-financed PCPs ILead solstc 3.0 3.0 3.0 9.0 Outside of 3 Consortia EC:24 PCP project evaluation Leiad solst 1 0 : 1.0 1.0 3.0 1 8RD

125 PHC project evaluation Lead solst2 1 .0 I I 1.0 : 1.0 3.0 1 8R

I Subtotal Consultant Sorvicmn 152.0 60.0 38.5 25.01 7.0 3.0 7.0 192.5 I: :~~~~~~~~~~~~~~~~~~--------- ----- :--:------: - -:-:-------:-- -- -.-

Fellovships/Study Tours; I. .. __ .. ~~__.~_ ........... : : : : : : :

: I Study toursolanning national training organizations foreign 13.0 1 3.0 IMD:R12 Study tour:observe PKC curriculum training methods Foreign : 2.0 3.0 :0 5.0: IIRD:

3 Study ToursObserv PONS curriculua/training ;Foreign Z 2.0 2.01 1 EC: 4 Study tour:practice management, finance, facilities :Foreign 2.0 3.0 : : 5.0 t 1 38RDII5 Fellovships:Trainee Primary Care doctors Foreign 1 1100.0 110.0 0: : 1 200.0 2100 PHC doctors I DRD 1I 6 Fllocuships:PHC trainors Foreign 30.0 : 30.0 1 1 1 160.0 110 traunors liROD : 7 Study Tour:Practice principals :Foreion 1 1100.0 .1 5.0 :1 5.0i I 2110.0 EC:

8 Study Tour0Practice Managesent,Finance !Foreign 2.0: 1 : : 2.0 I ECII 9 Fellomsbipsiledlcal Acdemy staff foreign 36.0 16.0 36.0 : 1108.0 -onth courses IEC I

I10 Study Tour:Analvtical servicn :Foreiqn 1.0 1.0 0.5 : 2.5 IEC II 11Study Tour:udgetary Policy review :Foreign 2.0 I 2.0 13 candidates n EC:112 Study ToursConference, pro-post graduate educ lForeign : 3.0 3.01 3.01 3.0 : 12.0 'for core lecturing teams I EC:I13 Study Tour;Health Care planning foreign 15.0 6.0 6.0 6.0 1 I 33.0 I ECi114 Study Tour:Conftrtnce, Undergraduate training foreign 1.0 1.0 11.0 1.0 : 1 4.0 EC: l115 Study Tour:Hoelth Care anageteotninforeation systems foreign 1.0 : 1.0 ECI

16 Study Tour:Conference, estAblish EACESHCNC ctivities :Foreign 1.0 1.0 1.0 : : 3.0 I EC II17 Study Tour:Hoalth Care Organizations IForeign 2.0 12.0 : : 4.0 I EC:

18 Fellowships:MIa Management Developmtnt !Foreign 36.0 136.0 36.0 27.0 S135.0 15 fellowshios IEC19 FellowshipsPhD Managesent Development lForeign 10B.0 1101.0 1108.0: 81.0 405.0 015 felloeshios I EC:

220 Fellowships:short-term course, Management Develoosent !Foreign 2.0 2.0 2.0 2.0 8.0 I EC:I21 Fellowships:Curriculus Development foreign 2.0 ,2.0 IEC 22 Fellowshies:Continuing Education fornion 2.0 2 2.0 : ECI

Subtotal Fellowshios/Study tours I 253.0 2432.0 1298.5 :125.0 : 1108.5 2 *- __-- __.__- .…- ---------------: --- --

- 61- .Page 3of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT'

Technical Assistance Summary by Project Component

-- - ------- - ---------- ---…------.---------

Role Schedule of Avaiiabilitv/Activitv IFIELD OF EXPERTISE of i-- : IREMARKS Finan-l

*Excert :CY1992:CY1993:CY1994:CY1995:CY1996:CY1997:CY1998:TOTAL I 1 cuor… ----------------.------ … --- … …~~~~--- - ---- ---

I3HEALTHNMANAGE.'.ENT: I

3A HOSPITAL ADlIISSION/OtSCHARSE INFORMATION J ACCOUNTING :1 I iI

I ConsultantlSaecialjst Services;

II edical records librarian hLeid solst! 4.0 1.2.0 11.0 :1.0 1.01 i 9.01 13RD2 Medical CarulEoidesiology :Lead solstl 2.0 3.01 3.0 :1.0 L .0 1 110.0: INRD 3AdsissionslOuschargm Info, Accounting Management !Lead solst. 0.5 27.0 30.0 17.0 i a 4.5 JI3RO

14 Admission/Discharge Info, Accounting Management !Assoc 10.5 12.0 112.01 8.0 1 32.5 I (RD5 Project evaluation :Lead solst: L .0 11.0 1 1.01 1.0 a s 4.0: I IRD 16 Educationial Progras design !Lead sp1st: 1.0 : l.0 1.0 I 1 01 1 3.01 1(3D

1 7Educational Program design :Assoc :12.0 112.0 :12.0 : i 36.0i (3RD:8 Financial Auditor :Lead solst: 1.01 1.0: 1.0 :1.0: 1.01 1.0: 1.0: 7.0: IDAD 9 Project evaluation !Assoc 1 I3.0 3.0 1 3.0: 3.0 3.0: 3.01 18.0 I 1(RD:

a… ~ ~ ------- ,---------~---- ------- …

Subtotal Consultant Services 1 21.0 62.0 64.0 :32.0: i.0 4.0 I4.01 194.0:

1 FmllOmShLos/Study Tours: a a a aa a a

L 1Accounting Management :FortLon 1 14.0 14.0 :3.0: i 1 11.01 :I3RD

Subtotal Fellowshios/'Study tours 1 4.0: 4.0: 3.0: 11.0:

138 PHARMtACEUTICAL MONITORING AND QUALITY CONTROL 1 1 1 1 . . ..---- ---- -- - --- --

1 Consultant/Soecielist Services: , , aa

1 1Drug Requlation/ftana9gemnt 'Lead solst: 1.0 :20.0:20.0 :12.0 : 3.0 1 jRD I2 Drug RegulationlllAfagement :Assoc L .0: 15.0:15.0: 7.0: 38.0i logRDoI3 Project evaluation !Lead solst! L .o: 1.0: . 1.0 : :0 4.0: (3RD14 Project evaluation :Assoc : 13.0 :3.0: 3.0: 3.0 1 1 1 12.01 IIDA1 5Translation setrvices !Lead smlst: 3.0 13.0 13.0 I 1 9.0 : 1(RD

Subtotal Local Consultant Services :14.0 122.0 22.0:11.0 4.0: I 63.0 i

1 Fellowships/Study Tours: 1 1 1 1 1 I 1 11 1

SIDrug monitoring I'Fortion .1 0.51I4.0: 4.0: 2.0: 1 i 10.5: I(3RD I

SabtotAl Fellowshiao/Study tours 0 .5 : 4.0 14.0 :2.0 : r 110.5:1 1

3C OUDSETIN6

1 Consultanit/Soecialist Services: : a a aa1 1

L IResource Allocation :Lead solst: 4.0: 2.0 12.01 2.0: 2.0 1 1 12.01 IN3DI 2Project Evaluation :Lead $Dist: I 3.0 1 : 3.0 1 1 1 6.0 :I (RD

3 Project Evaluation :Assoc 1 13.0 1 10 11.0 3.0 1 .0 IN1(3D 1

Susbtotal Consultant Services 1 14.0 9.01 3.0 13.0: 6.0: 26.0 1I

I FellowshioslStudy Tours: a aa a; 1 .I

I Study tour:observe resource allocation processes :Fareion 13.5 11.0 11.0 11.0 1 1.0 I : : 7.5 : (RD

----- ---- ------ ........~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~:---:---::

Annex A- 62 - Page 4 of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Technical Assistance Summary by Project Component

Role I Schedule of AvailabilitylActivitv t* FIELD Of EXPERTISE of ---- -------- 1 …- --- - -- --- RENARKS Finan-1I I Excert 1CY19"2CY19931CYI"41Y19951CYI996CY1997CY1998IT0TAL I cier I

1 3D NAHANEMENT DEVELOPMENT I i I I I II .. . a. _ 1 1.. : : : : 1. '1 t Consultant/Soecialist Services: I I I

---------------------- : : : * : : a a I a a a II IInstitutional develooment Lead solstl 2.0 1.0 1.0 : I 4.0 1 IBRD:1 2 Institutional development :Assoc I 3.0 3.0 3.0 9'0 I 90 : 1SRD1 3 Comouter prograssing ILead splstl 1.0 3.0 1 1 4.0: 1131O"

: 4 Establish syster of pre/post-graduate education Lead spIstl 3.0 6.0 6.0 3.0 , I : 310RI5 Establish system of prelpost-graduate education :Assoc : 6.0 12.0 12.0 112.0 6 0 i 48.0 1 1 :

16 Curriculum development- prelpost-graduste education Lead spist. 6.0 112.0 12.0 I6.0 2.0 : 1 38.O IDRD1 7 Currsculun development- pre/post-graduate education 'Assoc i6.0 i12 0 12.0 112.0 60 1 1 48.0 0: 130RD

8 Curr:culuo develoosent- continuing education Lead splstl 6.0 12.0 6.0 124.0 : IBIDIR9 Curriculun develoooent- continuing education !Assoc 6.0 12.0 112.0 6.0 3.0 1 39.0 : tDRD

10 Project evaluation Lead splst: 1.0 1.0 2.0 1.01 1.0 1.0 7.0 IBRD11 Project evaluation :Assoc 12.01 2.0 2.0 2.0 8.0 IBRD i12 HCID inforeation network development lead solst: 1.0 1 .0 1 .0 i3.0 IRD

:13 Translation nervices Ilad solst: 2.0 3.0 3.0 8.0 [ORD 1: a ------- :----, ---- : 1-----: --- -- a-- a- ---- ---- a-------:--

Subtotal Consultant Services 1 142.0 80.0 70.0 44.0 20.01 1.0 1.0 25R.0

I Fellowtships/Studv Tours: a

I Fllowshios: long-term courses, Bia :Foreign : 8.0 36.0 62.0 57.0 21.0 : 1 14.0 IIPN8 candidates IRD: 2 Fellowshios: long-term courses, PhD :foreign 8.0 136.0 72.0 86.0 57.0 121.0 1280.0 19 PhD candidates IBRD i

3 MCII continuing education Foreign 3.0 3.0 3.0 3.0 : 12.0 11PD 14 Study tour:inst:tutional dnvelooment !Foreigon 11.0 1.0 1.0 1.0 4.0 Ua RD 15 Study tour:Establish system of pre/oost-grad education lForeign i3.0 9.0 19.0 9.0 30.0 IDRD

1 6 Study tour:Curriculun developmt/undergraduate training foreign 13.0 3.0 3.0 3.0 1 1 12.0 a IPRDI7 Estab joint EACE CIID activities Foreign 1 3.0 3.0 3.0 t9.0 IBR3

a :-----:- ----- :----1--:------1-- ----- a - - -- - --a- -Subtotal Fellowshios/Study tours 1 129.0 1 91.0 1153.0 159.0 1 O 21.0 531.0 : a

3E HEALTH FINANCINa

I ConsultantlSocialist Services: I a : :g __......... __ _ a a a : : : a : a:

I Health financing study Ilad solstl : se-sus Contanct I 10a I

: Subtotal ConsulUnt Sntvicn : I

I Fellowships/Studv Tourst: : : a a I :

I Health economics Foreign 1 2.0 1.0: 1.0: 1.01 1.0 I 6.0 1 I ID I2 Health insurance Foreign 1 2.0 1.0: 1.0 1.0 : 1.01 : 6.0 l13 D

I Subtotal Fellooshios/Study tours : 1 4.0: 2.0 2.0 2.0 1 2.0: 12.0a

I ~~~~~~~~~~~~~~~Annex 4_-63 - Page 5 of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Technical Assistance Summary by Project Component

- .-- -- ---------- -. -. --------... _.--- .-.- -.. -_-1-,- ,:, .. :........ .. _ . _._._ ....... ....... -... __ -.. - ----------- - - ---....... ............... _._.. . ............. _

1 Role 2 Schedule of Avaiiablitv/ACt1Vitv I

FIELD OF EIPERTISE of - -- ----* -- --------- ------ 2EIIRI-S IFin-R: * Ezeert CY199: CY1932C51994 :CY1945: CY199t CY19972 CY1 99TOTAL 2 cier

4 REGIONAL HEALTH SERVICES II

14A/D REIOAL. MANANEMENT i INFRASTRUCTURE CONSOLIDATION 1 a I a

: Caultant/Soecialist Services: 2 2 a a

I I Projetct Nenoesmnt Lead solit 32.0 248.0: 4.0 0 4E.0 I .0 6.0 L. 6.0 194.0 24 PoSts (natl A 3 conshor) 1312 2 Develop Consortia santur/operations plans Lead nplst 2.0 1 a 2.0 IDI 3 Devlop Consortia consolination plan Lead solst 12.0 19.0 50.0 tfor 3 consortia IB3RD

4 Deloo architectural/onginterinq design standards 3Led solst2 S .0 0 3a0 : 2 9a0 Ifor 3 consorti II3RD5 Arch/Enoineering desipn/suoervis±on aLoid solst: a a 0.0 3 Luoo-sue contracts 3R0 2

: £ Project evaluation Lead splst 2.0 1.0 2.0 1.0 2 1.02 2.0 2 9.0 I2RD 27 Project Evaluation Lead selst: 6.0 6.0 6.0 6.0 6.0 6.0 2 36.0 I0

I I Translation services Lead solst 6.0 6.0 1 12.02 131D

I S-ubtotal Consultint Services $550 B5 80 1550 59.0 13.0 13.0 14.0 292.0 : :--------:-----:----- :----:------:-----'------:-----:------------- --------- ~-w--

FillcZvshios/Stuev Tours: 0.0:: v------------ : : : : : : : : : ~~~~~~~~~~~~~~~0.0:

Iftlsterolan dveSolrccnt :Forciqn t, 0 4.0 1, fcillcshios :IJRD2 Study tour; Tramzg visits to PlUs Foreign 4.0 4.0 B o. liRD

Subt'otal Fellorsh:opstStudv tours IB.0 4.0 0.0 0.0 0.0 0.0 a .o: 12.01

:~ ~ ~ ~~~~~~~~~~~~~~~..... -==--------- --- - ----------- - ---- - ---:------------:-----------

Consultant/Sootialist Services: : -------------- : : : : : : : : : ~~~ ~ ~ ~ ~~~~~~~~0.0:

I Adeistions/Disenargo Inforsation. Accounting n nagesent Load solst: 1.0 7.0 7.0 5.0 20.0 I1 candidate/consortia [BAJD:2 Adsisslons/Discharqs Intors^tion, Accounting Hnagoqnent.Assoc :1.5 4.5 5 0 5 0 I12.0 IEh

3Projectv*luston s1.0 1.0 1.0 I O 1.0 1.0 t,.0 I candidate/consorti IDRD:4 Project evaluation !Assoc : 0 0: .0 5.0 5 0 1.0 1.0 14.0 :IM0O

I5SFinancisl Auditor :Lsed solst: 2.0 2.0 I2.0 2.0 2.0 2.0 12,0 14.0 I1 candidate/consortia IIBRD

: ~ Subtotal Consultmt Serices 4 5 17a 5 16.0 14.0 6.0 4.0 4.0 I a,Y.0 a :t : ---- : ---- : : *---: ----- :----:~~~~~~~~~~~~~~--- -- ------ :---:----------:

: Fellonfhios/Study Tours: ° °: ---------- : : : : : : ' : : : ~~~~~~ ~~~~~~~~~0.0:

:IIkteu,tinge r.^.# 6,t :Foreion 11.5 9.0 9.0: 60 1:25.5 0

I Subtotal FtlloenhiesfStudy tours 1.5 9.0 9.0 * 0: 0.0 0.0 0.0 25.5: :: - -- ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~---- - :----- ----- ----- -- --- :-----::

Annex 4- 64 - Page 6 of 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Technical Assistance Summary by Project Component

z ____. _ __ " __ _ _ _ _ ........... . .......................... -- - ------ - ._ -................................................ .. ---- . ---------- - ----------------- _ - - ------Role Schedule of Availabilitv/Activitv

FIELD OF EXPERTISE of -------------- - ------ ----- REMARKS finan-IExcrt 2CY1992CCY193:CY199q4CY1Y95 CY1996CYIS972C9 98iTOTAL citr

:-- ------------ --- ___:__ __--:-----:------:-- -- : : ,- :---~~~--:------:-----: :

1 40 PFMRMACEUTICAL MONITORING AND QUALITY CONTROL 0.0t -----.--------------- 0 0 A

I Coeultant/Soecialist Services: -a 0.0I : : a a : a a : 0.0:

I I a Rgulationilaeaqeent Lead slit: 1.0 27.0 17.0 5.0 20.0 : 11301 2 Orq R"ulation/Ranaqnent lAssoc 11.0 .0 4.0 3.0 : 11.0 3 soecialists : IIRO

3 Project evaluation :Lnd sust 23.0 3.0 3 0 0 30 L 3.0 18.0 : lRO1 4 Project evaluation 'Assoc 30 3.0 3.0 30 3.0 3.0 18.0 23 soecialists IIRO

a .Subtotal Consulta nt Services 2 .0 16.0 17.0 14.0 6.0 6.0 .0 67. 0: a- ---, -- :- :- -- -- ------.-- a--- -

Fellowshios/Study Tours: a 0.0: ------- : : : : : W : : : ~~~~~~ ~~~~~~~~~~~~0.0:

: Orugq Monitoring IFortion 15 16.0 17.0 12.0 46.5 220 oarticiulconsor: :~~~~~~~~~~~~~~~~~----------: .----- -.- -: -:- :--:------:- - ---:---- --- -

Subtotsl Fellowshims/Studv tours 1.5 16.0 17.0 12.0 0.0 0.0 0.0 46.5 5

24E TECHNCL06Y/NATERIALS fAA6E.MENT aO .2_.---------- _ _ a___ : a a a o: a:a 0.0

: tonsultant/Soec.alist Services: a aa

,_ - - - ------ - - -- -- -a-- - ---- 0.0

I Eouioeent/Technoloqy eanaoeent Ledd solst; L 0 2.0 1.0 1 . 1.0 6.0 19RO2 Euipsent/Technoloy oanaaeeent Asscc 6.0 9.0 6.0 6.0 6.0 33.0 IIRO3 Naterials enaqesent- 'Lead solst: 1.0 2.0 1.0 1.0 1.0 i 6.0 IIRO4 MNaterials eananaeent :Assoc 6.0 9.0 6.0 6.0 6.0 33.0 IIRD

a a : : : : : … : - a a: - : -

Subtotal Consultant Services 4.0 2:2.0 14.0 14.0 14.0 0.0 0.0 78.0 : :-----:--: : -: : -- ,-- - ,~~~~~~~~~~~~~~~~~~~~-- : - ---: ----- ----

Fellovshios/Studv Tours; 0 0:~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~ ~ ~ ~~ a- - a a a a a : : a.:

I IStudv-tour:Translate Tech/latis Maiagqtent Sottsare iForein 3.0 1.0 4.0 2 RO192 2 Study-tour; Equimeent Nanaqement :Foreign 4,0 4.0 4.0 4.0 16.0 I2RO

3 Study-tour: Materials Itnaqnetnt Foreign 4.0 4.0 : 4.0 4.0 16.0 IIIROt~~~~~~~~~~~~ I--- -- -- --- a- --- a ----- a---- - --

Subtotal Felloushios/Study tours 11.0 1.0 1.0 9.0 8.0 0.0 0.0 36.0:--:- -a … -

- 65 - Annex 5Page 1 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitoring Indicators

Tvpg Unit Uutit/tatil: Distrebution of Guantities total TotalCoeoonn- of of Sast Cost Intut stcriptioA -- -- :Qt of siU Colt:

Input lnout llUsovul 192 113 19,4 1993 1994 1997 1990 Ineut rUSn OOOI2...... ........... ...... ...... s..:

:A. HEALTH PRCAOTIC.M

:1. Health Promotion Proqraao

: 9 STIL Con% */month 1.0 tetch Asnesnnt/Curr oev/EvIl 4 11 3 2 2 1 2: 27: 432LL Consult *i/onth 1.1 lPrograo Evaluation 3 12 12 12 2 2 2: 45: it1ST Fellow e/oonth 60 iHlth Curr Oev/Proq Evaluation S3 3 1: 94*Oenlopoentan Soread 20.0 :Healn Survey i 2s: 100a:: 250Oevelounentl Spread 500 .Hf Pruqram g rvelaeeent 1 20t 30? 30? 20? : 0oo,: 50:

: CCoauter paciaqt 5.0 :PC Harowaru/Piricherals I5 3 25Coopu 0aim annual 0.5 014 - Coeouter Hardvare 5 5 5 5 5 5 1EquiPment n ac ha 1 10.0 :Oftice Equineent 5 5 50

: Equplo 04 annual 1.0 0111 Oftic Eouipment 5 5 5 3 5 5 SO0: EpuE soott package 50.0 :Av Elp/oatls:Uourd.3 req,l sch: ,5 5 ZO: Equio O0I annual 10.0 :01 - AY Equipment 5 5 5 5 5 I S00

fSoftware package 10.0 3oqok/Ttchnical journals 5 3 5 5 5 5 5 5: 3350: Softvare packaqe 1 .2 :PC desktop publishinq Software: 5 5 10 1,:

Software annual 0.1 !fC Softvare license/upgrade 5 I 5 5 10 10 10 4

12. trintnq of Health Educators

KST/H Cons e/eonth 1 .0 I(rqanioe annual workshops I I I I I I 1 7 W2: ST/HL Con, I Soread z2.0 Arch/Enq@ services:ualrd Univ 7t0 SO3 1oo0: 231

L/T Fellow s/month 4.0 IMSc Public Health/HP (20 fIlil: 24 100 148 12t 42 440 1,170S/T Fellow /ssonth 6.0 :IM Proiedial/tour (50 (.l1l 22 40 54 44 24 : 1 : 1,466trainnq Vn/onth 3.0 ICshoog HP Progil kl:20 part 5 5 5 3 5 5 30 90Traning s/month 3.0 SO kshno Spl subIll w,l:750 par! 38 73 5 18 : 17: 1.12S::ulidtnqo I Spread 230.0 Uogrradna:Univ Krakok trg faci: 30 SOt t 1oo0: 230 Build OI I Spread 5.0 10411: Univ Krakow trsaninq faci 0? 50? 100:1 tOOt lOOt loo: : 23Etuleent I Sproed N40.0 Trainig Equipstntt Univ rat lOOt 100: 0EQuIP 019 t Soread 4.0 101 Univ lrakow traonn oui T Ot 100 100? 100l 1OO?: S 24Salaries a/month O.2 INatt HP Center: 7 add Staff 42 64 64 84 4 64 64 d 4& 109Salaries o/sonth 0.2 MContor HP: 2 add staff/Consor S3 72 72 72 12 72 72 4ta: 94:

13. Occupational Health :

STIHL Can so/onth 11.0 lOccuo health t11 esperts) 311.5 : tS 232:: LL Contult asoonth 1.1 Occup/indutt halth safety 14 6 2 25:

S/T Fellow a/soth 1 6.0 :Tour: Occ hith plan/aqt/eval 5 40

- 66 - nr, 5Page 2 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitorlng Indicators

1 .. *aswuuma.aaw,uu w...a .....nt.....wn I esIuau sn,i. $ aiuio sn As 8a ,.a.Iun.nuam e.u.. ssn ESSSgUls* R s n*oSSU :

I tteo Un:ti llitt/tot4i o hstr:vtian tt uotitas I tettal TotalC.OguN.t of ot liSm Cosl In: t Oe:crsptsos I .- …. :Qty of l co Cut.

[flout Input USIuOOOo ; 192 1943 1fl4 191 9 1I9S l1t9 1t Inout IIUSIOOOIhauattn on."osns.sna. 8san... aus n": ... s8sn.a S! is* s .f,.asa Stev *a...Sa agse..s**nSSSaas*ssogstss *.ss: avwn m sn. s nss,

11. P10*A9Y IWA CAREI -....-...- ... ... . ... S , I ..

I1. Ptirv Care PraCtices I-- I: :::|5 ST/I Cans 4/$oath 14.0 Ezost TA: INC and PCP 10.5 14.5 5I.5 1 2 2 3 40011P864ted LL Consult n/sonth 1.1 :PIrect Ev£laation I I I 3 Sloomnts s/SI Fellow Veoonth 8.0 ;Stuod tonrs 7 4 13 104

SIT Fciloo al:onth 8.2 :trainet PCP%/PC tramnrs 30 ISO 100 240 2.080tratmtfno o/ooth 3.0 M6hsio:PCP eqt.finnnl,fcsl,oqP 20 20 40 120trTaMing n/sonth 3.S :Caon:nu:ng education i 200 200 200 200 3o0 2,400Training I SPoud 20.0 eoshc:: PePC currcului planng lOt *5: 451: to0t: 20

v,eloosentt SOrevd 2400.0 !Rneira: suoogrt 52 20: 15 Li5 151 is, 15: 100o: 2.400cov@logenitA Sorsad 250.0 Ptal;:atons 25 15: 1 153 L S 1 1: 15' l00: 230

Devqloonent: Sored 300. : Public toucatmon 5t 20: 153 153 15: 152 15:: 100: 540Buildings Spread 10.0 Ugorde4 4Utinnal PhC center 1002 : 100i : 20

alul 0U1 t Soread 5.0 OPOC Center 0u 0£ 1002 100: 1002 too : 100 : 25Coooucer package 5.0 :PC r,owrt/P,righerrls 1 5 5 25

t Cacou OH annual O.5 :GAP. - Comouter Hardare 5 5 5 5 13: I3uiPEiont Soread 1 170.0 :nPoC Ctr:onffice/lAvncal cqo 100£ 100£: 170: SiUss 010 2 Spread 11.0 INP4C tqutniPSt a04 100£ 1001 100£ 100£ 100£ 100l : 102

Equtootnt ptackge 20.0 Trounsq tsouL: 5 acedgidess 5 I too: Eouto 04a annual 2.0 :004 traintng r 0qu S 5 5 5 5 50

Saft.are package 1.2 :PC ioftvar S academies 5 5Softeare annual 0.1 :PC So:itare ILcene/uagrido O 5 5 5 5 2Software ackage 10.0 4sdio?v%Utl etitl: S ocad i 5 5 5 i 1 10Softwbare packagei 20.0 :I0ktSIt#c£ journals: S acldtt 5 5 5 15 3001SalariNe eloanthi 0. Steering Coon: I II staff * 12 21 1bSalairis ouioth 0.4 :Stetring Con. 2 LL staff I 13 24 '4 141Salaries slooth 1 1.1 :t Pfrs Cars 1rd:l director 12 12 12 12 12 b0 UlSaiaries glmth 1 0.3 :Nat Pria Care W4 K staff 2 34 34 36 3 3 : 10SO IIISalaies o/t4tth 0.2 :11t Pret Care Ird:14 add staff: to 1i 14 lta 14U 146 1U3 1,024 205Oper/Aecnrrt Spread 120.0 RIPNC non-salary opor costs 10£ot 15£ IN 15£ 5 2 1£ 15: 100: 120

:~~~~~~~~~ : : : : : 1 EC1.St/K Cons o/oonth 1 .5 :Dn, acid uniti/tr9 nods asnet 14 12 1 S3 *1 IIlt

I FiuCed SIT Follo. a/eonth .1 :StaGy tours/fellohip5s i 40 134 41 5 222 1,604I l15mts Training o/sonth 3.1 sartoeps:Sev IW tea 125 125 125 75 3.044

L: Consult o/oonth 0.9 lastip of PCR facilities S3 3 9: 'lveleooesnt£ Spread i 125.0 :Public Educatin 25 25£ 25£ 25 100 12511Seeoloeent£ Spread 19.0 Currtculve cntrsece 3 3315 3SO lo 100£: 19IDvelooleat£ Spread M0 :Research nugoort 100 100£: I3IiosIdng%s units 25.2 Upgrsding of 300 PC 100 100 100 SO30 1 7,4 13lo)1 040 annual .s :PCP Ousildig 00I 0 100 200 SOO S3O OO i 405I hildngs 2 Spread 543.0 enoWeate 3 Acodehic facilitils Hz 3? 33S to 100£: 543 usId 0101 £ Spored 11.3 Acadgtoc hailding 040 i 0£ 33; in 100£ 100£ 100£: i 45

EquLpont packgeo 11.3 :PCP equltnt i 100 1to 100 3 200 3.375 2Eggip 0t0 annual 1.1 'old - RC, quigent 1 0 100 200 SOO 300 3O O 1,350Solttare t Spread s38.0 Library A tnto resorn : o0 52 In mt L t : 1002: 33

:2. Io-Service Training

t101 ST/lt Cons /so/th 1 .0 Espat MtARonsr/nurst ed/curr I J 7 1: saMood LL Consult sl/soth 1.1 Projet evaluation I II I 3fleo ts Training o/enth 3.0 PHCT staff training I 10O 100 200 200 200 300 2,400

Soaftue SI read 10.0 Training eaterials S1 132 251 251 2I. ICo: 10t

IEC ST/HIK Cons s/oonth 11.4 Proq Adss/tudqet/soat/enal 220.5 14S 15 15 47 1 .230Fituced Sit Fellow t/ooth . 3.1 Study tours/fslloshhips 32 1 13.5 1 735.3 594Ilitosts SIT Folloa e/eooth S., Lngot.r. fellowshipt : 144 144 144 103 540 *4.3St

Cooeatur I Soreod 13.1 :CUoeo9er Nardnart/Pornehsrals 100: 100£: ISEquls 040 I SSread 1.3 :0a1 Coseutor Nardart 0£ 100£ 100£ 100£ 100lot 1 7:

. . .....________ . . ~.............

-67 -Ane POLAND F~~~age 3 of 8

HEALTH SERVICES DEVELOPMENT PROJECTProject Implementatlon Schedule and Monitoring Indicators

l.iSttns..Ofl...fla . u......... :..O ... a.....A.. f...l........ S. ma"aw.swssa .. w#Ga-. ... *W-

laawuet of if Mae Cost Io3at Oe,cristsoa - - . - - 11 0 ,CuitI least toilet llOSS000l ~~~~~~~1,492 tits L194444 1 944 MA "?47 14 lagat ZIUSI90011l

tt/K4 Cons uoitO 1 14.0 I:1.oatA 15 1 Acct santl4oot 0.5 27 30 17 1 fl 1,04311ILI. Ca4sv!t */.et. 5.0 LUciL TA:*cct qt/dilaa/tWnl i2.5 V 27 LI 3 i 403 1

W / Feill. $0/00th 1,0 3/0, kcet sfalloqovat 4 4 3 t11 6a Training e/uoth 3.0 :4/0, kcct 80OdqOOet 1 24 24 Is 44 142i

I Cootetr gicos,. 330.w) :1101 Coo sOSfato I I 350ICasesOi 04 t*4 asi I 31.0 :5001 Casnga ser eveo 0din1 1 1 210 *Cuoje4tor 04eats;. 11.1 Vososi4: CONS R04156attu4l' 20 1o I Ss 534

Cuoa OAR af"tol 1.4 :1004004 Cfocoto' svscos O40 0 20 3* a8 311 38 231Cocoetor 040aqe16 4.0 :$sll mls.i Coss Ward/Softoare: 70 80 02 : 212t 1.40

*C4OON Din Sacasl 4.f:4 hal/ese Coaa'sto' ,10 000 Dn 0 10 130 212 212 212 :770*Ceeoetor packiqe f.4 mogfs eHls! Cote 15rst0/lotoaf: 125 125 77327 2.943* Coop Ole Vasseal o.4, motle4I4s C"ooftor tystOs 050 0 l2.5 250 327 327 327 1.2340

C4.eqtto, 0schaqe I .0 :Pilot Uorqe Moss. Kafg/Saftw4r! 2 2 isCsoloOUPI asoejl M . :Ptlst Lrg/HosoUsCe "sit OlO 2 2 2 2 2 2 It:Coloptor MaciSis 4.0 :Large mmoy: Coos Hard/softoareo 33 40 4 ht71Coop" O10 sasool 1 0.4 7.4rqot eliot Cao cll ost din4 0 13 73 74 74 74 l0tlissoecot package 10.0 :108l of fice floatsot I I to1lqaso 040 aiceol 1 1.0:044 Office CEwvasgeot l 1 1 1 I I 4Seftosre *scks, 1 12.0 :110:Su.ss/tocb Journal$ i 1 I I 1 I I I: 7 4saftwsro *4C4140 1 3.4 :V4ivog:Ouks/fQC.% jssrOi4 .I 20 30 34 34 1 26t 441Software pactaoe : 4. ludll Noso:Ioo.k$/tas jwoalsl 70 IS0 21?. 212 1 444 315Software s4ckaqe 0.8 ceot msosloobuas/tch Jouarnals 125 210 727 327 1,021 r.31Sotware9 ouckaqe I I.: :Larqt Nesu,ioos/TeKft Journals: 2 35 75 6t It 274 TV4Salaret"s eoNti 4. :1211 soc cresstal staff 1 4 4 e 44 4 0 4 472 1 134J

12. Pbss tlcsacl Oootstossq .

P/101. Coms a/oath 1 14.0 lI,o,t-tersO esat to: goal I I I 1 4t As4 LTIML. Coss iolomtb 1 14.0 :[B..t fIt Oiuq te4sl/sqt I 1 2 20 12 1 2 421LI Caisslt si.oati 1 .0 Local f8:ors, rs,sl/IAIa 4 21 21 10 3 : 4: 241SIT follow 4/000th 0.0 :0.154 edostorshq 0.5 A 2 I It 64:Trssaioq a/omth : .0 10ru4 switlrteg 1 & 20 120 46 1 244 1 63 Cuitor packaqo J 510.0 :FWs Cost ltds,8Sftostet I 1 2 1 4.100 CowocOAR aooss I SS.Ol:MMAlOCUgtsrfoWife00 1 2 2 2 I2 i2 4051JCosouter pucks,e ! 10.5 :Pilot Full POse Coss harl/toftl 1s 1 IS 1l8Car OAR b"dus I 1.1 :Pilot Phe elM Caos swato 0du: 15 3 Is U S 1 13:is Ls41ICasuotor pack.qe 1 10.5 IPsol Punr Cost H4rdiSaftw4re W 4 30 aS 261 : 2.44Cup,o 061 amsosa J 1.1 !h Poir. CAsseter syit. 0UN 0 130 285 21 205 265: 1.355aC48eoso te' 1c1a40 1 10.1 IV*soedJ Come eU4/Sft54? :. 1 00 t 9 I 9 34 50Celo's OAR anaehI 1 1.4 :Voivod C4aoitsr system Up1 a 20 30 34 34 3t i 2311Cosgoter package ! 10.5 Meall lse;s Coms esno/Ssftuare: 70 to 42 it?21 .24 CUse 010 mayI J 1.1 :Sal/lmn cosp,t05 hultS Om I 0 70 I50 212 212 212J I 1 644Countelr Mickoe 1. 10.5 Natdisi elost Come hs4d/IOtu5il 1235 I * 15 77 327: 3,4014Camr 0AR macal J 1.1 :111eolk61 oeoCojtest Slat00 0Du 0 123 210 32? 32 32 1y 1.1424 CuWlto' pocaqo 1. 14.i :Pilot Loo; fleece Caste 14*rd/0 2 I 2 24 cow canO umeat I 1.SJ:sIot V941osoeClasoutor %wel* 2 2 2 2 2 21 161Cosgate, ptackae 14.4 :Lare Wii#t Cue MONf/SlIft"V: 33 40 n 731 .m4

*Canp,OAR sasfal I 1.5 u.gl/kos COstestOSYtotOAR 0 33 73. 73 73 73 4731leeSspe.t I Spread W 0.0 :411alyttcl, eg411se0 * 100 too10oot 000ofoules 040 1 Wooed 160.0 :U10 hAnlytisco Cesspoot C4 100t loot t00t 1oot toot: I 400?14la5p.et package 10.0 lQfftce lqelOe4t 1 1* 11 1 lssspoO UR NW"l I 1.0 b0I0 -Offzc,lzAvisoot I I I I 1

*Softosrnopackage 1 2e.0 :nOs0obokitecs foeoroms 1 t 2 2 2 2 2 2 131 312?Software iotai 1ll 3.5 PesO Pha'i:kqositecn jobolsl it 145 3so so0 040 1 , .0160

* Soteorm kcC40e 1 .9 :V61,o:Sessslilece JoralsreI 20 30 3t 3t ?i26 s74 Saft..,.e pacteqe J 1.0 :Sull Koe:lsitl s/fecl jesnrls: 70 150 71 212 1 441 4C4

* Soffuane Oscosyl 1 3~~~~~~~.0 :0084 Xlesit100ki/fech jeveCiall 1232 250 327 327 11,024 1.0241O attuaro iscka4e 2.5 :Large lossaotlteltoca ,osro.4e 2 35 is 1I I1 .r 27' as41

Sal4inas i/otat 1 . :Ca astcresietal istaff 46 44 44 44 414 44 44 1 24 132Salaries *1Gd4th G 0. siol,d socroseetil staff 1 240 344 448 446 448 4s6il 2.472 4944

. ... ........... . .. .....~. ..- . -.. .-.. ... ..- - --

- 68 -Aex SPage 4 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitoring Indicators

Type Uit ilhst/Total uOstrahutzoa tf Quantities Total total ICoeaent of of late Cost Ioout Pescription - -- Oty 3410 Cdotte

Input hoet IMUSE@000 I 1992 t 1 91 9 i 19 7 t991M £995 Input :1US4000:

.C. NEATH iANUEJit

I .-

ST/HL Can */onth 11.0 Eject TA: IRiourtc alloc/eval 4 S 2 2 2 1S 240I LU Consult a/month 1.1 ocal TA: Proirct enaluation S I I I I I : s/rT Fllow /eonth 9.0 IStudv tour 3.S I I I I 40

traLnaq alsonth 3.0 Local trainaiqn ctnter staff I £ I I 4 12Conouter oichage 1 7.0 Strvcrt Harear package I 7Coou am atnnual 1 0.7 OU - Stryert ackaqe I I I I I I 14Cutout.' package 5.0 Dt Itaro.re/Peoi5rile 4 1 4 20C>oe 0111 annual 1 0.5 :oau C*ooutor Hardware 4 4 1 4 4 4 12Equipenent pacage 10.0 0Oftice Earutoenct I 1 10Equip 040 Annual 1.0 :OU0 Office Equipeent I I I I I

I Software package 1.2 Sorvtrt Software I 1 1License annual 0.1 Servirl Software lic"nso/uqed 1 1 1 1 1 1 1

t Software package L12 PC Sftenre 5 S *Liens# annual 1 0.1 'PC Sotts4ar lIconeouo;gradf 5 S 5 5 S I S 1Softtare package 1£.0 0 ooks/Toeh journals I I I I I I 7 70WSalarins s/onth 0.2 Cntor staff, 4 add staff 24 24 24 24 24 24 2' 143: 34:

4. It nngetft hvIpeatfnt tt -.-- -

ST/I. Con$ lientt 14.0 Short-t,re teuat TA 7 12 6 4 I I 1 S 174LtILT Con% w/eoth 14.0 Long-tore eznAt tA 12 20 16 * 2 I 42: 6LL Conault s/ooith 1.1 ELocl ongerts 2S 4 45 32 17 U2 112ILIT Folo. s/ooeth 4.0 :Long-ttre fellowships 1£ 72 134 143 15 21 :4* 1.!4SIT fellow VIaonth 1.0 Short-tore follusiStudy tours IS 19 19 1D : 7 17 34training o/sath 3.0 :Local traninm 9 16 to 9 9 4 £69 1tEIUip5t package 11.0 iConeutor lab (10 elacnl 1 2 3 41Equip 0a0 nnual 1 1.1 140- Office Equiplent 1 3 3 3 3 3 24Isoeuter package 20.0 :Server2A aaro.are/Periphels3 S 3 1c:oeu OOi anual 1 2.0 :0 ServerA Hardre 0 3 3 3 3 3 I 30Equeosnt packago 21.0 Iquipot:Av/offtcelC loea 3 I 3 sEquip 040U ual 2.1 :U - Offtce Equooent 0 3 3 3 3 3 32Softwnare pckage 1 21.0 lPack:ltoks/hv "Utls/Weel lit 3 3 3 3 3 3S t 371Softeare package 1 12.5 Snerver:A Software 3 S3 Liconst annual 0.9 lServoru2 Sottuare cupgrade 0 3 3 3 3 3 s: 13haildials t Sread 40.0 :O furoish facilitieu: entrs lOO Il 10:oild 0p Sreod 1.2 Facilities 040 O0 lOOt 140t 100£ 100£ to ol *oSalarits alloath 0.2 :4 staff per centerlI 34 72 72 n n 72: 39& 71Ooer/tccorrl Spread 30.0 oten-alary oeor costs (3 cntrnl St 14I 1Ut 1U lit £Ut 642: SO3

IS. Nalth Financin I

*eveloapeentS Spread 100.0 Health financinag study 0lO 0l2 1OOl0 1,100S/T Follow Ie/onth S6.0 Health EconoAoLC/tnsurnnco 4 2 2 2 2 12 9t Eanipsnt Uacuage 1 10.0 (ffice Equeisent toI 1 lt(si, at" annual I 1.0 :0 - ffitce Equgoant I I I I 1 1 , 4Coesuter packagt 1.0 tC #Ardwart0/pripelrals 1 51Cpu UOK annual t0.l eh -Cosouter Hardnare I I I I I 1 L 3Software package 1.2 tC Softoare I 1 1Ltcense annual 0.1 tC Software licens/npqrude I I I I 1 1

- 69 - 5Page 5 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitoring Indicators

183U332E122**8 138135323132$| t38 8.i$ w33tlS1.R, ,,,.n:.ssazuaasaXaus ua, :utg :,s, u.Sgu:s:g,tSssszms:sagwagms#g,sa,.,sn.,:ga.mn.:swwwsz zz,2J

Typc Unit t Unit/Total: ast1bUt:ft O0antst*ttt Total TotalCoeponent of of st Cost Input lescrotion - - - --- :Qty of 8ne Coot:

Input Inout NUS1 000) 1992 199q 1994 l1qq 199 1197 1998 Input lUSt O001

:0 REGIONAL HEALTH SERVICES:-----.-@------@-------.-.- : : :

1l. Reqionil HanageoentNational Projett leolpmentation Unit

: : - -~~ ~~~~---------------.------ : , S

ST/HL Cons s/scnth 16.0 1Preo asttrolan/quidelines/stds: 17 23 1 5 1 1 2 50 o00LT/HL Cons s/month 14.0 Project sqotl4 esortsl 1 3 48 4a 48 6 4 4 194 2.714LL Consult s/oonth 1.1 Praj eval/translation b 1: 6 A 4 4 6 48 54LL Consult o/uonth 1.1 :Coordinator: IPIU 1: 12 1: 12 12 12 1: 604 95LL Consult o/oonth 0.8 HL Tech: t5 tr NPIU 40 60 60 60 60 40 60 420 315LL Consult s/o/nth 0.4 ILL Tech: 64 tor NPIU 48 48 48 48 48 48 48 356 126S/T Fellow olmonth 8.0 :Nsterplan denvl/PIU visits 2 1 3 24Training o/sonth 3.0 Consortia devil 150 particl 100 100 200 400Computer packIge 5.0 :PC Hrdwrt:13 tor IPIU 3 3 iSCasou 0&M annual 0.5 :041 - Cooputer Harovare 3 3 3 3 3 3 9Sottuart package 1.2 PC Saft:03 tor NPIU 3 3 4License annual 0.1 PC Sottare licensu/upgraoe 5 3 5 3 3 3 2Equi0ernt package 10.0 0ffice eqp/ourn: NPIU oI 10Evuio 00 annual 1.0 01U - Oftice Equasaent 1 I I I 1 1 4Venlicles unit 20.0 :Vehicles: NPIU I 1 20oVeh Oi annual 2.0 :1 - Yvenac£es I I I I I 1 12

literials 7 Soread 5v.4 Ilaterails,supolies:NPIU ; 10o: I5 R1 15: 1s2 14: 15i: 100I:

Consor 1u Coordination OtticesWielkoaolsx, Pomerania. Ciechanow:

: - ----- ---- … ----

LL Consult a/lonth 1.1 ICoordinator: I CCOs 36 36 3c 34 36 3O 36 252 284LL Consult o/menth 0.9 HL Tech: t5 tor I CCOs 1iso iso iso iso eo e, iSo : 1.260 9454L Consult a/menth 0.4 LL Tech: 04 for 3 CC0s 144 144 144 144 144 14' 144 1.008 378S/T Fellow o/month 8.0 Ilasterplan devel/PiU visits - 6 3 9 72C3souter package 5 .0 !PC Hrdwre:t3 fcr 3 CC0s 9 9 45Coomp 011 annual 0.5 1010 - Conouter Hardware 9 9 9 9 9 rt: : 27Sottware package 1.2 :PC Sott:U3 tor 3 CCOs 9 9 itLicense annual 0.1 :PC Software lacense/uograde 9 9 9 9 9 9 :IEquioment package 10.0 :Otfice eqp/furn: 3 CC0s 3 3 s0Emuva 01h annual 1 .0 :00- Office Equipsent I 3 3 3 3 3 3 leVehicles unit 20.0 IVenicles: 3 CC0s 3 3 40Veh Olo annual 2.0 :01h Vehicles 3 3 3 3 3 3 36Materials I Spread 151.2 flaterials.supolis:3 CCs lot 15s Ill.: 15: 2i 1is: Is: 100:: isl

: ------- ~~~~~~~~~- -- ------ : -- :------- --e --- -- -:

I a~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

- 70 - 1lX 5Page 6 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitoring Indicators

: T100 Unit 2Unit/Tot8l : 0thIton of 0utities ITotal 2 TotalC-ment of of lass COat Input Geicrption I -- -- 0t Of -lse CostI I~~neut Ineut :IUSsZoo 000 I m i' 1 m 1990 5a I" I"i 19, Inmut 101 s"1

.SS_,.,,m.,u. ............ mf........ ,t8,., ....... ,.,,,,,, ...... , , .. , l,,.,,,,,,,, ............. ,,., .. ,S, . PS,,, ,,.,, ....... , n D0. IEIE1UL HEALtH SERVIC13

12. Imtrastructure Consolidation I Uaeisool s'eee u:Cntortia *

Sualdin;, I Spread 13112 :CwtnlidzSaort-term care facil: 5t 20: 20: 20. 201 IS'.: 10 It 13.112 hild 0411 I Sorad 242.2 :0UI: short-tere care tacit 01 S: 251 45? As1 853: I 502Equipment I Spread 13554 :Ccnsolid:Sahrt-tera care equip: 2S: 20! 20: 20: 1M': 1002.: 1U.54Eqouo 011 I Soread 1355.4 :0h: short-term care equip 0: 0t 25: 45? is: 1.: 2.962lulAdings units 25.0 Upqrade: Pris Care Pract bldgs 10 20 2S 25 25 12: 117 2: S*uild 0AR annual 0.5 :0i: PriS Care Pract bhdgs 0 10 20 S 5 10 105 140Equipment packag 1.20 Upqraoe: Prio Care Pract equip: 30 S 25 2S 12 117 1,404Equto0U annual 1 L.2 :040I Pris Care Pract equtLo 0 0 0 35 60 105 324

I LTIML Cons I Spread 1213 Archlengineeriaq services 10; 201 201 20t 20: 10': 1001t 123 2

: Pemerania Consortia* ~~~~. .. S....

Suilotnqs t Spread 7474 Consolid:Sbort-tera care facil 5: 20:: 20? 20: 201 15; 1001t 7,74SuLId 08h I Spread 15!.? :06R: snort-ters care facl 0 o: It 25: 41 65: 65: 2 343E-u:.0ent S Spread 7933 ;Coasolad:Short-ters care equip: 25: 20t 20: 20: 151: 100t: 1.93PEqu:o 01h Soread 793.3 :011: short-term care equiop 01 0t 25s 4t5l 51 iS:: 1.74!Buildinqs maits 25.0 Upgradle Pria Care Pract bldqs S t to 10 10 to0 1,7002BuSld 011 annual 0.5 2011: Prim Care Pract bldgs 0 5 20 38 48 582 HEqu;poent pactaqe 12.0 2Uuqraqe: Prim Care Pract equpo 20 18 10 10 10 fie 311Equip 0AR Annual 1.2 20n: Pris Care Prct equtoip 0 0 20 l8 48 58 17LT/HL Cons I Soread 750 Archlengineerang services IO1 20: 20: 20: 20: 10?: 1001: 750D

Ciechno Conortia S:

: lalings I Spreod 3459 Consolid:Shortetire care facil! 5t 20? 201 20: 20? 155: 100o: 3.459I Suild 0U1 I Spread 2 92 20U: short-term care focil 2 01 51 251 45? 5t 835: l12 Equipmnat t Spread 3576 ConsaliShort-tere care ouipl 25: 201 20: 20: I5: 100S 3,574

Equip 0UI Z Spread 3 27.4 0t11: short-tero care equip 2 01 0S 25? 45t sS iS:: : 772: Suuldings units 23.0 :Upgrade- Prim Care Pract bIdgs S 10 15 : 37s

Iluld 0811 annual 2 0.50UI: Pris Care Pract klogs ! 0 S 15 1 15 15 : 33Equimeont pacage O120 Upgrade: Prim Carn Pract quvpo IS 15 I0Equip OAK annual 1.2 0UI: Prim Care Pract equip 0 0 15 15 IS5 13 n:LTIML Cons t Soread 307 3rch/en9ineerinq serices 10t 202 20: 201 201 10t: 1000S 307

- 71 - &AMx 5Page 7 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Monitoring Indicators

Type Unt unft/totaI: : Dlstrikution of Oantities I total total Coepenent of of 'us Cost Input Description .. ...........- ......-......... . - .Qtr of la1t cost:

Inout Inou: (USI0001 1992 199 1994 1995 1996 1997 1998 Input :lUSt0001:135532,vgwwss..shI3uazzwI.ws.wua , , , *AS533,UtSU32IS2 UR,.S32S5*5833881*88S, ,. U.*S ,,,, , , .,, ,, 8.3.

. REilONAL HEALTH SERVICE:

13. Hospital A/0 Info/Accounting* - _ - - * . . ... _ . 2 . .. 1._ ...

STIHL Cons o/month 16.0 AI/0 Acct 6gtUlifiLAnAn aUdit 3 10 10 8 3 3 3 40 tO:LL Consult a/oonth 5.0 Local TA:Acct mqt/project oval 1.5 7.5 t 4 3 I 1 a 2 530SIT Fellow alsonth 8.0 :A/D, Ac:t manigseent 1.5 9 9 6 21 204training s/month 3.0 A/D, Acdt management 1.5 16 18 12 48: 143

* Computer paciaqe 14.0 Re1ion: Coop Hard/Softwarse 2 2 X 'ComPu CAN annual 1.4 Region Comouter system 04" 0 2 2 2 2 2 1'4'Comouter package 47.0 Voivod: Coop Hard/Softwre r3 1 10 470Coepu OI Annual 4.7 :Volvod Conputer systes 04I 0 3 9 10 10 10 1 197

* Cooputer package 46.5 Seall Hasp- Coop Hard/SaftiarS 13 13 12 38 1 274Coopu 04& annual 4.7 Sel/losp Compute' SYSm:e CIA 0 13 Z 38 38 38: : 712Cosputer package 71.0 Noiue Hosp0 Cooe Hard/Sot twr 7 t 21 1,491Coseu OUI annual 7.1 :Red/Hosp Casouter system 04 1 0 7 15 21 21 21 1 04CoOputer package 84.0 :Pilot Lrge Hcso:Comp Hard/Soft: I 1 04Cosou 0CA annual .4 :Pilot Lr; Hoso: CatO syst CAR 1 1 1 1 1 1 sCoa3uter package 84.0 Large Hosp: Case Hard/Software: 6 7 5 l8 1,512:CorneU OUI annual 38.4 Lrg/Hosp Cooouter systes OUt 0 6 13 18 8 i 413 1Software package 1 2.4 IRegton:Iooks/Teci journals 23 3 3 3 3 3 ta 43:Software Pactale : 3.6 2Votvod:8ooks/Teh journals 3 9 10 10 32 115S:otware paCkage 2.0 :Seall Hoso 9ooks/Tecn journals: 13 26 38 38 115 UnoSoftwart package 1 2.0 :Red Hos:Books/Tech journals 1 9 17 23 23 72 144Sottuare package 3.0 :Large Hoso:ocks/Tsch journals: I 7 14 19 19 40 1t10Salaries a/month 0.2 :Regional staff 288 289 2f8 288 298 288 1,728 344Salaries e/month 0.2 Voivod staff 1 54 0 60 60 40 312: i1Salaries o month 0.2 'Staff: Stall hosiital 79 162 229 229 228 229 1,152: 230:Salaries i/month 0.2 :Staff: Readus hospLtal 12 54 102 138 Is 138 138 7 720 144Salaries o/month 0.2 :Staff: Large nasostal 12 84 Iti 229 228 228 229 1,174 235

: - -- :--- . --- - - - - : - t : :~~~~~~~~~~~~~~~~~~

-72 - Aex SPage 8 of 8

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Project Implementation Schedule and Montoring Indicators

tyoe Unit lUnitITotal ' tnot et ofuanttes 2 total 2TotalICoponeent of of llase Cost Input 0Oscroption I-- - --. Oty of east cost.

Input Input 11USOOOI : z2 1 194 1993 199s Itti I91tt Input :1uSsosool:

tO. IESIOHL HEALTH SERVICES I * ' 2

14. Pharmaceutical letnitrn t

STIHL Cons s/oonth 16.0 Druq Regul/mgot/enal I I 10 10 S 3 3 SS3 401L UL Consult e/month 1.1 Drug Regull get/enal I A 7 a 3 3 3 2 33

S/T Feilos u/month .0 Drug eoutenng 1.3 16 17 IZ 47 t2Traininq c/month S 3.0 :Druq sonitor:ng 1.5 16 1e 12 46 143Casouter Package 14.0 2Reginn: Coop Hard/Software *3 42Coopu 0" annualI 1.4 tReqion: Cosouter system OH O 3 3 3 3 3: 21:CooPuter Package 14.1 2Voivad! Cato Hard/Software 3 It 10 141Cnonu 0/n annual 1.4 1Vainod Cooouter yste in I 0 3 9 10 10 10 59Csoputer Pckage B.5 Suall Hoso: ConS Hard/Software 13 LI I, 36: 323Coeepsu OI annual 0.9 Solleosq Cououter systeo Oatn 0 I3 2S 38 3S 36 13uCeeputer package 8. : Pilot Rid NHsp:Ceeo Hard/Saftw 2 2 17Campu Oca annual 0.9 Pilot ted hsp: Coop syst CAt 2 2 2 2 2 2 2 10ComPuter package 6.5 ftediu Hosp: Casp Hard/SfttAr 7 6 21 1I:Coopu OAt anual 0.9 ted/Hosp Cosputer systes Ot0 0 7 15 21 21 21 72:Cooputer package 12.6 :Pilot Lrge Haso:Coep Hard/Saft I 1 13Copoo 0ai annuai 1.3 :Pilot Lrg Hospi Coeo syste 0' 1 1 ! 1 1 ftComouter package 12.6 :Large Hoso: Coop Hard/Softuare 6 7 3 Il 227Compu Ofi annual 1.3 SLrglHosp Computer systes 0421 0 A 13 1e 1o 1 I 92 Equipaent packap : 10.0 'Office eqp: Regional office 33 30 Equip OU1 annual I 1.0 lOat -Office Equipment I 0 3 3 3 3 s15Softre Package L 6.0 Megionilooks/Tech journals 3 3 3 3 3 3 I lS 108SSoftare Package I 4.0 ivod:Mooks/Tecn journals 3 9 10 10t 32 192Software package 2 1.0 Smalt Hospilooks/TKfh journals 13 26 36 36 11 115Software package L 1.0 :Red Hosposooks/Tech journals 2 2 9 17 23 23 74 74IfSoftare oackage 2 2.5 Uirge Hosp:looks/Tach journal)s 1 7 14 19 It 60 ISOSalaries */month 2 0.2 :Rtgisnal staff 1 12 12 12 12 12 12 12 642 17:

2 Salaries e/eonth 0.2 uvo1vd staff I 36 106 120 120 120 120 120 744 1492'~~~~~~~~~ 2 : : : :

13. Naterials/Technology Na1agement I ' 2

IST/LL Cons a/eontIh 16.0 2Equip/technoamatls manageet I 2 4 2 2 2 12 1922 U Consult a/month 2 1.1 2lquip/techno/matls manaqet I 12 1 12 12 12 66 742L SIT Felteu a/oonth I 5.0 :Study tours 14):Eqp/satis at' 11 I S S 364 268t Training t Spread 15 f atercals/Tech oget 1 251 231 231 251 IOOT 1sI Computer package 1 20.0 2Servvr2a:10 pilot hosep center 11 11 2202L Co pu ODi annual 2.0 Oat * Ceoputer Hardware 2 11 11 11 11 11 11 132:

Ceomputer packaqe 3.0 PC Hardware: 110 pilot hspl 1 10 2 10 30I Ce pu 0411 nnual I 0.5 :611 - Computer Hardware I 10 10 10 10 10 10 30t fComputet Package I 5.0 PC Hardarel/feriph ISO hesp) 1 40 40' to: 4

toapu 0111 annual 0.5 3WI - Ceoputer Hardware I 40 f0 SO 90 10 I OVenicles package I 40.0 2taintenanc vehicles (10 hospl 10t 10 400Equip Oait annual I 4.0 :taf - tait"nace vehicle% 10 10 10 10 10 10: 2 240Equipment package 2 10.0 0ffice Equipment 4 : 4 40

: Equip O11 annual : 1.0 :01l -Office Equipment I 4 4 4 4 4 4 24Software package 1.3 Equtpsent managet softwaren 11 40 40 137License annual 0.1 :Software licenselupgrade t 11 S1 91 it l 92 432Software package 2 1.5 taterials esnaget software 4 4 : 12:License annual 0.1 :Software lncesse/apgrade 4 4 4 4 * * 3

: Softtwre Package 1.2 :PC Sottware tL 40 40 9 t19License annual 0.1 FC Sottware licenselugrade 911 S1 91 *1 *1 9 2Software Package 2 10.0 :looks/Tech journals 11 11 11 11 11 11 11i 77 70

.. . .--.--.......--- *--: -- :

- 73- Annexl 6

POLANDHEALTH SERVICES DEVELOPMENT PROJECT

Schedule of Disbursement

PercentageLoan Disbursement (Uss stn) Difference

.------ ................ Sector Disbursement Project

Calendar Fiscal Cunutat Profile OverProject --------- a--- ----------- Cumul- as X of ----------. ----- Regional

Year Year Semester Year Semster Periodic tive Total Regional Sankuide Prof1le.. . .......... ....................... .... ............ .................. ................ ........................... ...... ..............

Year 1 1992 1st 1992 2nd O.S a/ 0.5 - - -2nd 1993 1st 1.0 a/ 1.5 1X 3K 3X -2X

Year 2 1993 1st 2nd 8.0 b/ 9.5 7X 6X 6X 1X +

2nd 1994 1st 12.8 22.3 17X 10X 10K 7X .

Year 3 1994 1st 2nd 14.8 37.1 29X 14X 14X 15X +2nd 1995 1st 15.3 52.4 40X 22K 18K 18X +

Year 4 1995 1st 2nd 15.0 67.4 S2K 30K 26K 22X .

2nd 1996 1st 14.4 81.8 63X 38K 34X 25X +Year 5 1996 1st 2nd 10.5 92.3 71K 46X 46X 25X .

2nd 1997 1st 10.0 102.3 79K 58K 54K 21K +

Year 6 1997 1st 2nd 7.0 109.3 84K 66K 62K 18. +

2nd 1998 1st 6.8 116.1 89K 74K 74K 15K +Year 7 1998 1st 2nd 5.0 121.1 93K 82K 82X 11K +

2nd 1999 1st 4.9 126.0 97K 86K 90X 11X K

Year 8 1999 1st 2nd 4.0 c/ 130.0 100l 94K 94K 6%

2nd 2000 1st 98X 100K

Year 9 2000 1st 2nd 100K........ ........

Total 130.0. .............................................................................

Source: tDRD Central operations DepartmentNotes : There are no comparative disbursement profiles for Poland to date.

*/ Project Preparation Facility advances

b/ Initial deposit into Special Accountc/ Closing Date: June 30, 1999

-74 -Annex 7Page 1 of 2

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

Documents Available on Proiect File

1. Health System Reform Progosals, MOH, January 1990

2. Health Sector Overview--Issues and Options, Working Paper, World Bank,

May 1990.

3. Progress Report on Project Preparation, prepared by MOH, June 1991.

4. Health Facilities Infrastructure Assessment of Project Regions, prepared

by Danish Health Board, June 1991.

5. Health Services Development Prolect--Background Information on Proiect

Rezions, prepared by Danish Health Board, June 1991.

6. Survey of Health Resources in Proiect Regions, prepared by Danish Health

Board, June 1991.

7. Feasibility Study on a Proposed System for Monitoring of Distributionand Collection of-Statistics on Drugs in Poland, prepared by

APOTEKSBOLAGET, June 1991.

8. Occunational Safety and Health-Strategies and Action Plan, prepared by

C. Soutar, July 1991.

9. Development of Health Promotion Capability, prepared by Wales Health

Promotion Authority, July 1991.

10. Primary Health Care--Issues. Strategy and Action Plan, prepared by J.

Krister and C. Whitehouse, July 1991.

11. Health Management Information Systems, prepared by P. Caper, July 1991.

12. Introducing a National Health Insurance Scheme for Poland, prepared by

K. Henke, July 1991.

13. Development of Regional Health Services (Consortia), prepared by J.

Blanpain, August 1991.

14. Regional Health Services Planning, prepared by D. Bevan, Powys Health

Authority, September 1991.

- 75 - Annex 7Page 2 of 2

15. Implementation and Training Plans for Hospital Discharge Database,prepared by J. Curtis, September 1991.

16. Implementation Plan %or Cost Accounting and Admission and DischargeSystems, prepared by Kommudata, September 1991.

17. SuDDort for Reform of the Health Care System--Financing ProRosal,prepared by Commission of the European Communities, September 1991.

18. ImDlementation Plan for Technology Management, prepared by R. Morris,October, 1991.

19. Health Care Institutions Act (English Translation), October 1991.

20. Proiect ODeration Manual, December 1991.

- 76 - Annex 8

Page 1 of 3

POLAND

HEALTH SERVICES DEVELOPMENT PROJECT

Supervision Plan

Timing Staff Weeks Staffing

CY1992 50 weeks Bank resources (25 weeks) of which:

- Task manager (12 weeks)- Implementation/operation specialist

(10 weeks)- Other--not yet specified (3 weeks)

Supplementary technical inputs (throughbilateral/multilateral cooperation):

- Primary care (1 staff year - EC funded)- Information systems (health management

component) (9 weeks)- Health planning (regional health services

component) (6 weeks)- Health economist (finance, budgeting)

(4 weeks)- Management development specialist

(4 weeks)

CY1993 40 weeks Bank resources (20 weeks) of which:

- Task manager (12 weeks)- Implementation/Operation Specialist

(8 weeks)

Supplementary technical inputs (throughbilateral/multilateral cooperation):

- Public health specialist (healthpromotion) (2 weeks)

- Hedical education (primary carecurriculum) (3 weeks)

- Health economist (finance/budgetingaccounting) (3 weeks)

- Information systems (automation ofhospital A/D, accounting, drugmonitoring) (8 weeks)

- Equipment specialist (2 weeks)- Primary care (1 staff year - EC funded)

-77 - Annex 8Page 2 of 3

CY1994 31 weeks Bank resources (18 weeks) of which:

- Task manager (10 weeks)- Implementation/Operation Specialist

(8 weeks)

Supplementary technical inputs (throughbilateral/multilateral cooperation):

- Information systems specialist (healthmanagement component)(automation ofinformation systems countrywide)(6 weeks)

- Health planner (regional health)(5 weeks)

- Public health specialist (healthpromotion/primary care components)(2 weeks)

- Primary care (1 staff year - EC funded)

CY1995 30 weeks Bank resources (16 weeks) of which:

Task manager (8 weeks)- Implementation/Operation Specialist

(8 weeks)

Supplementary technical inputs (throughbilateral/multilateral cooperation):

- Public health specialist (healthpromotion) (5 weeks)

- Health economist (accounting, finance,budgeting) (3 weeks)

- Medical education (primary carecomponent) (3 weeks)

- Management development specialist (healthmanagement training) (3 weeks)

- Primary care (1 staff year - EC funded)

CY1996 25 weeks Bank resources (14 weeks) of which:

- Task manager (8 weeks)- Implementation/operation specialist

(6 weeks)

- 78 -8Page 3 of 3

Supplementary technical inputs (throughbilateral/multilateral cooperation):

| Information system specialist (4 weeks)- Health planner (regional health)

(3 weeks)- Program evaluation specialist (2 weeks)- Health economist (2 weeks)

CY1997 21 weeks Bank resources (14 weeks) of which:

- Task manager (8 weeks)- Implementation/operation specialist

6 weeks)

Supplementary technical inputs (throughbilateral/multilateral cooperation):

- Public health specialist (2 weeks)- Health system specialist (2 weeks)- Health economist (3 weeks)

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